Bypass vs. sleeve and its effects in non-alcoholic fatty liver disease: what is the best technique? / Bypass vs. sleeve e seus resultados na doença hepática gordurosa não alcoólica: qual a melhor técnica?

ABSTRACT Background: Strongly associated with obesity, non-alcoholic fatty liver disease is considered the hepatic manifestation of the metabolic syndrome. It presents as simple steatosis and steatohepatitis, which can progress to cirrhosis and its complications. Among the therapeutic alternatives is bariatric surgery. Aim: To compare the effect of the two most frequent bariatric procedures (sleeve and bypass) on liver disease regarding to epidemiological, demographic, clinical and laboratory parameters. Methods: The results of intraoperative and 12 months after surgery liver biopsies were used. The NAFLD activity score (NAS) was used to assess and compare the stages of liver disease. Results: Sixteen (66.7%) patients underwent Bypass procedure and eight (33.3%) Sleeve. It was observed that the variation in the NAFLD activity score was significantly greater in the Bypass group than in Sleeve (p=0.028) and there was a trend regarding the variation in fibrosis (p=0.054). Conclusion: Both surgical techniques were effective in improving the hepatic histology of most operated patients. When comparing sleeve and bypass groups, bypass showed better results, according to the NAS score.

RESUMO Racional: Fortemente associada à obesidade, a doença hepática gordura não alcoólica é considerada a manifestação hepática da síndrome metabólica. Ela apresenta-se como esteatose simples e esteato-hepatite, podendo evoluir para cirrose e suas complicações. Entre as alternativas terapêuticas está a cirurgia bariátrica. Objetivo: Comparar o efeito sobre a doença hepática dos dois procedimentos bariátricos mais frequentes - sleeve e bypass - e comparar dados epidemiológicos, demográficos, parâmetros clínicos e laboratoriais. Métodos: Utilizou-se o resultado das biópsias hepáticas realizadas no intra-operatório e 12 meses após a operação. O NAFLD activity score foi utilizado para avaliar e comparar os estágios da doença hepática. Resultados: Dezesseis (66,7%) pacientes foram submetidos ao bypass e oito (33,3%) ao sleeve. Observou-se melhora significativa no IMC e glicemia nas duas técnicas cirúrgicas enquanto que os níveis de fosfatase alcalina, ferritina, Gama-GT e TGP reduziram com significância apenas no grupo bypass. A redução no NAFLD activity score foi significativamente maior no grupo bypass que no sleeve (p=0,040). Conclusão: Ambas as técnicas foram eficazes em promover a melhora da histologia hepática da maior parte dos pacientes operados. Quando comparadas o bypass apresentou melhores resultados.

Hepatocarcinoma y trasplante hepático en Perú: resultados de 15 años del Departamento de Trasplantes del Hospital Nacional Guillermo Almenara Irigoyen - EsSalud / Liver transplant and hepatocellular carcinoma in Peru: outcome after 15 years in the transplant department of the Guillermo Almenara Hospital - EsSalud

El carcinoma hepatocelular (CHC) es una neoplasia con incidencia y prevalencia significativa en el mundo. Ésta en gran porcentaje se origina en el hígado cirrótico. El trasplante hepático bajo condiciones especiales, ha demostrado ser efectivo en el tratamiento simultáneo de ambas condiciones. En América latina la información es escasa. Este es un estudio de tipo descriptivo retrospectivo de corte transversal, cuyo universo es conformado por los primeros 200 trasplantes de hígado de nuestra serie (Años 2000-2015). Durante el periodo mencionado 26 (13%) pacientes tuvieron diagnóstico de CHC. De los 26 trasplantados con CHC, 21 (81%) pacientes fueron de sexo masculino. El promedio de edad fue 59,7 años. La etiología cirrótica más frecuente fue NASH con 9 (35%) casos, seguida de VHC y OH con 6 (23%). El promedio de AFP pre trasplante fue de 113,3. El ¨downstaging¨ fue realizado en 4 pacientes. La sobrevida global obtenida es de 90,9% a más de 5 años. La sobrevida libre de recurrencia en nuestra serie es de 95,5% a 5 años.

