Obesity Surgery

, Volume 21, Issue 3, pp 310–315 | Cite as

NAFLD and Insulin Resistance Do Not Increase the Risk of Postoperative Complications Among Patients Undergoing Bariatric Surgery—A Prospective Analysis

  • Tarsila Ribeireiro
  • James Swain
  • Michael Sarr
  • Michael Kendrick
  • Florencia Que
  • Schuyler Sanderson
  • Anuradha Krishnan
  • Kimberly Viker
  • Kymberly Watt
  • Michael CharltonEmail author
Clinical Research



Nonalcoholic fatty liver disease (NAFLD) and insulin resistance are common consequences of obesity and are highly prevalent among patients undergoing bariatric surgery. Insulin resistance and NAFLD have been reported to be associated with postoperative complications following major surgery.


We prospectively evaluated complications in a cohort of 437 consecutive patients undergoing bariatric surgery. Detailed metabolic profile was obtained prior to surgery, and liver biopsies were taken routinely during surgery.


Mean age was 47.8 years (20–77), and mean body mass index (BMI) was 48.5 kg/m2 (32–94). Common co-morbid conditions were metabolic syndrome (79%), obstructive sleep apnea (73%), and hypertension (60%). Seventy-seven percent underwent Roux-en-Y gastric bypass, 15% biliopancreatic diversion with duodenal switch, and 8% adjustable gastric banding. The operative approach was laparoscopic in 81% of patients. Liver histology was normal in 22% of patients. Seventy-eight percent of patients had NAFLD. Nonalcoholic steatohepatitis (NASH) was present in 18%. Advanced fibrosis (stage 3–4) was present in 5%. Complications were observed in 25% of the cohort, the most frequent being infection, occurring in 14%. The wound was the most frequent site of infection (9%). There were no cases of postoperative hepatic decompensation. Reoperation was necessary in 7%. In univariate analysis, the factors associated with complications were male gender (p = 0.009), type and approach of surgery (p = 0.023 and p = 0.0001, respectively), BMI (p = 0.000), serum creatinine (p = 0.023), and serum albumin (p = 0.0001). In multivariate analysis, the independent factors associated with complications in bariatric surgery were BMI (OR 1.039, 95% CI 1.010–1.068; p = 0.008), surgical approach (OR 2.696, 95% CI 1.547–4.698; p = 0.000), and serum albumin (OR 0.416, 95% CI 0.176–0.978; p = 0.044). NASH was not predictive of complications.


Bariatric surgery is a safe and efficient treatment for obesity. The occurrence of NAFLD or NASH without portal hypertension should not preclude the procedure.


Nonalcoholic fatty liver disease NAFLD Nonalcoholic steatohepatitis Morbid obesity Bariatric surgery Hepatic histopathology 


Conflict of interest disclosure

None of the authors have anything to disclose. This study was funded in its in entirety by the National Institutes of Health.


