The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss: A two-centre retrospective cohort study

Cholelithiasis, Gut Microbiota and Bile Acids after Bariatric Surgery-Can Cholelithiasis Be Prevented by Modulating the Microbiota? A Literature Review

BACKGROUND

Cholelithiasis is one of the more common complications following bariatric surgery. This may be related to the rapid weight loss during this period, although the exact mechanism of gallstone formation after bariatric surgery has not been fully elucidated.

METHODS

The present literature review focuses on risk factors, prevention options and the impact of the gut microbiota on the development of gallbladder stones after bariatric surgery.

RESULTS

A potential risk factor for the development of cholelithiasis after bariatric surgery may be changes in the composition of the intestinal microbiota and bile acids. One of the bile acids-ursodeoxycholic acid-is considered to reduce the concentration of mucin proteins and thus contribute to reducing the formation of cholesterol crystals in patients with cholelithiasis. Additionally, it reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. Patients who developed gallstones after bariatric surgery had a higher abundance of Ruminococcus gnavus and those who did not develop cholelithiasis had a higher abundance of Lactobacillaceae and Enterobacteriaceae.

CONCLUSION

The exact mechanism of gallstone formation after bariatric surgery has not yet been clarified. Research suggests that the intestinal microbiota and bile acids may have an important role in this.

Acute Kidney and Liver Injury Associated With Low-Dose Liraglutide in an Obese Adolescent Patient

In 2020, the US Food and Drug Administration approved liraglutide (glucagon-like-peptide-1-receptor-agonist) as an adjunctive therapy for weight management in adolescents aged 12 to 18 years in combination with a reduced-calorie diet and increased physical activity. The 2023 American Academy of Pediatrics guidelines recommend pharmacotherapy with glucagon-like-peptide-1-receptor-agonist as a second-line therapy in obesity management. Although reports in adults have suggested a link between liraglutide and adverse effects including hepatic injury and acute kidney injury (AKI), these effects have not previously been reported among adolescents treated with liraglutide for weight loss. We present a 17-year-old male who developed AKI and evidence of hepatic injury (significant elevation of hepatic transaminases) after 3 months administration of the lowest dosage of liraglutide (0.6 mg/day) for management of class III obesity. The patient experienced significant loss of appetite, weight loss, and melancholy during the treatment period. One month after discontinuing liraglutide, his mood had improved, his liver enzymes had returned to normal, and AKI had resolved. The Adverse Drug Reaction Probability Scale suggested a high likelihood of a causative association between liraglutide and his symptoms. Our report highlights the importance of vigilance in monitoring for these potential adverse effects among adolescents treated for obesity with any dose of liraglutide.

The impact of bariatric surgery on admissions for gastrointestinal complications and conditions associated with obesity: A nationwide study

BACKGROUND

Obesity worsens various gastrointestinal pathologies. While bariatric surgery ameliorates obesity, it substantially modifies the gastrointestinal system depending on surgery type, with limited data on subsequent impact on obesity-related gastrointestinal admissions.

METHODS

Using the 2012-2014 Nationwide Readmission Database, we included individuals with obesity who received vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), or hernia repair (HR-control surgery). Our main focus was the adjusted odds ratio (aOR) for gastrointestinal inpatient admissions within 6 months following surgery compared to the 6 months preceding it, while controlling for several confounding factors. Gastrointestinal admissions were grouped into postoperative complications or obesity-associated gastrointestinal conditions.

RESULTS

Our cohort included 140,103 adults with RYGB, 132,253 with VSG, and 12,436 HR controls. Postoperative gastrointestinal complications were most common after RYGB, prominently obstruction (aOR = 33.17, 95%CI: 18.01, 61.10), and Clostridium difficile infection (aOR: 12.52, 95%CI: 6.22, 25.19). VSG also saw significantly increased but less frequent similar conditions. Notably, for gastrointestinal conditions associated with obesity, acute pancreatitis risk was higher post-VSG (aOR = 6.26, 95%CI: 4.02, 9.73). Post-RYGB patients were most likely to be admitted for cholelithiasis with cholecystitis (aOR: 4.15, 95% CI: 3.24, 5.31), followed by chronic liver disease (aOR: 3.00, 95% CI: 2.33, 3.87). The risk of noninfectious colitis admissions was threefold higher after RYGB and VSG. No gastrointestinal conditions showed an increase after HR.

