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

Biliary complications associated with weight loss, cholelithiasis and choledocholithiasis

Biliary complications like cholelithiasis and choledocholithiasis are more common in bariatric surgery patients due to obesity and rapid weight loss. Patients with a body mass index > 40 face an eightfold risk of developing cholelithiasis. Post-bariatric surgery, especially after laparoscopic Roux-en-Y gastric bypass (LRYGB), 30% of patients develop biliary disease due to rapid weight loss. The aim of this review is to analyze the main biliary complications that occur after bariatric surgery and its management. A review of the literature was conducted mainly from 2010 up to 2023 with regard to biliary complications associated with bariatric patients in SciELO, PubMed, and MEDLINE. Patients undergoing LRYGB have a higher incidence (14.5%) of symptomatic calculi post-surgery compared to those undergoing laparoscopic sleeve gastrectomy at 4.1%. Key biliary complications within 6 to 12 months post-surgery include: Cholelithiasis: 36%; Biliary colic/dyskinesia: 3.86%; Acute cholecystitis: 0.98%-18.1%; Chronic cholecystitis: 70.2%; Choledocholithiasis: 0.2%-5.7% and Pancreatitis: 0.46%-9.4%. Surgeons need to be aware of these complications and consider surgical treatments based on patient symptoms to enhance their quality of life.

Gallstone formation and subsequent cholecystectomy after oncological gastric and esophageal resection

PURPOSE

Gallstone formation is increased after gastric (GR) or esophageal resection (ER); however, the exact pathophysiology is not fully understood yet. Symptomatic cholecystolithiasis and the need for subsequent cholecystectomy after upper gastrointestinal resection can alter the outcome in oncological patients. There is an ongoing discussion if these patients benefit from a simultaneous prophylactic cholecystectomy. This study aims to analyze the risk of gallstone formation after GR or ER and the perioperative course of a subsequent cholecystectomy.

METHODS

In this study, all patients were included, who underwent an oncological gastric or esophageal resection at the Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery in the years 2003-2021.

RESULTS

A simultaneous cholecystectomy was performed in 29.8% with GR and in 2.1% with ER (p < 0.001). There was no significant difference in complications or length-of-stay between patients with simultaneous vs. no simultaneous cholecystectomy. Newly developed gallstones tended to be more common after GR (16% vs. 10% ER), after reconstruction without preservation of the duodenal passage (17% vs. 11% with) and after GR with lymph node dissection (19% vs. 5% without). After ER, subsequent cholecystectomy was significant less frequently (11.4% vs. 2.9% OR) (p = 0.005). The subsequent cholecystectomy was performed openly in 57.1% with major complications classified as Clavien-Dindo ≥ 3a in 14.3%.

CONCLUSION

Based on the findings of our study, we do not recommend simultaneous cholecystectomy routinely in oncological gastric or esophageal resections. An individualized approach depending on risk factors like extensive lymphadenectomy or duodenal passage can be discussed.

Costs of Cancer Prevention: Physical and Psychosocial Sequelae of Risk-Reducing Total Gastrectomy

PURPOSE

Risk-reducing surgery for cancer prevention in solid tumors is a pressing clinical topic because of the increasing availability of germline genetic testing. We examined the short- and long-term outcomes of risk-reducing total gastrectomy (RRTG) and its lesser-known impacts on health-related quality of life (QOL) in individuals with hereditary diffuse gastric cancer syndrome.

METHODS

Individuals who underwent RRTG as part of a single-institution natural history study of hereditary gastric cancers were examined. Clinicopathologic details, acute and chronic operative morbidity, and health-related QOL were assessed. Validated questionnaires were used to determine QOL scores and psycho-social-spiritual measures of healing.

RESULTS

One hundred twenty-six individuals underwent RRTG because of a pathogenic or likely pathogenic germline CDH1 variant between October 2017 and December 2021. Most patients (87.3%; 110/126) had pT1aN0 gastric carcinoma with signet ring cell features on final pathology. Acute (<30 days) postoperative major morbidity was low (5.6%; 7/126) and nearly all patients (98.4%) lost weight after total gastrectomy. At 2 years after gastrectomy, 94% (64/68) of patients exhibited at least one chronic complication (ie, bile reflux, dysphagia, and micronutrient deficiency). Occupation change (23.5%), divorce (3%), and alcohol dependence (1.5%) were life-altering consequences attributed to total gastrectomy by some patients. In patients with a median follow-up of 24 months, QOL scores decreased at 1 month after gastrectomy and returned to baseline by 6-12 months.

CONCLUSION

RRTG is associated with life-changing adverse events that should be discussed when counseling patients with CDH1 variants about gastric cancer prevention. The risks of cancer-prevention surgery should not only be judged in the context of likelihood of death due to disease if left untreated, but also based on the real consequences of organ removal.

