Page 13 - World Journal of Laparoscopic Surgery

Comparative Study of the Effect of Various Bariatric Surgery Methods
indicators. Among the studies, the insufficient number of RCTs plays well as necrosis and inflammation of the liver, but there are
an important role in the lack of strong expression of the effects of variable results about its effect on the rate of liver fibrosis. Kafi
obesity surgery as the treatment of choice for NAFLD. has not recommended obesity surgery as a primary treatment
Non-alcoholic fatty liver disease includes a range of diseases for fatty liver. 14
that include simple accumulation of fat in the liver (steatosis without In the first phase of a study by Aldoheyan et al. published in
evidence of inflammation and cell damage) known as non-alcoholic March 2017, it states that fibrosis, steatosis, and NASH improved in
fatty liver, NASH (evidence of inflammation and cell damage in varying degrees at the end of 3 months in 27 patients undergoing
3
the liver), and finally cirrhosis. According to global studies, the obesity surgery. 15
prevalence is 25–33%, which varies in different populations. The Furthermore, few studies compared the effects of various
prevalence of fatty liver in diabetic patients is 75% and in patients with surgical procedures on liver and LFT tests. For example, a study by
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morbid obesity is 90–95%. One of the primary imaging procedures Kalinowski et al. in 2017 found that LFT worsens shortly after Roux-
for diagnosing liver steatosis is ultrasound scan. Ultrasound scan en-Y gastric bypass (RYGB) surgery and returns to baseline after
measures the echogenicity of the liver compared to the spleen and 1 year and that this increase in liver tests after sleeve surgery is less. 16
kidneys such that increased liver echogenicity indicates fatty liver. There are a number of separate surgical procedures in this
Ultrasound scan sensitivity is reported to be about 60–94%, and area. For example, a study conducted in 2017 by Ruiz–Tovar J et al.
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specificity is 84–95%, which increases with increasing liver fat. The showed that liver steatosis assessed by ultrasound showed 90%
NAFLD fibrosis score is one of the most widely used non-invasive complete recovery after sleeve surgery. 17
indicators for assessing liver status in this disease. 10 Another study by Manco et al. in 2017 showed that sleeve
Six variables are used in calculating NFS: Age, BMI, hyperglycemia surgery was able to eliminate NASH in all patients in general. It also
[impaired fasting glucose (IFG) or diabetes mellitus (DM)], platelet reversed stage 2 fibrosis in 90% of patients. They lost significantly
count, albumin, and AST/ALT ratio. These variables are entered into less weight using a gastric balloon, and it was almost insignificant
the following formula: in people who lost weight by nonsurgical methods. 18
In a study on 40 patients by Nascimento et al. in 2015, it was
2
NFS = −1.675 + 0.037 (Age in year) + 0.094 × BMI (kg/m ) + 1.13 × IFG found that the degree of liver fibrosis measured by the NFS ranged
or DM: yes = 0, No = 1 + 0.99ASTALT − 0.013 (Platelet count) 109 L × 0–7.1% in patients undergoing surgery in private centers and in
−0.66 × Alb (gm/dL) patients undergoing surgery. Surgery in government centers
The result is categorized as follows: −1.5 >NFS indicates the decreased from 30.8 to 23%. 19
absence of fibrosis (low probability) and (high probability) NFS In a 2017 review by Keneally S et al. eight RCTs examining the
>0.67 indicates advanced fibrosis and NFS between −1.4 and 0.66 combined effects of diet and exercise showed improved NAFLD
indicates intermediate fibrosis. 10 activity based on pathology, BMI and liver enzymes, particularly ALT. 20
Also, the existence of few studies showing an increase in Among the few studies with different results, there is a 2004 study
fibrosis after bariatric surgery requires further research. Moreover, by Kral et al. on 104 patients who underwent BPD surgery. According
the insufficient research on comparing different types of bariatric to this study, severe fibrosis decreased in 27% of patients after surgery,
surgery methods and their effects on NAFLD and comparing them but mild fibrosis appeared in 40% of patients after surgery. 21
with the nonsurgical method became a double motivation that due Few studies have examined imaging findings, among which is a
to the existence of a robust database in this field—optional and study by Major et al. in 2017 on 20 patients. In this study, ultrasound
comprehensive of various dimensions of NAFLD. In this study, an findings and liver enzymes were evaluated before and 12 months
attempt was made to remove the limitations of previous studies, after surgery. It was found that the amount of fatty liver decreased
such as low sample size and one-dimensional NAFLD study as much after surgery compared to before, based on ultrasound findings
as possible. In this research project, we decided to compare the using the Sheriff–Saadeh criterion. The ALT also changed from 64.5
effects of different types of bariatric surgeries on the grading and to 27.95 and the AST from 54.4 to 27.2. 22
severity of NAFLD and NASH in a retrospective descriptive study. Few studies have compared the effects of different surgical
Some prospective studies have suggested the possibility of procedures on NAFLD. Among them is a 2016 study by Nickel et al.
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increased liver fibrosis after bariatric surgery. A study conducted on 100 patients who underwent classic sleeve and bypass surgery.
by Ooi et al. in 2016 on 84 patients with NAFLD showed that the fatty This study compared non-invasive factors of liver fibrosis including
liver in these patients improved shortly after surgery, and weight NFS and showed that this index decreases significantly after
loss decreased by 10–15%—becomes significant in ALT levels. 12 surgery. Furthermore, they mentioned this reduction is higher after
A 2010 review published by Chavez–Tapia et al. reported that no classical bypass surgery than that after sleeve surgery, although the
clinical trials had been conducted on the effects of bariatric surgery difference disappeared 18 months after surgery. 23
on NAFLD in obese patients. They reported only 21 retrospective
and prospective studies in which the severity of steatosis and MAterIAls And Methods
inflammation improved, and four studies that showed an increase This study was performed using the Iranian National Obesity
in postoperative fibrosis. 7 Surgery Database (www.obesitysurgery.ir) (INOSD). Iranian National
A large 2010 study by Karcz et al. on 236 patients who underwent Obesity Surgery Database includes a computerized medical record
laparoscopic sleeve surgery and were followed for 3 years showed of obese patients. This database provides detailed information
that, first, there was a strong association between high levels of on demographics, prescribed drugs, clinical events, professional
transaminases and NASH based on the pathologic diagnosis. Among referrals, and hospital admissions. This study was a retrospective
patients with NASH, liver enzymes decreased by more than 50%. 13 cohort in the period 2010–2017, and the study population was
According to Harrison’s internal medicine textbook, most obese patients who had undergone obstructive surgeries or were
studies report obesity surgery to improve hepatic steatosis as not surgically diagnosed for various reasons. Inclusion criteria were

World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022) 109