Role of ursodeoxycholic acid in the prevention of gallstone formation after laparoscopic sleeve gastrectomy

Strain-dependent induction of primary bile acid 7-dehydroxylation by cholic acid

BACKGROUND

Bile acids (BAs) are steroid-derived molecules with important roles in digestion, the maintenance of host metabolism, and immunomodulation. Primary BAs are synthesized by the host, while secondary BAs are produced by the gut microbiome through transformation of the former. The regulation of microbial production of secondary BAs is not well understood, particularly the production of 7-dehydroxylated BAs, which are the most potent agonists for host BA receptors. The 7-dehydroxylation of cholic acid (CA) is well established and is linked to the expression of a bile acid-inducible (bai) operon responsible for this process. However, little to no 7-dehydroxylation has been reported for other host-derived BAs (e.g., chenodeoxycholic acid, CDCA or ursodeoxycholic acid, UDCA).

RESULTS

Here, we demonstrate that the 7-dehydroxylation of CDCA and UDCA by the human isolate Clostridium scindens is induced when CA is present, suggesting that CA-dependent transcriptional regulation is required for substantial 7-dehydroxylation of these primary BAs. This is supported by the finding that UDCA alone does not promote expression of bai genes. CDCA upregulates expression of the bai genes but the expression is greater when CA is present. In contrast, the murine isolate Extibacter muris exhibits a distinct response; CA did not induce significant 7-dehydroxylation of primary BAs, whereas BA 7-dehydroxylation was promoted upon addition of germ-free mouse cecal content in vitro. However, E. muris was found to 7-dehydroxylate in vivo.

CONCLUSIONS

The distinct expression responses amongst strains indicate that bai genes are regulated differently. CA promoted bai operon gene expression and the 7-dehydroxylating activity in C. scindens strains. Conversely, the in vitro activity of E. muris was promoted only after the addition of cecal content and the isolate did not alter bai gene expression in response to CA. The accessory gene baiJ was only upregulated in the C. scindens ATCC 35704 strain, implying mechanistic differences amongst isolates. Interestingly, the human-derived C. scindens strains were also capable of 7-dehydroxylating murine bile acids (muricholic acids) to a limited extent. This study shows novel 7-dehydroxylation activity in vitro resulting from the presence of CA and suggests distinct bai gene expression across bacterial species.

Long-term systemic effects of metabolic bariatric surgery: A multidisciplinary perspective

Background

Obesity is a global health crisis with profound implications on various body systems, contributing to a series of comorbidities. Metabolic Bariatric Surgery (MBS) has emerged as an effective treatment option for severe obesity, with significant weight reduction and potential systemic physiological alterations.

Objectives

This narrative review aims to provide a comprehensive analysis of the long-term effects of MBS on a wide array of body systems, including the heart, liver, kidneys, reproductive system, skin, lungs, digestive tract, pancreas, and blood, as well as related cancers of these organs.

Methods

A systematic search was conducted in academic databases (PubMed, ISI Web of Science, and Scopus) for observational studies and reviews published between July 2000 and December 2023, investigating the association between MBS and the subsequent function of different organ systems. High-quality studies were prioritized to ensure reliable evidence synthesis.

Results

MBS has demonstrated favorable outcomes in reducing cardiovascular disease risk, improving cardiac function, and alleviating heart failure symptoms. It has also been associated with improved respiratory function, remission of obstructive sleep apnea, and reduced cancer incidence and mortality. Additionally, MBS has shown benefits in managing gastrointestinal disorders, enhancing glycemic control, and promoting pancreatic beta-cell regeneration in type 2 diabetes mellitus. However, some methods of MBS are associated with a higher risk of cholelithiasis, GERD, and pancreatic exocrine insufficiency.

Conclusion

MBS has far-reaching systemic effects beyond weight loss, offering potential long-term benefits for various organ systems and comorbidities associated with obesity. For many patients with severe obesity, the potential benefits of Metabolic and Bariatric Surgery (MBS) can outweigh the associated risks. However, careful evaluation by a qualified healthcare professional is crucial to determine candidacy and ensure a successful outcome. Further research is needed to fully elucidate the long-term impacts and tailor personalized treatment approaches.

Ursodiol Prescriptions Following Bariatric Surgery: National Prescribing Trends and Outcomes

BACKGROUND

Rapid weight loss after bariatric surgery is a risk factor for gallstone development. Numerous studies have shown that ursodiol after surgery decreases rates of gallstone formation and cholecystitis. Real-world prescribing practices are unknown. This study aimed to examine prescription patterns for ursodiol and reassess its impact on gallstone disease using a large administrative database.

METHODS

The Mariner database (PearlDiver, Inc.) was queried using Current Procedural Terminology codes for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2011 and 2020. Only patients with International Classification of Disease codes for obesity were included. Patients with pre-operative gallstone disease were excluded. The primary outcome was gallstone disease within 1 year, which was compared between patients who did and did not receive an ursodiol prescription. Prescription patterns were also analyzed.

RESULTS

Three hundred sixty-five thousand five hundred patients fulfilled inclusion criteria. Twenty-eight thousand seventy-five (7.7%) patients were prescribed ursodiol. There was a statistically significant difference in development of gallstones (p < 0.001), development of cholecystitis (p = .049), and undergoing cholecystectomy (p < 0.001). There was a statistically significant decrease in the adjusted odds ratio (aOR) for the development of gallstones (aOR 0.81, 95% CI: 0.74, 0.89), development of cholecystitis (aOR 0.59, 95% CI: 0.36, 0.91), and undergoing cholecystectomy (aOR 0.75, 95% CI: 0.69, 0.81).

CONCLUSION

Ursodiol significantly decreases the odds of development of gallstones, cholecystitis, or cholecystectomy within 1 year following bariatric surgery. These trends hold true when analyzing RYGB and SG separately. Despite the benefit of ursodiol, only 10% of patients received an ursodiol prescription postoperatively in 2020.

