Association of Histopathological and Biochemical Aspects of NAFLD With the Severity of Liver Fibrosis in Individuals With Obesity: Cross-sectional Study.

BACKGROUND: Given the importance of fibrosis in the progression of non-alcoholic fatty liver disease (NAFLD), identifying biochemical and histopathological aspects associated with its severity is important to determine the course of disease in high-risk populations. OBJECTIVES: The study aims to investigate correlations between biochemical and histopathological variables associated with the occurrence and severity of NAFLD-related liver fibrosis in individuals with obesity. METHODS: This is a cross-sectional study which enrolled 171 individuals who underwent bariatric surgery at a tertiary university hospital. Clinical, laboratory, and histopathological hepatic characteristics were analyzed. Univariate and multivariate analyses were carried out to identify factors associated with the outcomes studied (severity of fibrosis staging) through simple and multiple regression models. RESULTS: Female were 87.7%, and the mean age was 38.4 ± 9.3 years. The most common histopathological abnormalities were macrovesicular steatosis (74.9%) and hepatocellular ballooning (40.4%). In the histopathological univariate analysis, liver fibrosis significantly correlated with severities of microvesicular steatosis (p = 0.003), lobular inflammation (p = 0.001), and NAS (p < 0.001). In the multivariate analysis, the degrees of microvesicular steatosis (p < 0.001) and NAS (p < 0.001) independently correlated with fibrosis severity. In the univariate biochemical analysis, fibrosis severity significantly correlated with levels of hemoglobin A1c (p = 0.004) and glucose (p = 0.01). In the multivariate analysis, glucose levels independently correlated with liver fibrosis degree (p = 0.007). CONCLUSION: Significant and independent associations were observed between the intensities of microvesicular steatosis, NAS, and glucose levels and the severity degree of liver fibrosis in individuals with obesity.

Impact of pre-operative weight loss on non-alcoholic fatty liver disease histopathology and insulin resistance in individuals undergoing bariatric surgery: a propensity matched cross-sectional comparison

ABSTRACT BACKGROUND: The effect of weight loss (WL) on histopathological aspects of non-alcoholic fatty liver disease (NAFLD) may provide further insights into the dynamics of hepatic recovery after WL. OBJECTIVE: To analyze the effects of pre-operative WL on insulin resistance- and NAFLD-related histology in individuals undergoing bariatric surgery (BS) with or without pre-operative WL. DESIGN AND SETTING: A matched cross-sectional study was conducted at a public university hospital and a private clinic in Campinas, Brazil. METHODS: An analytical, observational, cross-sectional study was conducted using prospectively collected databases of individuals who underwent BS and liver biopsy at either a public tertiary university hospital (with pre-operative WL) or a private clinic (without pre-operative WL). Random electronic matching by gender, age, and body mass index (BMI) was performed and two paired groups of 24 individuals each were selected. RESULTS: Of the 48 participants, 75% were female. The mean age was 37.4 ± 9.6. The mean BMI was 38.9 ± 2.6 kg/m2. Fibrosis was the most common histopathological abnormality (91.7%). Glucose was significantly lower in the WL group (92 ± 19.1 versus 111.8 ± 35.4 mg/dL; P = 0.02). Significantly lower frequencies of macrovesicular steatosis (58.3% versus 95.8%; P = 0.004), microvesicular steatosis (12.5% versus 87.5%; P < 0.001), and portal inflammation (50% versus 87.5%; P = 0.011) were observed in the WL group. CONCLUSION: Pre-operative WL was significantly associated with lower frequencies of macro- and mi- crovesicular steatosis, portal inflammation, and lower glycemia, indicating an association between the recent trajectory of body weight and histological aspects of NAFLD.

Identification of Predictors of Non-alcoholic Steatohepatitis and Its Severity in Individuals Undergoing Bariatric Surgery.