Role of Ursodeoxycholic Acid in the Prevention of Gallstones Formation in Bariatric Patients-a Systematic Review and Meta-Analysis of Randomised Trials

The aim of this meta-analysis was to assess whether treatment with ursodeoxycholic acid (UDCA) in patients who have undergone bariatric surgery reduces gallstone formation. A systematic literature search was performed using electronic databases (MEDLINE, Embase, CENTRAL, Web of Science, PROSPERO, Google Scholar and the WHO International Clinical Trials Registry platform). RCTs without restrictions on study language, year, status of publication and patient's age were used. Pooled risk ratios were calculated using a random-effects model. Subgroup analyses for drug dose, duration and procedure types were performed. Sensitivity analyses and a summary of findings table were generated to assess the robustness and the level of evidence provided, respectively. Fourteen trials were included (3619 patients, 2292 in UDCA vs 1327 in control group). Procedures included SG, RYGB, OAGB, AGB and Gastroplasty. UDCA dose ranged from 300 to 1200 mg per day. Gallstone formation occurred in 19.3% (8.3% in UDCA vs 38.1% in the control group). UDCA significantly reduced the risk of gallstone formation (14 trials, 3619 patients; RR 0.27, 95% CI 0.18-0.41; P < 0.001). UDCA significantly reduced the risk of symptomatic gallstone disease (6 trials, 2458 patients; RR 0.30, 95% CI 0.21-0.43; P < 0.001). No subgroup difference was found for different doses, duration and type of procedure performed. Oral UDCA treatment significantly reduces the risks of developing gallstones in postoperative bariatric patients from 38 to 8%. The use of 500 to 600 mg UDCA for 6 months is effective and should be implemented in all patients post-bariatric surgery.

Risk-Benefit Balance of Simultaneous Gastric Bypass or Sleeve Gastrectomy and Concomitant Cholecystectomy: A Comprehensive Nationwide Cohort of 289,627 Patients

OBJECTIVE

To assess the relevance of concomitant laparoscopic metabolic bariatric surgery (MBS) and cholecystectomy.

BACKGROUND

Because of the massive weight loss it induces, MBS is associated with an increase in the frequency of gallstones. However, no consensus yet exists on the risk-to-benefit ratio of a concomitant cholecystectomy (CC) during MBS to prevent long-term biliary complications.

METHODS

This nationwide retrospective cohort research was conducted in 2 parts using information from a national administrative database (PMSI). The 90-day morbidity of MBS with or without CC was first compared in a matched trial (propensity score). Second, we observed medium-term biliary complication following MBS when no CC had been performed during MBS up to 9 years after MBS (minimum 18 months).

RESULTS

Between 2013 and 2020, 289,627 patients had a sleeve gastrectomy (SG: 70%) or a gastric bypass (GBP: 30%). The principal indications of CC were symptomatic cholelithiasis (79.5%) or acute cholecystitis (3.6%). Prophylactic CC occurred only in 15.5% of the cases. In our matched-group analysis, we included 9323 patients in each arm. The complication rate at day 90 after surgery was greater in the CC arm [odds ratio=1.3 (1.2-1.5), P <0.001], independently of the reason of the CC. At 18 months, there was a 0.1% risk of symptomatic gallstone migration and a 0.08% risk of biliary pancreatitis. At 9 years, 20.5±0.52% of patients underwent an interval cholecystectomy. The likelihood of interval cholecystectomy decreased from 5.4% per year to 1.7% per year after the first 18 months the whole cohort, risk at 18 months of symptomatic gallstone migration was 0.1%, of pancreatitis 0.08%, and of angiocholitis 0.1%.

CONCLUSION

CC during SG and GBP should be avoided. In the case of asymptomatic gallstones after MBS, prophylactic cholecystectomy should not be recommended.

[Postoperative management]

Bariatric surgery results in significant weight loss, reduction or even remission of obesity-associated comorbidities, reduced mortality, and improved quality of life in many patients; however, obesity is a chronic disease, thus follow-up care is required after bariatric surgery. Furthermore, specific issues, such as micronutrient deficiencies and subsequent complications, can arise both in the short-term and the long-term. Abdominal pain after bariatric surgery must always be regarded as a serious symptom. A further focus should be on the diagnosis and treatment of dumping syndrome. Patients with type 2 diabetes should be regularly screened for recurrent hyperglycemia as well as specific sequelae, even though blood glucose levels may be substantially improved or normalized. In addition to centers with multidisciplinary teams, primary care and, in particular, general practitioners will play an increasingly more important role in the follow-up care after bariatric surgery.

The necessity and safety of simultaneous cholecystectomy during gastric surgery for patients with asymptomatic cholelithiasis

OBJECTIVES

The incidence of cholelithiasis is higher among individuals who have undergone gastric surgery. The benefits of concomitant gallbladder removal in asymptomatic gallstone patients remain uncertain. The aim was to investigate the necessity and safety of simultaneous cholecystectomy in this particular patient population.

METHODS

We performed a systematic review and meta-analysis to assess the incidence of asymptomatic cholelithiasis converting to symptomatic after gastric surgery and the complication rate associated with simultaneous cholecystectomy. PubMed, Embase, and the Cochrane Library were searched for relevant articles published until 10 March 202210 March 2022.

