Cholecystectomy after gastric bypass-incidence and complications

A prospective study on the effect of reoperations on abdominal pain after bariatric surgery: the OPERATE study

BACKGROUND

Abdominal pain after bariatric surgery (BS) is not uncommon. A number of patients require reoperation. Limited studies have investigated the outcome of reoperations for abdominal pain after BS.

OBJECTIVES

To assess abdominal pain and quality of life after reoperation in patients with abdominal pain after BS.

SETTING

Bariatric center in the Netherlands.

METHODS

The study involved patients with a reoperation for abdominal pain after BS. Patients completed questionnaires on abdominal complaints and quality of life after inclusion, 3 months, and 6 months after reoperation. Clinical data were collected from records. Patients were compared on the basis of preoperative provisional diagnoses and postoperative diagnoses.

RESULTS

A total of 179 patients were included, with laparoscopic Roux-en-Y gastric bypass (86.0%), at a median of 27 months [9.5-76.0] after BS. Six months after reoperation, 51.6% continued to experience pain. However, a decline in pain severity was observed (visual analog scale baseline 83.50 [75.0-95.0] and 6 months 0 [.0-44.0] (P < .001). Patients without postoperative diagnosis had more pain after 6 months (P = .048). Gastrointestinal Quality of Life Index improved over time for all patients (94-110) (P < .001); however, no significant improvement was observed in patients without a preoperative provisional diagnosis. The general indication of health decreased for all patients (P < .001).

CONCLUSIONS

Abdominal pain intensity decreased during follow-up upon reoperation after BS; however, in approximately one half of the patients, the pain remained and a decline in general health indication was observed regardless of postoperative diagnosis. These findings underscore the need for comprehensive management strategies to address post-BS pain and well-being.

Bariatric surgery and relevant comorbidities: a systematic review and meta-analysis

BACKGROUND

Obesity is a growing epidemic in the United States, and with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD).

METHODS

Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and non-randomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects.

RESULTS

Routine use of IOC was associated with a significantly decreased rate of common bile duct injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rates of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of the IOC group, but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications.

CONCLUSIONS

Low-quality data limited the conclusions that were drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Future research proposals are suggested to further answer the questions posed.

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.

Results from the Scandinavian Obesity Surgery Registry: A narrative review

In 2007, the Scandinavian Obesity Surgery Registry (SOReg) was started by the profession to monitor the results of bariatric surgery and to provide a high-quality database for research. In the end of August 2023, SOReg contains 88,379 patients (body mass index [BMI] 41.7 kg/m2 , 41.2 years, 77.1% females, gastric bypass 76.8%). In this narrative review, we demonstrate that preoperative weight loss is of value and that the laparoscopic double omega-loop technique is highly suitable for gastric bypass. Closing the mesenteric openings is, however, important. Swedish bariatric surgery has low mortality, and our results are comparative to those of other countries. Significant long-term improvements are found in common obesity-related diseases such as diabetes, hypertension, and sleep apnea. Furthermore, the risk for cardiac failure and major adverse cardiovascular events is significantly reduced. Pregnancy-related outcomes are also improved. Gastric bypass results in significant improvements in quality of life and seems to be cost saving. We have revealed that low socioeconomic status is associated with reduced chance of undergoing bariatric surgery and inferior outcomes. Of note, we have performed several randomized clinical trials within the registry database. In conclusion, high-quality national registry databases, such as SOReg, are important for maintaining high-quality care and present a platform for extensive research.

The burden of abdominal pain after bariatric surgery in terms of diagnostic testing: the OPERATE study

BACKGROUND

Abdominal pain after bariatric surgery (BS) is frequently observed. Despite numerous diagnostic tests, the cause of abdominal pain is not always found.

OBJECTIVES

To quantify type and number of diagnostic tests performed in patients with abdominal pain after BS and evaluate the burden and their yield in the diagnostic process.

SETTING

A bariatric center in the Netherlands.

METHODS

In this prospective study, we included patients who presented with abdominal pain after BS between December 1, 2020, and December 1, 2021. All diagnostic tests and reoperations performed during one episode of abdominal pain were scored using a standardized protocol.