Incidence and risk factors for cholelithiasis after bariatric surgery: a systematic review and meta-analysis

BACKGROUND

Obesity has been identified as an independent risk factor for cholelithiasis. As a treatment for obesity, bariatric surgery may increase the incidence of cholelithiasis. The risk factors for cholelithiasis after bariatric surgery remain uncertain. The purpose of this study was to explore the risk factors for postoperative cholelithiasis after weight-loss surgery and propose suggestions for clinical decision making.

METHODS

Four databases, PubMed, EMBASE, Web of Science and Cochrane, were systematically searched for all reports about cholelithiasis after bariatric surgery, and literature screening was performed following prespecified inclusion criteria. The included studies were all evaluated for quality according to the NOS scale. Data extraction was followed by analysis using Reviewer Manager 5.4 and StataSE 15.

RESULTS

A total of 19 articles were included in this meta-analysis, and all studies were of high quality. A total of 20,553 patients were included in this study. Sex [OR = 0.62, 95% CI (0.55, 0.71), P < 0.00001] and race [OR = 1.62, 95% CI (1.19, 2.19), P = 0.002] were risk factors for cholelithiasis after bariatric surgery. Surgical procedure, preoperative BMI, weight-loss ratio, smoking, hypertension, diabetes mellitus, and dyslipidemia were neither protective nor risk factors for cholelithiasis after bariatric surgery.

CONCLUSION

Caucasian race and female sex are risk factors for developing cholelithiasis after bariatric surgery; surgical procedure, BMI, weight loss ratio, hypertension, diabetes mellitus, dyslipidemia, and smoking are not risk factors for cholelithiasis after bariatric surgery.

Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures

Obesity by itself is a factor in the development of gallstone disease, and periods of weight loss after bariatric surgery further increase the risk of gallstone formation. In patients with obesity, hypersecretion of cholesterol may increase the risk of gallstone formation, which is approximately five-fold higher than that in the general population. The incidence of gallstone formation after bariatric surgery is 10-38% and often associated with a proportional increase in the risk of developing biliary complications. Routine postoperative administration of ursodeoxycholic acid (UDCA) is recommended to prevent gallstone formation. Several randomized trials have indicated that UDCA can effectively prevent gallstones and reduce the risk of cholecystectomy after bariatric procedures. The effective daily dose of UDCA in each study ranged from 500 to 1,200 mg, and it may be considered at least during the period of rapid weight loss (first 3-6 months postoperatively) to decrease the incidence of symptomatic gallstones.

Ursodeoxycholic acid for the prevention of gall stones after laparoscopic sleeve gastrectomy: a prospective controlled study

BACKGROUND

Obesity is a risk factor for cholelithiasis. Besides, rapid weight loss after bariatric surgery upsurges the rate of cholelithiasis and acute cholecystitis. This study aimed to compare gallstone development frequency after LSG under ursodeoxycholic acid (UDCA) prophylaxis.

METHODS

This prospective controlled study included 332 patients scheduled for LSG randomized to receive 500 mg UDCA daily for 12 months (UDCA Group) or no treatment (Control Group). Ultrasonography was done 6 and 12 months after surgery to detect gallstones. Cholecystectomy was done for complicated cases of cholelithiasis.

RESULTS

Seventy-one patients were lost to follow-up, and 3 developed severe adverse effects of UDCA and excluded. Data are presented for 130 patients in the UDCA group and 128 in the Control group. Collectively, 11 patients (8.5%) of the UDCA group and 41 (32.0%) of the Control group developed gall stones during the first postoperative year (p < 0.001). Cholecystectomy was indicated in 3 patients (2.3%) of the UDCA group and 9 (7.0%) of the Control group (p = 0.072). On multivariate analysis, higher BMI, dyslipidemia, and lacking UDCA prophylaxis were the independent factors significantly associated with stone development. Also, stone development was associated with higher weight loss after 6 and 12 months.

CONCLUSION

UDCA 500 mg once daily for 12 months after LSG is effective in reducing gallstone formation at 1 year. UDCA administration reduced the frequency of cholecystectomies from 7 to 2.3%. High BMI and dyslipidemia are the independent preoperative factors significantly associated with stone development.

Ursodeoxycholic acid for the prevention of gallstones and subsequent cholecystectomy after bariatric surgery: a meta-analysis of randomized controlled trials

BACKGROUND

This meta-analysis aimed to compare the incidence of gallstone formation, subsequent biliary disease and the need for cholecystectomy in untreated patients and patients treated with ursodeoxycholic acid (UDCA) following bariatric surgery.

METHODS

Randomized controlled trials (RCTs) comparing UDCA and controls for the prevention of gallstone formation after bariatric surgery published until February 2022 were selected and subjected to a systematic review and meta-analysis. Articles were searched in the MEDLINE, Web of Science and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Eleven randomized controlled studies were included, with a total of 2363 randomized patients and 2217 patients analysed in the UDCA group versus 1415 randomized patients and 1257 patients analysed in the control group. Considering analysed patients, prophylactic use of UDCA was significantly associated with decreased (i) gallstone formation (OR = 0.25, 95% CI = 0.21-0.31), (ii) symptomatic gallstone disease (GD) (OR = 0.29, 95% CI = 0.20-0.42) and consequently (iii) cholecystectomy rate (OR = 0.33, 95% CI = 0.20-0.55). The results were similar in ITT analysis, in the subgroup of patients undergoing sleeve gastrectomy or considering only randomized versus placebo studies.

CONCLUSIONS

Prophylactic use of UDCA after bariatric surgery prevents both gallstone formation and symptomatic GD and reduces the need for cholecystectomy.

Effect of ursodeoxycholic acid on gallstone formation after bariatric surgery: An updated meta-analysis

OBJECTIVE

Bariatric surgery increases the risk of postoperative gallstone formation. Many studies have proposed ursodeoxycholic acid (UDCA) as a preventive agent for postoperative gallstone formation. This study aimed to investigate the effect of UDCA on gallstone formation after bariatric surgery in patients without preoperative gallstones.

METHODS

PubMed, the Web of Science, the Cochrane Library, and EBSCO were searched for articles assessing the effect of UDCA on gallstone formation after bariatric surgery. The outcome was the incidence of postoperative gallstones. Odds ratios were used to assess dichotomous variables, and random-effects models were used for statistical analyses.