CONCLUSION

Despite weight loss, bariatric surgery was associated with an increased risk of hepato-pancreatobiliary and colitis admissions related to obesity in the first six postoperative months, with considerable variations in rates of gastrointestinal conditions by surgery type.

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.

Does previous gastrectomy history affect the surgical outcomes of laparoscopic cholecystectomy?

PURPOSE

This current study aimed to explore whether gastrectomy history influenced surgical outcomes while undergoing laparoscopic cholecystectomy (LC).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for eligible studies from inception to April 29, 2023. The Newcastle-Ottawa Scale (NOS) was adopted to assess the quality of included studies. The mean differences (MDs) and 95% confidence intervals (CIs) were calculated for continuous variables, and the odds ratios (ORs) and 95% CIs were calculated for dichotomous variables. RevMan 5.4 was used for data analysis.

RESULTS

Seven studies enrolling 8193 patients were eligible for the final pooling up analysis (380 patients in the previous gastrectomy group and 7813 patients in the non-gastrectomy group). The patients in the gastrectomy group were older (MD = 11.11, 95%CI = 7.80-14.41, P < 0.01) and had a higher portion of males (OR = 3.74, 95%CI = 2.92-4.79, P < 0.01) than patients in the non-gastrectomy group patients. Moreover, the gastrectomy group had longer LC operation time (MD = 34.17, 95%CI = 25.20-43.14, P < 0.01), a higher conversion rate (OR = 6.74, 95%CI = 2.17-20.26, P = 0.01), more intraoperative blood loss (OR = 1.96, 95%CI = 0.59-3.32, P < 0.01) and longer postoperative hospital stays (MD = 1.07, 95%CI = 0.38-1.76, P < 0.01) than the non-gastrectomy group.

CONCLUSION

Patients with a previous gastrectomy history had longer operation time, a higher conversion rate, more intraoperative blood loss, and longer postoperative hospital stays than patients without while undergoing LC. Surgeons should pay more attention to these patients and make prudent decisions to avoid worse surgical outcomes as much as possible.

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.

Prevalence of elevated alkaline phosphatase levels among post-bariatric surgery patients

INTRODUCTION

Little is known about the prevalence of elevated alkaline phosphatase in post-bariatric surgery patients due to under-utilization of this test after surgery. Elevated alkaline phosphatase levels are caused by hepatobiliary disease or bone resorption, which can lead to gallstones and osteoporosis. Early, post-operative measurement of alkaline phosphatase can prevent complications, thus reducing morbidity and overall healthcare costs. The purpose of this study was to determine the prevalence of elevated alkaline phosphatase levels among post-operative bariatric surgery patients.

METHODS

This was a retrospective study of patients 18 years or older, who underwent laparoscopic sleeve gastrectomy (LSG) at a Midwestern Weight Management Clinic between January 1, 2002 and December 31, 2020. Alkaline phosphatase levels, weight, body mass index (BMI), gamma-glutamyl transferase (GGT), parathyroid hormone (PTH), calcitriol, and calcitonin, vitamin D and multivitamin supplementation were measured at baseline, 3, 6, and 12 months post-surgery.

RESULTS

Two hundred thirty patients with mean age of 47 years and BMI of 44.6 were included with 80.9% (n = 186) female. Alkaline phosphatase was elevated relative to baseline for 36.1% of patients (n = 52) at 3 months post-surgery, 42.4% of patients (n = 56) at 6 months, and 43.3% of patients (n = 45) at 12 months (p < 0.001). There were six cases of documented cholelithiasis post-surgery.

