Dr. Steven E. Nissen, MD, MACC, Chief Academic Officer of the Heart, Vascular & Thoracic Institute at Cleveland Clinic talks about bariatric surgery and the new benefits it can have.
What is NASH and what are the causes, symptoms, and risks?
NISSEN: NASH is known as non-alcoholic steatohepatitis. It’s a mouthful, but it is fatty liver disease. What seems to happen is that some people who become obese, their liver is infiltrated with fat. And it’s important because it’s now become one of the leading causes of liver failure cirrhosis and transplantation.
What are the current treatments?
NISSEN: Unfortunately, there is no approved treatment for NASH. There are drugs that have been studied and have shown some effectiveness. But the Food and Drug Administration has not approved any medical therapy for this disorder. The only thing that seems to make a difference, which we’re going to talk about, is weight loss.
What part does weight loss play in the management of this condition?
NISSEN: We’ve known for years that losing weight seems to improve fatty liver disease, but it’s very hard for people to lose enough weight to make a difference. Typically, even with very aggressive diets, people lose only a few percent of their body weight and many of the people that have NASH are 50 or even 100 pounds overweight. Unfortunately, obesity is increasing at an alarming rate in the United States. So, more and more people are developing NASH.
Can you tell us about this wonder trial? What does SPLENDOR stand for?
NISSEN: SPLENDOR is a mouthful. It stands for surgical procedures and long-term effectiveness in NASH disease and obesity risk. My colleague, Dr. Aminian, is a very talented bariatric surgeon. He looked back through the records of the Cleveland Clinic Health System and found many people that had liver biopsies for suspected NASH. More than 500 of these people had undergone bariatric surgery. So, in matching those patients with a similar number of patients that didn’t have surgery, we could look at their long-term outcomes over many years.
How many people did researchers follow?
NISSEN: The total number was 1,158 patients. About 500 of whom had bariatric surgery and a little more than 600 of whom had just had medical treatment.
Over what time period and what did they end up finding?
NISSEN: The total follow-up time was 10 years. Now not everybody was followed but through our electronic medical records we could look out 10 years and see what happened to these patients. And what happened was very dramatic. The bariatric surgical patients lost an average of about 22% of body weight. So, if you’re 250 pounds, and lose 22%, that’s in a range of 50 pounds or more. In other words, a lot of weight loss. The medical treatment group lost only 4.6% of body weight which is really typical of what people can achieve with diet, exercise, and other interventions. The patients who underwent bariatric surgery had a dramatically lower risk of progression of NASH to cirrhosis, liver transplantation, and liver-related mortality. The reduction was as large as we’ve ever seen for any intervention, for any disease. It was an 88% reduction in the risk of developing end stage liver disease, such as cirrhosis. That is an incredibly powerful effect.
What would you like our viewers to know about the potential impact of bariatric surgery?
NISSEN: Well, there’s two impacts that we studied. One was the effect of bariatric surgery on progression of liver disease, cirrhosis transplantation, or death. But the other aspect we studied was what happened with cardiovascular outcomes. The effect was also very large. There was a 70% reduction in major cardiovascular outcomes of concern, such as heart attack, stroke, cardiovascular death and heart failure. There were dual benefits of bariatric surgery, the benefits on the liver, which were enormous, and the benefits on the heart, which were also very large. So, for those patients that have obesity, who have been diagnosed with NASH, bariatric surgery offers a very effective therapy that can be life changing.
Are there some patients where bariatric surgery is not the ideal or a recommended treatment?
NISSEN: First, bariatric surgery is not without complications. It’s done now through a laparoscope delivered through a small keyhole-type incision. But there are complications. There can be nutritional disturbances and other things. Some people will need a second operation because of complications from the first operation. People who undergo bariatric surgery must really want to lose weight and should be people who have tried hard to lose weight by other means but were unable and are psychologically prepared to do this for their long-term health benefit.
Are there risks for certain populations of patients in relation to the surgery?
NISSEN: Certainly, surgery is something we are careful about in people that have very advanced diseases, like heart disease, where maybe the stress of the surgery could trigger a heart attack. So, it’s one of those situations where you must weigh risk and benefit. What’s the risk of the surgery? What’s the benefit? And then present alternatives to the patient. We call this shared decision-making. The patient and their physicians discuss the options, understand the risks, and make a decision together to go forward. It is a very good option. There are certainly costs associated with it, although many insurers are now willing to pay for bariatric surgery. And then there are requirements for follow-up and for nutritional advice to prevent nutritional deficiencies.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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