RESULTS

A total of 18 studies including 4,827 participants met the inclusion criteria. The statistical results showed that the incidence of gallstones in the UDCA group was significantly lower than in the control group. Furthermore, the occurrence of symptomatic gallstones and cholecystectomy was significantly reduced.

CONCLUSIONS

In patients without preoperative gallstones, UDCA can effectively prevent the formation of gallstones after bariatric surgery. In addition, UDCA can significantly reduce the occurrence of symptomatic gallstones and the risk of postoperative cholecystectomy. Doses of 500 to 600 mg/d can be used as a measure to prevent postoperative gallstone formation.

Risk Factors for Symptomatic Gallstone Disease and Gallstone Formation After Bariatric Surgery

PURPOSE

Patients who undergo bariatric surgery are at risk for developing cholesterol gallstones. We aimed to identify risk factors that are associated with symptomatic gallstone disease and gallstone formation after bariatric surgery.

MATERIALS AND METHODS

We included participants of the UPGRADE trial, a multicenter randomized placebo-controlled trial on the prevention of symptomatic gallstone disease with ursodeoxycholic acid (UDCA) after bariatric surgery. The association between patient characteristics and symptomatic gallstone disease, and gallstone formation was evaluated using logistic regression analysis.

RESULTS

Of 959 patients, 78 (8%) developed symptomatic gallstone disease within 24 months. Risk factors were the presence of a pain syndrome (OR 2.07; 95% CI 1.03 to 4.17) and asymptomatic gallstones before surgery (OR 3.15; 95% CI 1.87 to 5.33). Advanced age (OR 0.95; 95% CI 0.93 to 0.97) was protective, and UDCA prophylaxis did not reach statistical significance (OR 0.64; 95% CI 0.39 to 1.03). No risk factors were identified for gallstone formation, whereas advanced age (OR 0.98; 95% CI 0.96 to 1.00), statin use (OR 0.42; 95% CI 0.20 to 0.90), and UDCA prophylaxis (OR 0.47; 95% CI 0.30 to 0.73) all reduced the risk.

CONCLUSION

Young patients with a preoperative pain syndrome and/or asymptomatic gallstones before bariatric surgery are at increased risk for symptomatic gallstone disease after surgery. Whether statins, either alone or in combination with UDCA prophylaxis, can further reduce the burden of gallstones after bariatric surgery should be investigated prospectively.

The effect of Tauroursodeoxycholic acid (TUDCA) and gut microbiota on murine gallbladder stone formation

INTRODUCTION AND OBJECTIVES

The incidence of gallstone-related disease steadily increased in the last few years. Here, we aimed to investigate the effect of tauroursodeoxycholic acid¹ (TUDCA) on preventing cholesterol gallstones formation in high-fat fed (HFD) mice.

MATERIAL AND METHODS

Specific pathogen-free male C57Bl/6 mice were fed a lithogenic diet² (LD group) alone or in combination with TUDCA (5g/kg diet) for 8 weeks. Upon sacrifice, serum, gallbladder, liver and small intestine were collected and the formation of gallstones or crystals in the gallbladder was analyzed. Additionally, the intestinal microbiota, and bile acid composition, serum lipids and hepatic lipids were studied.

RESULTS

Cholesterol gallstones with cholesterol crystals formed in mice of the LD-fed group (15/15, 100%). However, only cholesterol crystals were found in three mice without the presence of any gallstone in the TUDCA-treated group. Both serum and hepatic total cholesterol levels in the TUDCA group were significantly decreased compared with the LD group. Concomitantly, mRNA expression of Abcg5 and Abcg8 was significantly lower in the liver of the TUDCA group whilst mRNA transcripts for Abcb11, Acat2, and Cyp27 were significantly increased compared with the LD group. Additionally, the gallbladder cholesterol saturation index (1.06±0.15) in the TUDCA group was significantly decreased compared with the LD group. Interestingly, the ratio of Firmicutes/Bacteroides in the TUDCA group was increased 3x fold.

CONCLUSIONS

TUDCA can inhibit the absorption and synthesis of lipids in the small intestine by improving the intestinal microbiota in HFD-fed mice, thus reducing gallstone formation.

Management of biliary stones in bariatric surgery

Morbidly obese and post-bariatric surgery patients are at increased risk for biliary stones formation. The complications related to biliary stones may impose complexity on their management. This study aimed to review the management of biliary conditions in obese and bariatric patients. In this study, a narrative review was performed of the medical, surgical, and endoscopic procedures for the management of biliary stones and their related complications. Knowing the main prophylactic and therapeutic interventions options is essential for clinicians to properly manage the biliary stones in patients candidates or submitted to bariatric surgery.

Predictive Factors of Cholelithiasis After Prophylactic Administration of Ursodeoxycholic Acid Following Laparoscopic Bariatric Surgery: Tehran Obesity Treatment Study

PURPOSE

Cholelithiasis is a well-known consequence of obesity as well as rapid weight loss especially after bariatric surgery. A routine postoperative course of ursodeoxycholic acid (UDCA) is recommended as a prophylactic measure against gallstone formation. However, the efficacy of UDCA after bariatric surgery and predictors of cholelithiasis despite prophylaxis are not well understood. We assessed the incidence and predictors of de novo cholelithiasis after bariatric surgery in patients who received UDCA prophylaxis.

METHODS

Uniform data from 2629 consecutive patients who underwent either sleeve gastrectomy or gastric bypass between March 2013 and 2018 were collected prospectively. All patients received a 6-month course of UDCA 300 mg twice daily. Cholelithiasis was assessed with abdominal ultrasound at baseline as well as 6, 9, 12, 18, and 24 months postoperatively. The association between cholelithiasis and its predictors was examined by Cox proportional hazards models and restricted cubic spline regression.

RESULTS

The cumulative rate of cholelithiasis in 24 months after surgery was 10.8% (n = 283) with the greatest incidence within the first year. After multivariate analysis, 6-month body mass index (BMI) loss was found to be the only independent predictor for postoperative cholelithiasis (HR = 1.10 [95% CI: 1.04-1.16]). The concordance index for predicting cholelithiasis was 0.60 (0.56-0.64) for 6-month BMI loss.