RESULTS

A total of 441 patients were included; 401 (90.9%) were female, median time after BS was 37.0 months (IQR, 11.0-66.0) and mean percentage total weight loss was 31.41 (SD, 10.53). In total, 715 diagnostic tests were performed, of which 355 were abdominal CT scans, 155 were ultrasounds, and 106 were gastroscopies. These tests yielded a possible explanation for the pain in 40.2% of CT scans, 45.3% of ultrasounds, and 34.7% of gastroscopies. The diagnoses of internal herniation, ileus, and nephrolithiasis generally required only 1 diagnostic test, whereas patients with anterior cutaneous nerve entrapment syndrome, irritable bowel syndrome, and constipation required several tests before diagnosis. Even after several negative tests, a diagnosis was still found in the subsequent test: 86.7% of patients with 5 or more tests had a definitive diagnoses. Reoperations were performed in 37.2% of patients.

CONCLUSION

The diagnostic burden in patients with abdominal pain following BS is high. The most frequently performed diagnostic test is an abdominal CT scan, yielding the highest number of diagnoses in these patients.

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.

A Prospective Study on the Diagnoses for Abdominal Pain After Bariatric Surgery: The OPERATE Study

PURPOSE

Long-term follow-up after bariatric surgery (BS) reveals high numbers of patients with abdominal pain that often remains unexplained. The aim of this prospective study was to give an overview of diagnoses for abdominal pain, percentage of unexplained complaints, number and yield of follow-up visits, and time to establish a diagnosis.

MATERIALS AND METHODS

Patients who visited the Spaarne Gasthuis Hospital, The Netherlands, between December 2020 and December 2021 for abdominal pain after BS, were eligible and followed throughout the entire episode of abdominal pain. Distinction was made between presumed and definitive diagnoses.

RESULTS

The study comprised 441 patients with abdominal pain; 401 (90.9%) females, 380 (87.7%) had Roux-en-Y gastric bypass, mean (SD) % total weight loss was 31.4 (10.5), and median (IQR) time after BS was 37.0 (11.0-66.0) months. Most patients had 1-5 follow-up visits. Readmissions and reoperations were present in 212 (48.1%) and 164 (37.2%) patients. At the end of the episode, 88 (20.0%) patients had a presumed diagnosis, 183 (41.5%) a definitive diagnosis, and 170 (38.5%) unexplained complaints. Most common definitive diagnoses were cholelithiasis, ulcers, internal herniations, and presumed diagnoses irritable bowel syndrome (IBS), anterior cutaneous nerve entrapment syndrome, and constipation. Median (IQR) time to presumed diagnoses, definitive diagnoses, or unexplained complaints was 16.0 (3.8-44.5), 2.0 (0.0-31.5), and 13.5 (1.0-53.8) days (p < 0.001). Patients with IBS more often had unexplained complaints (OR 95%CI: 4.457 [1.455-13.654], p = 0.009). At the end, 71 patients (16.1%) still experienced abdominal pain.

CONCLUSION

Over a third of abdominal complaints after BS remains unexplained. Most common diagnoses were cholelithiasis, ulcers, and internal herniations.

Incidence of Asymptomatic Gallstones in Obese Patients Who Underwent Bariatric Surgery in Qassim Region at King Fahad Specialist Hospital

BACKGROUND

Gallstone is a significant health issue in the KSA and other developing countries. Multiple important risk factors have been identified as being associated with gallstones. Obesity is one of the risk factors for gallstone formation. Therefore, this study intends to determine the incidence of asymptomatic gallstone disease among the obese population in the Qassim region. The purpose of this study is to determine the incidence of asymptomatic gallstone in obese patients and the risk factors that contribute to its development in the Qassim region. As well as to compare the prevalence of gallstone disease between age groups and genders.

METHODOLOGY

A retrospective study of all patients who underwent bariatric surgery and had gallstones between January 2018 and January 2022 at King Fahad Specialist Hospital in Qassim Region, Saudi Arabia. The data, including age, gender, body mass index (BMI), and co-morbidities, will be collected from their charts.  Results: The current study included 295 patients with a mean age of 34.83 years (SD = 11.7) and 126 (42.7%) male participants. The most common comorbidity was diabetes mellitus, which was present in 54 (18.4%) participants, followed by hypertension in 42 (14.3%) participants. Of the 295 participants, 232 (78.6%) had asymptomatic gallstones, while 63 (14.3%) patients were symptomatic. The results showed that younger people (16-25 years) had the highest odds ratio of having asymptomatic gallstones compared to the reference group (>55 years). Gender was also significantly associated with asymptomatic gallstones, with males having higher odds of having asymptomatic gallstones than females. Participants with comorbidities other than diabetes mellitus had lower odds of having asymptomatic gallstones.

