Concomitant cholecystectomy during laparoscopic Roux-en-Y gastric bypass in obese patients is not justified: a meta-analysis

Long-term incidence of bariatric related procedures following laparoscopic gastric bypass: 15 to 20 years single institution experience

BACKGROUND

Long-term data on the likelihood of undergoing additional related operations after Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remain scarce.

OBJECTIVES

The aims of this study are to identify the long-term incidence of bariatric related operations, patient's predictive factors, and most common operations in the 15-20 years following LRYGB.

SETTING

Single Academic Institution, Center of Bariatric Excellence.

METHODS

We performed a retrospective analysis of all LRYGB performed at Single Institution from 2003 to 2008. All subsequent bariatric related operations performed were manually reviewed, excluding upper endoscopies. Kaplan-Meier analysis was utilized to estimate the time to procedure. Cox regression was used to determine patient's factors associated with time until procedure.

RESULTS

Of the 665 patients included, the median follow-up was 14 years. There were 248 (37.3%) patients with a related operation. After excluding panniculectomy, 199 (29.9%) had a related operation. The 3 most common operations were panniculectomy [n = 77 (12%)], followed by cholecystectomy [n = 64 (10%)], and internal hernia repair [n = 56 (8%)]. The Kaplan-Meier estimated incidence of related operation at 15 years was 43.7% and 35.3% after excluding panniculectomy. Females (HR = 1.77, 95% CI = [1.20, 2.62, p = 0.0039), age < 50 (HR = 1.42, 95% CI = [1.07, 1.88], p = 0.014), and BMI > 60 (HR = 2.77, 95% CI = [1.30, 5.91], p = 0.0083) were more likely to have a related operation.

CONCLUSION

Bariatric related operations are common after LRYGB. Nearly half of patients will eventually undergo a secondary operation as they approach 20 years post-LRYGB.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Abdominal Pain After Roux-en-Y Gastric Bypass: A Review

Importance

Roux-en-Y gastric bypass (RYGB) remains one of the most commonly performed operations for morbid obesity and is associated with significant long-term weight loss and comorbidity remission. However, health care utilization rates following RYGB are high and abdominal pain is reported as the most common presenting symptom for those seeking care.

Observations

Given the limitations of physical examination in patients with obesity, correct diagnosis of abdominal pain following RYGB depends on a careful history and appropriate use of radiologic, laboratory and endoscopic studies, as well as a clear understanding of post-RYGB anatomy. The most common etiologies of abdominal pain after RYGB are internal hernia, marginal ulcer, biliary disease (eg, cholelithiasis and choledocholithiasis), and jejunojejunal anastomotic issues. Early identification of the etiology of the pain is essential, as some causes, such as internal hernia or perforated gastrojejunal ulcer, may require urgent or emergent intervention to avoid significant morbidity. While laboratory findings and imaging may prove useful, they remain imperfect, and clinical judgment should always be used to determine if surgical exploration is warranted.

Conclusions and Relevance

The etiologies of abdominal pain after RYGB range from the relatively benign to potentially life-threatening. This Review highlights the importance of understanding key anatomical and technical aspects of RYGB to guide appropriate workup, diagnosis, and treatment.

A Severely Dilated Gallbladder With Multiple Gallstones After Concomitant Laparoscopic Sleeve Gastrectomy and Childbirth in a Hispanic Woman

Independent studies have associated laparoscopic sleeve gastrectomy (LSG) and pregnancy with a higher incidence of gallstones, especially in Hispanic populations. However, the synergistic impact of these risk factors is currently unknown. We present the case of a 42-year-old Hispanic woman who initially identified intermittent upper right abdominal pain, which worsened over the last four days before the presentation. Abdominal ultrasound indicated hepatic steatosis, hepatomegaly, and cholelithiasis. A hydropic gallbladder with numerous gallstones, surrounding pericholecystic inflammatory changes, and mild intra-abdominal and pelvic ascites was confirmed by computed tomography. The patient underwent an uneventful robotic-assisted cholecystectomy. A gross examination of the gall bladder measuring 15.5 x 6 x 5.5 cm revealed multiple stones measuring 1.0-1.5 cm in the lumen, the largest of which was impacted in the neck. This case underscores the importance of considering ethnicity and pregnancy history while assessing the post-LSG risk of incident cholelithiasis.

Incidence of symptomatic gallstones after bariatric surgery: the impact of expectant management

BACKGROUND

Bariatric surgery is the most effective treatment for sustained weight reduction and obesity-related comorbidities. The development of gallstones as a result of rapid weight loss is a well-known consequence of bariatric procedures. It remains unclear, if there is an increased risk of these gallstones becoming symptomatic.

METHODS

A retrospective analysis of 505 consecutive patients submitted to either Roux-en-Y Gastric Bypass or Sleeve Gastrectomy between January and December 2019 was performed. The aim of our study was to determine the incidence of symptomatic cholelithiasis in asymptomatic patients with their gallbladder in situ after bariatric surgery and to identify potential risk factors for its development.