BACKGROUND: As obesity reached epidemic proportions, non-alcoholic fatty liver disease (NAFLD) also had a worrisome parallel increase. The non-invasive differentiation of non-alcoholic steatohepatitis (NASH) from uncomplicated NAFLD remains an important challenge in current clinical practice. OBJECTIVE: To identify predictors of the occurrence and severity of NAFLD and NASH. METHODS: This is an analytical cross-sectional study which included individuals undergoing bariatric surgery. Participants were histologically classified according to the presence NASH and severity of NAFLD. Demographic, clinical, anthropometric, and biochemical aspects were analyzed and compared. RESULTS: Out of 171 individuals, 87.7% were female and the mean age was 38.4±9.3 years. The average BMI was 38±3.0 kg/m2. NAFLD was histologically confirmed in 74.9%; the commonest histopathological abnormalities were macrovesicular steatosis (74.9%) and ballooning (40.4%). Simple steatosis occurred in 30.4%, 44.4% presented with NASH, and 31% had severe NAFLD. NASH associated with higher levels of ALT (0.03), ALP (0.02), and glucose (0.02). Cutoff values were, respectively, 23 U/L, 67 U/L, and 81 mg/dL. Their concomitant use provided an 83.1% specificity for NASH. Severe NAFLD associated with diabetes (p=0.02), higher BMI (p=0.01), AST (p=0.04), ALT (p<0.01), ALP (p=0.01), glucose (p=0.02), and ferritin (p<0.01). BMI over 39.3 kg/m2 and ferritin over 178 ng/mL concomitantly provided a 70.5% accuracy for severe NAFLD. CONCLUSIONS: NASH and severe NAFLD associated with higher levels of ALT, ALP, and glucose. Severe NAFLD associated with higher BMI and higher ferritin levels in this group. The concomitant evaluation of these laboratory tests could help ruling out NASH and safely screening severe NAFLD.

Fibrotic NASH in Individuals with Obesity: a Cross-sectional Analysis of the Prevalence of this Significant Milestone of Disease Progression and Accuracy of a Non-invasive Marker for its Screening.

BACKGROUND: Fibrotic non-alcoholic steatohepatitis (NASH), i.e., the concomitant presence of active inflammation and fibrosis, represents a milestone in the natural history of NAFLD and a critical time point in its progression. The purpose of this study was to analyze the diagnostic accuracy of the non-invasive Fibrotic NASH Index (FNI) in individuals with obesity undergoing bariatric surgery. METHODS: This is a cross-sectional study, enrolling individuals who underwent bariatric surgery with liver biopsy at a tertiary university hospital. FNI was calculated, and a cutoff value was determined. Its diagnostic accuracy was then calculated through comparison with the gold standard test for this analysis (histopathological examination). RESULTS: Of 128 participants, 83.6% were female, and the average age was 39.8 ± 8.7 years. The mean BMI was 38.7 ± 5.7 kg/m2. NAFLD was histologically confirmed in 76.6%, of which 81.6% had NASH. Histologically confirmed fibrotic NASH was observed in 22.7% of the general study population, 29.6% of individuals with NAFLD, and 36.3% of those with NASH. The mean FNI was 0.18 ± 0.19. An optimal cutoff point of 0.21 was determined, with an overall accuracy of 90.1%, an 82.8% sensitivity, a 90.8% specificity, a 72.6% positive predictive value, and a 94.7% negative predictive value. CONCLUSIONS: FNI provided adequate accuracy in detecting and ruling out fibrotic NASH. Considering the importance of fibrotic NASH within the natural history of NAFLD progression and the fact that this marker uses simple variables, it may be of great importance in high-risk populations, and its external validation and use should be encouraged.

WEIGHT LOSS AND QUALITY OF LIFE AFTER ONE ANASTOMOSIS GASTRIC BYPASS: A 2-YEAR FOLLOW-UP STUDY.

•One anastomosis gastric bypass (OAGB) led to significant weight loss after 2 years. •OAGB associated was well-succeeded in regards to weight loss in most individuals. •OAGB led to significant improvement of quality of life (QoL) assessed by the BAROS system. •"Self-steem" and "work capacity" were the most positively affected QoL domains after OAGB. Background - Studies assessing quality of life (QoL) after one anastomosis gastric bypass (OAGB) are currently scarce. Objective - To analyze the main weight loss outcomes and QoL in individuals undergoing OAGB during a 2-year follow-up. Methods - This is a retrospective study based on a prospectively collected database including individuals which underwent OAGB at a tertiary-level university hospital. After 2-years, excess weight loss was assessed, and post-surgical therapeutical success was determined using Reinhold's criteria. QoL was assessed through the Bariatric Analysis and Reporting Outcomes System (BAROS). Results - Out of 41 participants, 90.2% were female and the average age was 38±8.3 years old. The average body mass index significantly decreased from 37.1±5.6 kg/m2 to 27±4.5 kg/m2 after 2-years (P< 0.001). The mean percentage of excess weight loss was 84.6±32.5%. Regarding weight loss outcomes, 61% were considered "excellent", while 26.8% were "good" according to Reinhold's criteria. With regards to QoL assessed by BAROS, most individuals achieved a score classified as either "excellent" (26.8%), "very good" (36.6%), or "good" (31.7%). The highest degrees of satisfaction achieved were in the domains "self-esteem" and "work capacity", in which 75.6% and 61%, respectively, were classified as "much better". Conclusion - OAGB associated with significant weight loss and resolution of obesity-related medical conditions, as well as relevant QoL improvement assessed by the BAROS system.