CONCLUSION

Early postoperative rapid weight loss as represented by 6-month BMI loss is the main predictor of de novo cholelithiasis after bariatric surgery, although this parameter does not have enough power for discrimination of postoperative cholelithiasis.

Concomitant Cholecystectomy for Asymptomatic Gallstones in Bariatric Surgery-Safety Profile and Feasibility in a Large Tertiary Referral Bariatric Center

BACKGROUND

Obesity is a risk factor for gallstone formation, which can be exacerbated by bariatric surgery-induced rapid weight loss. Current guidelines do not recommend concomitant cholecystectomy (CC) for asymptomatic gallstones during the bariatric surgery procedure. However, long-term follow-up studies have shown that the incidence of post-bariatric surgery symptomatic gallstones necessitating therapeutic cholecystectomy increases to 40%. Therefore, some surgeons advocate simultaneous cholecystectomy during the bariatric surgery for asymptomatic individuals. This study aims to evaluate the safety of performing cholecystectomy for asymptomatic gallstones during the bariatric procedure.

METHODS

Data from a consecutive series of patients that underwent primary laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB) or conversion of LSG to a LRYGB with or without concomitant cholecystectomy for asymptomatic gallstones between Jan 2010 and Dec 2017 were retrieved from the database. The primary endpoint was the complication rate. Secondary endpoints were the surgical operating room time (ORT) and the length of hospital stay (LOS).

RESULTS

Out of the 2828 patients who were included, 120 patients underwent a concomitant cholecystectomy during their bariatric procedure (LSG or LRYGB) for asymptomatic gallbladder stones and were compared to the 2708 remaining patients who only had bariatric surgery. None of the concomitant cholecystectomy patients developed a gallbladder-related complication. There was no significant increase in the rate of minor or major complications between the CC groups and the non-CC groups (LSG: 6.7% vs. 3.2%, p=0.132; LRYGB: 0% vs. 2.3%, p =0.55; and conversion of LSG to LRYGB: 20% vs. 7.1%, p = 0.125, respectively). In addition, there was no significant increase in the length of hospital stay (1.85 ±4.19 days vs. 2.24 ±1.82, p=0.404) for LSG group and (1.75 ±2.0 vs. 2.3 ±2.1, p=0.179) for LRYGB group. Adding the cholecystectomy to the bariatric procedure only added an average of 23 min (min) (27 min when added to LSG and 18 min when added to LRYGB).

CONCLUSION

As one of the largest series reviewing concomitant cholecystectomy in bariatric surgery, this study showed that in skilled laparoscopic bariatric surgical hands, concomitant cholecystectomy during bariatric surgery is safe and prevents potential future gallstone-related complications. Long-term large prospective randomized trials are needed to further clarify the recommendation of prophylactic concomitant cholecystectomy during bariatric surgery.

Management of gallstone disease prior to and after metabolic surgery: a single-center observational study

BACKGROUND

Rapid weight loss after bariatric surgery is a risk factor for gallstone formation. There are different strategies regarding its management in bariatric patients, including prophylactic cholecystectomy (CCE) in all patients, concomitant CCE only in symptomatic patients, or concomitant CCE in all patients with known gallstones. We present the safety and long-term results of the last concept.

METHOD

Retrospective single-center analysis of a prospective database on perioperative and long-term results of patients with laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) over a 15-year period. The minimal follow-up was 24 months. Concomitant CCE was intended for all patients with gallstones detected by preoperative sonography.

SETTING

Academic teaching hospital in Switzerland.

RESULTS

After exclusion of patients with a history of CCE (11.5%), a total of 1174 patients (69.6% LRYGB, 30.4% LSG) were included in the final analysis. Preoperative gallbladder pathology was detected in 21.2% of patients, of whom 98.4%, or 20.9% of the total patients, received a concomitant CCE. The additional procedure prolonged the average operation time by 38 minutes (not significant) and did not increase the complication rate compared with bariatric procedure without CCE (3.7% versus 5.7%, P = .26). No complication was directly linked to the CCE. Postoperative symptomatic gallbladder disease was observed in 9.3% of patients (LRYGB 7.0% versus LSG 2.3%, P = .15), with 19.8% of those patients initially presenting with a complication.

CONCLUSION

The concept of concomitant CCE in primary bariatric patients with gallstones was feasible and safe. Nevertheless, 9.3% of primary gallstone-free patients developed postoperative symptomatic gallbladder disease and required subsequent CCE despite routine ursodeoxycholic acid prophylaxis.

Incidence and risk factors for de novo cholelithiasis after bariatric surgery

INTRODUCTION

Obesity and rapid weight loss after bariatric surgery (BS) are risk factors for the development of cholelitiasis. The aim of this study is to know the incidence of the de novo symptomatic cholelitiasis (DNSC) after BS and to analyze the risk factors for its development.

METHODS

Single-centre retrospective observational study of patients undergoing BS between January 2010 and December 2017. The incidence of DNSC has been studied and sex, age, comorbilities, surgical tecnique, initial BMI and percentage of excess BMI lost (%EBMIL) at 6th, 12th and 24th postoperative months have been analyzed.

RESULTS

Among the 415 patients who underwent BS, 280 have been studied since they were not previously cholecystectomized and had a preoperative negative abdominal ultrasound. Twenty-nine developed DNSC (10,35%), with a remarkably higher increase in cumulative incidence during the first postoperative year (CI 5%, IC 95% 2,4-7,6). A higher percentage of excess BMI lost at the 6, 12 and 24 postoperative months was statistically significantly correlated with an increased risk of DNSC.

CONCLUSIONS

Incidence of DNSC and cholecystectomy after BS are relatively high, mainly during rapid weight loss period and even more the higher the percentage of excess BMI lost is. Concomitant cholecystectomy during BS in case of preoperative cholelithiasis regardless of symptoms and the use of ursodeoxycholic acid during the period of greater risk for DNSC development are two therapeutic options to consider.

The impact of ursodeoxycholic acid on gallstone disease after bariatric surgery: a meta-analysis of randomized control trials

BACKGROUND

Ursodeoxycholic acid (UDCA) is a bile acid that has been shown to reduce the formation of gallstones after significant weight loss.

