|Year : 2018 | Volume
| Issue : 1 | Page : 25-29
Bariatric surgery effect on patients with nonalcoholic fatty liver disease and type II diabetes mellitus
Mazen M Hassanain1, Nadia A Aljomah1, Fahad Y Bamehriz1, Hisham M Alkhalidi2, Maram M Alkhamash3
1 Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Liver Disease Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||17-Aug-2018|
Mazen M Hassanain
College of Medicine, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
Aims: To study the effect of sleeve gastrectomy in patients with type II diabetes mellitus and fatty liver disease.
Settings and Design: This is a prospective study that was conducted from September 2016 to 2017 in KSUMC Riyadh, Saudi Arabia.
Subjects and Methods: We obtained prospectively collected data from two longitudinal cohort studies at our institution. We included adults who were diagnosed with nonalcoholic fatty liver disease (NAFLD) and diabetes, with a body mass index (BMI) of >30 kg/m2, and who underwent sleeve gastrectomy.
Statistical Analysis Used: Data were analyzed using JMP® 13.0.0 for data management and reporting. Continuous data were reported as means and standard deviations if normally distributed or as medians and interquartile ranges otherwise. We also used the paired t-test and Chi-square test.
Results: Our population included 32 patients (mean age, 39.5 years). The preoperative and postoperative median BMIs were 42.1 and 34.2 kg/m2, respectively (P = 0.0003). The percentages of macrovascular steatosis pre- and postoperatively were 37.5 and 10, respectively (P = 0.0328). The patients who had complete diabetes mellitus (DM) remission postoperatively had a higher median BMI of 42.05 kg/m2 preoperatively and 35.7 kg/m2 postoperatively than that the patients who did not have remission (P = 0.0003). Regarding the age groups, 46.1% of patients aged <40 years at DM onset, and 34.6% of patients aged >40 years who had complete diabetes remission postoperatively, which was not statistically significant.
Conclusions: DM remission was statistically significant postoperatively. Remission occurred more in the higher BMI groups. There was no clear relationship between NAFLD and diabetes remission.
Keywords: Bariatric surgery, diabetes mellitus, nonalcoholic fatty liver disease
|How to cite this article:|
Hassanain MM, Aljomah NA, Bamehriz FY, Alkhalidi HM, Alkhamash MM. Bariatric surgery effect on patients with nonalcoholic fatty liver disease and type II diabetes mellitus. Saudi J Laparosc 2018;3:25-9
|How to cite this URL:|
Hassanain MM, Aljomah NA, Bamehriz FY, Alkhalidi HM, Alkhamash MM. Bariatric surgery effect on patients with nonalcoholic fatty liver disease and type II diabetes mellitus. Saudi J Laparosc [serial online] 2018 [cited 2019 Apr 24];3:25-9. Available from: http://www.saudijl.org/text.asp?2018/3/1/25/239210
| Introduction|| |
Bariatric surgery has become one of the most effective ways in managing obesity and many comorbidities, including diabetes mellitus (DM) and nonalcoholic fatty liver disease (NAFLD). Studies from the UK showed that 86% of patients with type II DM are obese, while in Australia, 53% are obese. NAFLD was reported to occur in up to 46% of a cohort from the US. Moreover, the presence of DM is one of the predictors for NAFLD in obese patients. In this study, we aimed to understand the relationship between NAFLD and type II DM in obese patients undergoing bariatric surgery.
| Subjects and Methods|| |
We collected data from patients participating in two longitudinal cohort studies at our institution entitled, “The effects of bariatric surgery on non-alcoholic fatty liver disease in patients with Gallstones” and “Prevalence of non-alcoholic fatty liver diseases in patients with gallstone,” which included 353 patients were collected from the databases, 289 were nondiabetic, 55 diabetics and 9 are unknown. Morbid obesity was diagnosed in 166 of the 289 and 31 of the 55 patients.
These two longitudinal cohort studies were being conducted by the Liver Disease Research Center at King Saud University; all patients provided their consent for clinical data collection coupled with biobanking in an effort to understand fatty liver disease. Our study was approved by the local ethics review board at our institution to access the stored data and blood samples.
We included all adult patients with a body mass index (BMI) of ≥30 kg/m2 and who underwent sleeve gastrectomy for the treatment of obesity. NAFLD was diagnosed using preoperative ultrasound and tissue biopsy during the bariatric surgery in equivocal cases. Patients with a history of alcoholism (>20 g/day); those who have evidence of autoimmune hepatitis, chronic hepatitis B or C virus, HIV, primary hemochromatosis, alpha-1-antitrypsin deficiency, Wilson's disease, or liver cirrhosis; pregnant women; and those who are currently taking known hepatotoxic medications were excluded from our study.
