Background

Lipid accumulation within hepatocytes can lead to cellular damage, necrosis and ultimately hepatic fibrosis, and is closely related to metabolic syndrome. Previously believed to be quite rare in adolescents, occult hepatic fibrosis has been increasingly identified in young patients with severe obesity.

Methods

Retrospective review of a prospectively collected registry of all patients undergoing sleeve gastrectomy at an academic children's hospital. Before sleeve gastrectomy, a standardized protocol was used to determine which patients would receive selective liver biopsy, including ultrasound presence of steatosis and ALT>22 U/L (in females) or >26 U/L (in males).Results:Of 148 patients undergoing sleeve gastrectomy, 52 underwent liver biopsy, either intraoperatively or during their preoperative workup. Of these, 51.9% (n=27) had evidence of fibrosis. In patients with fibrosis, 51.9% were stage I, 37.0% were stage II, and 11.1% were stage IV. Patients with fibrosis were significantly more likely diabetic (p=0.005), male (p=0.032), and not black or African American (p=0.008).

Results

In adolescents pursuing bariatric surgery at our institution, 18.2% had some degree of hepatic fibrosis, despite often having minimal laboratory or ultrasound findings. Our standardized protocol for selective liver biopsy had a pre-test probability of 51.9%. These findings suggest an imperative for earlier screening in adolescents with obesity to identify hepatic fibrosis and intervene medically or surgically before advanced fibrosis occurs. Adolescents with hepatic fibrosis require hepatology consultation for monitoring with counseling to avoid hepatotoxins, and ongoing multidisciplinary weight management intervention to prevent weight regain following surgery.