‘Best Treatment’ Weight Loss Surgery for Fatty Liver Disease

Bariatric surgery significantly reduces the risk of major adverse liver outcomes as well as major acute cardiovascular events (MACE) in patients with biopsy-proven non-alcoholic steatohepatitis (NASH), compared to similar patients who did not undergo biopsy. surgery, according to new research.

“This is the first study in the medical field to report a treatment modality associated with a decreased risk of major adverse events in patients with biopsy-proven NASH,” lead author Steven Nissen, MD, of Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio, said in a hospital statement.

“The SPLENDOR study shows that in patients with obesity and NASH, substantial and lasting weight loss achieved through bariatric surgery can simultaneously protect the heart and decrease the risk of progression to end-stage liver disease “, he underlined.

The study was published online on November 11 in JAMA.


The SPLENDOR study (Surgical Procedures and Long-Term Effectiveness in NASH Disease and Obesity Risk) included 1158 patients with biopsy-proven NASH without cirrhosis; 650 underwent weight loss surgery and the remaining 508 served as controls. Participants had a median age of 49.8 years, a median body mass index (BMI) of 44.1 kg / m2, and almost 64% were women.

Bariatric procedures included Roux-en-Y gastric bypass surgery, performed in 83% of patients, and sleeve gastrectomy, performed in the remaining 17%.

“The predefined primary endpoints were the incidence of major hepatic adverse reactions and MACE,” notes lead author Ali Aminian, MD, director, Bariatric & Metabolic Institute, Cleveland Clinic, Ohio. Major hepatic adverse events included progression to clinical or histologic cirrhosis, development of liver cancer, need for liver transplantation, or liver-related death.

MACE was a composite of coronary events, cerebrovascular events, heart failure, or cardiovascular death.

At a median follow-up of 7 years, five patients in the bariatric surgery group versus 40 patients in the non-surgical controls had presented a major adverse hepatic event.

At 10 years, the cumulative incidence of major hepatic adverse reactions was 88% lower in the bariatric surgery group, occurring in 2.3% of the surgical group, compared to 9.6% in the non-surgical group (hazard ratio [HR], 0.12; P = .01), report the investigators.

At the end of the study, 39 patients in the surgical group had undergone MACE compared to 60 patients in the control group. After 10 years, the cumulative incidence of MACE was 70% lower in the bariatric surgery group, at 8.5%, compared to 15.7% in the control group (RR: 0.30; P = .007).

Also at age 10, bariatric surgery also reduced mean body weight by 22.4% in those who had undergone an operation versus weight loss, on average, by 4.6% in non-surgical controls (P

However, the risk of major adverse events within 30 days of weight loss surgery was relatively high, at 9.5%, the authors note.

But in the first year after undergoing the procedure, only four patients (0.6%) had died from surgical complications, including two patients from a gastrointestinal leak.

The main treatment for NASH is weight loss

As the authors point out, obesity is the primary pathophysiological driver of NASH, and weight loss – regardless of how it is achieved – is currently the primary treatment for NASH.

“However, weight loss surgery is the most effective therapy available for obesity,” they point out.

Shanu Kothari, MD, president of the American Society for Metabolic & Bariatric Surgery, agrees, saying in a statement: “No treatment other than weight loss surgery has been shown to have such a significant effect on reducing the risk of ‘severe outcomes or death in patients with NASH. “

“Bariatric surgery should be considered a first-line treatment for these patients,” he said.

And as Aminian pointed out, there is currently no drug approved by the FDA for the treatment of fatty liver disease.

“The striking results of this study provide strong evidence that bariatric surgery should be considered an effective treatment option for patients with advanced fatty liver disease and obesity,” he added in the statement.

Aminian said he received research support and speaking fees from Medtronic. Nissen said he received research support from Medtronic and Ethicon.

JAMA. Published online November 11, 2021. Summary

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