CASE REPORT – OPEN ACCESS
InternationalJournalofSurgeryCaseReports39(2017)168–171
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International Journal of Surgery Case Reports
j o u r n a l h o m e p a g e :w w w . c a s e r e p o r t s . c o m
Biopsy-proven progressive fatty liver disease nine months post mini-gastric bypass surgery: A case study
Mohammad Ali Kalantar Motamedi
a, Nasser Rakhshani
b, Alireza Khalaj
c, Maryam Barzin
a,∗aObesityResearchCenter,ResearchInstituteforEndocrineSciences,ShahidBeheshtiUniversityofMedicalSciences,Tehran,Iran
bGastrointestinalandLiverDiseaseResearchCenter,IranUniversityofMedicalSciences,Tehran,Iran
cObesityTreatmentCenter,DepartmentofSurgery,ShahedUniversity,Tehran,Iran
a r t i c l e i n f o
Articlehistory:
Received21June2017
Receivedinrevisedform31July2017 Accepted31July2017
Availableonline18August2017
Keywords:
Mini-gastricbypass Bariatricsurgery Hepaticinsufficiency
Non-alcoholicfattyliverdisease Casereport
a b s t r a c t
INTRODUCTION:Mini-gastricbypass(MGB)isapopularbariatricprocedure.Itseffectonnon-alcoholic fattyliverdisease(NAFLD),however,hasnotyetbeencomprehensivelystudied.
PRESENTATIONOFCASE:A57year-oldnon-alcoholicfemalewithabodymassindexof42.8kg/m2under- wentMGBwithoutanyincident.AconcurrentliverbiopsyshowedanNAFLDactivityscore(NAS)of2/8 withoutfibrosis.Shepresentedatpostoperativemontheightwithedema,vagueabdominalpain,nau- sea,andvomitingandwashospitalized.HerBMIhaddroppedto25.7kg/m2.Herbloodworkuprevealed mildanemia,mildlyelevatedliverenzymes,andhypoalbuminemia(2.5g/dL).Liverultrasoundrevealed grade-2fattyliver.Shereceivedparenteralnutritionandintensivenutrientsupplementation.Never- theless,withregardtounsuccessfulsupportivemeasuresandrisingliverenzymes,revisionalsurgery
−gastrogastrostomy-wasperformed.HerliverbiopsydemonstratedaNASof7/8atthetimeofrevisional surgery.Herpostoperativecoursewasuneventfulandshewasdischargedafteroneweek.
DISCUSSION:BariatricsurgeryhasshownfavorableresultsregardingimprovementofNAFLDinmorbid obesity.Thisbeneficialeffecthasbeenlinkedtotheamountofweightloss.However,casereportshave showndeterioratingliverfunctionandNAFLDevenaftersignificantweightloss.Theyallhaveincommon significantweightlossinarelativelyshortperiodoftime.Theremayalsobeaconnectionbetweenspecific bariatricsurgeryproceduresandthisphenomenon.
CONCLUSION:Futurestudiescomparingtheeffectofvariousbariatricprocedures,includingMGB,are necessarytohelpcliniciansdecidetheoptimalprocedureforpatientswiththislivercondition.
©2017TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
While bariatric surgery is widely acceptedas thetreatment ofmorbidobesity,effectively loweringbodyweightandresolv- ingobesity-relatedcomorbidities,thechoiceofbariatrictechnique is still debatable, as many factors must betaken into account.
ComparedtothegoldstandardRoux-en-Ygastricbypass(RYGB), laparoscopicmini-gastricbypass(MGB)isarelativelynewandpop- ularmethodinsomecenters,owingtoitseasiertechnique,shorter learningcurveandoperativetimes,impressiveweightloss(WL), andlowercomplications[1].
Thistechnique incorporatesalonggastric tubecreatedfrom theincisuraangularistotheangleofHisovera36-Fbougieand
Abbreviations:RYGB,Roux-en-Ygastricbypass;MGB,mini-gastricbypass;WL, weightloss;NAFLD,non-alcoholicfattyliverdisease;BMI,bodymassindex;NAS, NAFLDactivityscore.
∗Correspondingauthor.
E-mailaddresses:[email protected],[email protected](M.Barzin).
anantecolicloopgastroenterostomyapproximately200cmdistal totheligamentofTreitz,causingmalabsorptionandconsequently WL.Morethan200caseshavebeenperformedinourcenterwith successfulresults;however,WLissometimesachievedattheprice ofmalnutritionanditsrelatedproblems.Itseffectonliverfunc- tion,moreover,hasnotspecificallybeenstudiedyet,includingits possibleeffectonnon-alcoholicfattyliverdisease(NAFLD).