OBJECTIVE

This study aimed to evaluate the impact of UDCA on the incidence of gallstones after bariatric surgery.

SETTINGS

An electronic search of PubMed (Medline), Cochrane Central Register of Controlled Studies (CENTRAL), Scopus (Elsevier) databases, EMBASE, CINAHL, Clinicaltrials.gov, and Web of Science.

METHODS

A meta-analysis of randomized control trials was performed. The primary outcome was the incidence of gallstones after bariatric surgery. Secondary outcomes included type of operation and time interval to and characteristics associated with gallstone formation.

RESULTS

Ten randomized control trials including 2583 patients were included, 1772 patients (68.6%) receiving UDCA and 811 (31.4%) receiving placebo. There was a significant reduction in gallstone formation in patients who received UDCA postoperatively (risk ratio [RR] .36, 95% confidence interval [CI] .22-.41, P  < .00001). The overall prevalence of gallstone formation was 24.7% in the control group compared to 7.3% in the UDCA group. A dose of ≤600 mg/day had a significantly reduced risk of gallstone formation compared to the placebo group (risk ratio .35; 95% CI .24-.53; P < .001). The risk reduction was not significant for the higher dose (>600 mg/day) group (risk ratio .30; 95% CI, .09-1.01, P = .05).

CONCLUSIONS

UDCA significantly reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. A dose of 600 mg/day is associated with improved compliance and better outcomes regardless of type of surgery. UDCA should be considered part of a standard postoperative care bundle after bariatric surgery.

Ursodeoxycholic acid for the prevention of gallstone disease after bariatric surgery

Background: The development of gallstone disease (GSD) after bariatric surgery is a significant problem. The prophylactic effect of ursodeoxycholic acid (UDCA) preparations on the occurrence of cholelithiasis after gastric bypass and longitudinal gastrectomy has been studied. Aims: The aim of the study was to evaluate the effectiveness of ursodeoxycholic acid preparations in the prevention of cholelithiasis in patients after bariatric surgery. Methods: The results of a year-long follow-up for 128 patients after bariatric surgery were analyzed. In 68 patients, the prophylaxis of the gallstone disease development was not performed. 60 patients took a daily 500 mg dose of UDCA orally. Results: Cholelithiasis had developed in 17 (25%) patients who did not undergo the prophylaxis of cholelithiasis. Of these, 10 (14.7%) underwent cholecystectomy. Among those patients who took UDCA drugs, stones in the gallbladder were found in 7 (11.6%), and only one patient (1.7%) required a surgical treatment. Conclusion: UDCA administration during the first year after bariatric surgery in the amount of 500 mg per day significantly reduces the likelihood of the de novo cholelithiasis development. The medical prophylaxis of gallstone disease should be included in the standards of bariatric patients' management.

Efficacy and Safety of Ursodeoxycholic Acid for the Prevention of Gallstone Formation After Gastrectomy in Patients With Gastric Cancer: The PEGASUS-D Randomized Clinical Trial

Importance

The incidence of gallstones has been reported to increase after gastrectomy. However, few studies have been conducted on the prevention of gallstone formation in patients who have undergone gastrectomy.

Objective

To evaluate the efficacy and safety of ursodeoxycholic acid (UDCA) in preventing gallstone formation after gastrectomy in patients with gastric cancer.

Design, Setting, and Participants

The PEGASUS-D study (Efficacy and Safety of DWJ1319 in the Prevention of Gallstone Formation after Gastrectomy in Patient with Gastric Cancer: A Multicenter, Randomized, Double-blind, Placebo-controlled Study) was a randomized, double-blind, placebo-controlled clinical trial conducted at 12 institutions in the Republic of Korea. Adults (aged ≥19 years) with a diagnosis of gastric cancer who underwent total, distal, or proximal gastrectomy were enrolled between May 26, 2015, and January 9, 2017; follow-up ended January 8, 2018. Efficacy was evaluated by both the full analysis set, based on the intention-to-treat principle, and the per-protocol set; full analysis set findings were interpreted as the main results.

Interventions

Eligible participants were randomly assigned to receive 300 mg of UDCA, 600 mg of UDCA, or placebo at a ratio of 1:1:1. Ursodeoxycholic acid and placebo were administered daily for 52 weeks.

Main Outcomes and Measures

Gallstone formation was assessed with abdominal ultrasonography every 3 months for 12 months. Randomization and allocation to trial groups were carried out by an interactive web-response system. The primary end point was the proportion of patients developing gallstones within 12 months after gastrectomy.

Results

A total of 521 patients (175 received 300 mg of UDCA, 178 received 600 mg of UDCA, and 168 received placebo) were randomized. The full analysis set included 465 patients (311 men; median age, 56.0 years [interquartile range, 48.0-64.0 years]), with 151 patients in the 300-mg group, 164 patients in the 600-mg group, and 150 patients in the placebo group. The proportion of patients developing gallstones within 12 months after gastrectomy was 8 of 151 (5.3%) in the 300-mg group, 7 of 164 (4.3%) in the 600-mg group, and 25 of 150 (16.7%) in the placebo group. Compared with the placebo group, odds ratios for gallstone formation were 0.27 (95% CI, 0.12-0.62; P = .002) in the 300-mg group and 0.20 (95% CI, 0.08-0.50; P < .001) in the 600-mg group. No significant adverse drug reactions were detected among the enrolled patients.

Conclusions and Relevance

Administration of UDCA for 12 months significantly reduced the incidence of gallstones after gastrectomy for gastric cancer. These findings suggest that UDCA administration prevents gallstone formation after gastrectomy in patients with gastric cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT02490111.

Ursodeoxycholic acid for the prevention of gallstone and subsequent cholecystectomy following gastric surgery: A systematic review and meta-analysis

BACKGROUND/PURPOSE

Patients who undergo gastric surgery are prone to form postsurgical gallstones. Debates still exist about the need for prevention and the selection of preventive methods. No studies had been reported comparing the efficacy of prophylactic ursodeoxycholic acid (UDCA) and prophylactic cholecystectomy (PC) for lowering postsurgical gallstone formation and subsequent cholecystectomy (SC) in patients who have undergone gastric surgery.