Thirty-two patients were included in the final analysis (16 men and 16 women). We compared the data of the patients before and after surgery by focusing on the HbA1c and fasting blood glucose (FBG) levels (NAS steatosis, lobular inflammation, hepatocyte ballooning, NAS score, and NAS fibrosis staging) and BMI. DM was diagnosed using the HbA1c level of ≥6.5% and FBG level of ≥5.8 mmol/l; the same cutoff point was also used to determine the remission rate of DM. Insulin resistance levels were also measured using the HOMA calculator.
Data were analyzed using the JMP ® 13.0.0 for data management and reporting. Continuous data were reported as means and standard deviations if normally distributed or otherwise as medians and interquartile ranges. We also used the paired t-test for examining the changes before and after surgery. Nominal data were presented as proportions and percentages; the Chi-square test was used for comparison.
| Results|| |
Our population included 16 men (50%) and 16 women (50%) with a mean age of 39.5 (±11.3) years. Eighteen patients aged <40 years (56.2%) and 14 (43.7%) aged >40 years in relation to the onset of DM. The preoperative and postoperative median BMIs were 42.1 kg/m 2 (range, 37.55–47.5) and 34.2 kg/m 2 (range, 29.4–36.7), respectively; the latter BMI was significantly lower with P = 0.0003. The median follow-up duration was 4 years and ranged from 3 to 5 years.
All patients in this study were diabetic at the study entry. Twenty-one (80.7%) of the patients had complete DM remission, 5 (19.2%) had no remission, and 6 were lost to follow-up. The total DM remission rate was 80.7% (P < 0.0001).
The median NAS steatosis score was 2 (range, 1–3). Ten patients had mild-to-moderate steatosis (31.2%) and 22 patients had severe steatosis (68.7%). The median score for NAS lobular inflammation was 1 (range, 0–1). The median score of NAS hepatocyte ballooning was 1 (range, 1–1). The total NAS score had a median of 4.5 (range, 3–5). The percentages of median microvascular and macrovascular steatosis were 5 (range, 3–10) and 37.5 (range, 16.2–68.7), respectively. Insulin resistance levels were also measured and resulted in a median of 3.4 (range, 2.7–5.1) with P = 0.0049 [Table 1].
|Table 1: Nonalcoholic fatty liver disease regression rates pre- and postoperatively|
Click here to view
The median NAS steatosis score was 1 (range, 0.5–1.5), including seven patients who had mild-to-moderate steatosis (77.7%) and two patients who had severe steatosis (22.2%); the rest of the patients (23) had no second biopsy. The median score for NAS lobular inflammation was 0 (range, 0–1). The NAS hepatocyte ballooning score was 1 (range, 0.5–1), and the NAS fibrosis score was 0.5 (range, 0–1.75). The percentages of microvascular and macrovascular steatosis were 2 (range, 0–5) and 10 (range, 2–30), respectively, and insulin resistance level median was 1.36 (range, 0.8–1.4) with P = 0.0049 [Table 1].
The patients who had complete DM remission postoperatively had a preoperative median BMI of 42.05 kg/m2 (range, 36.7–45.7) before surgery and 35.7 kg/m2 (range, 30.6–36.7) after surgery. The patients who did not have DM remission had a preoperative BMI of 38 kg/m2 (range, 35.8–53.9) and a postoperative BMI of 31.8 kg/m2 (range, 28.5–41.9; P = 0.0003).
The NAFLD markers were not statistically significant in relation to DM, except for the difference between macrovascular steatosis percentage pre- and postoperatively, which was statistically significant (P = 0.0328). The patients with DM remission had a median macrovascular steatosis percentage of 40 (range, 9.5–67.5) before surgery compared with that after surgery (15 [range, 7–45]). The nonremission group had a median macrovascular steatosis percentage of 35 (range, 11.5–55) preoperatively and 1.5 (range, 1–2) postoperatively, with no significant difference [Table 2].
|Table 2: Relationship between body mass index and diabetes mellitus remission|
Click here to view
The relationship between DM and sex was not statistically significant, complete remission was observed in 11 women (42.3%) and 10 men (38.4%) vs. 3 females (11.5%) and 2 males (7.6%) without DM remission.
The analysis of NAS steatosis preoperatively based on DM postoperatively showed that 7 (26.9%) patients of those who had complete remission had mild-to-moderate steatosis, while 14 (53.8%) patients had severe steatosis. In the comparison of those who did not have DM, 2 (7.6%) patients had mild-to-moderate steatosis, while 3 (11.5%) patients had severe steatosis.
