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Safety and Utility of Liver Biopsy During Bariatric Surgery in the New Zealand Setting

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Abstract

Background

Asymptomatic liver disease is common in bariatric patients and can be diagnosed with intraoperative biopsy. This study aimed to establish the risk-benefit profile of routine liver biopsy, prevalence of clinically significant liver disease, relationship between liver pathology and body mass index, and compare outcomes between ethnic groups.

Methods

This retrospective cohort study included all patients who had index bariatric surgery at Auckland City Hospital between 2009 and 2016. Diagnosis of liver disease was based on intraoperative biopsy histology. Outcomes included safety (biopsy-related complication) and utility (liver pathology meeting criteria for referral). Liver pathology and referral rates were compared between ethnic groups.

Results

Of 335 bariatric surgery patients, 234 (70%) underwent intraoperative liver biopsy. There were no biopsy-related complications. Histological findings were as follows: normal 25/234 (11%), non-alcoholic fatty liver disease (NAFLD) 207/234 (88%), and other pathological findings in 35/234 (15%). Histological finding meeting referral criteria was present in 22/234 (9%). Of these, 12/22 (55%) were referred. Number needed to biopsy to identify histology meeting referral criteria: n = 11. Māori had a similar NAFLD rate to non-Māori [51/56 versus 156/178, p = 0.48]. Pasifika patients had a higher rate than non-Pasifika [39/40 versus 168/194, p = 0.049]. Māori and Pasifika patients had similar referral rates to non-Māori and non-Pasifika [2/3 versus 5/9, p = 0.73; 2/2 versus 5/10, p = 0.19].

Conclusions

Intraoperative liver biopsy during bariatric surgery is safe and identified liver disease in 89%, with 9% meeting referral criteria. Pasifika patients have a higher rate of NAFLD than non-Pasifika.

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References

  1. Machado M, Marques-Vidal P, Cortez-Pinto H. Hepatic histology in obese patients undergoing bariatric surgery. J Hepatol. 2006;45(4):600–6.

    Article  PubMed  Google Scholar 

  2. Mofrad P, Contos MJ, Haque M, et al. Clinical and histologic spectrum of nonalcoholic fatty liver disease associated with normal ALT values. Hepatology. 2003;37(6):1286–92.

    Article  PubMed  Google Scholar 

  3. Sorrentino P, Tarantino G, Conca P, et al. Silent non-alcoholic fatty liver disease - a clinical-histological study. J Hepatol. 2004;41(5):751–7.

    Article  CAS  PubMed  Google Scholar 

  4. Castéra L, Foucher J, Bernard PH, et al. Pitfalls of liver stiffness measurement: a 5-year prospective study of 13,369 examinations. Hepatology. 2010;51(3):828–35.

    PubMed  Google Scholar 

  5. Myers RP, Pomier-Layrargues G, Kirsch R, et al. Discordance in fibrosis staging between liver biopsy and transient elastography using the FibroScan XL probe. J Hepatol. 2012;56(3):564–70.

    Article  PubMed  Google Scholar 

  6. Dulai PS, Sirlin CB, Loomba R. MRI and MRE for non-invasive quantitative assessment of hepatic steatosis and fibrosis in NAFLD and NASH: clinical trials to clinical practice. J Hepatol. 2016;65(5):1006–16.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Teixeira AR, Bellodi-Privato M, Carvalheira JB, et al. The incapacity of the surgeon to identify NASH in bariatric surgery makes biopsy mandatory. Obes Surg. 2009;19(12):1678–84.

    Article  PubMed  Google Scholar 

  8. Dolce CJ, Russo M, Keller JE, et al. Does liver appearance predict histopathologic findings: prospective analysis of routine liver biopsies during bariatric surgery. Surg Obes Relat Dis. 2009;5(3):323–8.

    Article  PubMed  Google Scholar 

  9. Leoni S, Tovoli F, Napoli L, et al. Current guidelines for the management of non-alcoholic fatty liver disease: a systematic review with comparative analysis. World J Gastroenterol. 2018;24(30):3361–73.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Praveenraj P, Gomes RM, Kumar S. Prevalence and predictors of non-alcoholic fatty liver disease in morbidly obese South Indian patients undergoing bariatric surgery. Obes Surg. 2015;5(11):2078–87.

    Article  Google Scholar 

  11. Petrick A, Benotti P, Wood GC, et al. Utility of ultrasound, trans-aminases, and visual inspection to assess nonalcoholic fatty liver disease in bariatric surgery patients. Obes Surg. 2015;25(12):2368–75.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Froehlich F, Lamy O, Fried M, et al. Practice and complications of liver biopsy. Dig Dis Sci. 1993;38(8):1480–4.

    Article  CAS  PubMed  Google Scholar 

  13. Janes CH, Lindor KD. Outcome of patients hospitalized for complications after outpatient liver biopsy. Ann Intern Med. 1993;118(2):96–8.

    Article  CAS  PubMed  Google Scholar 

  14. Thampanitchawong P, Piratvisuth T. Liver biopsy: complications and risk factors. World J Gastroenterol. 1999;5(4):301–4.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Population of Auckland AHB. Ministry of Health; [updated 2019 February 25; cited 2019 June 10]. Available from: https://www.health.govt.nz/new-zealand-health-system/my-dhb/auckland-dhb/population-auckland-dhb.