CONCLUSION

The present study's main finding is that obese patients receiving bariatric surgery had a significant prevalence of comorbidities and asymptomatic gallstones. According to the results, diabetes mellitus, male gender, and younger age may all be risk factors for the occurrence of asymptomatic gallstones in this population.

Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass

BACKGROUND

Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established.

OBJECTIVES

To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients.

SETTING

Swedish nationwide multi-registry study.

METHODS

The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and 2020.

RESULTS

Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3-52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001).

CONCLUSIONS

LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.

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.

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.

Cross-sectional E-survey on the Incidence of Pre- and Postoperative Chronic Pain in Bariatric Surgery

BACKGROUND

To assess the prevalence, incidence, location, and behavior of chronic pre- and postoperative pain in bariatric surgery, and the use of analgesics.

METHODS

A cross-sectional e-survey was conducted on 3928 post-bariatric patients and four-time points for pain assessment were evaluated: preoperative, on the ward, day 1 at home postoperatively, and present time (at the time of the e-survey). A numerical rating scale (NRS) was used to assess the level of pain (0 to 10). The general incidence of chronic pain was calculated, as also, subgroups were defined as group A (pre and postoperative chronic pain), B (preoperative pain, and no longer postoperative), and C (preoperative painless, postoperative chronic pain). Besides the pain intensity, location of pain, and the use of analgesics were investigated.

RESULTS

A total of 3279 patients (83.9%) responded to the survey. Preoperative and postoperative chronic pain was found in 343 (10.5%) and 264 (8.1%) patients, respectively. In group A, chronic pain was present in 4.8% of the patients; in group B, it was present in 5.7%; and in group C in 3.3% of the patients. Furthermore, in 4.5% of patients pain was located in the abdomen, which was higher as compared to before surgery (+ 2.3%, p < 0.001). The ORs for present postoperative chronic pain were OR 1.45, 1.7, and 1.71 (p = 0.002, 0.003, 0.003) compared to respectively preoperative chronic pain, pain at the ward, and pain at day 1 after surgery. Among all participants, 4.6% consumed chronic analgesics. Of these, paracetamol was used most frequently (3.8%), followed by tramadol (1.3%) and oxycodone (0.5%).

CONCLUSIONS

In this e-survey, chronic postoperative abdominal pain was prominent in patients after bariatric surgery. Of patients, 3.3% that were without preoperative chronic pain developed chronic pain after surgery. Opioid consumption in the queried population was relatively low.

Adipose Tissue, Bile Acids, and Gut Microbiome Species Associated With Gallstones After Bariatric Surgery

Several risk factors are associated with gallstone disease after bariatric surgery, but the underlying pathophysiological mechanisms of gallstone formation are unclear. We hypothesize that gallstone formation after bariatric surgery is induced by different pathways compared with gallstone formation in the general population, since postoperative formation occurs rapidly in patients who did not develop gallstones in preceding years. To identify both pathophysiological and potentially protective mechanisms against postoperative gallstone formation, we compared the preoperative fasting metabolome, fecal microbiome, and liver and adipose tissue transcriptome obtained before or during bariatric surgery of obese patients with and without postoperative gallstones. In total, 88 patients were selected from the BARIA longitudinal cohort study. Within this group, 32 patients had postoperative gallstones within 2 years. Gut microbiota metagenomic analyses showed group differences in abundance of 41 bacterial species, particularly abundance of Lactobacillaceae and Enterobacteriaceae in patients without gallstones. Subcutaneous adipose tissue transcriptomic analyses revealed four genes that were suppressed in gallstone patients compared with patients without gallstones. These baseline gene expression and gut microbiota composition differences might relate to protective mechanisms against gallstone formation after bariatric surgery. Moreover, baseline fasting blood samples of patients with postoperative gallstones showed increased levels of several bile acids. Overall, we revealed different genes and bacteria associated with gallstones than those previously reported in the general population, supporting the hypothesis that gallstone formation after bariatric surgery follows a different trajectory. Further research is necessary to confirm the involvement of the bile acids, adipose tissue activity, and microbial species observed here.