Weherebypresentacaseofmorbidlyobesepatientundergoing MGB,whoshowedbiopsy-provenprogressionofNAFLDnearlynine monthsaftersurgery.Thisworkhasbeenreportedinlinewiththe SCAREcriteria[2].
2. Presentationofcase
A57year-oldmiddle-easternnonalcoholicmorbidobesefemale presentedtoourbariatriccenterwithaninitialbodymassindex (BMI)of42.8kg/m2(weight=118kg,height=166cm)andobesity relatedhealthproblemsincludinghypertension(undertreatment bymetoprololandcaptopril)anddiabetesmellitus(diagnosed6
http://dx.doi.org/10.1016/j.ijscr.2017.07.062
2210-2612/©2017TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT – OPEN ACCESS
M.A.K.Motamedietal./InternationalJournalofSurgeryCaseReports39(2017)168–171 169
Table1
Liverbiopsyreportsatthetimeofprimaryandrevisionalsurgeries(at9months)andNAFLDactivityscore(NAS).
Biopsydetails MGB Revisionalsurgery(9months)
Item Extent SCORE
Steatosis Gradea,b <5% 0
5–33% 1 √
>33–66% 2 √
>66% 3
Location Zone3 0 √ √
Zone1 1
Azonal 2
Panacinar 3
Microvesicular steatosisb
Notpresent 0 √
Present 1 √
Inflammation Lobular
inflammationa,b
Nofoci 0
<2foci/200x 1 √
2–4foci/200x 2
>4foci/200x 3 √
Microgranulomasb Absent 0 √
Present 1 √
Largelipogranulomas Absent 0 √ √
Present 1
Portalinflammationc Nonetominimal 0 √
Morethanminimal 1 √
LivercellInjury Ballooninga,b None 0 √
Fewballooncells 1
Manycells/prominentballooning 2 √
Acidophilbodies Nonetorare 0 √ √
Many 1
Pigmented macrophagesc
Nonetorare 0 √
Many 1 √
Megamitochondria Nonetorare 0 √ √
Many 1
Otherfindings Mallory’shyaline Nonetorare 0 √ √
Many 1
Glycogenatednucleib Nonetorare 0 √
Many 1 √
Irondeposition Absent 0 √ √
Present 1
Fibrosisstage None 0 √ √
Perisinusoidalorperiportal 1 Mild,zone3,perisinusoidal 1A Moderate,zone3,perisinusoidal 1B
Portal/periportal 1C
Perisinusoidalandportal/periportal 2
Bridgingfibrosis 3
Cirrhosis 4
Totalscore 2 7
aComponentsofliverbiopsyusedinNAScalculation.
bSignifyingdeterioration.
c Signifyingimprovement.
monthspreviouslyandundercontrolatthetimeofpresentation bylifestylemodifications).Shewastaking50mcglevothyroxine pillsdailyforhypothyroidismandwaseuthyroid.Shehadbeen selectedaspartof theTehranObesityTreatment Study(TOTS), whichenrollsand followsupmorbidlyobesepatientsrequiring surgicalintervention[3].
Her preoperative evaluations revealed grade-I fatty liver withincreased liverechogenicity and span in ultrasonography.
Otherevaluationsincluding cardiac,pulmonary,and blood bio- chemistrieswereinsignificant.Viralmarkerswerealsonegative forhepatitis viruses.Moreover,noother causeforliverdisease wasidentified.SheunderwentMGBwithoutanyincidents,and wedgeandneedleliverbiopsieswereperformedatthetimeof theoperation(Table1).Thebiopsywasassessedbyaspecialized liverpathologistusinghematoxylin&eosin,Masson’strichrome, andIronstaining,andwasscoredaccordingtotheNAFLDactivity score(NAS)criteria[4],whichisthesumofsteatosisgrade(0–3), hepatocyteballooninggrade(0–2),andlobularinflammationgrade (0–3)inmicroscopicassessment(Table1).Resultshowedascore
of2fromapossiblemaximumof8.Steatosiswasseenin5–33%of thespecimenandinflammationin<2foci/200x,withnosignsof ballooning.Moreover,therewerenofeaturesoffibrosis(Fig.1A).
Shewasunderroutinepostoperativefollow-upat1,3,6,and 12months,andreceivedsupplementationforvitaminsandminer- als(Pharmaton®,BoehringerIngelheimInc.,IngelheimamRhein, Germany),aswellasursodiol,regularly.Shewasalsofollowingher post-operativeprotocolofatleast70–100g/dayofproteinintake withoutanydifficulties.HerbloodindicesandWLresultsarepro- videdinTable2.