RESULTS

Patients with asymptomatic cholelithiasis after gastric surgery were at a higher risk of developing symptomatic cholelithiasis compared to those without cholelithiasis (relative risk [RR] 2.28, 95% confidence interval [CI] 1.23-4.25) and those with unknown gallbladder conditions (RR 2.70, 95% CI 1.54-4.73). Additionally, patients who underwent simultaneous cholecystectomy did not face a higher risk of complications compared to those who only underwent gastric surgery (RR 0.86, 95% CI 0.48-1.53).

CONCLUSIONS

Simultaneous cholecystectomy is both necessary and safe for patients with asymptomatic cholelithiasis undergoing gastric surgery. It is crucial to assess the gallbladder's condition before gastric surgery, and if the gallbladder status is unknown, simultaneous cholecystectomy should be avoided.

The Incidence of Cholelithiasis After Bariatric Surgery in Saudi Arabia and Its Associated Risk Factors

INTRODUCTION

Saudi Arabia has one of the highest obesity rates (35.4%) in the world, and bariatric surgery (BS) has emerged as the most effective treatment for obesity and its comorbidities. Despite its effectiveness, it is a known risk factor for cholelithiasis. The aim of this study is to identify the incidence and risk factors that contribute to the development of symptomatic cholelithiasis after different types of bariatric surgery in Saudi Arabia.

METHODS

This is a cross-sectional study conducted among the Saudi adult population. The sample size was 706 participants who underwent bariatric surgery from all over Saudi Arabia. Data collection was done through a validated online self-reported survey.

RESULTS

Out of 706 participants who fulfilled the inclusion criteria, it was found that the incidence of gallstones (GS) after bariatric surgery was 18.8%. The most incidence was during the first year of surgery, where the number of individuals reached 80.4%. The majority were in females (22.9%) and those who underwent Roux-en-Y gastric bypass (RYGB) surgery (51.2%). Patients who had a body mass index (BMI) of >25 kg/m² significantly had a higher incidence of gallstones (23.1%) compared to those who had a lesser BMI (15.8%). As the analysis showed, the medication used to prevent the occurrence of gallstones can be considered one of the protective factors, where 85.4% of individuals who used these medications did not develop cholelithiasis.

CONCLUSION

 The incidence of gallstones after bariatric surgery was high, particularly within the first year of surgery. The increase in postoperative gallstone formation is correlated with hyperlipidemia and Roux-en-Y gastric bypass as basic predictive factors. On the contrary, the medication used to prevent the occurrence of gallstones is considered a protective factor.

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.

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean gastrointestinal patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The present practical guideline is intended for clinicians and practitioners in general medicine, gastroenterology, surgery and other obesity management, including dietitians and focuses on obesity care in patients with chronic gastrointestinal diseases.

METHODS

The present practical guideline is the shortened version of a previously published scientific guideline developed according to the standard operating procedure for ESPEN guidelines. The content has been re-structured and transformed into flow-charts that allow a quick navigation through the text.

RESULTS

In 100 recommendations (3× A, 33× B, 24 × 0, 40× GPP, all with a consensus grade of 90% or more) care of gastrointestinal patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially metabolic associated liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present practical guideline offers in a condensed way evidence-based advice how to care for patients with chronic gastrointestinal diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

[Cholecystolithiasis and intestinal bypass procedures]

With the increasing number of surgical interventions for obesity, the numbers of associated complications, such as gallstones after bariatric surgery are also increasing. The incidence of postbariatric symptomatic cholecystolithiasis is 5-10%; however, the numbers of severe complications due to gallstones and the probability of a necessary extraction of gallstones are low. For this reason, a simultaneous or preoperative cholecystectomy should only be carried out in symptomatic patients. Treatment with ursodeoxycholic acid reduced the risk of gallstone formation in randomized trials but not the risk of complications related to gallstones in cases of pre-existing gallstones. The most frequently used access route to bile ducts after intestinal bypass procedures is the laparoscopic approach via the stomach remnants. Other possible access routes are the enteroscopic approach as well as the endosonography-guided puncture of the stomach remnants.

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.

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.

Frequency of cholelithiasis in need of surgical or endoscopic treatment a decade or more after Roux-en-Y gastric bypass

BACKGROUND

Symptomatic cholelithiasis requiring treatment is a known side effect after Roux-en-Y gastric bypass (RYGB), but reported rates vary greatly. The objectives for this study were to evaluate the long-term frequency of surgical or endoscopic treatment for symptomatic cholelithiasis 10-15 years after RYGB and its relation to self-reported abdominal pain.

METHODS

Observational data from 546 patients who underwent RYGB at public hospitals in Central Norway between March 2003 and December 2009 were analyzed.

RESULTS

Median follow-up was 11.5 (range 9.1-16.8) years. Sixty-five (11.9%) patients had undergone cholecystectomy prior to RYGB. Out of the 481 patients with intact gallbladder, 77 (16.0%) patients underwent cholecystectomy and six (1.2%) patients had treatment for choledocholithiasis during the observation period. Median time from RYGB to cholecystectomy or treatment of choledocholithiasis was 51 (range 1-160) and 109 (range 10-151) months, respectively. Female sex was associated with an increased risk of subsequent cholecystectomy [OR (95% CI) 2.88 (1.31-7.15)], p < 0.05. There was a higher frequency of self-reported abdominal pain at follow-up [OR (95% CI) 1.92 (1.25-2.93)] among patients who underwent cholecystectomy before or after RYGB.