Perda de peso e qualidade de vida após o Bypass Gástrico de Anastomose Única: resultados de um seguimento de 2 anos / Weight loss and quality of life after one anastomosis gastric bypass: a 2-year follow-up study

ABSTRACT Background: Studies assessing quality of life (QoL) after one anastomosis gastric bypass (OAGB) are currently scarce. Objective: To analyze the main weight loss outcomes and QoL in individuals undergoing OAGB during a 2-year follow-up. Methods: This is a retrospective study based on a prospectively collected database including individuals which underwent OAGB at a tertiary-level university hospital. After 2-years, excess weight loss was assessed, and post-surgical therapeutical success was determined using Reinhold's criteria. QoL was assessed through the Bariatric Analysis and Reporting Outcomes System (BAROS). Results: Out of 41 participants, 90.2% were female and the average age was 38±8.3 years old. The average body mass index significantly decreased from 37.1±5.6 kg/m2 to 27±4.5 kg/m2 after 2-years (P< 0.001). The mean percentage of excess weight loss was 84.6±32.5%. Regarding weight loss outcomes, 61% were considered "excellent", while 26.8% were "good" according to Reinhold's criteria. With regards to QoL assessed by BAROS, most individuals achieved a score classified as either "excellent" (26.8%), "very good" (36.6%), or "good" (31.7%). The highest degrees of satisfaction achieved were in the domains "self-esteem" and "work capacity", in which 75.6% and 61%, respectively, were classified as "much better". Conclusion: OAGB associated with significant weight loss and resolution of obesity-related medical conditions, as well as relevant QoL improvement assessed by the BAROS system.

RESUMO Contexto: Existem poucos estudos que analisaram a qualidade de vida (QV) após o bypass gástrico de anastomose única (BGAU). Objetivo: Analisar os principais resultados de perda de peso e QV em indivíduos submetidos ao BGAU ao longo de 2 anos de seguimento. Métodos: Este é um estudo retrospectivo baseado em um banco de dados coletado prospectivamente que incluiu indivíduos submetidos ao BGAU em um hospital universitário de nível terciário. Após 2 anos, foi analisado o percentual de perda do excesso de peso (%PEP) e o sucesso terapêutico pós-cirúrgico foi classificado através critérios de Reinhold. A qualidade de vida foi avaliada por meio do Bariatric Analysis and Reporting Outcomes System (BAROS). Resultados: Dos 41 participantes, 90,2% eram do sexo feminino e a idade média foi de 38±8,3 anos. O índice de massa corporal médio diminuiu significativamente de 37,1±5,6 kg/m2 para 27±4,5 kg/m2 após 2 anos (P<0,001). O %PEP médio foi de 84,6±32,5%. Quanto à avaliação dos resultados de perda de peso, 61% foram considerados "excelentes", enquanto 26,8% foram "bons" segundo os critérios de Reinhold. Com relação à QV avaliada pelo BAROS, a maioria dos indivíduos obteve escores classificados como "excelente" (26,8%), "muito bom" (36,6%) ou "bom" (31,7%). Os maiores graus de satisfação alcançados foram nos domínios "autoestima" e "capacidade para o trabalho", nos quais 75,6% e 61%, respectivamente, foram classificados como "muito melhor". Conclusão: O BGAU associou-se à significativa perda de peso e resolução de comorbidades, bem como melhora relevante da qualidade de vida avaliada pelo sistema BAROS.

Application of Scores Assessing Histological Activity and Estimated Long-Term Risk Analysis of Hepatic Decompensation of Non-Alcoholic Fatty Liver Disease in Individuals Undergoing Bariatric Surgery.

BACKGROUND: Histological scores can estimate disease staging, allowing a standardization of the assessment of non-alcoholic fatty liver disease (NAFLD). The prediction of risk of NAFLD progression is relevant to allow the planning of interventions. OBJECTIVE: To analyze the application of the Iowa NAFLD decompensation risk score, the NAFLD activity score (NAS), and steatosis-activity-fibrosis score (SAF) and to assess correlations between these scores. METHODS: This is a retrospective cross-sectional study enrolling 76 individuals who underwent bariatric surgery at a tertiary university hospital. Liver biopsy was performed during procedures; histological scores were then assessed. The Iowa score was calculated using age, diabetes, and platelet count. RESULTS: 89.5% were female and mean age was 39.1 ± 9.6 years. Mean BMI was 38.2 ± 3.7 kg/m2. Steatosis (92.1%), hepatocellular ballooning (93.4%), lobular inflammation (93.4%), and fibrosis (97.4%) were the commonest histopathological findings. According to NAS, 22.4% had definite non-alcoholic steatohepatitis (NASH). According to SAF, 89.5% had moderate or severe NAFLD. The mean risks of NAFLD decompensation at 5, 10, and 12 years were 0.8%, 2.5%, and 2.9%, respectively. The group whose risk of decompensation was above 10% comprised 2.6% and 5.3% at 10 and 12 years, respectively. The severity assessed by SAF significantly associated with definite NASH diagnosis through NAS (p < 0.001). Iowa score did not correlate with both NAS/SAF scores. CONCLUSION: The Iowa score demonstrated that individuals with obesity present with a significant long-term risk of NAFLD-related events. There were high rates of moderate/severe forms of NAFLD assessed by NAS and SAF scores. There were no significant correlations between Iowa and NAS/SAF scores.

Microvesicular Steatosis in Individuals with Obesity: a Histological Marker of Non-alcoholic Fatty Liver Disease Severity.

BACKGROUND: In non-alcoholic fatty liver disease (NAFLD), steatosis can manifest through two distinct forms: macrovesicular (macroS) and microvesicular (microS). OBJECTIVE: To investigate the prevalence of microS and its association with biochemical parameters and NAFLD-related histological findings in individuals with obesity. METHODS: This is an observational retrospective cross-sectional study, enrolling individuals who underwent bariatric surgery and liver biopsy at a university hospital. A 1:2 propensity matching was performed to pair microS with isolated macroS; this matching enrolled variables "age," "gender," "body mass index (BMI)," and "obesity-associated medical problems." Clinical, biochemical, and histopathological aspects were then analyzed and compared. RESULTS: Of 115 participants, 88.7% were female; average age was 40.5 ± 5 years and mean BMI was 37.9 ± 3.3 kg/m2. Steatosis occurred in 82.6% (67.8% isolated macroS and 14.8% microS). MicroS is significantly associated with higher levels of alanine aminotransferase (ALT) (39.8 ± 26.4 vs. 26.7 ± 17.5; p = 0.04) and glucose (103.8 ± 52.6 vs. 83.3 ± 10.8; p = 0.03) and higher frequencies of moderate to severe macroS (41.2% vs. 2.0%; p < 0.001), portal fibrosis (100% vs. 50%; p < 0.001), perisinusoidal fibrosis (100% vs. 55.9%; p < 0.001), lobular inflammation (100% vs. 41.1%; p < 0.001), and portal inflammation (100% vs. 41.1%; p < 0.001). An independently positive association was observed between intensities of microS and macroS (p < 0.001). CONCLUSION: MicroS is significantly associated with higher levels of ALT and glucose and higher frequencies of moderate to severe macroS, hepatocellular ballooning, portal fibrosis, perisinusoidal fibrosis, lobular inflammation, and portal inflammation. These findings indicate that microS could be considered a reliable histological marker of NAFLD severity.

Endoscopic and histopathological assessment of individuals undergoing one anastomosis gastric bypass: a 2-year follow-up.

BACKGROUND: There is much debate over the occurrence of biliary reflux to the gastric pouch after one anastomosis gastric bypass (OAGB) and its potential risks. OBJECTIVE: To assess endoscopic and histopathological findings following a standardized protocol of biopsy collection two years after OAGB. METHODS: A historical cohort study was conducted, based on a prospectively collected database, which involved 39 participants who underwent OAGB. Participants underwent clinical evaluation and esophagogastroduodenoscopy at the time of surgery and 24 months afterward. Post-operatively, biopsy specimens in esophagogastric junction, pouch, and anastomosis were systematically collected. RESULTS: 92.3% of the participants were female and the mean age was 37 ± 8.5 years. The mean body mass index (BMI) significantly decreased from 37.6 ± 5.7 kg/m2 to 27 ± 4.1 kg/m2 after 2 years (p < 0.001). The mean %TWL was 27.2 ± 10.5%. The prevalence of non-erosive gastritis significantly increased from 25.6 to 51.3% (p = 0.02). Erosive gastritis significantly decreased from 28.2 to 10.3% (p = 0.04). Four cases of marginal ulcers were identified (10.3%). The commonest histopathological finding was mild inflammation in 74.3% (esophagogastric junction), 58.9% (pouch), and 71.8% (anastomosis). There was one case of focal intestinal metaplasia in each site of interest and no cases of dysplasia or severe inflammation. CONCLUSIONS: Using a standardized protocol of post-operative biopsy collection, low rates of severe endoscopic and histopathological abnormalities were observed two years after OAGB. Nevertheless, as most patients have histologically proven inflammation, bile in the gastric pouch, and endoscopic gastritis, long-term surveillance is essential because of the uncertain risk of these abnormalities.