Hepatocellular carcinoma (HCC) is a neoplasm with significant incidence and prevalence in the world. In large percentage it originates from a cirrhotic liver. Liver transplantation under special conditions is effective in the simultaneous treatment of both conditions. Information is scarce in Latin America. This is a cross-sectional study of the first 200 liver transplants of our series (Years 2000-2015). During this period, 26 (13%) patients had a diagnosis of HCC. Of the 26 transplanted with HCC, 21 (81%) patients were male. The average age was 59.7 years. The most frequent cirrhotic etiology was NASH with nine (35%) cases, followed by HCV and OH with six (23%). The average of AFP pre-transplant was 113.3. Downstaging was performed in four patients. The overall survival obtained is 90.9% over 5 years. The recurrence-free survival in our series is 95.5% at 5 years.

Síndrome hepatopulmonar y trasplante hepático: experiencia en el departamento de trasplantes del Hospital Nacional Guillermo Almenara Irigoyen - EsSalud / Hepatopulmonar syndrome and liver transplantation: experience in the transplantation department of the Guillermo Almenara Irigoyen National Hospital - EsSalud

Introducción: El síndrome hepatopulmonar (SHP) es una complicación grave de la enfermedad hepática, la cual se caracteriza por la presencia de vasodilatación intrapulmonar e hipoxemia progresiva, siendo el trasplante de hígado el único tratamiento efectivo. Objetivo: Mostrar nuestros resultados de los pacientes con síndrome hepatopulmonar sometidos a trasplante hepático. Materiales y métodos: Estudio retrospectivo, descriptivo y trasversal. Desde marzo del 2000 a diciembre del 2016 se realizaron 226 trasplantes de hígado. Del total, se excluyeron a 25 pacientes: 12 retrasplantes, 9 trasplantes dobles higadoriñon, 2 trasplantes con falla hepática aguda, 2 trasplantes en pacientes no cirróticos. De los 201 pacientes con diagnóstico pretrasplante de cirrosis hepática, 19 tuvieron criterios de SHP; quienes fueron distribuidos según edad, sexo, nivel de hipoxemia (pO2), score CHILD, score MELD. La reversibilidad de la hipoxemia post trasplante se midió con una cutt off de p0(2) >75 mmHg. Resultados: La prevalencia del SHP en nuestra serie fue 9,45%. La edad promedio fue 41 años (14-65); la relación M/F de 1,65. El 78,94% (15/19) fueron adultos. 89,5% (17/19) fueron score de CHILD B y C, y el 68,4% tuvieron SHP severo y muy severo. En el 94,11% de los pacientes se demostró reversibilidad del SHP. La tasa de mortalidad temprana en los pacientes con SHP fue 10,4%. Conclusiones: La prevalencia del SHP fue del 9,45%. Los pacientes trasplantados con y sin SHP tuvieron similar sobrevida.

Introduction: Hepatopulmonary syndrome (HPS) is a serious complication of liver disease, which is characterized by the presence of intrapulmonary vasodilation and progressive hypoxemia. Liver transplantation is the only effective treatment. Objective: To show our results of patients with hepatopulmonary syndrome undergoing liver transplantation. Materials and methods: Retrospective, descriptive and cross-sectional study. From March 2000 to December 2016; 226 liver transplants were performed. Of the total, 25 patients were excluded: 12 retransplantation, 9 liver-kidney combined transplants, 2 transplants for acute liver failure, 2 transplants in non-cirrhotic patients. Of the 201 patients with pretransplant diagnosis of liver cirrhosis, 19 filled criteria for SHP; who were distributed according to age, sex, hypoxemia level (pO2), Child-Pugh score and MELD score. The reversibility hypoxemia after liver trasplantation was measured with a cut-off of p0(2) >75 mmHg. Results: The prevalence of SHP in our series was 9.45%. The average age was 41 years (14-65); the M / F ratio of 1.65. The 78.94% (15/19) were adults. 89.5% (17/19) were Score of Child-Pugh B and C, and 68.4% had severe and very severe SHP. In 94.11% of patients, reversibility SHP founded. The early mortality rate (30 days) in patients with SHP was 10.4%. Conclusions: The prevalence of HPS in our series was 9.45%. Transplanted patients with and without SHP had similar survival.