RESULTS

Of the 505 patients included, 79 (15.6%) underwent either previous cholecystectomy. (n = 67, 84.8%) or concomitant cholecystectomy during bariatric surgery (n = 12, 15.2%). Among the remaining 426 (84.4%) patients, only 8 (1.9%) became symptomatic during the 12-month follow-up period. When compared with patients who remained asymptomatic, they had a higher median preoperative BMI (47.0 vs. 42.8, p = 0.046) and prevalence of cholelithiasis on preoperative ultrasound (62.5% vs. 10.7%, p = 0.001). Multivariate analysis revealed preoperative BMI and cholelithiasis on preoperative ultrasound as independent risk factors for symptomatic biliary disease (OR 1.187, 95%CI 1.025-1.376, p = 0.022 and OR 10.720, 95%CI 1.613-71.246, p = 0.014, respectively).

CONCLUSION

Considering a low incidence of symptomatic gallstones after bariatric surgery, concomitant cholecystectomy should only be performed in symptomatic patients undergoing bariatric surgery. Preoperative factors, such as a higher BMI and positive ultrasound for cholelithiasis, may be related to the development of symptomatic gallstones.

Eight-Centimeter Gallbladder Stone Post-Roux-en-Y Gastric Bypass: A Case Report

Cholelithiasis occurs when a stone forms in the gallbladder; when symptoms develop, the condition is termed symptomatic cholelithiasis. The correlation between bariatric surgery and post-operative symptomatic cholelithiasis has long been established. Presented is a case of a 56-year-old female status post-Roux-en-Y gastric bypass who developed symptomatic cholelithiasis and subsequently underwent cholecystectomy with the removal of an 8-centimeter (cm) gallbladder stone. This case report explores the benefits and limitations of watchful waiting versus prophylactic concomitant cholecystectomy among bariatric surgery patients, noting the difference between the bariatric sleeve and bypass anatomy for managing biliary complications.

Risk and Prophylactic Management of Gallstone Disease in Bariatric Surgery: a Systematic Review and A Bayesian meta-analysis

BACKGROUND

The frequency and management of gallstone disease (GD) in bariatric patients, including the role of routine prophylactic concomitant cholecystectomy (CCY), are still a matter of debate. This study aims to assess the risk of de novo GD in patients undergoing bariatric surgery (BS) and their predictive factors, as well as mortality and morbidity in prophylactic CCY compared to BS alone.

METHODS

We performed a systematic review, searching PubMed, EMBASE, and Web of Science until April 2021. We performed a Bayesian meta-analysis to estimate the risk of GD development after BS and the morbidity and mortality associated with BS alone versus BS + prophylactic CCY. Sources of heterogeneity were explored by meta-regression analysis.

RESULTS

The risk of de novo post bariatric GD was 20.7% (95% credible interval [95% CrI] = 13.0-29.7%; I² = 75.4%), and that of symptomatic GD was 8.2% ([95% CrI] = 5.9-11.1%; I² = 66.9%). Pre-operative average BMI (OR = 1.04; 95% CrI = 0.92-1.17) and female patients' proportion (OR = 1.00; 95% CrI = 0.98-1.04) were not associated with increased risk of symptomatic GD. BS + prophylactic CCY was associated with a 97% probability of a higher number of postoperative major complications compared to BS alone (OR = 1.74, 95% CrI = 0.97-3.55; I² = 56.5%). Mortality was not substantially different between the two approaches (OR = 0.79; 95% CrI = 0.03-3.02; I² = 20.7%).

CONCLUSION

The risk of de novo symptomatic GD after BS is not substantially high. Although mortality is similar between groups, odds of major postoperative complications were higher in patients submitted to BS + prophylactic CCY. It is still arguable if prophylactic CCY is a fitting approach for patients with a preoperative lithiasic gallbladder.

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.

Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis

BACKGROUND

Several therapeutic modalities have been proposed for the management of choledocholithiasis (CDL) following Roux-en-Y gastric bypass (RYGB), yet debate exists regarding the optimal management. The purpose of our study was to review the current literature to compare the efficacy of various techniques in the management of CDL post-RYGB.

METHODS

A comprehensive search of multiple databases was conducted. Studies reporting on the management of CDL in patients post-RYGB and including at least 5 patients were eligible for inclusion. The primary outcome was successful stone clearance. Secondary outcomes included procedure duration, length of hospital stay, and adverse events.

RESULTS

Of 3259 identified studies, 53 studies involving 857 patients were included in the final analysis. The mean age was 54.4 years (SD 7.05), 78.8% were female (SD 13.6%), and the average BMI was 30.8 kg/m2 (SD 6.85). Procedures described included laparoscopy-assisted ERCP (LAERCP), balloon-assisted enteroscopy (BAE), ultrasound-directed transgastric ERCP (EDGE), laparoscopic common bile duct exploration (LCBDE), EUS-guided intra-hepatic puncture with antegrade clearance (EGHAC), percutaneous trans-hepatic biliary drainage (PTHBD), and rendezvous guidewire-associated (RGA) ERCP. High rates of successful stone clearance were observed with LAERCP (1.00; 95% CI 0.99-1.00; p = 0.47), EDGE (0.97; 95% CI 0.9-1.00; p = 0.54), IGS ERCP (1.00; 95% CI 0.87-1.00), PTHBD (1.0; 95% CI 0.96-1.00), and LCBDE (0.99; 95% CI 0.93-1.00, p < 0.001). Lower rates of stone clearance were observed with BAE (61.5%; 95%CI 44.3-76.3, p = 0.188) and EGHAC (74.0%; 95% CI 42.9-91.5, p = 0.124). Relative to EDGE, LAERCP had a longer procedure duration (133.1 vs. 67.4 min) but lower complication rates (12.8% vs. 24.3%).