CONCLUSION

A significant proportion of participants experienced elevations in alkaline phosphatase following surgery, indicating that the prevalence of gallbladder pathology and bone resorption may be higher than previously thought. This merits additional investigation into these complications post-operatively to determine prevalence and avoid excess morbidity.

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.

Prevalence of Symptomatic Gallbladder Disease After Bariatric Surgery: A Literature Review

Introduction Gallbladder disease (GBD) encompasses several medical conditions, including gallbladder stone formation, biliary colic, and cholecystitis. These conditions may arise following bariatric surgery, including bypass or laparoscopic sleeve gastrectomy (LSG). The development of GBD after surgery may be attributed to various factors, including the formation of stones shortly after the procedure, the exacerbation of existing stones due to the surgery, or inflammation of the gallbladder. Rapid weight loss after surgery has also been proposed as a contributing factor. Methodology This observational study consisted of a review of retrospective hospital patient medical records of 350 adult participants who underwent LSG, with 177 participants included in the study after excluding those with cholecystectomy or GBD prior to surgery. The participants were followed for a median of two years, during which we recorded any hospitalizations, emergency department visits, clinic visits, and incidents of cholecystectomy or abdominal pain due to GBD. The participants were grouped into two: those with GBD and those without GBD after bariatric surgery, and quantitative data were summarized using mean and standard deviations. The data were analyzed using IBM SPSS Statistics for Windows, Version 20.0. (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp), with a statistical significance of P<0.05. Results In our retrospective study of 177 patients who underwent LSG, the incidence of GBD after bariatric surgery was 4.5%. Most patients with GBD after bariatric surgery were White, but this difference was not statistically significant. Patients with type 2 diabetes had a higher incidence of GBD after bariatric surgery than those without diabetes (8.3% vs. 3.6%, P=0.355). Patients with HTN had a lower incidence of GBD after bariatric surgery than those without HTN (1.1% vs. 8.2%, P=0.032). Anti-hyperglycemia medication use did not significantly increase the risk of GBD after bariatric surgery (7.5% vs. 3.8%, P=0.389). None of the patients on weight loss medication developed GBD after bariatric surgery, compared to 5% of patients who did not take weight loss medication. Our sub-data analysis showed that patients who developed GBD after bariatric surgery had a high BMI (above 40 kg/m2) before surgery, which decreased to 35 kg/m2 and below 30 kg/m2 at six months and 12 months post-surgery, respectively. Conclusions Our findings demonstrate that the prevalence of GBD after LSG is low and comparable to the general population without LSG. Thus, LSG does not increase the risk of GBD. We found that rapid weight loss after LSG is a significant risk factor for GBD. These findings suggest that patients who undergo LSG should be informed of the risks of GBD and undergo careful screening before surgery to detect any pre-existing gallbladder issues. Overall, our study highlights the importance of continued research into the factors associated with GBD after bariatric surgery and the need for standardized prophylactic measures to prevent this potentially serious complication.

Semaglutide for the treatment of obesity

Semaglutide is a glucagon-like peptide-1 receptor agonist that was recently approved by the US Food and Drug Administration for chronic weight management. This paper reviews data on the mechanism of action, weight-loss and cardiometabolic efficacy, and safety of semaglutide 2.4 mg/week for obesity. Semaglutide has demonstrated the largest weight loss of any obesity medication to date with reductions of approximately 15% of initial weight at 68 weeks, accompanied by improvements in cardiovascular risks factors and physical functioning. The approval of this medication provides patients with greater options for weight management.