CONCLUSION

With a median follow-up of more than 11 years after RYGB, one in six patients with an intact gallbladder at time of RYGB underwent cholecystectomy, and 1.1% of the patients needed surgical or endoscopic treatment for choledocholithiasis. Patients with a history of cholecystectomy reported a higher frequency of abdominal pain.

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.

Association Between Anti-Helicobacter pylori Antibody Seropositive and De Novo Gallstone Formation After Laparoscopic Sleeve Gastrectomy for Japanese Patients with Severe Obesity

PURPOSE

Patients who have undergone bariatric surgery are at risk for gallstone formation. However, the incidence of gallstone formation after bariatric surgery has not been adequately studied in the Japanese population. We aimed to elucidate the incidence and risk factors for gallstone formation after laparoscopic sleeve gastrectomy (LSG) for Japanese patients with severe obesity.

METHODS

We conducted a retrospective cohort study among patients with severe obesity treated with LSG between April 2017 and June 2020 at two institutions. Patients who had received previous cholecystectomy, had preoperative gallstones, and had received postoperative prophylactic ursodeoxycholic acid were excluded. Body weight, body mass index, and blood data were collected at each follow-up visit before and after the surgery. Follow-up abdominal ultrasonography was performed 6-12 months after surgery, and the incidence of gallstones was calculated. The association between the data and gallstone formation was evaluated.

RESULTS

During the study period, we performed LSG for 98 patients. Of these, 61 cases remained by above conditions and were examined using abdominal ultrasonography over 6 months after surgery. The incidence of gallstones was 23.0% and that of symptomatic gallstones was 3.3%. Anti-Helicobacter pylori antibody seropositive and titer were the only factors that showed significant association with de novo gallstone formation after LSG.

CONCLUSIONS

Anti-Helicobacter pylori antibody seropositive may be associated with de novo gallstone formation after LSG for Japanese patients with severe obesity.

European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal (GI) disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean GI patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The objective of the guideline is to give advice to all professionals working in the field of gastroenterology care including physicians, surgeons, dietitians and others how to handle patients with GI disease and obesity.

METHODS

The present guideline was developed according to the standard operating procedure for ESPEN guidelines, following the Scottish Intercollegiate Guidelines Network (SIGN) grading system (A, B, 0, and good practice point (GPP)). The procedure included an online voting (Delphi) and a final consensus conference.

RESULTS

In 100 recommendations (3x A, 33x B, 24x 0, 40x GPP, all with a consensus grade of 90% or more) care of GI patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially fatty liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present guideline offers for the first time evidence-based advice how to care for patients with chronic GI diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

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.

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.

Exploring the landscape, hot topics, and trends of bariatric metabolic surgery with machine learning and bibliometric analysis

Background

This study aimed to analyze the landscape of publications on bariatric metabolic surgery through machine learning and help experts and scholars from various disciplines better understand bariatric metabolic surgery's hot topics and trends.

Methods

In January 2021, publications indexed in PubMed under the Medical Subject Headings (MeSH) term 'Bariatric Surgery' from 1946 to 2020 were downloaded. Python was used to extract publication dates, abstracts, and research topics from the metadata of publications for bibliometric evaluation. Descriptive statistical analysis, social network analysis (SNA), and topic modeling with latent Dirichlet allocation (LDA) were used to reveal bariatric metabolic surgery publication growth trends, landscape, and research topics.

Results

A total of 21,798 records of bariatric metabolic surgery-related literature data were collected from PubMed. The number of publications indexed to bariatric metabolic surgery had expanded rapidly. Obesity Surgery and Surgery for Obesity and Related Diseases are currently the most published journals in bariatric metabolic surgery. The bariatric metabolic surgery research mainly included five topics: bariatric surgery intervention, clinical case management, basic research, body contour, and surgical risk study.

Conclusion

Despite a rapid increase in bariatric metabolic surgery-related publications, few studies were still on quality of life, psychological status, and long-term follow-up. In addition, basic research has gradually increased, but the mechanism of bariatric metabolic surgery remains to be further studied. It is predicted that the above research fields may become potential hot topics in the future.

Acute Cholecystitis in a Gastric Bypass Patient Complicated by Takotsubo Cardiomyopathy