  1. 1.
    Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988–1994 [see comments]. Diab Care. 1998;21:518–24.CrossRefGoogle Scholar
  2. 2.
    Sturm R. Increases in clinically severe obesity in the United States, 1986–2000. Arch Intern Med. 2003;163:2146–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–93.CrossRefPubMedGoogle Scholar
  4. 4.
    Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.CrossRefPubMedGoogle Scholar
  5. 5.
    Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547–59.PubMedGoogle Scholar
  6. 6.
    Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J Clin Gastroenterol. 2006;40:S5–10.PubMedGoogle Scholar
  7. 7.
    Angulo P. Nonalcoholic fatty liver disease [comment]. N Engl J Med. 2002;346:1221–31 [Review] [95 refs].CrossRefPubMedGoogle Scholar
  8. 8.
    Charlton M. Nonalcoholic fatty liver disease: a review of current understanding and future impact. Clin Gastroenterol Hepatol. 2004;2:1048–58 [Review] [117 refs].CrossRefPubMedGoogle Scholar
  9. 9.
    Noel M, Hickner J, Ettenhofer T, et al. The high prevalence of obesity in Michigan primary care practices. An UPRNet study. Upper Peninsula Research Network. J Fam Pract. 1998;47:39–43.PubMedGoogle Scholar
  10. 10.
    Flegal KM. The obesity epidemic in children and adults: current evidence and research issues. Med Sci Sports Exerc. 1999;31(11 Suppl):S509–14 [Review] [47 refs].PubMedGoogle Scholar
  11. 11.
    Popkin BM, Udry JR. Adolescent obesity increases significantly in second and third generation U.S. immigrants: the National Longitudinal Study of Adolescent Health. J Nutr. 1998;128:701–6.PubMedGoogle Scholar
  12. 12.
    Fraser A, Longnecker MP, Lawlor DA. Prevalence of elevated alanine aminotransferase among US adolescents and associated factors: NHANES 1999–2004. Gastroenterology. 2007;133:1814–20.CrossRefPubMedGoogle Scholar
  13. 13.
    Wolf AM, Busch B, Kuhlmann HW, et al. Histological changes in the liver of morbidly obese patients: correlation with metabolic parameters. Obes Surg. 2005;15:228–37.CrossRefPubMedGoogle Scholar
  14. 14.
    Lima ML, Mourao SC, Diniz MT, et al. Hepatic histopathology of patients with morbid obesity submitted to gastric bypass. Obes Surg. 2005;15:661–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Harnois F, Msika S, Sabate JM, et al. Prevalence and predictive factors of non-alcoholic steatohepatitis (NASH) in morbidly obese patients undergoing bariatric surgery. Obes Surg. 2006;16:183–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Papadia FS, Marinari GM, Camerini G, et al. Liver damage in severely obese patients: a clinical-biochemical-morphologic study on 1, 000 liver biopsies. Obes Surg. 2004;14:952–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Sorrentino P, Tarantino G, Conca P, et al. Silent non-alcoholic fatty liver disease—a clinical–histological study. J Hepatol. 2004;41:751–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Adams LA, Lymp JF, St S, et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology. 2005;129:113–21 [see comment].CrossRefPubMedGoogle Scholar
  19. 19.
    Kooby DA, Fong Y, Suriawinata A, et al. Impact of steatosis on perioperative outcome following hepatic resection. J Gastrointest Surg. 2003;7:1034–44.CrossRefPubMedGoogle Scholar
  20. 20.
    Castillo J, Fabrega E, Escalante CF, et al. Liver transplantation in a case of steatohepatitis and subacute hepatic failure after biliopancreatic diversion for morbid obesity. Obes Surg. 2001;11:640–2.CrossRefPubMedGoogle Scholar
  21. 21.
    Mason EE, Renquist KE, Huang YH, et al. Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction. Obes Surg. 2007;17:9–14.CrossRefPubMedGoogle Scholar
  22. 22.
    Grimm IS, Schindler W, Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol. 1992;87:775–9.PubMedGoogle Scholar
  23. 23.
    Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care. 1999;2:69–78.CrossRefPubMedGoogle Scholar
  24. 24.
    Zerr KJ, Furnary AP, Grunkemeier GL, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63:356–61.CrossRefPubMedGoogle Scholar
  25. 25.
    Gravante G, Araco A, Araco F, et al. Postobese patients and inherent surgical complications. Ann Plast Surg. 2006;56:585–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Van den Berghe G, Wouters PJ, Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med. 2003;31:359–66.CrossRefPubMedGoogle Scholar
  27. 27.
    NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med. 1991;115:956–61.Google Scholar
  28. 28.
    Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Jama. 2003;289:2560–72.CrossRefPubMedGoogle Scholar
  29. 29.
    Rodbard HW, Blonde L, Braithwaite SS, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13 Suppl 1:1–68.PubMedGoogle Scholar
  30. 30.
    Grundy SM, Brewer HB Jr, Cleeman JI, et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109:433–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Brunt EM, Janney CG, Di Bisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. Am J Gastroenterol. 1999;94:2467–74.CrossRefPubMedGoogle Scholar
  32. 32.
    Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3–60 month follow-up. Obes Surg. 2000;10:233–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279–89. discussion 289–91.CrossRefPubMedGoogle Scholar
  34. 34.
    Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial. Obes Surg. 2001;11:284–92.CrossRefPubMedGoogle Scholar
  35. 35.
    Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543–51.CrossRefPubMedGoogle Scholar
  36. 36.
    Weller WE, Rosati C, Hannan EL. Relationship between surgeon and hospital volume and readmission after bariatric operation. J Am Coll Surg. 2007;204:383–91.CrossRefPubMedGoogle Scholar
  37. 37.
    Dimick JB, Welch HG, Birkmeyer JD. Surgical mortality as an indicator of hospital quality: the problem with small sample size. Jama. 2004;292:847–51.CrossRefPubMedGoogle Scholar
  38. 38.
    Livingston EH, Huerta S, Arthur D, et al. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg. 2002;236:576–82.CrossRefPubMedGoogle Scholar
  39. 39.
    Jamal MK, DeMaria EJ, Johnson JM, et al. Impact of major co-morbidities on mortality and complications after gastric bypass. Surg Obes Relat Dis. 2005;1:511–6.CrossRefPubMedGoogle Scholar
  40. 40.
    Fernandez AZ Jr, Demaria EJ, Tichansky DS, et al. Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity. Ann Surg. 2004;239:698–702. discussion 702-693.CrossRefPubMedGoogle Scholar
  41. 41.
    Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909–17.CrossRefPubMedGoogle Scholar
  42. 42.
    Lancaster RT, Hutter MM. Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Surg Endosc. 2008;22:2554–63.CrossRefPubMedGoogle Scholar
  43. 43.
    Kleiner DE, Brunt EM, Van Natta M, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology. 2005;41:1313–21.CrossRefPubMedGoogle Scholar
  44. 44.
    Matteoni CA, Younossi ZM, Gramlich T, et al. Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. Gastroenterology. 1999;116:1413–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2010

Authors and Affiliations

  • Tarsila Ribeireiro
    • 1
  • James Swain
    • 2
  • Michael Sarr
    • 2
  • Michael Kendrick
    • 2
  • Florencia Que
    • 2
  • Schuyler Sanderson
    • 3
  • Anuradha Krishnan
    • 1
  • Kimberly Viker
    • 1
  • Kymberly Watt
    • 1
  • Michael Charlton
    • 1
    Email author
  1. 1.Division of Gastroenterology and HepatologyMayo ClinicRochesterUSA
  2. 2.Department of SurgeryMayo ClinicRochesterUSA
  3. 3.Division of Anatomic PathologyMayo ClinicRochesterUSA

Personalised recommendations