Hepatic Histopathology of Patients with Morbid Obesity Submitted to Gastric Bypass

Background: The authors analyze and describe the hepatic histopathology of patients with morbid obesity submitted to gastric bypass. Methods: A liver biopsy was performed in 112 patients at the beginning of gastric bypass, and clinical data (gender, age, BMI and associated diseases) were obtained from the patient records. Results: Among the patients, 74.1% (n=83) were females and 25.9% (n=29) were males, age 39.59±10.12 years, with BMI 48.79±7.54. Regarding the diseases associated with morbid obesity, arterial hypertension was observed in 67.9% (n=76) of the patients, joint diseases in 55.4% (n=62), dyslipidemia in 40.2% (n=45), and diabetes type 2 in 27.7% (n=31). 111 patients (99.1%) showed different types of non-alcoholic fatty liver disease (NAFLD) (types 1, 2, 3 and 4), with types 3 and 4 accounting for 57.7% (n=64). A significant association was observed between NAFLD type 4 and diabetes type 2 (P=0.018). The presence of glycogen nuclei was significantly correlated with steatosis (P=0.000), lobular inflammation (P=0.019) and perisinusoidal fibrosis (P=0.000). Conclusion: 1) Liver biopsy taken at gastric bypass reveals different types of NAFLD; 2) Diabetes type 2 is associated with NAFLD type 4; 3) Glycogen nuclei are correlated with steatosis, lobular inflammation and perisinusoidal fibrosis; 4) Steatosis represents the basic injury in NAFLD and is associated with hepato-cellular ballooning. 5) In view of the frequency of hepatic alterations, a biopsy should be part of the surgical protocol of morbid obesity, this method being the only one able to determine the presence of lesions and to stage fibrosis.     

Nonalcoholic Fatty Liver Disease of Obesity

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are part of the same continuum. They are a major, under-recognized cause of chronic liver disease. Good medical treatment options do not exist to date. The mainstay of treatment is weight loss. Bariatric surgery offers weight loss and improvement of NAFLD and NASH.     

Changes in Liver Histology Accompanying Massive Weight Loss after Gastroplasty for Morbid Obesity

Background: Nonalcoholic steatohepatitis (NASH) is common in morbid obesity. Our goal was to evaluate the alterations in liver histology and biochemistry before and after weight loss in 51 morbidly obese patients following Mason's vertical banded gastroplasty. Methods: Two biopsies were performed (on entry and after an average of 18 months), while 16 of these subjects had a third biopsy 17 months after the second. Results: On entry, steatosis and steatohepatitis (mostly grade 3) were present in 98.0% and fibrosis (mostly stage 2) in 94.1% of the subjects. After an excess weight loss of 66%, steatosis and steatohepatitis improved significantly (P<0.001). Although a significant overall decrease in fibrosis occurred (P=0.002), 21 patients (41.1%) did not change and only 6 patients (11.7%) increased in fibrosis. None developed cirrhosis. The decrease in steatohepatitis was significantly correlated (P=0.011) with the reduction of BMI. Fasting serum glucose, lipids, lipoproteins, transaminases, gamma-glutamyl transpeptidase, alkaline phosphatase and fibrinogen were also significantly improved at the time of the second biopsy. The third biopsy performed in 16 of the subjects showed further significant improvement in liver histology. Conclusion: NASH improved significantly with massive weight loss in non-diabetic, non-alcoholic, morbidly obese subjects, while fibrosis improved in nearly half of the patients.     