Factors influencing body weight one year after bariatric surgery

The significant outcome of bariatric surgery (BS) is weight loss, which may be affected by many factors, such as initial body weight before surgery, sex, and dietary intake. Moreover, rapid weight loss is associated with an increased incidence of postsurgical cholelithiasis. To investigate the observed weight loss outcomes during the first year after BS, we investigated the factors that may influence weight loss and to detect the efficacy of prophylactic ursodeoxycholic acid against gallstone formation. This was a retrospective cohort study of all patients with morbid obesity who underwent BS in the hospital and completed a 1-year follow up. Patients with a previous BS or a history of cholecystectomy before BS were excluded. Data were extracted from the medical records at multiple postoperative intervals. There was significant weight loss in terms of percentage of excess weight loss and reduction in body mass index postoperative. A significant correlation was found between the percent of excess weight loss and age, initial body mass index, and initial weight, but there was no significant correlation with sex or type of surgery. The incidence of postoperative cholecystectomy is almost negligible. A significant association was found between age and weight loss after BS. ursodeoxycholic acid is an effective prophylaxis to decrease the incidence of cholecystectomy after BS.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

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.

Sleeve gastrectomy in class 1 obesity: Assessment of operative outcomes

BACKGROUND

The risk/benefit ratio of sleeve gastrectomy (SG), especially in patients without type 2 diabetes (T2D), is unknown for patients with class 1 obesity.

OBJECTIVES

Assessment of operative outcomes of SG in class 1 obesity.

SETTING

Private practice.

METHODS

Candidates for a primary SG with body mass index 30-35 kg/m² after 5 years of unsuccessful dieting were included after informed consent was obtained. Participants who did not complete 3-month follow-up and those who underwent modified SGs were excluded. Data and complications were recorded prospectively. Patients were followed up at 3, 6, and 12 months and yearly thereafter. Definition of presence and remission of T2D and insulin resistance were set according to guidelines. Effects on weight loss parameters were evaluated with Wilcoxon signed-rank test.

RESULTS

Between 2012 and 2020, 143 consecutive SGs were performed in patients with class 1 obesity without conversion, leak, mortality, or a venous event. Two were lost to follow-up. In 141 participants, 2 bleedings and 1 colon perforation occurred (2.1% rate for acute life-threatening events). During a mean follow-up of 25.9 months; 1 case of functional stenosis and 4 cases of de novo symptomatic cholelithiasis clinically became evident in different patients, all requiring reoperation. Therefore a 5.6% rate of major complications were identified at 2 years. The benefit on weight loss was immediate and permanent (P < .001). T2D and insulin resistance were in remission in 100% and 98.1% of participants at 1 year, respectively.

CONCLUSION

The 5.6% major complication rate reflects a minimum because more de novo symptomatic gallstones and stenosis are yet to occur or overlooked. Additionally, this excludes patients with de novo reflux and malnutrition, dissatisfaction issues, or recidivism. Caution is required to freely operate on patients with class 1 obesity with no co-morbidity. Evidence-based outcome data are lacking to balance the reported risks.

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.

Cholelithiasis in patients treated with Glucagon-Like Peptide-1 Receptor: An updated meta-analysis of randomized controlled trials

Glucagon-Like Peptide-1 Receptor Agonists (GLP1-RA) has been associated with cholelithiasis in a previous meta-analysis. The publication of new trials suggests the need for an update. We collected trials with GLP1-RA vs. other therapies, calculating Mantel-Haenszel odds ratio (MH-OR, 95%CI). GLP1-RA significantly increased the risk of cholelithiasis (MH-OR 1.28 [1.11, 1.48]).

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.

Risk Factors for Cholecystectomy After Laparoscopic Roux-En-Y Gastric Bypass

BACKGROUND

Patients who have undergone bariatric surgery are at risk for subsequent cholecystectomy. We aimed to identify risk factors for cholecystectomy after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

We conducted a retrospective case-control study of patients who underwent LRYGB between 2013 and 2015. Cases underwent cholecystectomy because of biliary symptoms after LRYGB. For each case, two controls were selected without subsequent cholecystectomy. Logistic regression analyses were used to identify risk factors.