The relationship between NAS lobular inflammation, NAS hepatocyte ballooning, NAS score, NAS fibrosis staging, and DM was not statistically significant.
We divided our patients into two groups according to the age of DM onset: <40 years and >40 years. In the first group, 12 out of 18 patients (46.1%) had complete DM remission; in the second group, only 9 out of 14 (34.6%) patients had a remission, which was not statistically significant [Table 3].
|Table 3: Difference between the age groups in relation to diabetes mellitus remission|
Click here to view
| Discussion|| |
Our results showed that of the 32 patients, 80.7% had complete DM remission, 5 (19.2%) had no remission, and 6 were lost to follow-up. Their preoperative and postoperative median BMI was 42.1 (range, 37.55–47.5) and 34.2 (range, 29.4–36.7) kg/m2, respectively; the latter was significantly lower with P = 0.0003. The difference between the macrovascular steatosis percentage pre- and postoperatively showed P = 0.0328. In addition, the relationship between sex, NAS lobular inflammation, NAS hepatocyte ballooning, NAS score, NAS fibrosis staging, and DM was not statistically significant. Furthermore, the patients who had complete DM remission postoperatively had a median BMI of 42.05 kg/m 2 (range, 36.7–45.7) before surgery and 35.7 kg/m 2 (range, 30.6–36.7) after surgery. The median BMIs before and after surgery of the patients who did not have remission were 38 kg/m 2 (range, 35.8–53.9) and 31.8 kg/m 2 (range, 28.5–41.9), respectively. Regarding the age groups, 18 (56.2%) patients aged <40 years, and 14 (43.7%) aged >40 years. Of those who aged <40 and >40 years, 12 (46.1%) and 9 (34.6%) patients had complete DM remission, respectively. Conversely, 1 (3.8%) patient in the younger population had no DM remission, while 4 (15.3%) patients from the other group had DM remission.
A meta-analytic assessment of the prevalence, incidence, and outcomes of NAFLD was conducted by Younossi et al. and showed a prevalence of NAFLD reaching 25.24%. Middle East and South America had the highest prevalence, while Africa had the lowest. Furthermore, the prevalence of NAFLD will continue to be high, unless awareness is inculcated among the local population. Similarly, the prevalence of DM among adults aged >18 years has increased from 4.7% in 1980 to 8.5% in 2014 (as per the WHO report). These rates are one of the main indications to find several ways in treating such diseases; one of the most important methods was bariatric surgery, which has shown its effectiveness on DM remission and NAFLD regression. However, when DM coexist the NAFLD, the benefit from bariatric surgery remains unclear.
The most important finding from this study was the significant improvement in the blood sugar levels postoperatively, which supports those in the literature; our study showed that 80.7% of the patients had complete DM remission, which was statistically significant. In addition, insulin resistance levels were also reduced significantly following the surgery. In a retrospective cohort study conducted in Taiwan, the effect of bariatric surgery in 52 patients with type II DM was discussed. They showed that 18% of their patients had complete remission, while 14% had partial remission over a 5-year follow-up period. Another study investigated 55 patients with obesity and DM from China found that 85.2% of their patients who underwent gastric bypass had complete remission compared with the 78.6% of those who underwent sleeve gastrectomy. Similarly, Milone et al. also revealed that mini-gastric bypass and sleeve gastrectomy showed similar DM remission rates in 53 patients whose HbA1c levels dropped by − 22.57 ± 8.70 and − 22.67 ± 8.46, respectively, indicating that bariatric surgery is considered to be a primary treatment for patients with type II DM.
Obesity and insulin resistance are a major etiology in increasing the release of free fatty acids from adipocytes, which made us hypothesize that these two factors have a significant role in the development of NAFLD. Furthermore, by treating obesity using bariatric surgery, NAFLD will regress spontaneously; however, the relationship between the coexistence of obesity and insulin resistance with the intervention of sleeve gastrectomy remains unclear. Results showed that DM and even fatty liver have been improved after surgery; however, we could not detect the relationship even with measuring of insulin resistance levels, which could be because of the small sample size of the study. In addition, only 8% of the population who were included in the second study were obese, which could be another reason why we did not detect the relationship between them.
Conversely, 80.7% of the patients who had complete DM remission after surgery had higher BMIs than the 19.2% who had no remission. When we attempted to detect the reason behind such rate (19.2%) and the absence of DM remission, we found that such a population had lower BMIs than the remission group before surgery; this emphasizes that if the preoperative BMI is higher, the patients will be more likely to experience DM remission postoperatively.