Liver Damage in Severely Obese Patients: a Clinical-Biochemical-Morphologic Study on 1,000 Liver Biopsies

Background: Preoperative clinical and biochemical data and intraoperative liver biopsy of 1,000 obese patients submitted to biliopancreatic diversion (BPD) were analyzed, and correlations investigated. Methods: Of 2,645 patients submitted to BPD between May 1976 and November 2002, the last 1,000 consecutive obese patients with no history of alcohol consumption or infectious hepatitis were selected. Clinical data included: age, body weight, BMI, waist-to-hip ratio (W/H), arterial blood pressure, serum glucose, triglycerides, cholesterol, albumin/γ-globulin ratio, total, conjugated and unconjugated bilirubin, γ-GT, alkaline phosphatase, AST, ALT, and prothrombin time. The degree of steatosis, inflammation and fibrosis on intraoperative wedge liver biopsy was determined and scored. Liver steatosis >70% and presence of bridging fibrosis were analyzed separately. Results: Mean BMI was 48 kg/m². 263 patients had steatosis of >70%, and 79 had bridging fibrosis. Regression analysis showed an association between steatosis and AST, ALT, AST/ALT ratio, body weight, W/H, serum glucose, serum tryglicerides, BMI, γ-GT, age, and unconjugated bilirubin. Inflammation was significantly greater in older patients. Patients with bridging fibrosis had significantly higher values of serum glucose, AST, γ-GT, serum cholesterol and were significantly older. Bridging fibrosis was associated with diabetes, W/H >1, hypertension, albumin/γ-globulin ratio <1. Conclusion: Severe steatosis and bridging fibrosis seem to be associated with the metabolic syndrome. No reliable biochemical data could identify patients with severe chronic liver damage with sufficient sensitivity to avoid liver biopsy for diagnosis and staging of the disease.     

Weight Loss and Non-alcoholic Fatty Liver Disease: Falls In Gamma-Glutamyl Transferase Concentrations are Associated with Histologic Improvement

Background: The ability for aminotransferase levels to track histological features of non-alcoholic fatty liver disease (NAFLD) with weight loss has not been examined. Methods: We examined the effect of weight loss following laparoscopic adjustable gastric banding surgery on the histological features of NAFLD and plasma aminotransferase concentrations (AST, ALT and GGT) in 60 (12M, 48F) selected severely obese patients. All 120 paired biopsies were deidentified and scored for lobular steatosis, fibrosis, inflammation, Mallory bodies and NASH. Results: 30 patients (50%) had baseline histological features of non-alcoholic steatohepatitis (NASH). Repeat biopsies were taken at 29.5±10 months after baseline. Mean weight loss was 31.5±18 kg. There were improvements in AST, ALT, GGT, lobular steatosis, inflammation and fibrosis between baseline and follow-up (P<0.001 for all). Only 6 (10%) of repeat biopsies showed NASH. No change in aminotransferase concentrations predicted the change in steatosis, but changes in AST and GGT predicted improved scores for inflammation, fibrosis, Mallory bodies and NASH. The lowering of GGT best predicted the improvements in inflammation, fibrosis and NASH. Conclusion: With weight loss, falls in GGT and, to a lesser extent, in AST, are predictive of improved lobular inflammation and fibrosis, key prognostic features of NAFLD.     

Liver Pathology in Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass Surgery

Background: Non-alcoholic fatty liver disease is common. However,little is known about liver disease in the morbidly obese. Methods: 75 subjects (78% female, mean BMI 57 [40-108]) who had intra-operative liver biopsies at the time of Roux-en-Y gastric bypass surgery were studied. Results: 84% of subjects had steatosis while only about 20% had moderate to severe inflammation and fibrosis. 8% had bridging fibrosis or cirrhosis. The presence of fibrosis correlated strongly with the presence of inflammation (p<0.001) and steatosis (p=0.0011), but weakly with ALT (p=0.02) and not with AST (p= 0.12) or with BMI (p=0.34). Steatosis correlated with AST (p=0.04) and ALT (p=0.055), but not with BMI. Conclusion: Liver disease is not rare in the morbidly obese. The exact causes and mechanisms that lead from the very common isolated steatosis to inflammation and fibrosis remain unclear. Intra-operative liver biopsies during bariatric surgery may be helpful to screen for the presence of steatohepatitis and fibrosis.     