RESULTS

Between 2013 and 2015, 1780 primary LRYGBs were performed. We identified 233 (13.1%) cases who had undergone cholecystectomy after a median (IQR) of 12 (8-17) months, and 466 controls. Female gender (OR (95% CI) 1.83 (1.06-3.17)), Caucasian ethnicity (OR (95% CI) 1.82 (1.10-3.02)), higher percent total weight loss (%TWL) at 12 months (OR (95% CI) 1.06 (1.04-1.09)), and preoperative pain syndrome (OR (95% CI) 2.72 (1.43-5.18)) were significantly associated with an increased risk for cholecystectomy. Older age (OR (95% CI) 0.98 (0.96-0.99)) and preoperative statin use were associated with a reduced risk (OR (95% CI) 0.56 (0.31-1.00)). A dose-effect relationship was found between the intensity of preoperative statin and risk for cholecystectomy.

CONCLUSIONS

In our study, higher %TWL and preoperative pain syndrome were associated with an increased risk for cholecystectomy besides the traditional risk factors female gender and Caucasian ethnicity. These factors can be used to identify high-risk patients, who might benefit from preventive measures. Whether statins can protect bariatric patients from developing gallstones should be investigated prospectively.

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.

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.

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

BACKGROUND

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

OBJECTIVE

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

Concomitant cholecystectomy during bariatric surgery: The jury is still out

BACKGROUND

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

DATA SOURCES

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

CONCLUSIONS

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

The Type of Bariatric Surgery Impacts the Risk of Acute Pancreatitis: A Nationwide Study

Objective

We investigated whether vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass surgery (RYGB) have a differential impact on post-operative risk of acute pancreatitis (AP).

Methods

This retrospective study uses the 2012–2014 National Readmission Database. We compared morbidly obese patients who underwent VSG (n = 205,251), RYGB (n = 169,973), and hernia repair (HR) control (n = 16,845). Our main outcome was rates of AP within 6 months post- vs. 6 months pre-surgery in VSG, RYGB, and HR. We also investigated risk factors and outcomes of AP after bariatric surgery.

Results

The rates of AP increased post- vs. pre-VSG (0.21% vs. 0.04%; adjusted odds ratio [aOR] = 5.16, P < 0.05) and RYGB (0.17% vs. 0.07%; aOR = 2.26, P < 0.05) but not post-HR. VSG was associated with a significantly greater increase in AP risk compared to RYGB (aOR = 2.28; 95% CI: 1.10, 4.73). Furthermore, when compared to HR controls, only VSG was associated with a higher AP risk (aOR = 7.58; 95% CI: 2.09, 27.58). Developing AP within 6 months following bariatric surgery was mainly associated with younger age (18–29 years old: aOR = 3.76 for VSG and aOR: 6.40 for RYGB, P < 0.05) and gallstones (aOR = 85.1 for VSG and aOR = 46 for RYGB, P < 0.05). No patients developed “severe AP” following bariatric surgery.

Conclusions

More patients develop AP within 6 months after VSG compared to RYGB and controls. This risk is highest for younger patients and those with gallstones. Prospective studies examining mechanisms and prevention are warranted.

Safety issues with glucagon-like peptide-1 receptor agonists (pancreatitis, pancreatic cancer and cholelithiasis): Data from randomized controlled trials

AIM

Glucagon-like peptide 1 receptor agonists (GLP1-RA) have been associated with an increased risk of pancreatitis and pancreatic cancer. Prior meta-analyses of randomized controlled trials failed to show any significant increase of risk; however, those meta-analyses did not include the recently published cardiovascular outcome trials (CVOT) with GLP1-RA, which provide a substantial additional body of data. The aim of the present meta-analysis is to assess the effect of GLP1-RA on pancreatitis, pancreatic cancers and cholelithiasis.

MATERIALS AND METHODS

A Medline search for GLP-1 receptor agonists (exenatide, liraglutide, lixisenatide, albiglutide, dulaglutide or semaglutide) was performed, collecting all randomized clinical trials with a duration >11 weeks, enrolling patients with type 2 diabetes and comparing a GLP-1 receptor agonist with placebo or any other non-GLP-1 receptor agonist drug.