Relationships of hepatic histopathological findings and bile microbiological aspects with bile duct injury repair surgical outcomes: A historical cohort.

Backgrounds/Aims: To analyze relationships of hepatic histopathological findings and bile microbiological profiles with perioperative outcomes and risk of late biliary stricture in individuals undergoing surgical bile duct injury (BDI) repair. Methods: A historical cohort study was carried out at a tertiary university hospital. Fifty-six individuals who underwent surgical BDI repair from 2014-2018 with a minimal follow-up of 24 months were enrolled. Liver biopsies were performed to analyze histopathology. Bile samples were collected during repair procedures. Hepatic histopathological findings and bile microbiological profiles were then correlated with perioperative and late outcomes through uni- and multi-variate analyses. Results: Forty-three individuals (76.8%) were females and average age was 47.2 ± 13.2 years; mean follow-up was 38.1 ± 18.6 months. The commonest histopathological finding was hepatic fibrosis (87.5%). Bile cultures were positive in 53.5%. The main surgical technique was Roux-en-Y hepaticojejunostomy (96.4%). Overall morbidity was 35.7%. In univariate analysis, liver fibrosis correlated with the duration of the operation (R = 0.3; p = 0.02). In multivariate analysis, fibrosis (R = 0.36; p = 0.02) and cholestasis (R = 0.34; p = 0.02) independently correlated with operative time. Strasberg classification independently correlated with estimated bleeding (R = 0.31; p = 0.049). The time elapsed between primary cholecystectomy and BDI repair correlated with hepatic fibrosis (R = 0.4; p = 0.01). Conclusions: Bacterial contamination of bile was observed in most cases. The degree of fibrosis and cholestasis correlated with operative time. The waiting time for definitive repair correlated with the severity of liver fibrosis.

Roux-en-Y Gastric Bypass as a Treatment for Hepatic Iron Overload: An Exploratory Study.

BACKGROUND: Excess bodily iron content is commonly associated with obesity and metabolic associated medical conditions and is thought to lead to cardiovascular disease. The effect of Roux-en-Y gastric bypass (RYGB) on hepatic iron overload remains to be determined. OBJECTIVE: To assess the evolution of histologically proven hepatic iron overload after RYGB. METHODS: This is an exploratory historical cohort study in which 42 individuals who underwent RYGB, and then a second surgical procedure had paired liver biopsies collected. Hepatic iron overload and NAFLD features were assessed through histopathological examination. Biochemical iron metabolism parameters were also assessed. RESULTS: The mean age at RYGB was 47 ± 10.2 years and 92.9% were female. The average time elapsed between RYGB and the second surgical procedure was 20.6 ± 15.4 months. The mean percentage of total weight loss between the two procedures was 26.7 ± 9.4%. Significant reductions in ferritin (220.8 ± 202.9 vs. 101.6 ± 116.7 ng/mL; p = 0.006), hemoglobin (13.7 ± 1.8 vs. 12.1 ± 2.6 g/dL; p = 0.01), and red blood cell count (4.7 ± 0.7 vs. 4.3 ± 0.5 106/mm3; p = 0.003) were observed, as well as reductions in the frequencies of steatosis (83.3% vs. 23.8%; p < 0.0001) and steatohepatitis (52.4% vs. 11.9%; p < 0.0001). The frequency of hepatic iron overload significantly decreased from 16.7 to 2.4% (p = 0.03). CONCLUSION: RYGB led to a significant decrease in hepatic iron overload, emerging as a possible therapeutical tool for this condition in individuals with obesity and dysmetabolic iron overload syndrome.

