Non-Alcoholic Steatohepatitis and GS surgery

[SummerShadow 27]

Hi everyone. Well, I had my first appointment with the surgeon on April 18 and all went well and quickly, which surprised me. The surgeon knows, and we discussed briefly, that I was diagnosed with NASH last year. He was non-plussed and said that would improve with weight loss, mentioned nothing about it posing a problem during or after surgery. However, a co-worker of my husband had the banding done, is having to have it re-done (whatever that means), and he told my husband yesterday that his surgeon told him that if he found a fatty liver that he would terminate the surgery. So then I went online to read about NAFLD and NASH (which is what I have) and gastric sleeve surgery. Confusing confusing confusing information.....

A couple of research papers said it helps and doesn't pose too many complications unless the person has cirrhosis and/or portal hypertension. As of my biopsy last year I have neither of those. But other articles, etc say that the liver will "Shred" or "Tear" and bruise due to it's larger size due to the fat. There wasn't any mention by my liver specialist, nor was it in the copies of the biopsy results, that stated my liver was enlarged. BUT... which of the information is true??? Will my liver shred or tear if it's fatty and they try to do this surgery, or.....????

Anyone else have fatty liver, and if so... what was your experience?

[PatientEleventyBillion 851]

No no no.

First off, liver disease is a comorbidity that adds to the importance of getting this surgery done.

Second, the issue with liver disease and the surgery has to do with both the size of the liver (hence the liver shrinking pre-operative diet - livers with fatty infiltration will be larger and more slippery and harder to control with laparascopic instruments, the liver literally sits right on top of the stomach and must be moved out of the way) and the "hardness" of the liver. As the liver moves from NASH to fibrosis to cirrhosis, the liver hardens significantly. The risk that is run is that when the surgeon uses tools to move the liver out of the way, the liver can crack and bleed, and you could hemorrhage to death. Have you ever had a fibroscan done? MRI/MRE?

Fatty liver is not a logical indication of not doing the surgery.. it's a condition of necessity of having this surgery done.. a hardened liver is, on the other hand, something that would, and should, make a surgeon nervous.

The staging of NA liver disease is as follows: Nothing, NAFLD (fatty liver), NASH (steatohepatitis), fibrosis, cirrhosis. I was stage 3 fibrosis, near the stage of cirrhosis (irreversibility). I just had this surgery and my liver looked fantastic.

Edited April 28, 2017 by PatientEleventyBillion

[SummerShadow 27]

11 minutes ago, PatientEleventyBillion said:

No no no.

First off, liver disease is a comorbidity that adds to the importance of getting this surgery done.

Second, the issue with liver disease and the surgery has to do with both the size of the liver (hence the liver shrinking pre-operative diet - livers with fatty infiltration will be larger and more slippery and harder to control with laparascopic instruments, the liver literally sits right on top of the stomach and must be moved out of the way) and the "hardness" of the liver. As the liver moves from NASH to fibrosis to cirrhosis, the liver hardens significantly. The risk that is run is that when the surgeon uses tools to move the liver out of the way, the liver can crack and bleed, and you could hemorrhage to death. Have you ever had a fibroscan done? MRI/MRE?

Fatty liver is not a logical indication of not doing the surgery.. it's a condition of necessity of having this surgery done.. a hardened liver is, on the other hand, something that would, and should, make a surgeon nervous.

The staging of NA liver disease is as follows: Nothing, NAFLD (fatty liver), NASH (steatohepatitis), fibrosis, cirrhosis. I was stage 3 fibrosis, near the stage of cirrhosis (irreversibility). I just had this surgery and my liver looked fantastic.

I am SO glad to hear your liver is better!!!! Wow! That's a blessing for sure!

As for my liver.... my enzymes were elevated, sending me to a specialist. Blood work showed the score for probable NASH, then I was scheduled for biopsy... where they go in through the jugular. Results were NASH with no fibrosis, cirrhosis, nor portal hypertension. I was put on prednisone (was on it a horrid 3 months) because my specialist thought I had/have autoimmune hepatitis, though the biopsy results showed NO interface hepatitis. I really want a second opinion on that as none of it made sense due to the lack of the defining factor (interface hepatitis) and any antibodies in my blood work. There was also no indication whatsoever in the biopsy results that my liver was enlarged and, in fact, said it was normal size.

I'm assuming, then, that things will go well. I did read one research paper that said (and I knew this already) that rapid weight loss can cause inflammation, etc. in the liver. One risk vs another, I suppose.

What you said makes perfect sense to me, and unless they see something different during the surgery I'm sure everything will be fine.

Thank you so much for the info, Patient, and I'm so so SO glad the surgery helped with your liver issues!

[PatientEleventyBillion 851]

Thank you, but yes, your issue is very light, at least, for now.

I've seen other patients who had VSG even with cirrhotic liver. Of course, 1) the risk was higher to them, and 2) the surgeon was EXTREMELY careful when doing it, and had much higher demands of them pre-operatively. It's very important people understand that the risk isn't the same with everyone. It depends on numerous factors that cater to one's individual case, but some general logic applies.. those with more comorbities have increased risk of something going wrong during surgery, but that risk is dramatically increased anyways just living life.

There should be no justification for, as you mentioned about someones doctor threatening not do have surgery because of fatty liver, not doing a surgery because of NAFLD+NASH. Even if the liver is enlarged, as it would be in the vast majority of obese people (particularly if their obesity is diet related), it's amazing how fast the liver will shrink doing a proper pre-operative diet. One who is obese should also note that weight should fall off along with the liver shrinking, it's virtually the same mechanism.

I would tell that person to find another doctor, should be easy.. that one just seems like an idiot. NAFLD and NASH do not add much risk to the surgery whatsoever. Fibrosis does add a bit, and cirrhosis adds significant risk.

As for weight loss causing fatty liver, it would be in all likelihood if one is starving themselves. The ketogenic diet for example puts the body into ketosis (initial panic stage) but with decent Protein it will adjust when it realizes all is fine. If one is simply starving themselves the body changes from utilizing carbs for energy synthesis to utilizing carbs for storage. This excess glucose made will overwhelm the liver's reserves and cause fat infiltration as it converts the glucose to fatty acid for long term energy utilization. Its a defense mechanism. Then when the person starts eating normal again the body gains significant weight back, which also causes more fatty infiltration. Weight loss, when done the healthy way, will not negatively impact the liver whatsoever, in fact, it will utilize the fat within the liver, allowing the liver to, by itself, heal and regenerate hepatocytes.. if the body's immune system did it instead (as is the case with progressive liver disease), it would simply damage the liver with fibrosis (fibrotic scarring occurring as a result of the immune system trying to heal the liver in its own way).

Edited April 28, 2017 by PatientEleventyBillion