METHODS

We did a systematic review to identify studies from PUBMED, EMBASE, and the Cochrane database through 30 June 2020. We conducted direct and indirect comparisons of each prophylaxis using conventional and network meta-analysis. Studies with patients who have no history of cholecystectomy and who have not had preoperative gallstone were included.

RESULTS

The excellent preventive effects of PC and UDCA were demonstrated for gallstone formation (odds ratio [OR] 0.05, [95% CI 0.01, 0.22] and 0.20, [95% CI 0.16, 0.24], respectively) and the need for SC (OR 0.10, [95% CI 0.02, 0.57] and OR 0.22, [95% CI 0.14, 0.35], respectively) than control group. The UDCA group showed a tendency to generate more gallstones (OR 3.74, [95% CI 0.88, 15.82]) and a greater need for SC (OR 2.19, [95% CI 0.47-10.14]) than did the PC group without statistical significance.

CONCLUSIONS

Prophylaxis for gallstone formation may be needed for patients who undergo gastric surgery to reduce troublesome morbidities. Prophylactic UDCA seems to be a reasonable preventive method for postsurgical gallstone formation to ensure clinical benefit while reducing the burden of subsequent cholecystectomy for the patient as compared to a PC.

The Role of Ursodeoxycholic Acid (UDCA) in Cholelithiasis Management After One Anastomosis Gastric Bypass (OAGB) for Morbid Obesity: Results of a Monocentric Randomized Controlled Trial

INTRODUCTION

Bariatric surgery leads to rapid weight loss, a well-known risk factor for gallstone formation. Postoperative biliary complication rate requiring cholecystectomy is between 0.9 and 7.5% after laparoscopic sleeve gastrectomy and between 6 and 50% after laparoscopic gastric bypass. Several authors recommended ursodeoxycholic acid (UDCA) administration to reduce gallstone formation after diet-induced weight reduction. The aim of this randomized monocentric study is to evaluate gallstone incidence after prophylactic administration of UDCA in patients undergoing one anastomosis gastric bypass (OAGB).

METHODS

Patients undergoing OAGB were prospectively randomized into 2 groups: the UDCA group receiving oral UDCA 600 mg/days for 6 months in the immediate postoperative days, and the control group not administered with UDCA. Each group included 95 patients. Abdominal ultrasound, clinical evaluation, and quality of life scoring with Gastrointestinal Quality of Life Index (GIQLI) were performed postoperatively in all patients at 3, 6, and 12 months.

RESULTS

At 12 months of postoperative follow-up, 4 (4.2%) and 24 patients (25.2%) showed gallstones in the UDCA group and control group, respectively (p < 0.05). Among those who developed gallstones, 8 (28.6%) cases were symptomatic whereas 20 (71.4%) did not show any symptom. No statistically significant difference in GIQLI score between the two groups was found.

CONCLUSION

OAGB, as other malabsorbent procedures, appears to have higher rate of cholelithiasis than purely restrictive procedures. In our prospective randomized controlled study, a regular postoperative UDCA intake during the first 6 months seems to significantly reduce cholelithiasis incidence after OAGB, with no case of intolerance reported. Further studies are needed to assess this issue.

Effectiveness of ursodeoxycholic acid treatment in the prevention of gallstone formation after laparoscopic sleeve gastrectomy

BACKGROUND

Bariatric surgery is a critical risk factor for cholelithiasis. This study aimed to investigate the role of treatment with ursodeoxycholic acid (UDCA) in the prevention of gallstone formation after laparoscopic sleeve gastrectomy (SG) in morbidly obese patients.

METHODS

Patients who underwent SG for morbid obesity from January 2016 to September 2016 were evaluated. Patients without hepatobiliary disorders were included. Patients were divided into two groups based on whether they did (Group I) or did not receive treatment with UDCA (Group II). Indication for UDCA treatment was symptomatic alkaline reflux. Demographic characteristics, comorbid diseases, preoperative blood parameters, early and late period weight loss rates, and gallstone development were monitored and compared between the groups.

RESULTS

Ninety-six of 155 patients met the inclusion criteria. Group I and II included 49 and 47 patients, respectively. The mean age was 39.1 ± 10.8 (range 18-69) years and the mean follow-up period was 20.75 ± 6.6 (range 12-34) months. Gallstone formation was significantly lower in Group I compared to Group II [5 patients (10.2%) vs. 21 patients (44.6%), p<.001]. Moreover, the absence of UDCA treatment was independently and significantly associated with gallstone formation (hazard ratio: 3.08; 95% confidence interval: 1.73-5.50; p<.001) in multivariate analyses. There was no difference in weight loss rates between the two groups at the early or late periods.

CONCLUSIONS

Treatment with UDCA seems to be effective in the prevention of gallstone formation after sleeve gastrectomy. Furthermore, early and late period weight loss rates were not found to have significant effects on the risk of cholelithiasis.

Impact of Baseline BMI and Adherence to Follow-Up on the Outcome of Sleeve Gastrectomy in Treatment of Adolescent Obesity

BACKGROUND

Adolescent obesity is considered a public health challenge. Sleeve gastrectomy (SG) may be considered a safe option for treatment of adolescent obesity. This study aimed to assess the outcomes of SG in treatment of severe obesity in adolescents, with emphasis on the impact of baseline body mass index (BMI) and adherence to follow-up.

METHODS

This was a single-center retrospective cohort study on adolescents with severe obesity who underwent SG at a tertiary referral bariatric center. The main outcome measures were weight loss, improvement in comorbidities at 12 months postoperatively, and complications.

RESULTS

A total of 72 adolescent patients (47 female) of a mean BMI of 47.9 ± 7.1 kg/푚² were enrolled in the study. The mean %TWL was 34.94 ± 9.35 and the mean %EWL was 73.47 ± 22.12. Complete remission was recorded in all patients with type 2 diabetes mellitus (DM), pre-DM, and sleep apnea, in 80% of patients with hypertension, and 57% of patients with hypothyroidism. The long-term complication rate after SG was 18%. Patients with higher preoperative BMI had significantly (p = 0.018) lower %EWL at 1 year.