Effect of transient obstructive cholestasis on liver histology: a cross-sectional study

ABSTRACT BACKGROUND: The role of transient obstructive cholestasis on liver histology remains undetermined. OBJECTIVE: To investigate whether transient cholestasis impairs liver histology. DESIGN AND SETTING: Cross-sectional study at a public university hospital (UNICAMP), Brazil. METHODS: 169 individuals undergoing cholecystectomy, with or without cholestasis. were enrolled. Histopathological findings were correlated with clinical and biochemical characteristics. RESULTS: Biliary hepatopathy was more frequent in individuals with resolved cholestasis than in those with active obstruction or no jaundice (P < 0.01), as also were fibrosis and ductular proliferation (P = 0.02). Cholestasis was commoner in individuals with resolved obstruction than in those with no history (P < 0.01) or active cholestasis (P < 0.05). Biliary hepatopathy was associated with longer duration of cholestasis (P < 0.001) and higher bilirubin levels (P = 0.02) in individuals with active obstruction; with lower body mass index (P = 0.02) and longer cholestasis (P < 0.001) in individuals with resolved obstruction; and with longer cholestasis (P < 0.001) and longer interval between endoscopic retrograde cholangiopancreatography and surgery (P = 0.03) overall. In individuals with active obstruction, duration of cholestasis (R = 0.7; P < 0.001) and bilirubin levels (R = 0.6; P = 0.004) were independently correlated with cholestasis severity. Duration of cholestasis (R = 0.7; P < 0.001) was independently correlated with ductular proliferation severity. CONCLUSIONS: Transient cholestasis was associated with significant histopathological changes, even after its resolution. Longer duration of obstruction correlated with greater severity of histopathological changes, especially cholestasis and ductular proliferation. This emphasizes the need for early treatment of obstructive cholestasis.

Is there a link between non-alcoholic fatty liver disease aspects and pancreatic cancer? Results of a case-matched study.

BACKGROUND AND AIMS: An association between non-alcoholic fatty liver disease (NAFLD) and pancreatic ductal adenocarcinoma (PDAC) has been previously suggested. This study aims at investigating this association and at identifying potential links between variables of the NAFLD spectrum and PDAC. METHODS: A cross-sectional case-matched analytical and comparative study was carried out to analyze patients undergoing surgical resection of PDAC and compare them to a control group of individuals undergoing cholecystectomy at a public tertiary teaching hospital, matched by sex, age and BMI. Hepatic histopathological examinations were compared between cases and controls. RESULTS: Of 56 individuals, 36 were male (64.3%) and the median age was 61.5 years old (interquartile range: 57.5 - 70). The participants' median BMI was 24.3 kg/m2 (interquartile range: 22.1-26.2 kg/m2). Microvesicular steatosis (p=0.04), hepatocellular ballooning (p=0.02), fibrosis (p=0.0003) and steatohepatitis (p=0.03) were significantly more frequent in the group of cases. Odds ratios for hepatocellular ballooning (6.2; 95%CI: 1.2-31.8; p=0.03), fibrosis (9.3; 95%CI: 2.5-34.1; p=0.0008) and steatohepatitis (3.9; 95%CI: 1.1-14.3; p=0.04) were statistically significant in relation to the PDAC prevalence. CONCLUSIONS: Significant associations were identified between histopathological aspects of NAFLD (microvesicular steatosis, hepatocellular ballooning, fibrosis, and steatohepatitis) and PDAC.

Effect of transient obstructive cholestasis on liver histology: a cross-sectional study.

BACKGROUND: The role of transient obstructive cholestasis on liver histology remains undetermined. OBJECTIVE: To investigate whether transient cholestasis impairs liver histology. DESIGN AND SETTING: Cross-sectional study at a public university hospital (UNICAMP), Brazil. METHODS: 169 individuals undergoing cholecystectomy, with or without cholestasis. were enrolled. Histopathological findings were correlated with clinical and biochemical characteristics. RESULTS: Biliary hepatopathy was more frequent in individuals with resolved cholestasis than in those with active obstruction or no jaundice (P < 0.01), as also were fibrosis and ductular proliferation (P = 0.02). Cholestasis was commoner in individuals with resolved obstruction than in those with no history (P < 0.01) or active cholestasis (P < 0.05). Biliary hepatopathy was associated with longer duration of cholestasis (P < 0.001) and higher bilirubin levels (P = 0.02) in individuals with active obstruction; with lower body mass index (P = 0.02) and longer cholestasis (P < 0.001) in individuals with resolved obstruction; and with longer cholestasis (P < 0.001) and longer interval between endoscopic retrograde cholangiopancreatography and surgery (P = 0.03) overall. In individuals with active obstruction, duration of cholestasis (R = 0.7; P < 0.001) and bilirubin levels (R = 0.6; P = 0.004) were independently correlated with cholestasis severity. Duration of cholestasis (R = 0.7; P < 0.001) was independently correlated with ductular proliferation severity. CONCLUSIONS: Transient cholestasis was associated with significant histopathological changes, even after its resolution. Longer duration of obstruction correlated with greater severity of histopathological changes, especially cholestasis and ductular proliferation. This emphasizes the need for early treatment of obstructive cholestasis.