RESULTS

Of the 113 trials fulfilling inclusion criteria, 13 did not report information on pancreatitis, whereas 72 reported no events in all treatment groups. The incidence of pancreatitis and pancreatic cancer with GLP1-RA was not significantly different from that observed in comparator arms (MH-OR [95% CI] 0.93 [0.65-1.34], P = .71, and 0.94 [0.52-1.70], P = .84, respectively), whereas, a significantly increased risk of cholelithiasis (MH-OR [95% CI] 1.30 [1.01-1.68], P = .041) was detected.

CONCLUSIONS

Presently available data confirm the safety of GLP-1 receptor agonists for pancreatitis. Conversely, therapy with those drugs is associated with an increased risk of cholelithiasis, which deserves further investigation.

Cholecystectomy after gastric bypass-incidence and complications

BACKGROUND

Although cholecystectomy incidence is known to be high after Roux-en-Y gastric bypass (RYGB) surgery, the actual increase in incidence is not known. Furthermore, the outcome of cholecystectomy after RYGB is not known.

OBJECTIVES

To estimate cholecystectomy incidence before and after RYGB and to compare the outcome of post-RYGB cholecystectomy with the cholecystectomy outcome in the background population.

SETTING

Nationwide Swedish multiregister study.

METHODS

The Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (n = 79,386) and the Scandinavian Obesity Surgery Registry (n = 36,098) were cross-matched for the years 2007 through 2013 and compared with the National Patient Register.

RESULTS

The standardized incidence ratio for cholecystectomy before RYGB was 3.42 (2.75-4.26, P<.001); the ratio peaked at 11.4 (10.2-12.6, P<.001) 6-12 months after RYGB, which was 3.54 times the baseline level (2.78-4.49, P<.001). After 36 months, the incidence ratio had returned to baseline. The post-RYGB group demonstrated an increased risk of 30-day postoperative complications after cholecystectomy (odds ratio 2.13, 1.78-2.56; P<.001), including reoperation (odds ratio 3.84, 2.76-5.36; P<.001), compared with the background population. The post-RYGB group also demonstrated a higher risk of conversion, acute cholecystectomy, and complicated gallstone disease and a slightly prolonged operative time, adjusted for age, sex, American Society of Anesthesiologists class, and previous open RYGB.

CONCLUSION

Compared with the background population, the incidence of cholecystectomy was substantially elevated already before RYGB and increased further 6-36 months after RYGB. Previous RYGB doubled the risk of postoperative complications after cholecystectomy and almost quadrupled the risk of reoperation, even when intraoperative cholangiography was normal.

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

PURPOSE

Postoperative cholelithiasis (CL) is a latent complication of bariatric surgery. The aim of this study was to evaluate the role of ursodeoxycholic acid (UDCA) in the prevention of CL after laparoscopic sleeve gastrectomy (LSG).

METHODS

This was a retrospective analysis of the prospectively collected data of patients with morbid obesity who underwent LSG. Patients were subdivided into two groups: Group I, which did not receive prophylactic treatment with UCDA after LSG; and Group II, which received UCDA therapy for 6 months after LSG. Patients' characteristics, operation duration, weight loss data, and incidence of CL at 6 and 12 months postoperatively were collected.

RESULTS

A total of 406 patients (124 males, 282 females) with a mean age of 32.1 ± 9.4 years were included. The mean baseline body mass index (BMI) was 50.1 ± 8.3 kg/m². Group I comprised 159 patients, and Group II comprised 247 patients. The two groups showed comparable demographics, % excess weight loss (EWL), and decrease in BMI at 6 and 12 months after LSG. Eight patients (5%) developed CL in Group I, whereas no patients in Group II did (P = 0.0005). Preoperative dyslipidemia and rapid loss of excess weight within the first 3 months after LSG were the risk factors that significantly predicted CL postoperatively.

CONCLUSION

The use of UCDA effectively reduced the incidence of CL after LSG in patients with morbid obesity. Dyslipidemia and rapid EWL in the first 3 months after LSG significantly predisposed patients to postoperative CL.