Bariatric Surgery Versus Non-alcoholic Steato-hepatitis
Condition: Non Alcoholic Steatohepatitis
MeSH terms: Fatty Liver; Non-alcoholic Fatty Liver Disease
Study type: Interventional

Summary: 
      Bariatric-metabolic surgery is effective in treating the cluster of conditions forming the
      metabolic syndrome, strictly associated with NAFLD and NASH. Recently, we and other authors
      have shown also in the long term (up 5 years) with randomized-controlled trials (RCTs) that
      bariatric-metabolic surgery allows remission of type 2 diabetes and obesity reduction, which
      are the two major pathogenetic factors of NASH development, with maintenance of weight loss.

      Few small and mainly retrospective studies have shown that bariatric surgery is effective in
      improving NASH histologic picture in obese subjects.

      The aim of our proposal is to conduct a 3 arm single centre, superiority, RCT comparing
      Roux-en-Y Gastric Bypass (RYGB) with Sleeve Gastrectomy (SG) and with Intensive Lifestyle
      Modifications (ILM) for the treatment of Non-Alcoholic Steato-Hepatitis.
    

Detailed description: 
      This is a Randomized Controlled multicentre Trial involving the Catholic University
      (Professor Geltrude Mingrone as PI and Professor Marco Raffaelli as co-PI)

      The research question in PICOT format (P) - Population: Adults 25 to 70 years of age and BMI
      ≥ 30 and ≤55 kg/m2 with histological diagnosis of NASH.

      (I) - Intervention: Roux-en-Y Gastric Bypass or Sleeve Gastrectomy, both plus lifestyle
      counseling.

      (C) - Comparison: Intensive Lifestyle Modifications. (O) - Outcome: the histological
      resolution of NASH without worsening of fibrosis at 1 year after the interventions.

      (T) - Time: One year after the intervention started.

      1.3.3.2 Research Goals

        -  The primary aim of our study is to assess the effects of bariatric-metabolic surgery or
           ILM on NASH at 1 year after the interventions.

        -  Secondary aims are to assess the safety of bariatric surgery and the improvement of at
           least 1 stage of liver fibrosis without worsening of NASH, insulin sensitivity , T2DM,
           and lipoprotein profile changes.

      The liver biopsy will be performed at baseline and at 1 year follow-up. Another liver biopsy
      will be performed at 3 and 5 years follow-up.
    

Intervention name(s): RYGB; SG; Intensive Lifestyle Modification
Intervention type(s): Procedure; Procedure; Other
Intervention description(s): Roux-&-Y Gastric Bypass (RYGB) involves the use of a surgical stapler to create a small and vertically oriented gastric pouch with a volume of 30 ml. The upper pouch is completely divided by the gastric remnant and is anastomosed to the jejunum, 75 cm distally to the Treitz's ligament , through a narrow gastrojejunal anastomosis in a Roux-en-Y fashion. Bowel continuity is restored by an entero-entero anastomosis, between the excluded biliary limb and the alimentary limb, performed at 100 cm from the gastrojejunostomy. Lifestyle modification counselling is provided to each patient.; The SG is created using a linear stapler with two sequential 4.8/60-mm green load firings for the antrum, followed by two or three sequential 3.5/60-mm blue loads for the remaining gastric corpus and fundus. The stapler is applied alongside a 48-Fr calibrating bougie. The resection line is performed avoiding the ''critical area'' by resecting the fundus 1.5 cm from the angle of His. Staple lines are buttressed with bovine pericardial strips. The resected stomach is grasped at the antral tip by a laparoscopic grasper and retrieved through one of the trocar sites. A methylene blue dye test by a nasogastric tube is routinely performed at the end of the procedure. The residual gastric remnant capacity is 60-80 ml. Drains are not routinely placed, and the nasogastric tube is removed at the end of the procedure. Upper gastrointestinal contrast (Gastrografin) study is performed on the first postoperative day. Lifestyle modification counselling is provided to each patient.; Resting calorie requirements will be calculated via the Harris Benedict equation (24) and an activity factor, and subjects will be instructed not to change their activity level other than that suggested by physicians during the study. The diet will contain 1/3 kcal less than the calculated energy expenditure and 30% fat of which 10% saturated, 55% lower glycemic index carbohydrates and 15% proteins.
The participants will be encouraged to gradually increase their walking to achieve 10,000 steps per day. A moderate intensity physical activity program of 1 hour of aerobic exercise 2-3 hours per week will be recommended to all subjects. Their physical activity will be assessed by IPAQ-SF.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment