H. Collins, G. Beban, J. Windsor, R. Ram, N. Evennett, B. Loveday Auckland City Hospital, Auckland, New Zealand

Transcription

1 UTILITY AND SAFETY OF ROUTINE LIVER BIOPSY DURING BARIATRIC SURGERY H. Collins, G. Beban, J. Windsor, R. Ram, N. Evennett, B. Loveday Auckland City Hospital, Auckland, New Zealand

2 BACKGROUND Prevalence of NAFLD in bariatric patients up to 98% 1,2 NASH in 24-98% 1 Cirrhosis in 1.4-4% 1,3 Visual inspection of the liver has low sensitivity and specificity in diagnosing NASH 4,5 Complication rates 0-2.5% 3

3 AIMS To determine: 1. Histological spectrum of liver disease in Auckland City Hospital bariatric surgery patient population 2. Liver biopsy safety profile 3. Whether liver biopsy result changes patient management 4. Differences between rates of NAFLD in Maori and Pacific Island populations, as well as rates of referral

4 METHODS Retrospective cohort study Inclusion: index bariatric surgery at Auckland City Hospital ( ), intraoperative liver biopsy Review of electronic data Complication: bleeding, bile leak or damage to other anatomical structure necessitating transfusion or re-intervention Utility outcomes: referral to hepatology service Referral to hepatology service: fibrosis stage three and/or alternative diagnosis to NASH

5 RESULTS Liver biopsy - 70% (234/335) Biopsy patients: Median LOS days (range: ) Mean age - 45 years (range: 20 68) 2.4 female : 1 male Zero complications attributed to biopsy

6 PRIORITISED ETHNICITY PROCEDURE Other Pacific Island 1% Other 2% Middle Eastern 2% Asian 2% Tongan 2% Cook Island Maori 4% Indian 5% Laparoscopic single anastomosis gastric bypass (2%) New Zealand European 41% Samoan 10% Other European 7% Laparoscopic roux en Y gastric bypass (39%) Maori 24% Laparoscopic sleeve gastrectomy (59%)

7 ANTHROPOMETRIC DATA TOTAL Initial weight (kg) Initial BMI (kg/m 2 ) Pre-op weight Pre-op BMI weight BMI 134 (85-234) 48 (32-75) 123 (81-222) 43 (31-80) FEMALE Initial weight Initial BMI Pre-op weight Pre-op BMI weight BMI 130 (85-190) 48 (33-71) 114 (81-222) 43 (31-80) MALE Initial weight Initial BMI Pre-op weight Pre-op BMI weight BMI 143 (96-234) 46 (32-75) 130 (95-191) 42 (31-65) -13-4

8 ANTHROPOMETRIC DATA TOTAL Initial weight (kg) Initial BMI (kg/m 2 ) Pre-op weight Pre-op BMI weight BMI 134 (85-234) 48 (32-75) 123 (81-222) 43 (31-80) FEMALE Initial weight Initial BMI Pre-op weight Pre-op BMI weight BMI 130 (85-190) 48 (33-71) 114 (81-222) 43 (31-80) MALE Initial weight Initial BMI Pre-op weight Pre-op BMI weight BMI 143 (96-234) 46 (32-75) 130 (95-191) 42 (31-65) -13-4

9 ANTHROPOMETRIC DATA TOTAL Initial weight (kg) Initial BMI (kg/m 2 ) Pre-op weight Pre-op BMI weight BMI 134 (85-234) 48 (32-75) 123 (81-222) 43 (31-80) FEMALE Initial weight Initial BMI Pre-op weight Pre-op BMI weight BMI 130 (85-190) 48 (33-71) 114 (81-222) 43 (31-80) MALE Initial weight Initial BMI Pre-op weight Pre-op BMI weight BMI 143 (96-234) 46 (32-75) 130 (95-191) 42 (31-65) -13-4

10 HISTOLOGICAL FINDINGS Entirely normal NAS 2 NAS 3-4 NAS 5 Fibrosis stage 1 Fibrosis stage 2 Fibrosis stage 3 Fibrosis stage 4 Cirrhosis 4% 3% 0.4% 2% 6% 11% 15% 17% 41% Number of patients