Preoperative Low Energy Diet Diminishes Liver Size

Background: A limited view of the gastro-esophageal area in obese patients is often aggravated by an enlarged liver due to fatty infiltration. Preoperative decrease in liver size would help surgeons, particularly those not used to working with morbidly obese patients. Methods: 50 morbidly obese patients booked for laparoscopic gastric banding undertook a 2-week, preoperative low energy liquid diet. Ultrasound measurements of the left lobe of the liver and body analysis were undertaken at the start of the diet, and again at the conclusion of the diet (preoperatively). Changes in liver size were compared to body analysis changes. Results: There was a highly significant decrease in liver size in the 2 weeks, which correlated with BMI and weight loss. There was no correlation with fat loss. No large left lobe of the liver was encountered at surgery nor caused any problem in any patients with successful preoperative weight loss. Conclusions: Preoperative restriction of dietary energy will reduce liver size, and is accurately predicted by associated weight loss.     

Histologic Variation of Grade and Stage of Non-alcoholic Fatty Liver Disease in Liver Biopsies

Background: Sampling error regarding disease grade and stage has been ascribed to needle liver biopsies in patients with chronic liver disease. Although several studies evaluating sampling error in liver biopsies exist, none have investigated this phenomenon in patients with non-alcoholic fatty liver disease (NAFLD). This study aims to determine the rate and extent of sampling error in liver biopsies obtained from patients undergoing Roux-en-Y gastric bypass (RYGBP) surgery for morbid obesity. Methods: 10 morbidly obese patients underwent simultaneous liver biopsies from the right and left hepatic lobes during an open examination preceding the RYGBP procedure. The biopsies were subsequently randomly evaluated and then blindly re-evaluated by a liver pathologist. Degrees of inflammatory activity and fibrosis were determined and scored for each sample using a semi-quantitative system with 3 grades and 4 stages. Results: No grading differences were observed, and 3 patients (30%) had a difference of at least 1 stage between the right and left lobes. One patient had a 2-stage difference in paired samples, with significantly different biopsy sizes and number of portal tracts. Blinded histologic re-evaluation did not result in grading or staging scores that differed from the original evaluation. Conclusions: Liver biopsy samples taken from the right and left hepatic lobes showed similar grades of disease activity, but differed in histopathologic staging in 30% of the NAFLD patients. Obtaining an adequately sized biopsy (>1.0 cm in length with >10 portal tracts) greatly reduces sampling error.     

Morbid Obesity,Hypertensive Disease and the Renin-Angiotensin-Aldosterone Axis

Background: Resistance to insulin and secondary hyperinsulinemia seem to be the putative link between morbid obesity (MO) and hypertensive disease (HD). Adipose tissue can secrete leptin and angiotensinogen, among other substances. Leptin activates the sympathetic nervous system, leading to HD. Angiotensinogen is a substrate for renin, therefore taking part in the renin-angiotensin-aldosterone axis and the regulation of blood pressure. In MO, both hypertrophy and hyperplasia of the adipocytes lead to an increase in the secretion of both substances, leading to loss of the equilibrium between the levels of both hormones. The aim of the present study was to evaluate these abnormalities and their potential reversibility following bariatric surgery. Methods: Data from 100 patients with MO was retrospectively evaluated. Anthropometric data, the plasma renin activity (PRA), plasma levels of aldosterone, ACE, potassium and sodium were collected both prior to surgery and 6, 12, 24 and 36 months after surgery. Results: The waist-hip ratio (WHR) before surgery allowed classification of our patients in two groups: central obesity (WHR ≥0.90 in men and ≥0.85 in women); peripheral obesity (WHR <0.90 in men and <0.85 in women). In patients with central obesity, high levels of PRA, aldosterone and ACE with sodium retention and potassium loss and high insulin levels, were found. These changes were not found in patients with peripheral obesity. After gastric bypass, these abnormalities tended to disappear, mainly in the first 6 months. Conclusions: The reduction of BMI and WHR after gastric bypass confirmed this operation to be effective against MO. The high basal levels of insulin and the high rate of HD and diabetes in patients with central obesity seem to indicate that they suffer a metabolic syndrome with significant hormonal imbalances and sodium retention. Patients with peripheral obesity only showed a peripheral resistance against insulin, probably with a shorter duration of the hormonal action, but they did not show hormonal abnormalities or sodium retention. After gastric bypass these abnormal hormone levels tended to normalize.     