Is there a link between non-alcoholic fatty liver disease aspects and pancreatic cancer? Results of a case-matched study / Existe ligação entre a doença hepática gordurosa não alcoólica e o câncer de pâncreas? Resultados de estudo caso-controle

ABSTRACT Background and Aims: An association between non-alcoholic fatty liver disease (NAFLD) and pancreatic ductal adenocarcinoma (PDAC) has been previously suggested. This study aims at investigating this association and at identifying potential links between variables of the NAFLD spectrum and PDAC. Methods: A cross-sectional case-matched analytical and comparative study was carried out to analyze patients undergoing surgical resection of PDAC and compare them to a control group of individuals undergoing cholecystectomy at a public tertiary teaching hospital, matched by sex, age and BMI. Hepatic histopathological examinations were compared between cases and controls. Results: Of 56 individuals, 36 were male (64.3%) and the median age was 61.5 years old (interquartile range: 57.5 - 70). The participants' median BMI was 24.3 kg/m2 (interquartile range: 22.1-26.2 kg/m2). Microvesicular steatosis (p=0.04), hepatocellular ballooning (p=0.02), fibrosis (p=0.0003) and steatohepatitis (p=0.03) were significantly more frequent in the group of cases. Odds ratios for hepatocellular ballooning (6.2; 95%CI: 1.2-31.8; p=0.03), fibrosis (9.3; 95%CI: 2.5-34.1; p=0.0008) and steatohepatitis (3.9; 95%CI: 1.1-14.3; p=0.04) were statistically significant in relation to the PDAC prevalence. Conclusions: Significant associations were identified between histopathological aspects of NAFLD (microvesicular steatosis, hepatocellular ballooning, fibrosis, and steatohepatitis) and PDAC.

RESUMO Histórico e objetivos: a associação entre a doença hepática gordurosa não alcoólica (DHGNA) e o adenocarcinoma ductal pancreático (ACDP) foi sugerida anteriormente. Este estudo visa investigar esta associação e identificar possíveis ligações entre as variáveis do espectro da DHGNA e o ACDP. Métodos: foi realizado estudo transversal caso-controle analítico e comparativo para analisar pacientes submetidos a ressecção cirúrgica de ACDP e compará-los a grupo controle de indivíduos submetidos a colecistectomia em hospital público terciário de ensino, pareados por sexo, idade e IMC. Os exames histopatológicos hepáticos foram comparados entre casos e controles. Resultados: dos 56 indivíduos, 36 eram do sexo masculino (64,3%) e a idade mediana era de 61,5 anos de idade (intervalo interquartil 57,5-70). A mediana do IMC dos participantes foi de 24,3 kg/m2 (intervalo interquartil 22,1 26,2). Esteatose microvesicular (p = 0,04), balonização hepatocelular (p = 0,02), fibrose (p = 0,0003) e esteato-hepatite (p = 0,03) foram significativamente mais frequentes no grupo de casos. As razões de chances para balonização hepatocelular (6,2; IC 95%: 1,2 - 31,8; p = 0,03), fibrose (9,3; IC 95%: 2,5 - 34,1; p = 0,0008) e esteato-hepatite (3,9; IC 95%: 1,1 - 14,3; p = 0,04) foram estatisticamente significativas em relação à prevalência de ACDP. Conclusões: houve associações significativas entre aspectos histopatológicos de DHGNA (esteatose microvesicular, balonização hepatocelular, fibrose e esteato-hepatite) e a ocorrência de ACDP.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

PANCREATICODUODENECTOMY WITH VENOUS RESECTION: AN ANALYSIS OF 30-DAY MORBIDITY AND MORTALITY.