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.

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.

Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass

Background: Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). Furthermore, in these patients, CBDS are difficult to extract due to the altered upper gastrointestinal anatomy following GBP. The aim of the present study was to assess outcome after various management methods applied in the counties of Stockholm and Uppsala, Sweden. Methods: Data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) and the Swedish Obesity Surgery Register (SoReg) were crossmatched to identify all patients who had undergone gallstone surgery after GBP, where CBDS were found at intraoperative cholangiography, in the Stockholm and Uppsala counties 2009-2013. A retrospective review of patient records was performed for all patients identified. Results: In all, 55 patients were identified. These were managed as follows: expectancy (N = 11); transgastric ERCP (N = 2); laparoscopic choledochotomy (N = 3); open choledochotomy (N = 5); transcystic stone extraction (N = 12); and other approach (N = 13). In nine cases, data on management could not be found. There were nine cases of minor postoperative complication. No retained stones were registered. The operation time was longer for transgastric ERCP (p = 0.002), and the postoperative stay was longer following open and laparoscopic choledochotomy (p < 0.001). There was no statistically significant difference between any of the methods regarding the incidence of postoperative complications (p = 0.098). Discussion: Further development of techniques for managing CBDS discovered in patients undergoing cholecystectomy after previous GBP are needed, as well as more comparative studies with greater statistical power.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incidence and risk factors for de novo cholelithiasis after bariatric surgery

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term Emergency Department Visits and Readmissions After Laparoscopic Roux-en-Y Gastric Bypass: a Systematic Review

PURPOSE

There is considerable evidence on short-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB), but data on long-term outcome is scarce, especially on postoperative emergency department (ED) visits and readmissions. We aim to systematically review evidence on the incidence, indications, and risk factors of ED visits and readmissions beyond 30 days after LRYGB.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Embase.com , Cochrane Library, and PsycINFO was performed. All studies reporting ED visits and readmissions > 30 days after LRYGB, with ≥ 50 patients, were included. PRISMA statement was used and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Twenty articles were included. Six studies reported on ED visits (n = 2818) and 19 on readmissions (n = 276,543). The rate of patients with an ED visit within 90 days after surgery ranged from 3.9 to 32.6%. ED visits at 1, 2, and 3 years occurred in 25.6%, 30.0%, and 31.1% of patients. Readmissions within 90 days and at 1-year follow-up ranged from 4.1 to 20.5% and 4.75 to 16.6%, respectively. Readmission was 29% at 2 years and 23.9% at 4.2 years of follow-up. The most common reason for ED visits and readmissions was abdominal pain.

CONCLUSION

Emergency department visits and readmissions have been reported in up to almost one in three patients on the long-term after LRYGB. Both are mainly indicated for abdominal pain. The report on indications and risk factors is very concise. A better understanding of ED visits and readmissions after LRYGB is warranted to improve long-term care, in particular for patients with abdominal pains.

Prevalence and Risk Factors for Chronic Abdominal Pain After Roux-en-Y Gastric Bypass Surgery: A Cohort Study

OBJECTIVE

To investigate the prevalence and risk factors for chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) surgery.

SUMMARY BACKGROUND DATA

Abdominal pain is a frequent postoperative complication after RYGB surgery. Even if there have been defined several long-term complications, the literature regarding patients with unexplained chronic abdominal pain is sparse.

METHODS

A single-center register-based cohort study with inclusion of all patients who underwent RYGB surgery between 2010 and 2015. Data from multiple registries, medical records, and a questionnaire were used. Patients with chronic abdominal pain were defined as those using strong analgesics, diagnosed with chronic pain, or referred to a specialized pain clinic. Patients with severe self-reported abdominal pain were defined as those reporting abdominal pain more than 2 times weekly within the last month.

RESULTS

A total of 787 patients were followed for a median of 63 months. The prevalence of postoperative chronic abdominal pain was 11% and the prevalence of severe self-reported abdominal pain was 21%. Preoperative use of strong analgesics was a risk factor for chronic abdominal pain (OR, 2.26; 95% CI, 1.59-3.23) and severe self-reported abdominal pain (OR 2.82, 95% CI 1.64-4.84). Further risk factors for severe self-reported pain were unemployment or retirement (OR 1.80, 95% CI 1.09-2.93), postoperative complications (OR 2.75, 95% CI 1.44-5.22), and smoking (OR 1.80, 95% CI 1.09-2.96).