11 INCIDENTAL FINDINGS Finding Number of patients % referred Chronic hepatitis 16 44% (7/16) Nodular regenerative hyperplasia 6 4/6 Biliary tract inflammation 4 2/4 Non-necrotising granulomas of unclear significance 2 1/2 Hepatitis B carrier 2 1/2 Portal HTN 1 100% (1/1) Alpha-1-antitrypsin deficiency 1 0% (0/1) Granulomatous portal tract disease 1 100% (1/1) Autoimmune cholangiopathy 1 100% (1/1) Disproportionate fibrosis and portal chronic inflammation 1 100% (1/1) Total 34 54% (19/35)

12 REFERRAL RATES 58% (7/12) had NAFLD that met referral criteria to hepatologist and were referred 42% (5/12) had NAFLD that met referral criteria to hepatologist and were NOT referred

13 SUBGROUP ANALYSIS Obesity rate 6 General population 32% 1 Maori 50% 1.56 Pacific Island 69% 2.15 Obesity rate relative to general population Proportion of total operations Proportion of ethnicity of NZ population 7 Maori 23.9% 15.8% 1.51 Pacific Island 17.1% 6.5% 2.63 Surgery rate relative to proportion of population

14 SUBGROUP ANALYSIS Obesity rate 6 General population 32% 1 Maori 50% 1.56 Pacific Island 69% 2.15 Obesity rate relative to general population Proportion of total operations Proportion of ethnicity of NZ population 7 Maori 23.9% 15.8% 1.51 Pacific Island 17.1% 6.5% 2.63 Surgery rate relative to proportion of population

15 SUBGROUP ANALYSIS Obesity rate 6 General population 32% 1 Maori 50% 1.56 Pacific Island 69% 2.15 Obesity rate relative to general population Proportion of total operations Proportion of ethnicity of NZ population 7 Maori 23.9% 15.8% 1.51 Pacific Island 17.1% 6.5% 2.63 Surgery rate relative to proportion of population

16 SUBGROUP ANALYSIS Maori NAFLD - 91% (51/56) vs 88% (156/178), p=0.48 Referral rate - 67% (2/3) in Maori vs non-maori 56% (5/9) p=0.73 Pacific Island NAFLD - 98% (39/40) vs 87% (168/194), p=0.049 Referral rate - 100% (2/2) vs 50% (5/10), p=0.19

17 CONCLUSION Intraoperative liver biopsy is a safe test Comparable rates of NAFLD to international data Detects clinically significant NAFLD in 5% and other findings in 14.5% 89% had NAFLD Nearly half with NAFLD meeting referral criteria not referred Pacific Island patients had significantly higher rates of NAFLD Referral rates do not differ significantly for Maori and Pacific Islanders

18 RECOMMENDATIONS Continue performing intraoperative liver biopsy Develop clear criteria for referral to hepatologist and therefore improve referral rates Consider: Pacific Island patients have higher rates of NAFLD, are they being referred later?

19 REFERENCES 1. Machado M, Marques-Vidal P, Cortez-Pinto H. Hepatic histology in obese patients undergoing bariatric surgery. Journal of Hepatology 45 (2006) Shinhiti Morita, Dalísio De Santi Neto, Flávio Hiroshi Ananias Morita, Nina Kimie Morita, Suzana Margareth Ajeje Lobo. Prevalence of Non-alcoholic Fatty Liver Disease and Steatohepatitis Risk Factors in Patients Undergoing Bariatric Surgery. Obesity Surgery 25(12) (2015) Kamal K. Mahawar1 & Chetan Parmar1 & Yitka Graham1,2 &Ayman Abouleid1 William R. J. Carr1 & Neil Jennings1 &Norbert Schroeder1 & Peter K. Small. Routine Liver Biopsy During Bariatric Surgery: an Analysis of Evidence Base. Obesity surgery 26 (2016) Teixeira AR, Bellodi-Privato M, Carvalheira JB, et al. The incapacity of the surgeon to identify NASH in bariatric surgery makes biopsy mandatory. Obesity Surgery;19(12): Shalhub S, Parsee A, Gallagher SF, et al. The importance of routine liver biopsy in diagnosing nonalcoholic steatohepatitis in bariatric patients. Obesity Surgery. 2004;14(1): NZ Health Survey 2016/2017. Obesity statistics.