Morbid Obesity and Gastric Bypass Surgery: Biochemical Profile

Background: Morbid obesity (MO) and the pathologies associated with it constitute an important public health problem, accounting for 7% of the health expenditure in industrialized countries. An important percentage of this expense is attributed to the different biochemical tests performed in these patients, who suffer from several metabolic derangements. We evaluated the basic biochemical abnormalities in MO patients and their reversibility by weight loss after gastric bypass, to standardize the surveillance of the different metabolic abnormalities in obese patients. Methods: By a retrospective analysis on 125 patients operated in our hospital, we evaluated anthropometric and biochemical data before and 1, 3, 6, 12 and 24 months after gastric bypass. Results: Preoperatively hyperinsulinemia, hyperglycemia, dyslipidemia and hypertensive disease were present, and began to improve 1 and 3 months after surgery (although not significantly) and significantly at 6, 12 and 24 months after it. We also observed deficient protein nutrition and a deficiency of micronutrients both before bypass and during the follow-up. Conclusion: After gastric bypass, a marked decrease in insulin occurred, with normalization of blood pressure and the biochemical parameters associated with the metabolic syndrome. We propose a biochemical follow-up protocol for MO patients.     

Duodenal Switch Without Gastric Resection after Failed Gastric Restrictive Surgery for Morbid Obesity

Background: Several surgical treatments have been proposed for patients in whom gastric restrictive operations have failed. The aim of this study was to analyze the effectiveness and safety of duodenal switch (DS) with restoration of normal gastric capacity in such patients. Methods: Between May 2001 and May 2003, 11 DS with restoration of normal gastric capacity were performed without other gastric procedures in patients who had had previous gastric restrictive operations which had failed because of inadequate weight loss or weight regain. Data were collected and follow-up was 2 years for all patients. Results: At the original operation, mean BMI was 47.3 (range 38-53) kg/m², and mean age was 42 years. 7 of the 11 patients (63.6%) had previous vertical banded gastroplasty, and 4 of the 11 (36.4%) had previous laparoscopic adjustable gastric banding. Mean percentage weight regain and mean BMI at the time of DS were 92.1% and 44.6 (range 35-53) kg/m² respectively. After the second operation, mean BMI at 6 months was 35.4 kg/m², at 12 months 31.7 kg/m² and at 24 months 28.6 kg/m². The % excess weight loss was 41.1 after 6 months, 56.6 after 12 months and 69.6 after 2 years. There was minor morbidity and no mortality. Conclusion: After this experience, we suggest that patients with failed gastric restrictive operations (weight regain or inadequate weight loss) may undergo DS with restoration of normal gastric capacity. This second operation proved to be safe and effective.     

Predictors of Nonalcoholic Steatohepatitis (NASH) in Obese Patients Undergoing Gastric Bypass

Background: Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are conditions gaining increasing recognition in hepatology as a potential cause of cirrhosis and end-stage liver disease. Obesity is one of the main risk factors. The aims of this study were to determine the frequency of NAFLD in obese patients and to identify variables that predict NASH. Methods: A prospective study was conducted of obese patients undergoing gastric bypass over a 20-month period. Assessment included liver function tests and evaluation of insulin resistance with the homeostatic model assessment (HOMA-IR). Liver biopsy was performed in all patients at the time of surgery. Clinical and biochemical variables were analyzed using a multivariate analysis to identify independent predictors of NASH. Results: 127 consecutive patients were included (62% female, 38% male, mean age 40±11 years, mean body mass index 42±6 kg/m²). Arterial hypertension was present in 52 patients (41%) and type 2 diabetes in 18 (14%). NAFLD was confirmed in 80 patients (63%), 47 (37%) had simple steatosis, and 33 (26%) had NASH. Cirrhosis was found in 2 patients corresponding to 1.6% of the total population. On multivariate analysis, AST >31 (IU/L) (OR 3.38, CI 1.17-9.8) and HOMA-IR >5.8 (OR 4.18, CI 1.39-12.49) independently predicted NASH. Conclusions: NAFLD is highly prevalent in morbidly obese patients. A high proportion of these patients exhibit NASH on histological examination. Insulin resistance represents the main predictor of NASH.     