BACKGROUND: Pancreaticoduodenectomy (PD) with the resection of venous structures adjacent to the pancreatic head, even in cases of extensive invasion, has been practiced in recent years, but its perioperative morbidity and mortality are not completely determined. OBJECTIVE: To describe the perioperative outcomes of PD with venous resections performed at a tertiary university hospital. METHODS: A retrospective study was conducted, classified as a historical cohort, enrolling 39 individuals which underwent PD with venous resection from 2000 through 2016. Preoperative demographic, clinical and anthropometric variables were assessed and the main outcomes studied were 30-day morbidity and mortality. RESULTS: The median age was 62.5 years (IQ 54-68); 55% were male. The main etiology identified was ductal adenocarcinoma of the pancreas (82.1%). In 51.3% of cases, the portal vein was resected; in 35.9%, the superior mesenteric vein was resected and in the other 12.8%, the splenomesenteric junction. Regarding the complications, 48.7% of the patients presented some type of morbidity in 30 days. None of the variables analyzed was associated with higher morbidity. Perioperative mortality was 15.4% (six patients). The group of individuals who died within 30 days presented significantly higher values for both ASA (P=0.003) and ECOG (P=0.001) scores. CONCLUSION: PD with venous resection for advanced pancreatic neoplasms is a feasible procedure, but associated with high rates of morbidity and mortality; higher ASA e ECOG scores were significantly associated with a higher 30-day mortality.

Duodenopancreatectomia com ressecção venosa: análise de morbidade e mortalidade em 30 dias / Pancreaticoduodenectomy with venous resection: an analysis of 30-day morbidity and mortality

ABSTRACT BACKGROUND: Pancreaticoduodenectomy (PD) with the resection of venous structures adjacent to the pancreatic head, even in cases of extensive invasion, has been practiced in recent years, but its perioperative morbidity and mortality are not completely determined. OBJECTIVE: To describe the perioperative outcomes of PD with venous resections performed at a tertiary university hospital. METHODS: A retrospective study was conducted, classified as a historical cohort, enrolling 39 individuals which underwent PD with venous resection from 2000 through 2016. Preoperative demographic, clinical and anthropometric variables were assessed and the main outcomes studied were 30-day morbidity and mortality. RESULTS: The median age was 62.5 years (IQ 54-68); 55% were male. The main etiology identified was ductal adenocarcinoma of the pancreas (82.1%). In 51.3% of cases, the portal vein was resected; in 35.9%, the superior mesenteric vein was resected and in the other 12.8%, the splenomesenteric junction. Regarding the complications, 48.7% of the patients presented some type of morbidity in 30 days. None of the variables analyzed was associated with higher morbidity. Perioperative mortality was 15.4% (six patients). The group of individuals who died within 30 days presented significantly higher values for both ASA (P=0.003) and ECOG (P=0.001) scores. CONCLUSION: PD with venous resection for advanced pancreatic neoplasms is a feasible procedure, but associated with high rates of morbidity and mortality; higher ASA e ECOG scores were significantly associated with a higher 30-day mortality.

RESUMO CONTEXTO: A duodenopancreatectomia (DP) com ressecção de estruturas venosas adjacentes à cabeça do pâncreas, mesmo em casos de invasão extensa, tem sido praticada nos últimos anos, mas sua morbidade e mortalidade perioperatórias não são completamente determinadas. OBJETIVO: Descrever os resultados perioperatórios de DP com ressecções venosas realizadas em um hospital terciário universitário. MÉTODOS: Foi realizado estudo retrospectivo, classificado como coorte histórica, envolvendo 39 indivíduos submetidos à DP com ressecção venosa entre 2000 e 2016. Foram estudadas variáveis demográficas, clínicas e antropométricas pré-operatórias e os desfechos principais foram a morbidade e mortalidade em 30 dias. RESULTADOS: A mediana de idade foi 62,5 anos (IQ 54-68), sendo 55% dos indivíduos do sexo masculino. A principal etiologia identificada foi o adenocarcinoma ductal de pâncreas (82,1%). Em 51,3% dos casos, a veia porta foi submetida à ressecção; em 35,9%, a veia mesentérica superior foi ressecada e nos outros 12,8%, a junção esplenomesentérica. Em relação às complicações, 48,7% dos pacientes apresentaram algum tipo de morbidade em 30 dias. Nenhuma das variáveis analisadas associou-se à maior morbidade. A mortalidade perioperatória foi 15,4% (seis pacientes). O grupo de indivíduos que cursou com mortalidade em 30 dias apresentou escores significativamente mais altos de ASA (P=0,003) e ECOG (P=0,001). CONCLUSÃO: A DP com ressecção venosa para neoplasias avançadas do pâncreas é um procedimento factível, porém que se acompanha de altos índices de morbidade e mortalidade; escores de ASA e ECOG altos são fatores significativamente associados à maior mortalidade.

PANCREATICODUODENECTOMY: IMPACT OF THE TECHNIQUE ON OPERATIVE OUTCOMES AND SURGICAL MORTALITY.

BACKGROUND: Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s. AIM: To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication. METHOD: Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication. RESULTS: Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001). CONCLUSION: There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study.

BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.