CONCLUSIONS

One in 10 patients undergoing RYGB surgery developed chronic abdominal pain requiring strong analgesics, and one in five suffered from severe abdominal pain. Risk factors were preoperative use of strong analgesics, unemployment, postoperative complications, and smoking.

Altered bile acid kinetics contribute to postprandial hypoglycaemia after Roux-en-Y gastric bypass surgery

BACKGROUND/OBJECTIVES

Bile acids (BA) act as detergents in intestinal fat absorption and as modulators of metabolic processes via activation of receptors such as FXR and TGR5. Elevated plasma BA as well as increased intestinal BA signalling to promote GLP-1 release have been implicated in beneficial health effects of Roux-en-Y gastric bypass surgery (RYGB). Whether BA also contribute to the postprandial hypoglycaemia that is frequently observed post-RYGB is unknown.

METHODS

Plasma BA, fibroblast growth factor 19 (FGF19), 7α-hydroxy-4-cholesten-3-one (C4), GLP-1, insulin and glucose levels were determined during 3.5 h mixed-meal tolerance tests (MMTT) in subjects after RYGB, either with (RYGB, n = 11) or without a functioning gallbladder due to cholecystectomy (RYGB-CC, n = 11). Basal values were compared to those of age, BMI and sex-matched obese controls without RYGB (n = 22).

RESULTS

Fasting BA as well as FGF19 levels were elevated in RYGB and RYGB-CC subjects compared to non-bariatric controls, without significant differences between RYGB and RYGB-CC. Postprandial hypoglycaemia was observed in 8/11 RYGB-CC and only in 3/11 RYGB. Subjects who developed hypoglycaemia showed higher postprandial BA levels coinciding with augmented GLP-1 and insulin responses during the MMTT. The nadir of plasma glucose concentrations after meals showed a negative relationship with postprandial BA peaks. Plasma C4 was lower during MMTT in subjects experiencing hypoglycaemia, indicating lower hepatic BA synthesis. Computer simulations revealed that altered intestinal transit underlies the occurrence of exaggerated postprandial BA responses in hypoglycaemic subjects.

CONCLUSION

Altered BA kinetics upon ingestion of a meal, as frequently observed in RYGB-CC subjects, appear to contribute to postprandial hypoglycaemia by stimulating intestinal GLP-1 release.

Incidence and risk factors for de novo cholelithiasis after bariatric surgery

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A 3-Year MBSAQIP propensity-matched analysis of Roux-en-Y gastric bypass with concomitant cholecystectomy: Is the robotic or laparoscopic approach preferred?

BACKGROUND

The primary objective of this study was to compare outcomes of patients undergoing minimally invasive RYGB (MIS/RYGB) versus MIS/RYGB with concomitant Cholecystectomy (CCY). A secondary objective was to compare the outcomes for laparoscopic RYGB (LRYGB) and robotic RYGB (RRYGB) with concomitant CCY.

METHODS

Outcomes of 117,939 MIS/RYGB with and without CCY were propensity-matched (Age, Gender, BMI, Comorbidities), 10:1, using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2015-2017. The MIS/RYGB with CCY were then separated into LRYGB and RRYGB cases for comparison. Exclusion criteria included emergency cases, conversions to open, and age less than 18.

RESULTS

The operative time and length of stay (LOS) was significantly increased with addition of concomitant CCY. There was no significant difference in readmission, reoperation, intervention, morbidity, or mortality. The RRYGB with CCY approach was associated with a significantly longer operative times compared to the LRYGB with CCY (177 vs. 135 min, p < 0.0001). The laparoscopic and robotic groups demonstrated no significant difference LOS, readmission, reoperation, intervention, morbidity, or mortality rates.

CONCLUSIONS

Our study demonstrates that concomitant cholecystectomy increased the operative time and length of stay. However, concomitant CCY was not associated with any increased morbidity. The study demonstrated no significant difference in morbidity between robotic and laparoscopic approach. The robotic approach, however, was associated with a significantly longer operative time compared to the laparoscopic approach. While the indications for CCY remain controversial, concomitant CCY does not convey additional risk regardless of operative approach.