CONCLUSION

LAERCP and EDGE had high rates of success in the management of CDL post-RYGB. LAERCP had fewer complications but was associated with longer procedure times. BAE had lower success rates than both LAERCP and EDGE.

Incidence of Symptomatic Cholelithiasis Following Laparoscopic Roux-en-Y Gastric Bypass Is Comparable to Laparoscopic Sleeve Gastrectomy: A Cohort Study

BACKGROUND

A few comparative studies have assessed the incidence of symptomatic cholelithiasis after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). However, they have shown inconsistent results. The present study has been designed based on comparing LSG and LRYGB regarding the incidence of symptomatic cholelithiasis and determining factors related to symptomatic cholelithiasis development after these procedures.

METHODS

This retrospective cohort study was conducted on 1163 patients aged ≥ 18 years old who underwent LRYGB (n = 377) or LSG (n = 786) from July 2006 to November 2019. The participants had no previous history of gallstones. A Cox-proportional hazard regression was used to assess associations between the types of procedures and the risk of symptomatic cholelithiasis. The univariable and then multivariable analysis were used to reveal the predictors of symptomatic cholelithiasis.

RESULTS

The mean person-time follow-up was 34 months (95% CI: 32.2 to 36.1 months). The incidence of symptomatic cholelithiasis was 8.3% over the follow-up period. There was no significant association between the risk of symptomatic cholelithiasis development and the type of surgical procedure (HR: 1.35, 95% CI: 0.75 to 2.41). Females had a 2.3-fold higher risk of symptomatic cholelithiasis than males, according to the multivariable Cox regression (HR: 2.31, 95% CI: 1.23 to 4.33). In addition, there was an inverse association between the administration of UDCA and the incidence of symptomatic cholelithiasis (HR: 0.13, 95% CI: 0.01 to 0.99). Our findings indicated that age, baseline body mass index (BMI), percentage of weight loss (%WL) after three and six months following surgery, postoperative pregnancy, and obesity-related comorbidities did not predict the risk of symptomatic cholelithiasis.

CONCLUSION

The present study illustrates no significant differences between LRYGB and LSG regarding symptomatic cholelithiasis occurrence. Our findings indicate that administration of UDCA has a protective effect against symptomatic cholelithiasis while, female gender is the main predictor of symptomatic cholelithiasis.

Analysis of the Management of Cholelithiasis in Bariatric Surgery Patients: a Single-Center Experience

PURPOSE

Cholelithiasis is an issue in bariatric surgery patients. The incidence of cholelithiasis is increased in morbidly obese patients. After bariatric surgery, the management maybe sometimes challenging. There is no consensus about how to deal with cholelithiasis prior to bariatric surgery.

MATERIALS AND METHODS

A retrospective review from our prospectively collected bariatric surgery database. Primary bariatric procedures from 2009 to 2020 were included. Prevalence of cholelithiasis and its management prior to bariatric surgery and the incidence and management of postoperative biliary events were analyzed.

RESULTS

Over 1445 patients analyzed, preoperatively cholelithiasis was found in 153 (10.58%), and 68 out of them (44.44%) were symptomatic. Seventy-six patients had a concomitant cholecystectomy. In those cases, the bariatric procedure did not show increased operative time, length of stay, morbidity, or mortality compared to the rest of primary bariatric procedures. Twelve patients (15.58%) with previous cholelithiasis and no concomitant cholecystectomy presented any kind of biliary event and required cholecystectomy. De novo cholelithiasis rate requiring cholecystectomy was 3.86%. Postoperative biliary events both in de novo and persistent cholelithiasis population did not show any difference between the type of surgery, weight loss, and other characteristics.

CONCLUSIONS

Cholelithiasis was present in 10.58% of our primary bariatric surgery population. Concomitant cholecystectomy was safe in our series. Non-surgical management of asymptomatic cholelithiasis did not lead to a higher risk of postoperative biliary events. The global postoperative cholecystectomy rate was equivalent to the general population.

Characterization and Risk Factors for Early Biliary Complications Following Elective Bariatric Surgery: an Mbsaqip Analysis

INTRODUCTION

Patients undergoing bariatric surgery are at risk of postoperative biliary complications. This study aims to characterize biliary complications occurring within 30 days of bariatric surgery and to determine factors associated with their occurrence.

METHODS AND PROCEDURES

The 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was analyzed comparing patients with early biliary complications to those without. Early biliary complications were defined by any reoperation, reintervention, or readmission due to gallstones within 30 days of surgery. Patients undergoing elective sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were included; patients with prior surgery were excluded. Bivariate analysis compared groups using chi-squared for categorical data and ANOVA for continuous data was performed. Multivariable modeling was performed to determine factors independently associated with early biliary complications.