  16. Obesity statistics. Ministry of health; [updated 2018 November 15; cited 2019 June 10]. Available from: https://www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/obesity-statistics.

  17. Pasifika People in NZ. Ministry for Pasifika Peoples. [Cited 2019 June 10]. Available from: https://www.mpp.govt.nz/Pasifika-people-in-nz.

  18. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494–503.

    Article  CAS  PubMed  Google Scholar 

  19. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 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(6):1313–21.

    Article  PubMed  Google Scholar 

  21. McCormack L, Yeh L-C, Braybrook B, et al. Tupu Ola Moui. Pasifika health chart book 2012. Wellington: Ministry of Health; 2012. [cited 2019 25 Feb]. Available from: https://www.health.govt.nz/publication/tupu-ola-moui-Pasifika-health-chart-book-2012

    Google Scholar 

  22. Ministry of Health. Ethnicity data protocols. Wellington: Ministry of Health; 2017. [cited 2019 26 Feb]. Available from: https://www.health.govt.nz/publication/hiso-100012017-ethnicity-data-protocols

    Google Scholar 

  23. Hsiang J. Chronic liver diseases: with a focus on hepatitis B, type 2 diabetes, and statins [PhD thesis]. [Auckland]: University of Auckland; 2016. 161 p.

  24. Agresti A. An introduction to categorical data analysis. 2nd ed. New Jersey: John Wiley & Sons, Inc; 2007.

    Book  Google Scholar 

  25. Barbois S, Arvieux C, Leroy V, et al. Benefit–risk of intraoperative liver biopsy during bariatric surgery: review and perspectives. Surg Obes Relat Dis. 2017;13(10):1780–6.

    Article  PubMed  Google Scholar 

  26. Helling TS, Helzberg JH, Nachnani JS, et al. Predictors of nonalcoholic steatohepatitis in patients undergoing bariatric surgery: when is liver biopsy indicated? Surg Obes Relat Dis. 2008;4(5):612–7.

    Article  PubMed  Google Scholar 

  27. Kleiner DE, Berk PD, Hsu JY, et al. Hepatic pathology among patients without known liver disease undergoing bariatric surgery: observations and a perspective from the Longitudinal Assessment of Bariatric Surgery (LABS) Study. Semin Liver Dis. 2014;34(1):98–107.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Simo KA, McKillop IH, McMillan MT, et al. Does a calculated “NAFLD fibrosis score” reliably negate the need for liver biopsy in patients undergoing bariatric surgery? Obes Surg. 2013;24(1):15–21.

    Article  Google Scholar 

  29. Mahawar KK, Parmar C, Graham Y, et al. Routine liver biopsy during bariatric surgery: an analysis of evidence base. Obes Sur. 2016;26(1):177–81.

    Article  Google Scholar 

  30. Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome. Ann Surg. 2005;242(4):610–7.

    PubMed  PubMed Central  Google Scholar 

  31. Mummadi RR, Kasturi KS, Chennareddygari S, et al. Effect of bariatric surgery on nonalcoholic fatty liver disease: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2008;6(12):1396–402.

    Article  PubMed  Google Scholar 

  32. Brenner DA. Reversibility of liver fibrosis. Gastroenterol Hepatol. 2013;9(11):737–9.

    Google Scholar 

  33. Lee Y, Doumouras AG, Yu J, et al. Complete resolution of nonalcoholic fatty liver disease after bariatric surgery: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2019;17(6):1040–60.

    Article  PubMed  Google Scholar 

  34. Mahawar KK, Parmar C, Graham Y, et al. Monitoring of liver function tests after Roux-en-Y gastric bypass: an examination of evidence base. Obes Surg. 2016;26(10):2516–22.

    Article  PubMed  Google Scholar 

  35. Coppell KJ, Miller JC, Gray AR, et al. Obesity and the extent of liver damage among adult New Zealanders: findings from a national survey. Obes Sci Pract. 2015;1(2):67–77.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Health Quality & Safety Commission New Zealand. Atlas of healthcare variation. [cited 2019 Jan 17]. Available from: https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/diabetes.

  37. Crantock LR, Dillon JF, Hayes PC. Diagnostic laparoscopy and liver disease: experience of 200 cases. Aust NZ J Med. 1994;24(3):258–62.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Auckland City Hospital, 2 Park Road, Auckland, 1023, New Zealand

    Hannah Collins, Grant Beban, Rishi Ram, David Orr & Nicholas Evennett

  2. University of Auckland, Auckland, New Zealand

    John Windsor

  3. University of Melbourne, Melbourne, Australia

    Benjamin Loveday

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Correspondence to Hannah Collins.

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The authors declare that they have no conflict of interest.

Ethical Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

For this type of study, formal consent is not required.

Ethics approval from Central Health and Disability Ethics Committee, Ministry of Health, Wellington, New Zealand. Ethics ref. 17/CEN/127.

Consent Statement

This was a retrospective study where no identifying data was collected. All data was collected in a de-identified database by a single investigator. Informed consent was not required.

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Collins, H., Beban, G., Windsor, J. et al. Safety and Utility of Liver Biopsy During Bariatric Surgery in the New Zealand Setting. OBES SURG 30, 313–318 (2020). https://doi.org/10.1007/s11695-019-04161-3

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