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.

Cholecystectomy After Previous Bariatric Surgery with Special Focus on Pregnant Patients-Results from Two Large Nationwide Registries

BACKGROUND

Biliary complications during pregnancy is an important issue. The aim of this study was to examine if there is an increased risk to perform cholecystectomy during pregnancy in patients with previous bariatric surgery in comparison to other females subjected to cholecystectomy.

METHODS

The Nationwide Swedish Registry for Gallstone Surgery (GallRiks) and the Scandinavian Obesity Surgery Registry (SOReg) were combined. Female patients 18-45 years old were included. The study group was patients with a history of bariatric surgery whom were pregnant at the time of cholecystectomy. This group was compared with pregnant patients without previous bariatric surgery and non-pregnant with and without previous bariatric surgery.

RESULTS

In total, 21,314 patients were included and 292 underwent surgery during pregnancy. From 1282 patients identified in both registers, 16 patients were pregnant at the time of cholecystectomy. Acute cholecystectomy was performed in 5922 (28%) non-pregnant and 199 (68%) pregnant (p < 0.001), including 11/16 (69%) pregnant with previous bariatric surgery. When comparing all pregnant patients, those with previous bariatric surgery had longer operative time (p = 0.031) and length of stay (p = 0.043), but no differences were seen when only comparing patients with an acute indication for surgery. There was no difference in complications comparing pregnant patients with previous bariatric surgery with non-pregnant, both with and without previous bariatric surgery.

CONCLUSIONS

Cholecystectomy during pregnancy in patients with previous bariatric surgery seems to be safe. The increased risk seen in the non-pregnant group after previous bariatric surgery is not seen in pregnancy, possibly due to an optimization of the circumstances at surgery.

Chronic abdominal pain and persistent opioid use after bariatric surgery

Background and aims Bariatric surgery remains a mainstay for treatment of morbid obesity. However, long-term adverse outcomes include chronic abdominal pain and persistent opioid use. The aim of this review was to assess the existing data on prevalence, possible mechanisms, risk factors, and outcomes regarding chronic abdominal pain and persistent opioid use after bariatric surgery. Methods PubMed was screened for relevant literature focusing on chronic abdominal pain, persistent opioid use and pharmacokinetic alterations of opioids after bariatric surgery. Relevant papers were cross-referenced to identify publications possibly not located during the ordinary screening. Results Evidence regarding general chronic pain status after bariatric surgery is sparse. However, our literature review revealed that abdominal pain was the most prevalent complication to bariatric surgery, presented in 3-61% of subjects with health care contacts or readmissions 1-5 years after surgery. This could be explained by behavioral, anatomical, and/or functional disorders. Persistent opioid use and doses increased after bariatric surgery, and 4-14% initiated a persistent opioid use 1-7 years after the surgery. Persistent opioid use was associated with severe pain symptoms and was most prevalent among subjects with a lower socioeconomic status. Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction. Changes in absorption have been briefly investigated, but the identified alterations could not be separated from alterations caused solely by excessive weight loss, and medication formulation could influence the findings. Subjects with persistent opioid use after bariatric surgery achieved lower weight loss and less metabolic benefits from the surgery. Thus, remission from comorbidities and cost effectiveness following bariatric surgery may be limited in these subjects. Conclusions Pain, especially chronic abdominal, and persistent opioid use were found to be prevalent after bariatric surgery. Physiological, anatomical, and pharmacokinetic changes are likely to play a role. However, the risk factors for occurrence of chronic abdominal pain and persistent opioid use have only been scarcely examined as have the possible impact of pain and persistent opioid use on clinical outcomes, and health-care costs. This makes it difficult to design targeted preventive interventions, which can identify subjects at risk and prevent persistent opioid use after bariatric surgery. Future studies could imply pharmacokinetic-, pharmacodynamics-, and physiological-based modelling of pain treatment. More attention to social, physiologic, and psychological factors may be warranted in order to identify specific risk profiles of subjects considered for bariatric surgery in order to tailor and optimize current treatment recommendations for this population.