RESULTS

We evaluated 750,498 patients with 691 (0.1%) experiencing early biliary complications. Patients with early biliary complications were more often female (87.7% vs 79.6%, p < 0.001). Patients with early biliary complications required significantly more reoperations (86.0% vs 1.1%, p < 0.001), readmissions (82.5% vs 3.6%, p < 0.001), and reinterventions (15.8% vs 1.2%, p < 0.001). Female gender (OR 1.89; CI 1.47-2.44; p < 0.001), postoperative weight loss (OR 1.08; CI 1.06-1.09, p < 0.001), and LRYGB (OR 1.51, CI 1.27-1.79; p < 0.001) were substantial independent predictors of early biliary complications.

CONCLUSIONS

Early post-bariatric surgery biliary complications occur uncommonly but confer substantial morbidity. Female gender, postoperative weight loss, and RYGB are the greatest predictors for early biliary complications. Evaluation of preventative measures in these high-risk groups is needed.

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.

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.

Excess Body Weight and Gallstone Disease

Background

Approximately one fifth of adults are diagnosed with gallstones worldwide. Of these, around 25% develop gallstone disease (indicated by the presence of symptoms) and undergo cholecystectomy.

Summary

The risk of gallstones is influenced by a combination of genetic and lifestyle factors, such as excess body weight. In fact, body mass has been demonstrated to be a major risk factor for symptomatic gallstones. Rapid weight loss can also initiate a prolithogenic state and further increase the likelihood of either gallstone formation or existing gallstones becoming symptomatic; however, sensible weight loss strategies can mitigate this risk. This review discusses the role of excess body weight and the risk of gallstone disease, as well as the options available for the prevention of symptomatic gallstones.

Key Messages

Healthy weight loss diets combined with regular physical activity can promote successful weight loss and weight maintenance and reduce the risk of gallstones. Should rapid weight loss be required for health reasons or be expected, e.g., after bariatric surgery, prophylactic ursodeoxycholic acid during the period of weight reduction has been demonstrated to reduce the incidence of gallstones formation or symptomatic gallstone occurrence. The recent German guidelines on gallstones recommend simultaneous cholecystectomy during bariatric surgery but only for those with preexisting symptomatic stones.

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.

Global Variations in Practices Concerning Roux-en-Y Gastric Bypass-an Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures

INTRODUCTION

There is significant variation in practices concerning Roux-en-Y gastric bypass (RYGB) among bariatric surgeons, but there is currently a lack of robust data on the nature and extent of these variations. The purpose of this study was to understand global variations in practices concerning RYGB.

METHODS

A questionnaire-based survey on Survey Monkey® was created, and the link was shared freely on various social media platforms. The link was also distributed through a personnel email network of authors.

RESULTS

A total of 657 surgeons from 65 countries completed the survey. Crohn's disease and liver cirrhosis were considered absolute contraindications for RYGB by 427 surgeons (64.98%) and 347 surgeons (53.30%), respectively. More than 68.5% of surgeons performed routine upper GI endoscopy while 64.17% performed routine ultrasound of abdomen preoperatively. The majority of surgeons (77.70%) used the perigastric technique for Gastric pouch creation. Approximately, 79.5% used orogastric bougie. More than 70% of the respondents did not use any staple line reinforcement routinely. Only 17.67% of surgeons measured the whole small bowel length, and the majority of surgeons (86.5%) used constant length of BP limb. Approximately, 89% used constant length of alimentary limb. Approximately, 95% of surgeons preferred antecolic bypass, and more than 86% routinely closed the Petersen defect. Marginal ulcer prophylaxis was used by the majority (91.17%). Almost 95% of surgeons recommended lifelong vitamin and mineral supplements.

CONCLUSION

This survey identifies global variations in practices concerning RYGB. It identifies several areas for future research and consensus building.

Increased Incidence of Symptomatic Cholelithiasis After Bariatric Roux-En-Y Gastric Bypass and Previous Bariatric Surgery: a Single Center Experience

BACKGROUND

Bariatric surgery predisposes patients to cholelithiasis and therefore the need of a subsequent cholecystectomy; however, the incidence of cholecystectomy after bariatric surgery is debated.

AIM AND METHODS

Medical records of 601patients hospitalized for bariatric surgery between January 2010 and July 2018 were reviewed. Our aim was to evaluate the incidence of cholecystectomy following different types of common bariatric procedures. All patients who developed cholelithiasis and a subsequent cholecystectomy were included. Cholelithiasis was diagnosed by clinical criteria and characteristic ultrasound findings.