Similarly, the number of patients who had complete remission and severe NAS steatosis exceeds the remission rate of DM compared with that of those with mild and moderate steatosis; this indicates that patients with severe NAS steatosis score will benefit more from surgery regarding their DM status than those with mild or moderate steatosis. Furuya et al. performed edge liver biopsy in 18 patients with NAFLD to assess the effect of bariatric surgery and found that steatosis disappeared in 84% of the patients, and 75% had fibrosis regression. Hepatocellular ballooning was not found in 50%, and 81% had a mild lobular inflammatory infiltrate remaining.
The relationship between macrovascular steatosis and DM was also similar to that of a previous analysis since patients with high macrovascular steatosis scores had better remission rates than those who had low scores. This supports a previous finding regarding the relationship between high BMIs and lipid levels before surgery and the outcome after it since they will get better DM remission rates comparable to the lesser BMIs.
Twelve patients (46.1%) in our study had complete DM remission, including 9 (34.6%) patients aged >40 years. In addition, 1 (3.8%) patient in the younger population had no DM remission, while 4 (15.3%) patients from the other group had DM remission. No significant difference was noted between the early- and late-onset groups, which differs from that of Aung et al.; they compared early- and late-onset DM by dividing their population into those aging <40 and >40 years and found that their early-onset group achieved a better glycemic control than their late-onset group.
| Conclusions|| |
Sleeve gastrectomy has a significant impact on DM remission rates; however, no direct relationship between NAFLD and DM remission was detected.
This research was sponsored by the Saudi journal of laparoscopy.
Financial support and sponsorship
This study was sponsored by Saudi journal of laparoscopy.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hennings DL, Baimas-George M, Al-Quarayshi Z, Moore R, Kandil E, DuCoin CG, et al.
The inequity of bariatric surgery: Publicly insured patients undergo lower rates of bariatric surgery with worse outcomes. Obes Surg 2018;28:44-51.
Daousi C, Casson IF, Gill GV, MacFarlane IA, Wilding JP, Pinkney JH, et al.
Prevalence of obesity in type 2 diabetes in secondary care: Association with cardiovascular risk factors. Postgrad Med J 2006;82:280-4.
Thomas MC, Zimmet P, Shaw JE. Identification of obesity in patients with type 2 diabetes from Australian primary care: The NEFRON-5 study. Diabetes Care 2006;29:2723-5.
Williams CD, Stengel J, Asike MI, Torres DM, Shaw J, Contreras M, et al.
Prevalence of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and liver biopsy: A prospective study. Gastroenterology 2011;140:124-31.
Praveenraj P, Gomes RM, Kumar S, Karthikeyan P, Shankar A, Parthasarathi R, et al.
Prevalence and predictors of non-alcoholic fatty liver disease in morbidly obese South Indian patients undergoing bariatric surgery. Obes Surg 2015;25:2078-87.
Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M, et al.
Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology 2016;64:73-84.
Al-hamoudi W, El-Sabbah M, Ali S, Altuwaijri M, Bedewi M, Adam M, et al.
Epidemiological, clinical, and biochemical characteristics of Saudi patients with nonalcoholic fatty liver disease: A hospital-based study. Ann Saudi Med 2012;32:288-92.
Hsu CC, Almulaifi A, Chen JC, Ser KH, Chen SC, Hsu KC, et al.
Effect of bariatric surgery vs. medical treatment on type 2 diabetes in patients with body mass index lower than 35: Five-year outcomes. JAMA Surg 2015;150:1117-24.
Yang J, Wang C, Cao G, Yang W, Yu S, Zhai H, et al.
Long-term effects of laparoscopic sleeve gastrectomy versus roux-en-Y gastric bypass for the treatment of Chinese type 2 diabetes mellitus patients with body mass index28-35 kg/m(2). BMC Surg 2015;15:88.
Milone M, Di Minno MN, Leongito M, Maietta P, Bianco P, Taffuri C, et al.
Bariatric surgery and diabetes remission: Sleeve gastrectomy or mini-gastric bypass? World J Gastroenterol 2013;19:6590-7.
Sasaki A, Nitta H, Otsuka K, Umemura A, Baba S, Obuchi T, et al.
Bariatric surgery and non-alcoholic fatty liver disease: Current and potential future treatments. Front Endocrinol (Lausanne) 2014;5:164.
Furuya CK Jr., de Oliveira CP, de Mello ES, Faintuch J, Raskovski A, Matsuda M, et al.
Effects of bariatric surgery on nonalcoholic fatty liver disease: Preliminary findings after 2 years. J Gastroenterol Hepatol 2007;22:510-4.
Aung L, Lee WJ, Chen SC, Ser KH, Wu CC, Chong K, et al.
Bariatric surgery for patients with early-onset vs. late-onset type 2 diabetes. JAMA Surg 2016;151:798-805.
[Table 1], [Table 2], [Table 3]