Pathophysiological connections between gallstone disease, insulin resistance, and obesity

Obesity and cholesterol gallstone disease (GSD) are frequently coexisting diseases; therefore and considering the current worldwide obesity epidemics, a precise understanding of the pathophysiological relationships between GSD and insulin resistance (IR) is important. Classically, obesity has been understood as a risk factor for GSD and the gallbladder (GB) viewed as a simple bile reservoir, with no metabolic roles whatsoever. However, consistent evidence has showed that both GSD and cholecystectomy associates with fatty liver and IR, raising the possibility that the GB is indeed an organ with metabolic regulatory roles. Herein, we review the pathophysiological mechanisms by which GSD, IR, and obesity are interconnected, with emphasis in the actions of the GB as a regulator of bile acids kinetics and a hormone secreting organ, with metabolic actions at the systemic level. We also examine the relationships between increased hepatic lipogenic in IR states and GSD pathogenesis. We propose a model in which GSD and hepatic IR mutually interact to determine a state of dysregulated lipid and energy metabolism that potentiate the metabolic dysregulation of obesity.

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.

High-Frequency of Computer Tomography and Surgery for Abdominal Pain After Roux-en-Y Gastric Bypass

INTRODUCTION

Acute, intermittent, and chronic abdominal pain is a common complaint after Roux-en-Y gastric bypass (RYGB).

OBJECTIVES

The aim of the study was to evaluate the use of medical imaging and the need for surgery treating abdominal pain after RYGB in a cohort with long-term follow-up.

METHODS

Data from 569 patients who underwent RYGB as the primary bariatric procedure at a public hospital in Norway between April 2004 and June 2011 were prospectively registered in a local quality registry for bariatric surgery. All abdominal imaging and abdominal surgical procedures were registered until August 2017.

RESULTS

Mean follow-up was 100 months (61-159). During the observation period, 22% had one CT, 9% had two CTs, 4% had three CTs, and 5% had four or more CTs for abdominal pain. Twenty-two percent underwent abdominal surgery, as 16% had one and 6% had two or more operations and gynecological procedures excluded. The purpose of operation was postoperative complications (1.4%), suspected internal herniation (9.3%), cholecystectomy (9.3%), appendectomy (2.3%), hernias (3.2%), and perforated ulcer in the gastrojejunal anastomosis (0.7%). Mean time interval was 42 ± 27 months from RYGB to cholecystectomy and 51 ± 26 months for suspected IH.

CONCLUSION

With a mean follow-up period of more than 8 years after RYGB, 40% of the patients suffered from abdominal pain, needing one or more CT scans. The need for surgery treating suspected internal hernia and cholecystectomy was equal, at 9.3% for both procedures, but the mean time from RYGB to operation was shorter for cholecystectomies.

Does pregnancy increase the risk of cholecystectomy following bariatric surgery? A cross-sectional cohort study

BACKGROUND

Reproductive-aged women constitute a substantial proportion of patients who undergo weight loss procedures. While the risk of gallstone disease after such procedures has been addressed extensively, the impact of pregnancy on gallstone disease after bariatric procedures has not been reported.

OBJECTIVES

To explore the effects of pregnancy on cholecystectomy rates after laparoscopic sleeve gastrectomy (LSG).

SETTING

A university hospital.

METHODS

A cross-sectional cohort study of reproductive aged women (18-45 yr) who underwent LSG. The association between pregnancy and cholecystectomy was evaluated with Cox regression analysis.

RESULTS

Of 1056 women of childbearing age who underwent LSG during 2006-2017, 128 (12.1%) subsequently experienced a pregnancy. Median follow-up durations were 3.9 and 4.9 years for women who did and did not conceive, respectively (P < .001). The median time from procedure to conception was 509 (374-1031) days. Overall, 117 (11.1%) women underwent cholecystectomy after LSG. The rate of cholecystectomy among those who conceived was higher than among those who did not (18.8% versus 10.0%, P = .005). In an unadjusted analysis, pregnancy was associated with an increased risk of cholecystectomy (hazard ratio [95% confidence interval]: 3.97 [2.58, 6.09], P < .0001). The association between pregnancy and cholecystectomy persisted after controlling for confounding factors (hazard ratio [95% confidence interval]: 3.82 [2.47, 5.92], P < .0001). Among those who experienced pregnancy, lower gestational weight gain was the only factor found to be associated with cholecystectomy after surgery (P = .05).

CONCLUSIONS

Pregnancy is associated with a 4-fold increased risk of cholecystectomy after LSG. Thus, the desire for future pregnancy should be considered before LSG.