RESULTS

We retrospectively evaluated 580 patients with an average follow-up of 12 months (range 6-24 months). Twenty-one patients were excluded because of missing data. Mean age was 48 ± 19 years (78% females). Twenty-nine patients (5%) underwent laparoscopic cholecystectomy (LC) before the bariatric surgery, and 58 patients (10%) performed concomitant LC with the bariatric procedure due to symptomatic gallstone disease (including stones, sludge, and polyps). There were 203 laparoscopic sleeve gastrectomy (SG) (35%), 175 laparoscopic gastric band (LAGB) (30%), 55 Roux-en-Y gastric bypass (RYGB) (9.5%), and 147 (25%) mini gastric bypass (MGB) procedures during the study period. At the follow-up period, 36 patients (6.2%) developed symptomatic cholelithiasis, while the most common clinical presentation was biliary colic. There was a significant difference between the type of the bariatric procedure and the incidence of symptomatic cholelithiasis after the operation. The incidence of symptomatic gallstone formation in patients who underwent RYGB was 14.5%. This was significantly higher comparing to 4.4% following SG, 4.1% following LAGB, and 7.5% following MGB (p = 0.04). We did not find any predictive risk factors including smoking; BMI at surgery; change in BMI; comorbidities such as diabetes, hyperlipidemia, hypertension, and COPD for gallstone formation; or a subsequent cholecystectomy. Interestingly we found that previous bariatric surgery was a risk factor for gallstone formation and cholecystectomy, 13/82 patients (15.8%) compared to 23/492 patients (4.6%) among those without previous bariatric operation (p < 0.001)].

CONCLUSION

Our data demonstrate that patients with previous bariatric surgery or patients planned for RYGB are at high risk to develop postoperative symptomatic gallbladder disease. Concomitant cholecystectomy during the bariatric procedure or alternatively UDCA treatment for at least for 6 months to avoid the high incidence of postoperative symptomatic gallstones should be considered in those asymptomatic patients.

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.

Asymptomatic Cholelithiasis and Bariatric Surgery: a Comprehensive Long-Term Analysis of the Risks of Biliary Disease in Patients Undergoing Primary Roux-en-Y Gastric Bypass

PURPOSE

Currently, there is little consensus on management of the in situ gallbladder of patients undergoing gastric bypass. Our aim was to evaluate outcomes of selective concomitant cholecystectomy (CCY) and long-term biliary outcomes after Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

We performed a retrospective analysis of patients undergoing laparoscopic RYGB (LRYGB) between 2008 and 2018. Chi-square, Fisher's exact, or Wilcoxon rank-sum tests were used to compare outcomes. Concomitant CCY was performed on a selective basis.

RESULTS

Three thousand and four patients underwent a RYGB (LRYGB n = 2458, open RYGB n = 546). Fifty-two percent (n = 1670) of patients had undergone CCY at any stage. Thirty-one percent of patients (n = 933) had CCY prior to RYGB, 13% (n = 403) had a concomitant CCY and 13% (n = 214) of the remainder required interval CCY. In the LRYGB subgroup, 29.9% (n = 735) had a prior CCY; 12.9% (n = 202) of those with an in situ gallbladder required interval CCY. Those who underwent concomitant CCY/LRYGB (n = 328) were compared with LRYGB alone (n = 1231). The concomitant CCY group was significantly older and had higher percentage of females, higher preoperative BMI, higher Charlson Comorbidity Index, and a higher medication count. There was no significant difference in BMI nadir, length of stay, complications, or mortality. Interval CCY had a higher incidence of CCY-related complications.

CONCLUSION

Our study suggests a higher percentage of bariatric patients with in situ gallbladders will undergo interval CCY than documented in recently published guidelines. Concomitant CCY can be performed without an increase in length of stay or complications. Interval CCY may be associated with a higher complication rate.

Temporary Trans-gastric Stent Deployment Over a 20 French Gastrostomy for Single-Stage Endoscopic Retrograde Cholangiopancreatography After Gastric Bypass

INTRODUCTION

Treatment of pancreato-biliary disorders after gastric bypass is challenging due to altered anatomy. Several techniques have been proposed to overcome this condition; however, none has emerged as the gold standard treatment. Furthermore, a decision-making algorithm evaluating when and why apply one technique over another is still lacking.

OBJECTIVES

To describe a novel trans-gastric approach to allow endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass (RYGB) anatomy soon after prior laparoscopic cholecystectomy (LC) and to propose a decision-making algorithm for selection of the most suitable technique according a tailored approach.

SETTING

Private hospital.

METHODS

Between January and March 2020, patients with Roux-en-Y gastric bypass anatomy referred to our tertiary center to undergo ERCP after recent laparoscopic cholecystectomy were retrospectively evaluated. A 20 french (Fr) gastrostomy was performed during cholecystectomy. A single-stage ERCP was carried out by means of temporary trans-gastric stent deployment over a 20 Fr gastrostomy.

RESULTS

A total of 5 patients (mean age 41; mean body mass index 48.3) were enrolled. ERCP was performed after an average of 2 days from surgery. Technical and clinical success was achieved in 100%. No adverse events occurred. Spontaneous closure of the gastrostomy after its bedside removal was observed in all cases.

CONCLUSIONS

Our approach allows to perform a single-stage ERCP in RYGB patients, early after LC, with no need of any other re-interventions. Any surgeon facing unexpected biliary disorders, during LC, can easily perform a 20 Fr gastrostomy thus allowing the patient to undergo early ERCP without any delay.

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.

