Improved Metabolic Parameters Achievable / Surgery for Obesity and Related Diseases 11 (2015) 442–450 [19] Sartorio A, Del Col A, Agosti F, et al. Predictors of non-alcoholic fatty liver disease in obese children. Eur J Clin Nutr 2007;61: 877–83. [20] Schwimmer JB, Deutsch R, Kahen T, et al. Prevalence of fatty liver in children and adolescents. Pediatrics 2006;118:1388–93. [21] Fraser A, Longnecker MP, Lawlor DA. Prevalence of elevated alanine aminotransferase among US adolescents and associated factors: NHANES 1999-2004. Gastroenterology 2007;133: 1814–20. [22] Park HS, Han JH, Choi KM, Kim SM. Relation between elevated serum alanine aminotransferase and metabolic syndrome in Korean adolescents. Am J Clin Nutr 2005;82:1046–51. [23] Imhof A, Kratzer W, Boehm B, et al. Prevalence of non-alcoholic fatty liver and characteristics in overweight adolescents in the general population. Eur J Epidemiol 2007;22:889–97. [24] Zhou YJ, Li YY, Nie YQ, et al. Prevalence of fatty liver disease and its risk factors in the population of South China. World J Gastroenterol 2007;13:6419–24.

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[25] Tominaga K, Fujimoto E, Suzuki K, Hayashi M, Ichikawa M, Inaba Y. Prevalence of non-alcoholic fatty liver disease in children and relationship to metabolic syndrome, insulin resistance, and waist circumference. Environ Health Prev Med 2009;14:142–9. [26] Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Radiology 1991;178:253–8. [27] Angulo P, Hui JM, Marchesini G, et al. The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD. Hepatology 2007;45:846–54. [28] Zimmet P, Alberti KG, Kaufman F, et al. The metabolic syndrome in children and adolescents—an IDF consensus report. Pediatr Diabetes 2007;8:299–306. [29] Lee Y, Shin H, Vassy JL, et al. Comparison of regional body composition and its relation with cardiometabolic risk between BMImatched young and old subjects. Atherosclerosis 2012;224:258–65. [30] Kang SM, Yoon JW, Ahn HY, et al. Android fat depot is more closely associated with metabolic syndrome than abdominal visceral fat in elderly people. PLoS One 2011;6:27694.

Editorial comment

Bariatric surgery for nonalcoholic fatty liver disease in adolescents with severe obesity Nonalcoholic fatty liver disease (NAFLD) is defined as excess liver fat infiltration (greater than 5% on liver biopsy), in the absence of excessive alcohol intake or viral, autoimmune, or drug-induced liver disease, and is found in approximately 70% of adults with severe obesity (body mass index (BMI) Z35 kg/m2) [1]. While steatosis may be a relatively benign finding in and of itself, it may advance to Nonalcoholic Steatohepatitis (NASH), cirrhosis, and hepatocarcinoma. NASH is observed in 30% of individuals with NAFLD and is characterized by the presence, on liver biopsy, of necroinflammation with variable amounts of fibrosis in addition to steatosis [2]. An important concept links metabolic diseases, such as type 2 diabetes, to the risk of progression of NAFLD to NASH; i.e., individuals with NAFLD that have metabolic diseases are at particularly high risk for progression to NASH [3,4]. Nowadays, NAFLD is the most common cause of chronic liver disease in the pediatric population and association to obesity, metabolic diseases, and progression to NASH and cirrhosis follows the same pattern that is observed in the adult population [5]. The mainstay treatment for NAFLD and NASH is weight loss, and few bariatric surgery cohort studies in adults with biopsy proven NAFLD or NASH have documented by repeated liver biopsy that bariatric surgery can significantly improve NAFLD and NASH [6]. Of note, an important recent study from France [7], in which adults with severe obesity and biopsy proven NAFLD and NASH had liver biopsies at 5 years of follow-up after Roux-en-Y gastric bypass (RYGB) (n ¼ 681) or

laparoscopic adjustable gastric banding (LAGB) (n ¼ 555), has shown that RYGB patients had superior weight loss (total weight loss: 25.5% after RYGB versus 21.4% after LAGB, P o .001) and significantly superior improvement in all NAFLD/NASH histologic and biochemical parameters. In this issue of SOARD, Loy and colleagues [8] reported 2 year outcomes of LAGB in 56 adolescents that were suspected to have abnormal liver fat content either by ultrasound (93%), elevated serum AST or ALT (4%) or both (32%). Reported outcomes in Loy’s study were 45.7% average excess weight loss, a significant decreased in the “NAFLD Fibrosis Score” and other significant changes in waist measures, systolic blood pressure, serum insulin, triglycerides, and HDL. This report is a significant addition to the sparse literature on outcomes of bariatric surgery in the adolescent population, and shows very good 2-year weight loss results with the use of the LAGB. However, while the study attempts to address the important topic of NAFLD resolution with bariatric surgery in the pediatric population, its methodological limitations prevent it from doing it directly. Main reasons are the absence of histologic confirmation of NAFLD by liver biopsies and that the “NAFLD Fibrosis Score” [9–11] (used to draw inferences about changes in NAFLD in the study) was designed and validated solely to help stratify risk for hepatic fibrosis in those suspected of having NFALD (thus to consider offering these patients a liver biopsy), but not to measure longitudinal changes in NALFD. Despite these limitations, the study findings

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documents that adolescents with severe obesity can be treated safely with LAGB and obtain short-term, significant weight loss and metabolic benefits in the setting where it was studied. Two important questions remain: First, would the poorer, longer term outcomes of LAGB in adult patients from many other US and European series with high rate of reoperations, device related complications, and sub-optimal weight loss [12,13] also be the fate of these adolescents as they are followed longer into their adult lives? Second, would any of the other bariatric surgical techniques provide for a more effective treatment of NAFLD/NASH in adolescents? The first question can be answered by following these LAGB patients longer; the second can be answered with an effort from the pediatric bariatric surgical community in properly designing and conducting comparative studies. Guilherme M. Campos, M.D., Section of MIS and Bariatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health David A. Lanning, M.D., Ph.D. Division of Pediatric Surgery, Department of Surgery, Children’s Hospital of Richmond, Virginia Commonwealth University References [1] Ray K. NAFLD-the next global epidemic. Nat Rev Gastroenterol Hepatol 2013;10:621.

[2] Brunt EM, Kleiner DE, Wilson LA, Belt P, Neuschwander-Tetri BA. Network NCR. Nonalcoholic fatty liver disease (NAFLD) activity score and the histopathologic diagnosis in NAFLD: distinct clinicopathologic meanings. Hepatology 2011;53:810–20. [3] Anstee QM, Targher G, Day CP. Progression of NAFLD to diabetes mellitus, cardiovascular disease or cirrhosis. Nat Rev Gastroenterol Hepatol 2013;10:330–44. [4] Campos GM, Bambha K, Vittinghoff E, et al. A clinical scoring system for predicting nonalcoholic steatohepatitis in morbidly obese patients. Hepatology 2008;47:1916–23. [5] Bozic MA, Subbarao G, Molleston JP. Pediatric nonalcoholic fatty liver disease. Nutr Clin Pract 2013;28:448–58. [6] Rabl C, Campos GM. The impact of bariatric surgery on nonalcoholic steatohepatitis. Semin Liver Dis 2012;32:80–91. [7] Caiazzo R, Lassailly G, Leteurtre E, et al. Roux-en-Y Gastric Bypass Versus Adjustable Gastric Banding to Reduce Nonalcoholic Fatty Liver Disease: A 5-Year Controlled Longitudinal Study. Ann Surg 2014;260:893–9. [8] Loy JJ, Youn HA, Schwack B, Kurian MS, Ren-Fielding CJ, Fielding GA. Improvement in Non Alcoholic Fatty Liver Disease and Metabolic Syndrome in Adolescents Undergoing Bariatric Surgery. Surg Obes Relat Dis 2015;11(2):452–9. [9] Treeprasertsuk S, Bjornsson E, Enders F, Suwanwalaikorn S, Lindor KD. NAFLD fibrosis score: a prognostic predictor for mortality and liver complications among NAFLD patients. World J Gastroenterol 2013;19:1219–29. [10] Torres DM, Harrison SA. NAFLD: Predictive value of ALT levels for NASH and advanced fibrosis. Nat Rev Gastroenterol Hepatol 2013;10:510–1. [11] Sowa JP, Heider D, Bechmann LP, Gerken G, Hoffmann D, Canbay A. Novel algorithm for non-invasive assessment of fibrosis in NAFLD. PloS one 2013;8:e62439. [12] Himpens J, Cadiere GB, Bazi M, Vouche M, Cadiere B, Dapri G. Long-term outcomes of laparoscopic adjustable gastric banding. Arch Surg 2011;146:802–7. [13] Kindel T, Martin E, Hungness E, Nagle A. High failure rate of the laparoscopic-adjustable gastric band as a primary bariatric procedure. Surg Obes Relat Dis 2014;10:1070–5.

Bariatric surgery for nonalcoholic fatty liver disease in adolescents with severe obesity.

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