Silverman E M, Sapala J A, Appelman H D
Department of Pathology, University of Michigan, Ann Arbor 48109-0602, USA.
Am J Clin Pathol. 1995 Jul;104(1):23-31. doi: 10.1093/ajcp/104.1.23.
Morbid obesity has been associated with hepatic steatosis and occasional cirrhosis. Despite producing weight loss, intestinal bypass procedures formerly performed to correct morbid obesity, often worsened steatosis and fibrosis, and occasionally resulted in hepatic failure. Current surgical procedures of choice for morbid obesity involve gastric bypass with gastrojejunostomy. Ninety-one liver biopsies taken at the time of gastric bypass for morbid obesity (mean body weight 125.8 kg), and 106 biopsies taken from the same patients from 2 to 61 months later (mean body weight 89.4 kg) were studied. Steatosis and perisinusoidal fibrosis were assessed in histologic sections. Serum albumin, alkaline phosphatase, aspartate aminotransferase (AST), and total bilirubin levels were measured before most biopsies were taken. Both pre- and post-gastric bypass hepatic steatosis varied directly with body weight (r = .5231, P < .001). Steatosis varied inversely with length of time after gastric bypass (r = .4590, P < .001). Of the original biopsies, 37% had lipid vacuoles in at least 26% of hepatocytes. After gastric bypass, 65 patients had reduced steatosis, 18 patients with no steatosis, and 5 patients with minimal steatosis had no change, and 3 patients had increased steatosis. Pre-gastric bypass biopsies from 13 patients had perisinusoidal fibrosis (PSF) that was marked with bridging in three patients, was moderate in one patient, and slight in nine patients. Following gastric bypass, PSF was eliminated in 10 patients, reduced in one patient, and the same in two patients. One patient developed PSF after gastric bypass. Of the three patients who had undergone previous intestinal bypass procedures, two had slight PSF in the biopsies taken at the time of gastric bypass, and one of these had slight PSF in the follow-up biopsy. Serum biochemical abnormalities tended to be slight. Before gastric bypass, serum albumin was low in 11% of cases, alkaline phosphatase was high in 14% of cases, AST was high in 11% of cases, and total bilirubin was high in 1% of cases. After gastric bypass, there was a small reduction in mean serum albumin from 43 g/L before to 41 g/L afterward (P < .05), and a slight rise in mean total bilirubin from 7.0 mumol/L before to 9.6 mu mol/L afterward (P < .01). Most hepatic fatty change and probably some PSF occurring in morbidly obese persons is reduced or eliminated with weight loss following gastric bypass surgery.
病态肥胖与肝脂肪变性及偶发的肝硬化有关。尽管以往用于矫正病态肥胖的肠道分流手术能减轻体重，但常常会使脂肪变性和纤维化恶化，偶尔还会导致肝衰竭。目前治疗病态肥胖的首选外科手术是胃旁路加胃空肠吻合术。对91例因病态肥胖接受胃旁路手术时进行的肝活检（平均体重125.8千克）以及106例在术后2至61个月从同一患者身上获取的活检（平均体重89.4千克）进行了研究。在组织学切片中评估脂肪变性和窦周纤维化情况。在大多数活检前测量血清白蛋白、碱性磷酸酶、天冬氨酸转氨酶（AST）和总胆红素水平。胃旁路手术前后的肝脂肪变性均与体重呈正相关（r = 0.5231，P < 0.001）。脂肪变性与胃旁路手术后的时间长度呈负相关（r = 0.4590，P < 0.001）。在最初的活检中，37%的样本至少26%的肝细胞中有脂质空泡。胃旁路手术后，65例患者的脂肪变性减轻，18例无脂肪变性，5例脂肪变性轻微的患者无变化，3例患者脂肪变性加重。13例患者胃旁路手术前的活检存在窦周纤维化（PSF），其中3例有桥接，1例为中度，9例为轻度。胃旁路手术后，10例患者的PSF消失，1例减轻，2例不变。1例患者胃旁路手术后出现PSF。在之前接受过肠道分流手术的3例患者中，2例在胃旁路手术时的活检有轻微PSF，其中1例在随访活检中仍有轻微PSF。血清生化异常往往较轻。胃旁路手术前，11%的病例血清白蛋白低，14%的病例碱性磷酸酶高，11%的病例AST高，1%的病例总胆红素高。胃旁路手术后，血清白蛋白均值从术前的43克/升略有下降至术后的41克/升（P < 0.05），总胆红素均值从术前的7.0微摩尔/升略有上升至术后的9.6微摩尔/升（P < 0.01）。胃旁路手术后体重减轻，大多数病态肥胖者出现的肝脂肪变以及可能的一些PSF会减轻或消除。