Common Bile Duct Stones After Roux-en-Y Gastric Bypass: Same Issue, Different Ways to Deal with

Background: Obesity is a complex chronic disease, which represents a severe and growing health issue all over the world. Bariatric surgery is an option when medical treatments failed. The average of complications is low. Common bile duct stones in a patient who underwent weight loss surgery, especially Roux-en-Y gastric bypass, one anastomosis gastric bypass, or duodenal switch, is challenging due to the difficult access to the biliary duct. Methods: We describe the different techniques we used to perform the treatment of common bile duct stones after a gastric bypass was performed. Results: The highlights of the different treatments to solve this big issue that is common bile duct after gastric bypass are described, such as the endoscopic, the surgical, the percutaneous, and combined ones. Conclusion: There are several therapeutic options; many of them have already demonstrated excellent results. Even though there is not a gold standard technique, the total endoscopic approach performed by trained hands should be the first line of treatment. Percutaneous approach represents also a safe and effective option that can avoid reoperations in an important number of patients. However, the choice will depend on the severity of the case to face with, the availability of resources, and the experience of the team.

A Single-Center Experience with Minimally Invasive Transgastric ERCP in Patients with Previous Gastric Bypass: Lessons Learned and Technical Considerations

As bariatric surgery increases, there is a growing population of patients with biliary obstruction and anatomy which precludes transoral access through endoscopic retrograde cholangiopancreatography (ERCP). Minimally invasive transgastric ERCP (TG-ERCP) offers a feasible alternative for the treatment. A retrospective review was performed of all patients who underwent laparoscopic or robotic-assisted TG-ERCP between 2010 and 2017. Chart abstraction collected demographics, procedural details, success rate, and postoperative outcomes. Forty patients were identified, of which 38 cases were performed laparoscopically and two robotically. Median operative time was 163 minutes, with an estimated blood loss of 50 cc. TG-ERCP was performed successfully in 36 cases (90%); sphincterotomy was completed in 35 patients (97%). Sixty per cent already had a cholecystectomy; in the remaining patients, it was performed concurrently. Major complications included stomach perforation (n = 1), pancreatitis (n = 3), and anemia requiring transfusion (n = 2). In patients with biliary obstruction and anatomy not suitable for ERCP, TG-ERCP can be performed in a minimally invasive fashion, with a high rate of technical success and low morbidity. We describe a stepwise, reproducible technique because it is an essential tool for the shared armamentarium of endoscopists and surgeons.

Predictive factors of gallstone formation after sleeve gastrectomy: a multivariate analysis of risk factors

PURPOSE

Obesity and bariatric surgery are both risk factors for cholelithiasis (CL). However, most previous studies have focused on Roux-en-Y gastric bypass, and limited published data are available for sleeve gastrectomy (SG).

METHODS

Patients were evaluated in two groups depending on the presence of gallstones (Group I, present; Group II, absent). Demographic characteristics, comorbid diseases, pre-operative blood values, and early and late weight loss rates were compared between the groups.

RESULTS

The study included 111 patients with a mean age of 38.9. The mean follow-up period was 20.6 (12-39) months. During follow-up, gallstone formation was observed in 36.9% (n = 41) of patients. Thirteen patients (31.8%) had symptomatic cholelithiasis that was resolved with laparoscopic cholecystectomy. The mean interval between sleeve gastrectomy and the detection of cholelithiasis was 210 days and the mean time of post-operative cholecystectomy was 540 days. A multivariate analysis showed that only dyslipidemia was independently and significantly associated with gallstone formation. There was no significant difference in the weight loss rate between the groups.

CONCLUSIONS

Although CL development was found to be associated with rapid weight loss in several published studies in post-SG patients, the present study showed no significant difference between the groups in terms of early or late weight loss. Pre-operative dyslipidemia may be associated with an increased risk of developing CL.

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.

Synchronous Laparoscopic Insertion of Peritoneal Dialysis Catheter and Cholecystectomy in Patients with End-Stage Renal Disease and Gallstones – Our Experience

In patients with end-stage renal disease who are candidates for peritoneal dialysis (PD) and have gallstones or gallbladder polyps, it is advised to perform synchronous insertion of PD catheter and cholecystectomy. With gallbladder removal at the time of peritoneal catheter insertion we can avoid infective complications, such as acute cholecystitis and possible PD failure. This article presents our experience with synchronous laparoscopic cholecystectomy and insertion of a PD catheter.

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography for choledocholithiasis after Roux-en-Y gastric bypass: A case report

Background

Exclusion of the stomach after Roux-en-Y gastric bypass (RYGB) makes access to the biliary tree very challenging for the surgeon or the endoscopist. Different techniques have been described to overcome this downside, including laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP), which is an outstanding method to access the remnant stomach in order to reach the duodenal papilla. The use of this technique is associated with a high success rate.

Presentation of case

Here we present the case of a 57-year-old patient with altered RYGB anatomy. The patient underwent laparoscopic cholecystectomy. Intraoperative cholangiography revealed the presence of a stone in the common bile duct. A laparoscopy-assisted transgastric ERCP was performed successfully. During the procedure, the duodenoscope was introduced through a gastrostomy, obviating the need for an intragastric trocar. The patient evolved favorably and was discharged on second postoperative day without any complications.