Atpostoperativemontheight,shepresentedwithedema,vague abdominalpain,nausea,andvomitingandwasadmitted.Shehad lostsignificantweightduringthisperiod,approximatingherideal body weight (BMI=25.7kg/m2, excessweight loss=95.9%).Her bloodworkuprevealedmildanemia,mildlyelevatedliverenzymes, aswellasmoderatetoseverehypoalbuminemia(2.5g/dL).Hep- atitis markers were rechecked and confirmed negative.A liver ultrasoundstudyrevealedgrade-IIfattyliver.Upperendoscopic assessmentwasinsignificantandshowedthesmallstomachpouch
CASE REPORT – OPEN ACCESS
170 M.A.K.Motamedietal./InternationalJournalofSurgeryCaseReports39(2017)168–171
Fig.1. (A)Photomicrographatprimarybariatricsurgery,showingballooning(arrow)andsteatosis(arrowhead).(B)Photomicrographatrevisionalsurgery,showingmore prominentballooning(arrows),steatosis(arrowhead),andneutrophilicsatellitosis(circles).
Table2
Patient’spreoperativeandpostoperativeweightindicesandbloodvalues.
Variable Normalvalues Preoperative Postoperative
3months 8months Revisionalsurgery
Weight,kg 55–69 118 96 71 70
BMI,kg/m2 20–25 42.8 35.1 25.7 25.4
EWL% – – 44.8 95.9 97.9
FBS,mg/dL 70–100 110 82 90 66
HbA1c,% <5.7 5.5 5 – –
ALT,U/L 7–55 31 28 38 64
AST,U/L 8–48 28 26 33 104
ALP,U/L 45–115 167 167 82 68
Totalbilirubin,mg/dL 0.4–1.5 1 1.1 1.5 1.2
TSH,U/mL 0.39–6.16 2.5 – 3.6 –
TotalProtein,g/dL 6.3–7.9 – – 5.2 5.2
Albumin,g/dL 3.5–5 5.2 – 2.5 3.3
Calcium,mg/dL 8.5–10.2 10.1 – 8.1 8.5
Magnesium,mg/dL 1.6–2.9 2 – 2.1 1.9
Zinc,mcg/dL 70–110 101 – 89 135
Copper,mg/dL 80–155 119 – 131 –
VitaminB12,pg/mL 211–946 175 – – 1196
VitaminD3,ng/mL >30 66.7 – – 70
PlasmaIron,mcg/dL 39–149 88 – 91 –
WBC,103/mcL 4–10 6.15 3.8 5.21 5.71
RBC,106/mcL 4.2–5.4 4.1 – 3.89 3.02
Hemoglobin,g/dL 12–15.5 14 11 11.2 8.8
Hematocrit,% 35–45 42.4 33.8 33.8 27.1
MCV,fL 77–98 – – 86.9 89.7
Platelet,103/McL 150–450 262 219 314 278
BMI,bodymassindex;EWL,excessweightloss;FBS,fastingbloodsugar;HbA1c,glycosylatedhemoglobinlevel;ALT,alanineaminotransferase;AST,aspartateaminotrans- ferase;ALP,alkalinephosphatase;TSH,thyroidstimulatinghormone;WBC,whitebloodcells;RBC,redbloodcells;MCV,meancorpuscularvolume.
withmilderythemaatgastro-jejunalanastomosissite.Othereval- uations failedtofind anetiology for her liverdysfunction.She receivedtotalparenteralnutritionandintensiveintravenouspro- tein,lipid,andnutrientsupplementation.Herconditionhadnot improvedone week later, with rising liver enzymes, at which timerevisionalsurgerywasdecided.Agastrogastrostomywasper- formedsuccessfully,andanotherliverbiopsydoneconcurrently, demonstratingaNASof7/8(Table1).Steatosiswasseenin33–66%
ofthespecimenwith>4foci/200×ofinflammationandprominent ballooning.Nofeaturesoffibrosiswerepresent(Fig.1B).
Shebegantorecoverafterwards,andherliverfunctionnormal- ized.Shewasdischargedfromthehospitalafteroneweekingood health.