Outcome and Complications of Gastric Bypass in Super-Super Obesity versus Morbid Obesity

Background: Roux-en-Y gastric bypass (RYGBP) reduces the co-morbidities of obesity. Patients with super-super obesity (BMI ≥60) present additional technical and medical challenges. This study compares the results in super-super-obese patients with patients with a BMI of <60 over a 5.5-year period. Methods: Retrospective analysis was performed of the 504 patients who underwent open RYGBP from January 1999 through June 2004. Patients were divided into 2 groups: Group A (444 patients) had a BMI <60, and Group B (60 patients) had a BMI ≥60, and also had a greater percentage of males. The groups were otherwise similar in demographics and co-morbidities. Results: Concomitant ventral herniorrhaphy was performed in 23 patients (5%) in Group A and in 3 patients (5%) in Group B. Concomitant cholecystectomy was done in 11.2% in Group A and 10% in Group B. Group A patients had an incidence of leaks of 1.3%, and there were no leaks in Group B. Wound infection rate for Group A was 5% vs 1.7 % in Group B (NS). Mortality for both groups was similar. The stricture rate for Group A was 0.9% compared with 1.7 % for Group B. After 1 year, excess weight lost was 41.7% in Group A and 38.3% in Group B. The development of anemia was not statistically different (8.3% vs 11.0 %). Incidence of postoperative gallbladder disease and incisional hernia was similar. Conclusions: Super-super-obese patients should not be excluded from RYGBP because of a perceived increased risk based upon BMI.     

Effect of Massive Weight Loss induced by Bariatric Surgery on Serum Levels of Interleukin-18 and Monocyte-Chemoattractant-Protein-1 in Morbid Obesity

Background: Morbid obesity is associated with insulin resistance (IR), chronic inflammation and premature atherosclerosis. Since vascular inflammation may contribute to the increased risk of cardiovascular morbidity and mortality of these patients, we studied circulating Interleukin-18 (L-18) and monocyte-chemoattractant-protein-1 (MCP-1) levels in 37 patients with morbid obesity before and after significant weight loss induced by bariatric surgery and their preoperative and postoperative associations with C-reactive protein (CRP) and IR-associated factors. Methods: High sensitivity assays were used to measure concentrations of fasting CRP, IL-18 and MCP-1. Differences between patients before and after bariatric surgery were analyzed by Student's paired t-test. To investigate the associations of the observed reductions of values, delta of parameters were calculated and preoperative, postoperative and delta data were tested by univariate and multivariate linear regression. Results: After a mean follow-up period of 26.5 months and a massive weight loss of 35 kg induced by bariatric surgery, circulating IL-18 levels decreased by 37% (P<0.001) and circulating MCP-1 levels by 47% (P<0.001). Multiple linear regression of delta values of IL-18 showed that only 2-hour glucose (P=0.008) remained independently and significantly associated with IL-18, whereas multiple linear regression analysis of delta values of MCP-1 revealed that only delta of HOMA-IR (P<0.001) remained independently and significantly associated with MCP-1, respectively. Conclusions: Because both biomarkers have been shown to play an important role in the development and progression of atherosclerosis, the observations presented in this study could be of clinical relevance for morbidly obese patients undergoing bariatric surgery.     