Discussion

Transgastric laparoscopy-assisted ERCP represents an effective approach for the management of biliary complications after RYGB, even if there is a long interval between the two interventions, as occurred in the present case. Other methods described for accessing the biliary tree in patients with altered RYGB anatomy are double-balloon ERCP and endoscopic ultrasound-directed transgastric ERCP. We elected to perform the laparoscopy-assisted approach because choledocholithiasis was diagnosed transoperatively, thus, avoiding the need for secondary procedures or interventions.

Conclusion

Transgastric laparoscopy-assisted ERCP is a feasible procedure with low complication rates and is used in treating patients with altered RYGB anatomy who present with biliary tract disorders. The use of transgastric laparoscopy-assisted ERCP allows endoscopic treatment and cholecystectomy to be performed in a single setting.

•

Case report of a patient with altered RYGB anatomy, which presented choledocholithiasis.

•

There are several ways to treat this disorder on patients with this condition.

•

Laparoscopic Assisted Trans-gastric ERCP is a feasible and secure option.

A comparison of short-term postoperative outcomes including nutritional status between gastrectomy with simultaneous cholecystectomy and gastrectomy only in patients with gastric cancer

Objective

We aimed to evaluate the effect of simultaneous cholecystectomy on the short-term postoperative outcomes and nutritional status in patients with gastric cancer.

Methods

We retrospectively reviewed data from 4,820 patients with gastric cancer who underwent gastrectomy from January 2011 to December 2016. Patients who underwent only gastrectomy (N=4,578) were matched to those who underwent simultaneous cholecystectomy during gastrectomy (N=242) at a 1:1 ratio using propensity score matching analysis. The nutritional status and inflammatory responses preoperatively and postoperatively and postoperative outcomes were compared between the groups.

Results

The simultaneous cholecystectomy group showed more intraoperative blood loss and a longer operative time than the gastrectomy only group [150.0 (100.0, 200.0) mL vs. 100.0 (100.0, 200.0) mL, P=0.006; 176.0 (150.0, 210.0) min vs. 155.0 (128.0, 188.0) min, P<0.001, respectively]. Intraoperative event rate, postoperative complication rate, and postoperative recovery did not differ between the groups. All parameters including body weight, the hemoglobin level, absolute lymphocyte count, total protein level, albumin level, fasting glucose level, and prognostic nutritional index excluding the cholesterol level were not significantly different between the groups, and their changing patterns were similar. Although the cholesterol level was significantly lower in the simultaneous cholecystectomy group than in the gastrectomy only group at all follow-up points, the mean value of the decreased cholesterol level was within normal range.

Conclusions

In gastric cancer patients with gallbladder disease, simultaneous cholecystectomy is safe and not associated with additional nutritional loss.

Patients Remain at High Risk of Gallstones Development Late (10 y) After Sleeve Gastrectomy?

BACKGROUND

Sleeve gastrectomy (SG) is an established bariatric procedure which produces substantial and rapid weight loss and hence can lead to an increase in gallstones development.

OBJECTIVES

To demonstrate the early and late appearance of gallstones after SG.

MATERIALS AND METHODS

A prospective protocol was established in consecutive patients submitted to SG. Clinical and ultrasound evaluations were performed early (1 to 2 y) and late after surgery (over 6 y).

RESULTS

From 109 patients included, 13 (13.1%) had a previous and 10 (10.1%) had simultaneous cholecystectomy at the time of SG. Therefore, 86 patients were submitted to surveillance. Seven patients were unreachable, leaving 79 patients for late follow-up. Forty-five patients (57%) had alithiasic gallbladder late after surgery, whereas 34 patients (43%) showed appearance of gallstone. From them, 53% developed gallstones late after surgery (mean, 7.5 y). Among the group with early development of stones, 69% were symptomatic and in the latter group only 17%.

CONCLUSIONS

Study with 92% of follow-up late after SG demonstrated a 43% development of gallstones: half earlier and half late after surgery. We emphasize the need for late control to detect the real appearance of gallstones after SG.

The effect of concomitant cholecystectomy and sleeve gastrectomy on morbidity in high-risk obese patients with symptomatic gallstones

Introduction

Obesity is an independent risk factor for gallstones. In obese patients, gallstone is more symptomatic than in non-obese people.

Aim

To present the early results of laparoscopic sleeve gastrectomy (LSG) and concomitant cholecystectomy (CC) performed in patients with symptomatic gallstone accompanied by at least one additional systemic disease to obesity and to investigate its effect on morbidity.

Material and methods

Patients undergoing sleeve gastrectomy for morbid obesity between January 2016 and August 2018 were retrospectively studied. Twenty-seven patients who underwent laparoscopic sleeve gastrectomy and concomitant cholecystectomy due to symptomatic gallstone stones were included in this study. The patients were divided into two groups according to the applied surgical technique: laparoscopic sleeve gastrectomy and concomitant cholecystectomy (n = 27) and laparoscopic sleeve gastrectomy (n = 70). The results of an additional operation on these patients and their perioperative complications were evaluated.

