Surgery and Procedures for Nonalcoholic Steatohepatitis (NASH)

Nonalcoholic steatohepatitis (NASH) is a serious liver condition in which too much fat buildup in the liver leads to inflammation and liver damage. If left untreated, NASH can progress to advanced liver disease, liver cancer, cirrhosis, and liver failure.¹

Fortunately, some surgeries and procedures can help manage NASH and improve liver health. The 2 main procedures include:^1,2

• Weight loss surgery (bariatric surgery)
• Liver transplant

Weight loss surgery

Obesity is a big risk factor for developing NASH. For this reason, weight loss surgery (bariatric surgery) may be recommended for people with NAFLD or NASH who have obesity. Studies have shown that weight loss surgery can help:³

• Improve liver function
• Reduce inflammation
• Reduce fat buildup
• Keep liver disease from getting worse

Who is eligible for weight loss surgery?

Weight loss surgery is typically recommended for people who have severe obesity and have been unable to lose weight through diet and exercise alone. This usually means a person has to have a body mass index (BMI) over 40, or they must have a BMI of 35 in addition to a serious health problem like heart disease or diabetes.⁴

Candidates for weight loss surgery get a detailed evaluation and counseling before moving forward with this type of procedure. This is to make sure they understand the risks and benefits. It is also to ensure they are committed to making the necessary lifestyle changes after surgery for long-term success.⁴

What happens during weight loss surgery?

Weight loss surgery is designed to help people lose weight by changing the digestive process. There are several types of weight loss surgeries. They generally work by either restricting the amount of food the stomach can hold or by reducing the absorption of nutrients in the digestive tract. After weight loss surgery it is important to limit the amount of food you eat and follow the diet recommendations of your surgical team.^3,5

Several types of weight loss surgery may be used for those with NAFLD or NASH:^3,5

• Sleeve gastrectomy – The surgeon removes a large portion of the stomach, leaving behind a smaller, banana-shaped sleeve. This reduces the size of the stomach and limits the amount of food it can hold.
• Roux-en-Y gastric bypass – The surgeon creates a small pouch at the top of the stomach. They attach it directly to the small intestine, bypassing a portion of the stomach and the first section of the small intestine.
• Adjustable gastric banding – The surgeon places a silicone band around the upper part of the stomach to create a small pouch.

Liver transplant

In severe cases of NASH where the liver is severely damaged and not responding to other treatments, a liver transplant may be necessary. Recent data show that NASH and nonalcoholic fatty liver disease (NAFLD) are the 2 leading causes of liver transplants in the United States.¹

Who is eligible for a liver transplant?

Liver transplants are reserved for people whose liver no longer works well enough to keep them alive. A liver transplant is for those with cirrhosis and who are now developing symptoms of liver disease and have not responded to other NASH treatments.^1,2

To be eligible for a liver transplant, you must undergo a thorough evaluation by a transplant team of doctors and specialists. Your team will take the following things into account when deciding whether a liver transplant is right for you:^1,2

• Overall physical health
• Severity of liver disease
• Stage of NASH
• Emotional and mental health
• Willingness to stick to post-transplant care, which includes taking post-transplant medicines and leading a healthy lifestyle
• History of alcohol misuse

What happens during a liver transplant?

A liver transplant is a major surgical operation. During a liver transplant, a surgeon replaces the diseased liver with a healthy liver. This healthy liver can come from either a deceased or living donor.²

After the surgery, there is a risk that the body will reject the new liver. To prevent liver rejection, a transplant recipient must take immunosuppressive medicines for the rest of their life.²

People who get a liver transplant have a higher risk of post-transplant infections and life-threatening heart events like cardiac arrest. It is crucial to be closely monitored and get regular medical checkups. Maintaining a healthy lifestyle and taking immunosuppressive drugs as prescribed are 2 key parts of liver transplant success.¹

What is the process of receiving a liver transplant?

If you meet the above criteria and are deemed eligible for a transplant, you will be placed on the national transplant waiting list. In the United States, this list is maintained by the United Network for Organ Sharing (UNOS). UNOS prioritizes people based on factors such as:²

• Severity of illness
• Blood type
• Body size
• Time spent waiting

Once you are on the list, you must wait for a suitable donor liver to become available. The wait time can vary widely depending on factors such as:²

• Your medical condition
• Blood type
• Availability of donor organs

Each time a new liver becomes available, it is matched to a recipient based on compatibility issues such as blood type, tissue type, and organ size. The transplant center will notify you when it has matched you with a liver. Your transplant procedure is then scheduled.²

The process of waiting for a liver donation can be challenging and uncertain. You may need to undergo regular medical monitoring and may have changes to your health while waiting for a transplant. Talk with your transplant team and follow their recommendations for managing your condition while you are on the waiting list. Support from family, friends, and support groups can be helpful during this waiting period.²

Questions to ask your doctor about NASH procedures

If you or a loved one is exploring treatment options for NASH, here are some important questions to discuss with your healthcare provider:^2,4

• What are the risks and benefits of each treatment option for NASH?
• Am I a candidate for a liver transplant or weight loss surgery?
• Who is eligible for liver transplant and weight loss surgery?
• Are there any other treatments or procedures that I should consider?
• What lifestyle changes can I make to improve my liver health and manage NASH?
• Are there any clinical trials or research studies available for NASH treatment?
• What are the expected outcomes and long-term prognosis for NASH treatment?

Communicate openly with your healthcare team so you can make informed decisions about your NASH treatment plan. Be sure to discuss any concerns or questions you may have about managing NASH.