Benefit–risk of intraoperative liver biopsy during bariatric surgery: review and perspectives

Abstract Nonalcoholic fatty liver disease (NAFLD) is a metabolic complication of obesity that encompasses a spectrum of conditions, including hepatic steatosis, nonalcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver disease. Screening for NAFLD is important to limit progression, allow early detection of carcinoma, and follow the need for liver transplantation. Although noninvasive markers exist, hepatic histologic evaluation remains the gold standard for diagnosis. To reduce the risk of complications after liver biopsy but increase the accuracy of NAFLD diagnosis, hepatic tissue can be sampled during bariatric surgery. This practice raises the question whether liver biopsies should be systematically carried out intraoperatively to screen for NAFLD or limited to patients who have positive results for noninvasive markers of NASH. The aim of this systematic review was to determine the prevalence of NASH in patients with obesity undergoing bariatric surgery, the performance of noninvasive markers of NASH and complications of intraoperative liver biopsy. Meta-analysis found an overall NASH prevalence of .25 (95% confidence interval, .12–.39), with a high level of heterogeneity (I2 = 97%) across studies. The review showed that each noninvasive marker alone was unable to discriminate between patients with a normal liver and others. Conversely, intraoperative biopsy was related to some complications. Results from a clinical practices questionnaire in specialized centers for obesity care in France showed a large degree of heterogeneity. A prospective study would be interesting to evaluate an algorithm based on noninvasive markers for clinical decision making to determine the pertinence of liver biopsy during bariatric surgery.