Prevalence of Non-alcoholic Steatohepatitis in Morbidly Obese Subjects Undergoing Gastric Bypass

Background: Obesity is the most common cause of non-alcoholic steatohepatitis (NASH). This is a prospective study to determine the incidence and severity of NASH in patients undergoing Roux-en-Y gastric bypass (RYGBP) for morbid obesity. We also examined the relationship between NASH and potential risk factors. Methods: In 48 consecutive patients at RYGBP, a core liver biopsy was obtained from the left lateral segment. A single liver pathologist reviewed the histology for steatosis, ballooning/disarray, necroinflammation, and fibrosis. Results: 84% of patients were female, and average BMI was 51. 18% had WHR >1. The following risk factors were present: DM 16%; hyperlipidemia 61%; HTN 47%; and abnormal LFTs 18%. 90% had abnormal liver histology, and 56% qualified for the diagnosis of NASH. Only DM and abnormal LFTs were found to be significantly related to NASH. Conclusions: NASH is a common co-morbidity of obesity and requires systemized grading and staging to develop accurate knowledge of the incidence, severity, natural history and impact of weight loss.     

Prevalence and Predictive Factors of Non-Alcoholic Steatohepatitis (NASH) in Morbidly Obese Patients Undergoing Bariatric Surgery

Background: In patients with morbid obesity selected for bariatric surgery, previous studies have shown a prevalence of NASH varying from 2.6% to 91%. The prevalence of NASH and extensive fibrosis were studied in a prospective cohort of patients with morbid obesity requiring bariatric surgery, to identify predictive factors of NASH. Methods: From July 01 to Sept 02, every patient requiring bariatric surgery had a liver biopsy. The diagnosis of NASH was established using Lee's criteria. Results: 92 patients (85 women, age 38 ± SEM 11 years) were analyzed. Mean BMI was 45.7 ± 5.1 kg/m². 35 patients had lobular inflammation. 9 patients had steatosis associated with lobular necrotic and inflammatory foci and ballooning degeneration or pericellular fibrosis. No cirrhosis or extensive fibrosis was evidenced. The prevalence of NASH in this population was 9.8%. Waist/hips ratio and BMI were independent predictors of lobular inflammation, but only BMI was an independent factor of NASH in multivariate analysis. Conclusion: In this prospective cohort of patients at bariatric surgery, the prevalence of NASH was 9.8%. BMI was the only predictive factor for NASH.     

The Comparison of Scoring Scales for Liver Biopsy Assessment in Morbidly Obese Patients Undergoing Bariatric Surgery

Background: Many scoring systems have been applied for the grading and staging of non-alcoholic fatty liver disease (NAFLD). There is no consensus according to semiquantitative scales for the assessment of steatosis, inflammatory grading, and fibrosis staging in NAFLD. Methods: We analysed 24 consecutive patients who underwent bariatric surgery. The grading for steatosis was estimated according to the systems proposed by Brunt and by Dixon. Brunt's scale and Scheuer's scale modified by Gabriel were used for inflammatory activity and fibrosis staging. Additionally, types of NAFLD disease were diagnosed according to Matteoni's classification. Results: Steatosis was observed in 88% and steatohepatitis in 54% of patients. We observed portal, periportal and pericellular fibrosis. Neither bridging fibrosis nor cirrhosis were found. Extent of steatosis estimated according to Dixon and Brunt's scales was positively associated with appearance of steatohepatitis. The comparison of Dixon's and Brunt's scales according to grade of steatosis demonstrated a statistically significant difference. Inflammatory activity grades and fibrosis stages assessed according to Scheuer and Brunt scales differ significantly. Inflammatory activity evaluated with the Brunt scale was associated with the extent of steatosis and occurrence of steatohepatitis. Conclusions: Non-advanced forms of liver fibrosis do not appear to be dependent on steatosis and inflammatory grade in NAFLD. It is necessary to find the precise estimation of extent of steatosis especially occupying less than 1/3 or 1/4 of the lobule area. Brunt's scale seems to be more useful for the estimation of liver biopsy in NAFLD. It is essential to create a consensus for evaluation of steatosis and necroinflammatory grading and fibrosis staging in NAFLD.     