3. Discussion
NAFLDisanextremelyprevalentcounterpartofmorbidobe- sity,inupto90%ofthispopulation,andrangesfrommildfattyliver changesandsteatosistonon-alcoholicsteatohepatitis(NASH),with thepossibilityofprogressiontoliverfibrosiswithlongstandingdis-
ease[5].Bariatricsurgeryingeneralhasshownimpressiveresults onresolutionofthiscondition,inupto85%ofthepatients[6].How- ever,evidenceregardingtheeffectofvariousbariatrictechniques onNAFLDisincomprehensive,andnearlynonexistentregarding MGB.ThisreportprovidesaprobablyunprecedentedeffectofMGB onliverfunction,provenbyhistology.
Thisoverallbeneficialeffectofbariatricsurgeryhasbeenshown in different parameters of the liver function, including histo- logicfeaturesofNAFLD,asparateaminotransferase(AST),alanine aminotransferase (ALT), alkaline phosphatase, and gamma glu- tamyltransferase[6,7].Thisimprovementhasbeenshowntobe similarinthefewavailablestudiesbetweenmalabsorptive(RYGB) and restrictive techniques (sleeve gastrectomy) [8,9], withthe exceptionofadjustablegastricbanding,whichdemonstratedlower improvementrates [10].Thiscan probablybeexplainedbythe lowerWLachievedbythisprocedure.
TheassociationbetweenimprovementofNAFLDandthemag- nitude of WL hasbeen consistently observed in the literature [6].However,itissuggestedthatNAFLDimprovementcouldbe throughnon-weightdependentmechanismsaswell[11],and a
CASE REPORT – OPEN ACCESS
M.A.K.Motamedietal./InternationalJournalofSurgeryCaseReports39(2017)168–171 171
linkwasalsoobservedbetweensignificantimprovementofNAS andALTnormalizationmuchsoonerthansignificantWLgoalshave beenachieved[12].Ontheotherhand,threecasereportshavebeen publishedfordeteriorating liverfunctionafterbariatric surgery despite successful weightloss results, one after bilio-intestinal bypasssurgery[13],anotherafterbiliopancreaticdiversionsurgery [14],andthethirdwasapatientofoursafterMGB.Thepresentcase, however,issurprisingbecauseitshowsseveredeteriorationofliver histologyfromNAS2–7,asearlyasninemonthsaftersurgery.
Althoughthereisnoconvincingexplanationforthispresen- tation,rapidWLisacommonfeature;ourpatientachievedher idealbodyweightinasearlyas9months.Theremayalsobealink betweenthemechanismofweightlossandspecificbariatricpro- cedures,asshownina studyof comparisonbetweenRYGBand MGBin 50 patients,where MGBpatientsdemonstrated signifi- cantlypoorerliverfunctiontestsatoneyear,despitebetterWL results[15].Inaddition,thesurgicaltechniqueitselfisofparticu- larimportanceandwillaffectthepostoperativecourse.Similarto whatLeeetal.reportedintheirexperiencewithatailoredbypass limblengthaccordingtoBMI[16],wesuggestindividualizingthe MGBsurgicaltechniqueineachpatientbymeasuringbowellength duringtheoperationandthendecidingthelengthofbypassedlimb.
ThismayleadtoamorecontrolledandsustainedWL,whichcan helpminimizeunfavorablepostoperativeevents.
4. Conclusion
Thiscase reportservestohighlighttheimportanceoffuture comprehensivestudiescomparingthe effectof differentproce- dures on liver function, NAFLD, and NASH. Their results may consequentlyaffectthechoiceofbariatrictechniqueforindividuals withliverconditionssuchasNAFLD.
Conflictofinterest None.
Funding
Thisresearchdidnotreceiveanyspecificgrantfromfunding agenciesinthepublic,commercial,ornot-for-profitsectors.
Ethicalapproval
ThisstudyhasbeenapprovedbytheHumanResearchReview CommitteeoftheEndocrineResearchCenter,ShahidBeheshtiUni- versityofMedicalSciences,No.2ECRIES93/03/13.
Consent
Informedconsentwasobtainedfromtheindividualincluded inthestudy.Ethical approvalfor this studywasobtainedfrom theHumanResearchReviewCommitteeoftheEndocrineResearch Center, Shahid Beheshti University of Medical Sciences (No.
2ECRIES93/03/13).
Authorcontribution
MAKM–datacollectionandinterpretation,writingthepaper, criticalrevisionofthemanuscript.
MB–studydesign,datacollectionandinterpretation,critical revisionofthemanuscript.
NR–datacollection,finalapprovalofthemanuscript.
AK–IFSO-certifiedsurgeon,datacollection,finalapprovalofthe manuscript.
Guarantor
MaryamBarzin,MD,PhD.
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