Background. Gallbladder disease is a common condition after gastric bypass surgery. Even after weight loss, many bariatric patients continue to suffer from comorbid conditions. Takotsubo cardiomyopathy is a rare condition that mimics acute cardiac ischemia but seems to be caused by a catecholamine storm triggered by intense stress. Case Report. A 62-year-old female presented with acute right upper quadrant (RUQ) pain to the ER. She had a history of laparoscopic gastric bypass 5 years ago and had been noncompliant for 2 years. This noncompliance included missing follow-up appointments, gaining weight which caused poorly controlled DM, and not taking her vitamin supplements. Upon presentation, her WBC was elevated, her LFTs were normal, and imaging showed acute calculous cholecystitis. She was admitted and started on antibiotics with plans for laparoscopic cholecystectomy. The next day, she developed acute chest pain, and troponins were elevated with ST changes on EKG. Echocardiography showed a ballooned left ventricle indicative for Takotsubo cardiomyopathy. Symptomatic treatment including antibiotics, betablocker, and thiamine infusion was initiated. At three-month follow-up, ejection fraction had improved from <20% to >50%. The patient underwent interval laparoscopic cholecystectomy, which was technically very challenging due to severe ongoing acute and chronic cholecystitis. There were no cardiac issues, but the patient developed an abscess in the gallbladder fossa, which was successfully treated with oral antibiotics. Conclusions. Takotsubo cardiomyopathy complicating acute cholecystitis has thus far not been reported. Our patient had a history of gastric bypass and was noncompliant with vitamin supplementation. Thiamine deficiency may have contributed to the cardiac condition (wet beriberi).

Acute Cholecystitis: A Review

IMPORTANCE

Gallbladder disease affects approximately 20 million people in the US. Acute cholecystitis is diagnosed in approximately 200 000 people in the US each year.

OBSERVATIONS

Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis. Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness. The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness. Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis. When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test. Following diagnosis, early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8% for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. During pregnancy, early laparoscopic cholecystectomy, compared with delayed operative management, is associated with a lower risk of maternal-fetal complications (1.6% for early vs 18.4% for delayed) and is recommended during all trimesters. In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up (15.2%) compared with nonoperative management (29.3%). A percutaneous cholecystostomy tube, in which a drainage catheter is placed in the gallbladder lumen under image guidance, is an effective therapy for patients with an exceptionally high perioperative risk. However, percutaneous cholecystostomy tube placement in a randomized trial was associated with higher rates of postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%). For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy.

CONCLUSIONS AND RELEVANCE

Acute cholecystitis, typically due to gallstone obstruction of the cystic duct, affects approximately 200 000 people in the US annually. In most patient populations, laparoscopic cholecystectomy, performed within 3 days of diagnosis, is the first-line therapy for acute cholecystitis.

Gallbladder-preserving cholecystolithotomy

INTRODUCTION

Cholecystectomy is the preferred option for symptomatic gallstones. Gallbladder-preserving cholecystolithotomy (GPC) is proposed to satisfy the specific surgical patients with high-risks, biliary deformity and suffered from concomitant gallstone and choledocholithiasis.

AREAS COVERED

This review summarizes and compares the various GPC operations for cholelithiasis in some specific cases.

EXPERT OPINION

Transmural GPC mainly focuses on the gallstones, including endoscopic minimally invasive cholecystolithotomy (EMIC)-, natural orifice transluminal endoscopic surgery-, and endoscopic ultrasonography (EUS)-GPC. These GPC procedures potentially preserve gallbladder integrity and function after clearance of gallstones. Additionally, transmural GPC may overcome the disadvantages of cholecystectomy, including cosmetic considerations and postoperative complications. However, the stone recurrence rate of EMIC varies greatly from 4.92% to 40.0%, and based on limited studies, long-term adverse events due to gallbladder mucosa and natural lumen injury are largely unknown in transmural GPC. Thus, transmural GPC may be an alternative to cholecystectomy for surgical patients with high-risks and abnormal biliary anatomy. Endoscopic retrograde cholangiopancreatography-based transcystic GPC may be promising for some specific patients with concomitant gallstones and choledocholithiasis, since gallbladder integrity and function may be completely preserved as the gallbladder wall was hardly injured and the function of sphincter of Oddi was retained.

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.

Cholecystectomy Concomitant with Bariatric Surgery: Safety and Metabolic Effects

BACKGROUND

Obesity and fast weight loss in the postoperative period of bariatric surgery increase significantly the risk of cholelithiasis. Moreover, emerging evidence has pointed out the role of bile acids as possible metabolism and weight loss enhancers. This study aims to analyze the influence of cholecystectomy (CL) concomitant with bariatric surgery on weight loss, metabolic repercussions, and postoperative morbidity.

STUDY DESIGN

Retrospective cohort study. A total of 363 medical records were analyzed between 2002 and 2017, with 255 patients divided into four groups: with concomitant CL: sleeve gastrectomy (SG + CL group) and Roux-en-Y gastric bypass (GB + CL group); without concomitant CL: sleeve gastrectomy (SG group) and RYGB (GB group).

RESULTS

CL concomitant with bariatric surgery is not related to worse long-term metabolic outcomes when compared to isolated bariatric surgery. In the postoperative follow-up of the isolated bariatric surgeries, 18 (16.5%) patients underwent cholecystectomy. There was no statistical difference between the groups regarding post-surgical complications.

CONCLUSION

CL did not lead to worse metabolic outcomes and was also not related to a higher incidence of postoperative complications. Cholelithiasis and cholecystitis are important concerns in the postoperative period of bariatric surgery and a careful evaluation of the concomitant procedure should be performed.

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.

Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review

Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.

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.