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

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

Pros and cons of gastric bypass surgery in individuals with obesity and type 2 diabetes: nationwide, matched, observational cohort study

OBJECTIVES

Long-term effects of gastric bypass (GBP) surgery have been presented in observational and randomised studies, but there are only limited data for persons with obesity and type 2 diabetes mellitus (T2DM) regarding postoperative complications.

DESIGN

This is a nationwide observational study based on two quality registers in Sweden (National Diabetes Register, NDR and Scandinavian Obesity Surgery Register, SOReg) and other national databases.

SETTING

After merging the data, we matched individuals with T2DM who had undergone GBP with those not surgically treated for obesity on propensity score, based on sex, age, body mass index (BMI) and calendar time. The risks of postoperative outcomes (rehospitalisations) were assessed using Cox regression models.

PARTICIPANTS

We identified 5321 patients with T2DM in the SOReg and 5321 matched controls in the NDR, aged 18-65 years, with BMI >27.5 kg/m² and followed for up to 9 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed risks for all-cause mortality and hospitalisations for cardiovascular disease, severe kidney disease, along with surgical and other medical conditions.

RESULTS

The results agree with the previously suggested lower risks of all-cause mortality (49%) and cardiovascular disease (34%), and we also found positive effects for severe kidney disease but significantly increased risks (twofold to ninefold) of several short-term complications after GBP, such as abdominal pain and gastrointestinal conditions, frequently requiring surgical procedures, apart from reconstructive plastic surgery. Long-term, the risk of anaemia was 92% higher, malnutrition developed approximately three times as often, psychiatric diagnoses were 33% more frequent and alcohol abuse was three times as great as in the control group.

CONCLUSIONS

This nationwide study confirms the benefits and describes the panorama of adverse events after bariatric surgery in persons with obesity and T2DM. Long-term postoperative monitoring and support, as better selection of patients by appropriate specialists in interdisciplinary settings, should be provided to optimise the outcomes.

Abdominal Pain After Roux-En-Y Gastric Bypass for Morbid Obesity

Background and Aims:

Roux-en-Y gastric bypass is widely used as treatment of morbid obesity. Weight loss, effects on obesity-related co-morbidities and quality of life are well documented post Roux-en-Y gastric bypass. Other outcome measures are less well studied. This review explores aspects of prevalence, diagnostic evaluations, etiology, and treatment of abdominal pain specific to Roux-en-Y gastric bypass.

Methods:

The review is based on PubMed searches and clinical experience with Roux-en-Y gastric bypass. Symptoms in the early postoperative phase (<30 days) were not included.

Results:

Based on limited evidence, up to about 30% of the patients may perceive recurrent abdominal pain post Roux-en-Y gastric bypass in the long term. A substantial subset of patients will need health-care evaluation for acute abdominal pain and hospital admission. The etiology of abdominal pain is heterogeneous and includes gallstone-related disease, intestinal obstruction, anastomotic ulcerations and strictures, intestinal dysmotility, dysfunctional eating, and food intolerance. Surgical treatment and guidance on diet and eating habits may allow symptom relief. The cause of pain remains undefined for a subset of patients. Impact of abdominal pain post Roux-en-Y gastric bypass on the perception of well-being, quality of life, and patient satisfaction with the procedure needs to be further evaluated and may be influenced by complex interactions between new symptoms post Roux-en-Y gastric bypass and relief of pre-existing symptoms.

Conclusion:

Abdominal pain should be part of follow-up consultations post Roux-en-Y gastric bypass. Future studies should focus on combined evaluations before and after surgery to enlighten potential casual relationships between abdominal pain and Roux-en-Y gastric bypass.

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

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

Morbidity of cholecystectomy and gastric bypass in a national database

BACKGROUND

There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated.

METHODS

Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored.

RESULTS

There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1·35, 95 per cent c.i. 1·09 to 1·68; P = 0·006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2·02, 1·44 to 2·85; P < 0·001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1·72, 1·14 to 2·60; P = 0·010). Simultaneous cholecystectomy added 61·7 (95 per cent c.i. 56·1 to 67·4) min (P < 0·001) to the duration of surgery.

CONCLUSION

Cholecystectomy should be performed before, not during or after, RYGB.