CONCLUSION

SG is an effective and safe surgical procedure for adolescents with severe obesity. It was associated with a significant weight loss, high comorbidity remission rates, and no mortality or serious complications. Lower baseline BMI and better adherence to follow-up were associated with better outcome of SG.

Simultaneous surgeries in bariatric surgery (literature review)

Based on the available publications, the article presents an analysis of the studies on the simultaneous implementation of cholecystectomy, ventral and paraesophageal hernia repair during a bariatric intervention. If there is a clinical picture of chronic calculous cholecystitis, simultaneous cholecystectomy is justified and does not lead to a significant increase in the number of complications. In the case of asymptomatic gallstones, the optimal tactics remains controversial, both a surgical treatment and observation are possible. In the absence of gallstone disease, all patients after the surgical correction of the excess weight are prescribed ursodeoxycholic acid, while performing preventive cholecystectomy is not recommended. A simultaneous ventral hernia repair is justified only for small defects ( 10 cm) of the anterior abdominal wall. If a paraesophageal hernia is detected in patients with morbid obesity, bariatric surgery may be combined with cruroraphy.

Incidence and risk factors for de novo cholelithiasis after bariatric surgery

INTRODUCTION

Obesity and rapid weight loss after bariatric surgery (BS) are risk factors for the development of cholelitiasis. The aim of this study is to know the incidence of the de novo symptomatic cholelitiasis (DNSC) after BS and to analyze the risk factors for its development.

METHODS

Single-centre retrospective observational study of patients undergoing BS between January 2010 and December 2017. The incidence of DNSC has been studied and sex, age, comorbilities, surgical tecnique, initial BMI and percentage of excess BMI lost (%EIMCP) at 6th, 12th and 24th postoperative months have been analyzed.

RESULTS

Among the 415 patients who underwent BS, 280 have been studied since they were not previously cholecystectomized and had a preoperative negative abdominal ultrasound. Twenty-nine developed DNSC (10.35%), with a remarkably higher increase in cumulative incidence during the first postoperative year (5%, 95% CI 2,4-7,6). A higher percentage of excess BMI lost at the 6, 12 and 24 postoperative months was statistically significantly correlated with an increased risk of DNSC.

CONCLUSIONS

Incidence of DNSC and cholecystectomy after BS are relatively high, mainly during rapid weight loss period and even more the higher the percentage of excess BMI lost is. Concomitant cholecystectomy during BS in case of preoperative cholelithiasis regardless of symptoms and the use of ursodeoxycholic acid during the period of greater risk for DNSC development are two therapeutic options to consider.

Changes in plasma bile acids are associated with gallbladder stones and polyps

BACKGROUND

The development of gallbladder disease (GBD) is related to bile acid (BA) metabolism, and the rate of BA circulation increases the risk of biliary cancer. However, it is unclear whether patterns of circulating bile acids (BAs) change in patients with benign GBDs such as gallbladder stones and polyps. Herein, we compared and characterised plasma BA profiles in patients with cholecystolithiasis and non-neoplastic polyps with healthy controls, and explored relationships between plasma BA profiles, demographics, and laboratory test indices.

METHODS

A total of 330 subjects (13 healthy controls, 292 cholecystolithiasis and 25 non-neoplastic polyps) were recruited and plasma BA profiles including 14 metabolites from patients with pathologically confirmed cholecystolithiasis and non-neoplastic polyps were compared with controls. BAs were quantitated by liquid chromatography and mass spectrometry, and statistical and regression analyses of demographics and laboratory test indices were performed.

RESULTS

Females displayed a higher burden of GBD than males (63.36% cholecystolithiasis, 60% non-neoplastic polyps). Cholecystolithiasis and non-neoplastic polyps were associated with increased plasma total secondary BAs, while levels of primary BAs were lower than in healthy controls. Plasma ursodeoxycholic acid (UDCA), tauroursodeoxycholic acid (TUDCA), glycyurdeoxycholic acid (GUDCA), taurochenodeoxycholic acid (TCDCA) and glycochenodeoxycholic acid (GCDCA) were decreased significantly in GBDs, and ursodeoxycholic acid (UDCA) was negatively correlated with white blood cell count and neutrophil percentage.

CONCLUSIONS

Secondary BA levels were higher in patients with cholecystolithiasis and non-neoplastic polyps. White blood cell count and percentage of neutrophil in peripheral blood were negatively correlated with UDCA, indicating an anti-inflammation effect of UDCA.

A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity

PURPOSE

Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO).

METHOD

The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies.

RESULTS

Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76).

CONCLUSION

In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.

Effectiveness of Ursodeoxycholic Acid in the Prevention of Cholelithiasis After Sleeve Gastrectomy

PURPOSE

The use of ursodeoxycholic acid (UDCA) to prevent gallstone formation after sleeve gastrectomy (SG) is still debated. Furthermore, no study has assessed the effectiveness of UDCA on gallstone formation after the first postoperative year. Our aim was to compare the incidence of cholelithiasis (CL) at 1 and 3 years after SG between patients treated or not treated with UDCA.

MATERIALS AND METHODS

From January 2008, a postoperative ultrasound monitoring was scheduled for all patients who underwent SG in our institution. Patients with a preoperative intact gallbladder who performed at least one ultrasound at 1 year after SG were included. We compared the incidence of CL between patients operated before October 2013 who did not receive UDCA and those operated from October 2013 who received UDCA 500 mg once daily for 6 months postoperatively.

RESULTS

The incidence of CL at 1 year after SG was 28% in the 46 non-treated and 3.5% in the 143 treated patients (p < 0.001). UDCA reduced the proportion of cholecystectomies from 11% to 1.4% (p = 0.012). Thus, the number of patients needed to treat to avoid a cholecystectomy was about 10. Only 2 patients (1.4%) stopped UDCA for adverse effects. No gallstone appeared at 3 postoperative years in the 61 patients who performed an ultrasound at this time.

CONCLUSION

UDCA 500 mg once daily for 6 months postoperatively is effective and well tolerated to prevent CL at midterm after SG. We recommend UDCA treatment in all patients after SG with an intact preoperative gallbladder. However, large randomized studies are needed to establish guidelines for prevention of gallstone formation after SG.