Health-Related Quality of Life in Morbid Obesity

Background: In order to evaluate the impact of severe obesity and its treatment on quality of life (QoL), it would be important to first identify the areas of QoL most likely to be affected by the disease. Methods: We first constructed a list of 187 items potentially related to QoL of patients with morbid obesity. From this list, consecutive candidates for bariatric surgery were asked to identify what they felt were the most significant items and to grade their importance. The item impact was determined from the proportion of patients who identified it as important, and the mean importance score attributed to this item (impact score = frequency X importance). Results: 100 patients (68 female; mean body mass index 51.5 kg/m²; mean age 42) were interviewed. Overall, the impact of morbid obesity was more important in women than in men. The areas of impairment were very similar in both groups, with the important difference that women ranked their dissatisfaction with physical appearance higher than men. The items having the most important impact on QoL clustered into 7 domains: 1) activity/mobility; 2) symptoms; 3) personal hygiene/clothing; 4) emotions; 5) social interactions; 6) sexual life; and 7) eating behavior. Conclusion: The impact of morbid obesity on QoL is not limited to the activity/mobility domain. Morbid obesity contributes to the impairment of all domains of what is usually referred to as "health-related quality of life".     

Surgical Treatment of Morbid Obesity in Schizophrenic Patients

Background: Newer antipsychotic medications have greatly improved the treatment of schizophrenia, but they are known to be associated with serious weight gain. Little is known about treatment of morbid obesity in this population. Methods: 5 patients with schizophrenia and morbid obesity were studied.Weight loss was compared with that achieved by 165 non-psychotic patients who also underwent bariatric surgery during a 1-year period. Results: 5 morbidly obese patients with schizophrenia underwent bariatric surgery between February 1999 and April 2003. All patients were well controlled on antipsychotics. The median BMI was 54 (51-70) and all had obesity-related co-morbities. All patients had been previously treated unsuccessfully with conservative methods of weight reduction. 3 patients had a duodenal switch operation, 1 patient had a sleeve gastrectomy, and 1 had conversion of a silastic ring gastroplasty to biliopancreatic diversion. All patients were maintained on their antipsychotic medications until 24 hours before surgery. Median percent excess weight loss at 6 months was comparable to that achieved in the control group. Conclusions: Good control of schizophrenia may be achieved by newer therapies but at the risk of weight gain. The results of bariatric surgery in such patients are comparable to those of non-psychotic morbidly obese patients. Further follow-up is needed, but the results are encouraging.     

Histological Changes in the Liver of Morbidly Obese Patients: Correlation with Metabolic Parameters

Background: Obesity is a major risk factor for fatty liver disease. The purpose of this study was: 1) to determine the degree of steatosis, inflammation and fibrosis in liver biopsies of morbidly obese patients in relation to their body fat distribution and metabolic status, and 2) to examine the course of liver enzyme changes with surgically-induced weight loss. Methods: The study population included 179 morbidly obese bariatric surgical patients (82% female, 18% male, mean age 39±0.7 (SEM) years, BMI 52±0.6 kg/m², excess body weight 80±1.8 kg). All patients tested negative for hepatitis and HIV. Liver biopsies were taken intra-operatively. Hepatic enzyme activities were measured along with lipid parameters, fasting glucose, insulin and leptin. Results: Liver biopsies showed that 47% of morbidly obese females and 85% of males had >30% of hepatocytes filled with fat droplets. Clinically significant hepatic steatosis was associated (P<0.01) with: a) metabolic aberrations, i.e.hyperlipidemia, hyperglycemia, b) male gender, c) abdominal adiposity, and d) elevated hepatic aminotransferase activities. Hepatic inflammation was found in 47% of females and 55% of males, and 'moderate' fibrosis occurred in 12% of males and 6% of females. Postoperatively, the activity of hepatic aminotransferases declined after an initial increase in response to weight loss, with normalization of values occurring at an excess weight loss of 50% (P<0.0001). Conclusion: The majority of morbidly obese patients have >30% steatosis of the liver. The incidence of steatosis is higher for males than females, possibly due to their visceral obesity and associated metabolic aberrations.