Results

A total of 97 patients were included in the study. The mean age of the patients was 40.58 ±10.36 years. There was no statistically significant difference between groups in terms of complications (p = 0.669). The difference in the duration of the operation was statistically significant (p < 0.001).

Conclusions

Concomitant cholecystectomy may be presented as an alternative surgical procedure due to the demonstration that concomitant cholecystectomy can be performed safely in comorbid obese patients, with a risk of becoming symptomatic in the rest of life at a certain rate, and low risk of complications in asymptomatic patients.

Intragastric single-port surgery (IGS) accesses the gastric remnant and allows ERCP for common bile duct stones after RYGB: a simple solution for a difficult problem

BACKGROUND

Patients who have undergone a Roux-en-Ygastric bypass (RYGB) and suffer from choledocholithiasis postoperatively pose a medical dilemma. Treatment of the cholestasis can be complicated because of the altered anatomy in these patients. The gastric remnant and duodenum are isolated from the pancreaticobiliary limb, making endoscopic retrograde pancreatography (ERCP) challenging and often impossible.

OBJECTIVE

To describe a method for safe introduction of the endoscope into the gastric remnant through intragastric single-port surgery (IGS), thus allowing for simultaneous cholecystectomy.

SETTING

Pilot clinical study.

METHODS

The present study is a nonrandomized clinical series describing our preliminary results using a transgastric inserted single-port device for ERCP after RYGB. The series includes 8 patients who underwent IGS ERCP after RYGB.

RESULTS

The technique was successfully applied for intraoperative ERCP through a transgastric inserted single-port device (Gelpoint Mini, Applied Medical, Rancho Santa Margarita, CA). Papilotomy was easily achieved without complications. Average operative time was 144.75 minutes. The patients recovered without complications and could be discharged after a mean of 4.38 days.

CONCLUSIONS

The novel IGS technique is safe and effective and can be applied to perform ERCP in patients with RYGB anatomy. Transgastric single port ERCP was simple to perform, achieved excellent results, and allowed for endoscopic treatment and cholecystectomy to be performed in a single procedure. The technique can be indicated in patients with complicated gallstone obstruction under altered anatomy after RYGB.

Ursodeoxycholic acid in the prevention of gallstones in patients subjected to Roux-en-Y gastric bypass1

Purpose

To evaluate the contribution of ursodeoxycholic acid (UDCA) in the first 12 months after Roux-en-Y gastric bypass in the prevention of gallstone formation.

Methods

A community-based clinical trial was conducted. A total of 137 patients were included in the study; 69 were treated with UDCA, starting 30 days after the surgery, at a dose of 150 mg twice daily (300 mg/day) over a period of 5 consecutive months (GROUP A), and 68 were control patients (GROUP B). The patients were followed-up, and ultrasonography was performed to determine the presence of gallstones at various times during follow-up. Demographic, anthropometric and comorbid indicators were obtained. The data were subjected to normality tests and evaluated using appropriate tests.

Results

Patients did not differ in their baseline characteristics. Of the 69 patients who used UDCA, only one patient developed cholelithiasis (1%), whereas 18 controls (26%) formed gallstones (OR = 24.4, p <0.001). Also, other factors were found not to influence the formation of calculi, such as pre-operative or postoperative hepatic steatosis or diabetes (p = 0.759, 0.468, 0.956).

Conclusion

The results demonstrated that patients who did not use UDCA showed a 24.4-fold greater probability of developing 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.

Is Concomitant Cholecystectomy Necessary for Asymptomatic Cholelithiasis During Laparoscopic Sleeve Gastrectomy?

BACKGROUND

There is not any consensus on concomitant cholecystectomy for asymptomatic gallbladder stones during laparoscopic sleeve gastrectomy (LSG). The aim of this study was to evaluate the surveillance results of the LSG patients who have asymptomatic gallbladder stones and did not undergo cholecystectomy.

METHODS

Patients who underwent laparoscopic sleeve gastrectomy with preoperatively detected gallbladder stones and completed at least 6 months follow-up were included in the study. Concomitant cholecystectomy was performed for symptomatic patients while it was not performed for asymptomatic subjects. At the end of the follow-up time, symptoms and signs related to gallbladder disease were recorded. Clinical and demographic characteristics were compared between symptomatic and asymptomatic patients.

RESULTS

Between February 2012 and October 2016, 312 laparoscopic sleeve gastrectomies were performed. Among the patients, 24 were regarded as asymptomatic cholelithiasis, and cholecystectomy was not performed. The mean follow-up period was 27 (6-58) months. The mean preoperative BMI was 50.0 ± 7.6 kg/m², and at the end of the follow-up time, it decreased to 35.6 ± 8.8 kg/m². Five (20.8%) patients experienced biliary colic. Acute cholecystitis or obstructive jaundice was not observed in any of the patients. Characteristics of patients who developed symptomatic gallbladder disease (n = 5) were not significantly different from those of patients who remained asymptomatic (n = 19).

CONCLUSIONS

The risk of becoming symptomatic for asymptomatic cholelithiasis is very close to the healthy population after sleeve gastrectomy. Although further studies with a high number of cases are needed, we suggest only observation for asymptomatic gallbladder stones in patients who will undergo sleeve gastrectomy.