Cholelithiasis After Sleeve Gastrectomy and Effectiveness of Ursodeoxycholic Acid Treatment

Aim: Few adverse effects may occur after bariatric surgery, one being the formation of gallstones. The aim of this study is to determine the incidence of cholelithiasis after laparoscopic sleeve gastrectomy (LSG) and whether ursodeoxycholic acid (UDCA) treatment reduces gallstone formation. Materials and Methods: Gall bladders of all patients planned for LSG were preoperatively checked by ultrasonography (USG). Patients who had no documented gallbladder pathology before LSG and who had USG at 12th month and 2 years follow-up after LSG were included in the study. The incidences of newly developed cholelithiasis, cholecystectomy, and endoscopic retrograde cholangiopancreatography (ERCP) requirement in patients who did not receive any UDCA treatment (pre-2015 protocol, n = 128) was compared with the corresponding numbers in patients who regularly used 500 mg/day oral UDCA for 6 months after the LSG (post-2015 protocol, n = 152). Results: Between January 2012 and October 2018, 717 LSGs were performed in two centers and after exclusions, 280 patients were eligible for evaluation. Sixty-four of 280 (23%) patients developed cholelithiasis after LSG and cholecystectomy was performed in 24 patients (8.6%) for symptomatic cholelithiasis. In the non-UDCA group, 48 patients developed cholelithiasis (n = 48/128, 37.5%) compared with 16 patients in the UDCA group (n = 16/152, 10.5%) (P < .001). Compared with 5 patients in the UDCA group, 19 patients underwent cholecystectomy (39.6%) in the non-UDCA group due to symptomatic cholelithiasis (P = .55) and 5 of these patients also required an ERCP. No ERCP became necessary in the UDCA group (P = .2). Conclusions: An almost fourfold decrease in the rate of new gall stone formation with 500 mg daily UDCA treatment was impressive and may suggest routine UDCA treatment after LSG. Given the rate of exclusions and follow-up differences among the groups, certainly, randomized trials, with less exclusion are needed to provide conclusive evidence.

Systematic review of management of gallbladder disease in patients undergoing minimally invasive bariatric surgery

The introduction and subsequent widespread adaptation of minimally invasive approaches for bariatric surgery have not only changed the outcomes of bariatric surgery but also called into question the management of co-morbid surgical conditions, in particular gallbladder disease. The American Society for Metabolic and Bariatric Surgery Foregut Committee performed a systematic review of the published literature from 1995-2018 on management of gallbladder disease in patients undergoing bariatric surgery. The papers reviewed generated the following results. (1) Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended. (2) In symptomatic patients who are undergoing bariatric surgery, concomitant cholecystectomy is acceptable and safe. (3) Ursodeoxycholic acid may be considered for gallstone formation prophylaxis during the period of rapid weight loss. (4) Routine preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients. In the era of minimally invasive surgery, the management of gallbladder disease in patients undergoing bariatric surgery continues to evolve.

Effect of oral ursodeoxycholic acid on cholelithiasis following laparoscopic sleeve gastrectomy for morbid obesity

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a definitive solution for morbid obesity and its related co-morbidities. Cholelithiasis is a postoperative complication of LSG. The use of ursodeoxycholic acid (UDCA) after LSG is a proposed solution to reduce the incidence of cholelithiasis.

OBJECTIVE

To evaluate the effect of UDCA prophylaxis on cholelithiasis following LSG in morbidly obese patients.

SETTING

Two university hospitals in Egypt, Cairo, and Beni Suef Universities' hospitals.

METHODS

This prospective study was conducted between July 2015 and March 2018 and included 200 patients scheduled for LSG. They were randomly divided into 2 groups. The UDCA group received a postoperative prophylaxis regimen for prevention of cholelithiasis in the form of 250 mg twice daily of UDCA for 6 months. The control group did not receive prophylactic treatment. Abdominal ultrasound was done at 3, 6, 9, and 12 months for all patients to detect cholelithiasis. The primary outcome measure was cholelithiasis.

RESULTS

Only 6% of the UDCA group developed cholelithiasis compared with 40% in the control group (P < .001). Age, sex, initial body mass index, and excess weight loss at 6 months did not significantly affect cholelithiasis.

CONCLUSION

UDCA treatment for 6 months after LSG is effective in the prevention of cholelithiasis.

Concomitant cholecystectomy during bariatric surgery: The jury is still out

BACKGROUND

We sought to compare clinical outcomes of concomitant cholecystectomy during four different types of bariatric surgery vs. bariatric surgery alone.

DATA SOURCES

A systematic literature search of PubMed and Cochrane databases was conducted in accordance with the PRISMA guidelines. Thirty studies were included in this study, reporting data on 13,675 patients. Our findings suggest a higher rate of anastomotic leak/stricture in the case of concomitant cholecystectomy with gastric bypass compared to those who had gastric bypass alone. The scarcity of data concerning sleeve gastrectomy, adjustable gastric banding and biliopancreatic diversion prevented us from quantifying possible difference of outcomes between the examined treatment groups.

CONCLUSIONS

This study highlights the small number and poor quality of available studies referring to the role of simultaneous cholecystectomy during bariatric surgery.

Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention

Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.

Ursodeoxycholic Acid in the Prevention of Gallstone Formation After Bariatric Surgery: an Updated Systematic Review and Meta-analysis

We aim to review the available literature on obese patients treated with ursodeoxycholic acid (UDCA) in order to prevent gallstone formation after bariatric surgery. A systematic literature search was performed in PubMed, Cochrane library, and Scopus databases, in accordance with the PRISMA guidelines. Eight studies met the inclusion criteria incorporating 1355 patients. Random-effects meta-analysis showed a lower incidence of gallstone formation in patients taking UDCA. Subgroup analysis reported fewer cases of gallstone disease in the UDCA group in relation to different bariatric procedures, doses of administered UDCA, and time from bariatric surgery. Adverse events were similar in both groups. Fewer patients required cholecystectomy in UDCA group. No deaths were reported. The administration of UDCA after bariatric surgery seems to prevent gallstone formation.

Recent advances in understanding and managing cholesterol gallstones

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.