Cholecystectomy as a risk factor for metabolic dysfunction-associated fatty liver disease: unveiling the metabolic and chronobiologic clues behind the bile acid enterohepatic circulation

Metabolic dysfunction-associated fatty liver disease (MAFLD) is highly prevalent worldwide. Recent clinical and experimental studies have addressed the association between cholecystectomy and MAFLD, confirming that cholecystectomy is an independent risk factor for MAFLD. In this review, we describe the epidemiologic evidence that links cholecystectomy to MAFLD, and discuss the possible mechanisms behind these connections, in order to unveil the metabolic and chronobiologic signals conveyed by the waves of the bile acid enterohepatic circulation.

Endoscopic ultrasonography (EUS) -guided visceral anastomoses: indications and techniques

BACKGROUND

Technologic advancements in the field of therapeutic endoscopy have led to the development of minimally invasive techniques to create gastrointestinal anastomosis instead of surgical interventions. Examples of the potential clinical applications include bypassing malignant and benign gastric outlet obstruction, providing access to the pancreato-biliary tree in those who have undergone Roux-en-Y gastric bypass, and relieving pancreato-biliary symptoms in afferent loop syndrome.

METHODS

starting from the available literature, aim of this narrative review is to summarize indications and techniques of endoscopic ultrasonography-guided visceral anastomoses.

RESULTS

A critical review of literature on the new EUS-guided anastomoses.

CONCLUSIONS

Increasing evidences are accumulating demonstrating advantages of EUS guided visceral anastomoses. These new procedures represent a novel, minimally invasive alternative for managing different type of intestinal obstruction.

Bridged one-anastomosis gastric bypass: technique and preliminary results

PURPOSE

One-anastomosis gastric bypass (OAGB) is an established bariatric procedure performed worldwide. We developed a modification of OAGB leaving a bridge at the cranial 2 cm of the fundus as a gastro-gastric fistula to allow for endoscopic access to the bypassed stomach. We present the preliminary results of 44 patients who underwent this technique in our hospital.

METHODS

We analyzed, retrospectively, data collected prospectively on 44 patients who underwent our bridged one-anastomosis gastric bypass (BOAGB) procedure between September, 2018 and November, 2020.

RESULTS

The mean age of the patients was 45.2 ± 9.3 years (range 20-66 years). The mean preoperative body mass index (BMI), weight, and HbA1c values were 41.5 ± 6.4 kg/m² (range 35-59), 116 ± 22.7 kg, and 8.2 ± 2.1%, respectively. After a median follow-up period of 18 months (11-26 months), the mean postoperative BMI was 28.4 ± 3.2 kg/m² (range 21-38), the mean total weight loss was 35.8 ± 13.5 kg (range 20-80 kg), and the mean percentage of excess weight loss (%EWL) and the percentage of total weight loss (%TWL) were 79.8 ± 16.1% (range 47-109) and 30.6 ± 6.9% (range 19-48), respectively. The mean postoperative HbA1c level was 6.3 ± 0.9%. There were two early complications (stenosis and bleeding) and one late complication (marginal ulcer).

CONCLUSION

Patients who underwent BOAGB lost weight similarly to those who underwent OABG as reported in the literature, without an apparent increase in complications related to the technique. Randomized studies with longer term follow-up are needed.

Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass: a meta-analysis

BACKGROUND

Bariatric surgery could increase the risk of cholelithiasis, although it is unclear whether the incidence rates of cholelithiasis are similar after different bariatric procedures.

OBJECTIVES

To compare the incidence rates of cholelithiasis after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in people with obesity.

SETTING

Meta-analysis of cohort studies.

METHODS

We searched the PubMed and Web of Science databases for relevant studies before December 2020, and estimated the summary odds ratios (OR) and 95% confidence intervals (CI) using a random-effects model or fixed-effects model, according to the heterogeneity.

RESULTS

In total, 8 cohort studies were included in this meta-analysis, and 94,855 and 106,844 participants received SG and RYGB, respectively. Compared with those receiving RYGB, the summary results showed that participants receiving SG had a 35% lower rate of cholelithiasis (OR, .65; 95% CI, .49-.86). Also, the participants receiving SG had a significantly lower incidence of cholecystectomy than those receiving RYGB (OR, .54; 95% CI, .30-.99). In a subgroup analysis, SG was associated with a significantly lower incidence of subsequent cholelithiasis than RYGB in both Western and non-Western countries. SG led to a significantly lower incidence of cholelithiasis than RYGB only when the follow-up was <2 years instead of over 2 years.

CONCLUSION

Participants receiving SG had a significantly lower incidence of cholelithiasis than those receiving RYGB, particularly within the first 2 years after the bariatric surgery.

Intersection of smoking, e-cigarette use, obesity, and metabolic and bariatric surgery: a systematic review of the current state of evidence

BACKGROUND

Millions of Americans qualify for metabolic and bariatric surgery (MBS) based on the proportion of the population with severe obesity. Simultaneously, the use of electronic nicotine/non-nicotine delivery systems (ENDS) has become epidemic.

OBJECTIVE

We conducted a timely systematic review to examine the impact of tobacco and ENDS use on post-operative health outcomes among MBS patients.