Nonalcoholic fatty liver disease and bariatric surgery: a comprehensive review / Doença hepática gordurosa não alcoólica e cirurgia bariátrica: uma revisão abrangente

ABSTRACT CONTEXT AND OBJECTIVE: Nonalcoholic fatty liver disease (NAFLD) has been increasingly diagnosed worldwide and is now recognized as a source of public health concern. It comprises a wide spectrum of histological features that range from simple steatosis to severe forms of fibrosis, steatohepatitis and even cirrhosis. The impact of bariatric surgery on the course of NAFLD in individuals with obesity has been extensively studied. DESIGN AND SETTING: Narrative review; public university hospital. METHODS: A comprehensive review was conducted based on an online search on the electronic databases MEDLINE and LILACS using the MeSH terms "fatty liver" and "bariatric surgery". RESULTS: The exact mechanisms that lead to improvement in NAFLD following bariatric surgery are not completely understood. Since Roux-en-Y gastric bypass (RYGB) is the bariatric surgical procedure most performed worldwide, it is also the one from which the effects on NAFLD have been most studied, although there is also consistent evidence regarding the effects from gastric banding, sleeve gastrectomy and biliopancreatic diversions. CONCLUSION: According to the currently available evidence, bariatric surgery leads to significant improvement in NAFLD. Further research, especially by means of randomized controlled trials enrolling larger cohorts of individuals, is needed to determine the optimal procedure for this group of subjects.

RESUMO CONTEXTO E OBJETIVO: A doença hepática gordurosa não alcoólica (DHGNA) tem sido diagnosticada com maior frequência em todo o mundo na atualidade, sendo agora reconhecida como motivo de preocupação em saúde pública. Abrange um amplo espectro de alterações histológicas que variam desde a simples esteatose até formas graves de fibrose, esteato-hepatite e até cirrose. O impacto da cirurgia bariátrica sobre o curso da DHGNA em indivíduos com obesidade tem sido profundamente estudado. TIPO DE ESTUDO E LOCAL: Revisão narrativa; hospital universitário público. MÉTODOS: Uma revisão abrangente da literatura foi conduzida baseada na pesquisa on-line nas bases de dados eletrônicas MEDLINE e LILACS por meio dos termos MeSH "fígado gorduroso" e "cirurgia bariátrica". RESULTADOS: Os mecanismos exatos que levam à melhora da DHGNA após a cirurgia bariátrica não são completamente conhecidos. Como o bypass gástrico em Y de Roux é a cirurgia bariátrica mais realizada em todo o mundo, é também o procedimento cujos efeitos sobre DHGNA foram mais estudados, embora haja também evidências consistentes sobre os efeitos de banda gástrica, gastrectomia vertical e derivações biliopancreáticas. CONCLUSÃO: De acordo com as evidências atualmente disponíveis, a cirurgia bariátrica leva à melhora significativa da DHGNA. Mais estudos, especialmente por meio de ensaios clínicos randomizados e controlados, recrutando coortes maiores de indivíduos, são necessários para determinar o melhor procedimento para esse grupo de pacientes.

Duodenal jejunal bypass attenuates non-alcoholic fatty liver disease in western diet-obese rats

PURPOSE: To evaluate the effects of duodenal-jejunal bypass (DJB) on serum and hepatic profiles of obese rats fed on a western diet (WD). METHODS: Twenty eight male Wistar rats were fed a standard rodent chow diet (CTL group) or WD ad libitum. After 10 weeks, WD rats were submitted to sham (WD SHAM) or duodenal-jejunal bypass (WD DJB). Body weight, fat pad depots, glycemia, insulinemia, HOMA-IR, TyG, lipids profile and hepatic analyses were evaluated two months after surgery. RESULTS: The WD SHAM group presented greater obesity, hyperglycemia, hyperinsulinemia, insulin resistance, hypertriglyceridemia and hepatic steatosis than the CTL group. WD DJB rats presented decreased serum glucose and insulin resistance, when compared to WD SHAM animals, without changes in insulinemia. In addition, DJB surgery normalized serum TG and attenuated TG accumulation and steatosis in the liver of the WD DJB group. Hepatic ACC and FAS protein expressions were similar in all groups. CONCLUSION: Duodenal-jejunal bypass attenuates hepatic parameters of non-alcoholic fatty liver disease in obese rats fed on a western diet. .