Routine Liver Biopsy During Bariatric Surgery: an Analysis of Evidence Base

Abstract

Non-alcoholic fatty liver disease and non-alcoholic steato-hepatitis are common in patients undergoing bariatric surgery. Non-alcoholic steato-hepatitis can progress to cirrhosis of the liver and hepatocellular carcinoma. Non-invasive methods of diagnosing non-alcoholic steato-hepatitis are not as accurate as liver biopsy, and bariatric surgery presents a unique opportunity to carry out a simultaneous liver biopsy. Routine liver biopsy can help early and accurate diagnosis of obesity-associated liver conditions. This has led some surgeons to argue for routine liver biopsy at the time of bariatric surgery. However, most bariatric surgeons remain unconvinced and liver biopsy is currently not routine practice with bariatric surgery. This review examines published scientific literature to ascertain the usefulness of routine liver biopsy at the time of bariatric surgery.

Accuracy of non-invasive liver stiffness measurement and steatosis quantification in patients with severe and morbid obesity

“…However, to date, intraoperative liver biopsy has not been widely applied as a standard procedure during bariatricmetabolic surgery, and non-invasive screening tools have not been independently validated for patients with severe to morbid obesity. Therefore, NASH and advanced fibrosis is at risk to be overlooked in bariatric-metabolic patients, but may lead to an increased intra-and perioperative risk (28).…”

American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings

“…124 While the vast majority of persons undergoing bariatric surgery have NAFLD, only approximately 8.5% have F3 and F4 (cirrhosis) at the time of intraoperative liver biopsy 125 , and 2% to 4% have unexpected cirrhosis diagnosed at the time of surgery. 126 This is in part related to presurgical screening and likely reluctance to proceed with surgery in those with known stable early or advanced cirrhosis. Bariatric surgery should not be considered in persons with decompensated cirrhosis due to the increased postoperative mortality.…”

AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease

“…Although currently accepted criteria for bariatric surgery are BMI ≥ 40 kg/m 2 irrespective of metabolic comorbid disease or BMI ≥ 35 kg/m 2 with comorbidities (T2DM or pre-DM, uncontrolled hypertension, osteoarthritis of hip or knee, urinary incontinence), NAFLD/NASH is increasingly accepted as a comorbid condition benefitting from bariatric surgery. [410,411] The overwhelming majority of patients undergoing bariatric surgery have NAFLD and many have NASH; however, the prevalence of advanced hepatic fibrosis and cirrhosis is low in published series, [412] in part due to presurgical screening that often excludes those with evidence of chronic liver disease or cirrhosis.…”