METHODS

PRISMA guidelines were used as the search framework. Keyword combinations of either "smoking," "tobacco," "e-cigarette," "vaping," or "ENDS" and "bariatric surgery," "RYGB," or "sleeve gastrectomy" were used as search terms in PUBMED, Science Direct, and EMBASE. Studies published in English between January 1990 and June 2020 were screened.

RESULTS

From the 3251 articles found, a total of 48 articles were included in the review. No articles described a relationship between ENDS and post-operative health outcomes in MBS patients. Seven studies reported smokers had greater post-MBS weight loss, six studies suggested no relationship between smoking and post-MBS weight loss, and one study reported smoking cessation pre-MBS was related to post-MBS weight gain. Perioperative use of tobacco is positively associated with several post-surgery complications and mortality in MBS patients.

CONCLUSIONS

Combustible tobacco use among MBS patients is significantly related to higher mortality risk and complication rates, but not weight loss. No data currently is available on the impact of ENDS use in these patients. With ENDS use at epidemic levels, it is imperative to determine any potential health effects among patients with severe obesity, and who complete MBS.

Shortening and Plication of Entero-enterostomy for Intussusception in Roux-en-Y Gastric Bypass: Video Report

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered by a large percentage of bariatric surgeons' the operation of choice for obesity surgery as reported by Melvin (J Gastrointest Surg. 4:398-400, 2004). It is considered a generally safe procedure with a low percentage of complications. One of these complications is small bowel obstruction which has different etiologies. A rare cause of intestinal obstruction is intussusception at the entero-enterostomy as reported by Arapis et al. (Surg Obes Relat Dis. 1:23-33, 2019) and Sneineh et al. (OBES SURG 30:846-850, 2020). The accurate incidence of intussusception after LRYGB is unknown but Simper et al. (Surg Obes Relat Dis. 4:77-83, 2008) found a 0.15% incidence in their study. Diagnosis of intussusception requires a high index of suspicion because neither physical examination nor imaging is sensitive. CT scan might identify the problem, but a negative CT scan image does not rule out intussusception. Treatment of intussusception varies according to the clinical picture of the patient at the presentation. These variations may include conservative treatment up to resection of the entero-enterostomy and do a re-anastomosis as discussed by Daellenbach et al. (OBES SURG 21:253-263, 2011). The video aims to present an alternative option for surgical management of intussusception of the entero-enterostomy following LRYGB which to our knowledge was not published before.

The Short-Term Effects of Transit Bipartition with Sleeve Gastrectomy and Distal-Roux-en-Y Gastric Bypass on Glycemic Control, Weight Loss, and Nutritional Status in Morbidly Obese and Type 2 Diabetes Mellitus Patients

PURPOSE

The aim of this study was to compare the postoperative metabolic and nutritional outcomes after transit bipartition with sleeve gastrectomy (TB-SG) and distal-Roux-en-Y gastric bypass (D-RYGB).

MATERIALS AND METHODS

A retrospective evaluation was made of 109 morbidly obese patients who underwent TB-SG or D-RYGB. Primary outcomes included metabolic variables such as glycemic control and serum lipid levels, and secondary outcomes consisted of nutritional deficiencies and weight loss after surgical procedures.

RESULTS

During the study period, 83 and 26 patients underwent D-RYGB and TB-SG, respectively. The preoperative characteristics and nutritional status of the groups were similar. D-RYGB resulted in significantly higher weight loss rates in the first 3 months, but the percentage of excess weight loss (EWL %) was not different in the 12-month follow-up period. Although D-RYGB provided faster glycemic control due to early weight loss, there was no difference between the two groups. At the end of the follow-up period, the TB-SG was associated with significantly less deficiency of vitamin D, vitamin B12, iron, and folic acid. Anastomosis leakage was more common in the D-RYGB technique. The overall complication rates of the groups were similar.

CONCLUSION

TB-SG is a safe and effective alternative to D-RYGB for the treatment of obesity-related metabolic disorders with fewer nutritional deficiencies.

Image-Guided Surgery for Common Bile Duct Stones After Roux-en-Y Gastric Bypass

Background: The relationship between obesity with common bile duct stone (CBDS) is close and increases after a Roux-en-Y gastric bypass (RYGB). Due to the anatomical modification, direct endoscopic access is not always possible. For this reason, image-guided surgery (IGS) by percutaneous transhepatic biliary drainage (PTBD) of the common bile duct (CBD) could be a first-line approach for the treatment of post-RYGB choledocholithiasis. The aim of this study was to analyze the feasibility and safety of CBDS treatment after RYGB with IGS. Materials and Methods: We present a descriptive retrospective observational multicentric study on the treatment of choledocholithiasis in patients operated on for RYGB using IGS through a minimally invasive approach by PTBD. The diagnosis of CBDS was made according to the symptoms of the patients, supported by blood tests, and medical images. Treatment was planned in two stages: in the first step, a PTBD was performed, and in the second step the choledocholithiasis was removed. Results: Of a total of 1403 post-RYGB patients, 21 presented choledocholithiasis. Of these, n = 18 were included. Symptoms were reported in n = 15 (8 cholestatic jaundice, 7 cholangitis), whereas n = 3 were asymptomatic. Percutaneous treatment was performed in all these patients, treated with a balloon and stone basket. A hyperamylasemia without pancreatitis was observed in 3 patients. No complications or deaths associated with the procedure were reported. The average hospital stay was 8.6 days. Conclusion: IGS is an interesting option for the treatment CBDS after RYGB. For these patients, PTBD is feasible and safe.

Gastric pouch sero-myotomy for persistent dysphagia after roux-en-Y gastric bypass: Video report

•

Dysphagia after roux en Y gastric bypass can be related to problems at the pouch itself.

•

An initial step in the management should be trial of endoscopic dilalation.

•

Laparoscopic sero-myotomy is a valid and feasible option for the treatment of proximal gastric stricture.

•

Revisional operations after sleeve gastrectomy can cause this kind of strictures.

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most common bariatric operations done worldwide [1]. About 6.6% of the LSG is being converted to laparoscopic roux-en-Y gastric bypass (LRYGB), most commonly due to inadequate weight loss (65%) and severe reflux (26%) [2]. The most common late complications after LRYGB are dumping, small bowel obstruction, internal hernia, weight regain, marginal ulcer, strictures of the gastro-jejunostomy [3] and rarely proximal stricture at the gastric pouch as our presented case. Treatment options for such a case may start with endoscopic dilatation and if not succeeded it may warrant surgical intervention as shortening of the pouch and redo of the gastrojejunostomy proximal to the stricture or even total gastrectomy and esophago-jejunal anastomosis. Sero-myotomy of the gastric pouch can be done as the same technique which can be used in sero-myotomy of sleeved stomach with stricture [4] and spare resection of the pouch.

This report aims to present a new option of surgical management for proximal stricture of the gastric pouch after LRYGB which to our knowledge was never published in the literature.

The Incidence and Risk Factors of Cholelithiasis Development After Bariatric Surgery in Saudi Arabia: A Two-Center Retrospective Cohort Study

Background: Rapid weight loss after bariatric surgery is a known risk factor for cholelithiasis development. This study aimed to estimate the incidence of cholelithiasis following bariatric surgery among morbidly obese patients who underwent bariatric surgery. Methods: This is a retrospective cohort study of all morbidly obese patients who underwent bariatric surgery in King Abdulaziz Medical City (Riyadh, Saudi Arabia) or King Abdulaziz Hospital (Al Ahsa, Saudi Arabia) between January 2015 and December 2018. Patients with a history of cholecystectomy or previous bariatric surgery were excluded. We estimated the incidence rate of cholelithiasis among the cohort. We also examined the associated risk factors of cholelithiasis development. Results: The study cohort contained 490 patients (38.7% males; 61.43% females) with a mean age of 36.87 ± 11.44 years. Most patients (58.54%) were followed up for 12 months. The incidence of cholelithiasis post-operation was 6.53% (n = 32). The average period of cholelithiasis formation was 12-24 months. The percentage of total weight loss (TWL%) was significantly associated with the development of cholelithiasis post-operatively. Conclusion: A significant association was found between weight loss following bariatric surgery and the incidence of cholelithiasis. Gender, age, and comorbidities were not associated with the formation of cholelithiasis. We recommend regular follow-up appointments with thorough patient education about gradual weight loss to reduce the risk of developing cholelithiasis.

Is It Safe to Recommend Cholecystectomy Whenever Gallstones Develop After Bariatric Surgery?

BACKGROUND

Cholelithiasis (ChL) is common after bariatric surgery (BS). Laparoscopic cholecystectomy (LC), the preferential treatment, is usually recommended only to symptomatic patients. LC may be, however, beneficial to asymptomatic patients as well. A prerequisite to such a policy is that it must be safe. This study aimed to assess whether, in post-bariatric (Post-Bar) patients who develop gallstones, LC achieves the same results as those reported in the general population.

METHODS

A cohort of 376 patients undergoing elective LC had their medical records reviewed. Patients were divided into non-bariatric (Non-Bar) and Post-Bar groups, and then compared for characteristics and surgical outcomes.

RESULTS

The study included 367 patients, 292 Non-Bar and 75 Post-Bar. Considering characteristics, Post-Bar patients were younger (44.5 ± 11.8 vs 48.4 ± 14.1) and less symptomatic (2.4% vs 19.8%) and had a higher BMI (32.2 ± 4.8 vs 30.8 ± 4.4) than Non-Bar patients. Regarding surgical outcomes, mortality (none), morbidity (1%, only in Non-Bar patients), readmission (1%, only in Non-Bar patients), conversion to laparotomy (0.6%, only in Non-Bar patients) showed no difference between the groups. Operative time (42.6 ± 14.4 min in Non-Bar and 38.2 ± 12.6 min in Post-Bar patients) tended to be lower in Post-Bar patients, p = 0.054. Same-day discharge was higher in Post-Bar patients (98.6%) than in Non-Bar patients (90.4%), p = 0.03.

CONCLUSIONS

Compared with Non-Bar patients, LC in Post-Bar patients showed not only similar morbimortality, readmissions, and conversions but also even a higher same-day discharge rate and a trend to lower operative times.

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.