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Lin H, Baker JW, Meister K, Lak KL, Martin Del Campo SE, Smith A, Needleman B, Nadzam G, Ying LD, Varban O, Reyes AM, Breckenbridge J, Tabone L, Gentles C, Echeverri C, Jones SB, Gould J, Vosburg W, Jones DB, Edwards M, Nimeri A, Kindel T, Petrick A. American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass. Surg Obes Relat Dis 2024; 20:895-909. [PMID: 39097472 DOI: 10.1016/j.soard.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). OBJECTIVE This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). METHODS PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. RESULTS Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. CONCLUSIONS This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.
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Affiliation(s)
- Henry Lin
- Department of Surgery, Signature Healthcare, Brockton, Massachusetts.
| | - John W Baker
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Kathleen L Lak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - April Smith
- Department of Pharmacy, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | | | - Geoffrey Nadzam
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lee D Ying
- Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Oliver Varban
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Angel Manuel Reyes
- Department of General Surgery, St. Michael Medical Center, Silverdale, Washington
| | - Jamie Breckenbridge
- Department of General Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Lawrence Tabone
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Charmaine Gentles
- Department of Surgery, Northshore University Hospital, Manhasset, New York
| | | | - Stephanie B Jones
- Department of Anesthesiology, Northwell Health, New Hyde Park, New York
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wesley Vosburg
- Department of Surgery, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Daniel B Jones
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Abdelrahman Nimeri
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tammy Kindel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anthony Petrick
- Department of Surgery, Geisinger Medical Center, Danville, Pennsylvania
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Ribeiro Jr MA, Tebar GK, Niero HB, Pacheco LS. Biliary complications associated with weight loss, cholelithiasis and choledocholithiasis. World J Gastrointest Pharmacol Ther 2024; 15:95647. [PMID: 38983103 PMCID: PMC11229836 DOI: 10.4292/wjgpt.v15.i4.95647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/23/2024] [Accepted: 07/01/2024] [Indexed: 07/04/2024] Open
Abstract
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.
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Affiliation(s)
- Marcelo A Ribeiro Jr
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City, Abu Dhabi 11001, United Arab Emirates
- Department of Surgery, Pontifical Catholic University of São Paulo-Campus Sorocaba, Sorocaba 18030070, SP, Brazil
| | - Gabriela K Tebar
- Department of Surgery, Pontifical Catholic University of São Paulo-Sorocaba, Sorocaba 18030070, SP, Brazil
| | - Helena B Niero
- Department of Surgery, Pontifical Catholic University of São Paulo-Campus Sorocaba, Sorocaba 18030070, SP, Brazil
| | - Leticia S Pacheco
- Department of Surgery, Pontifical Catholic University of São Paulo-Campus Sorocaba, Sorocaba 18030070, SP, Brazil
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Yang W, Wu H, Cai X, Lin C, Luo Y, Hu S, Li Z, Jiao R, Bai S, Liu G, Yang X, Ji L. Weight reduction and the risk of gallbladder and biliary disease: A systematic review and meta-analysis of randomized clinical trials. Obes Rev 2024; 25:e13725. [PMID: 38346789 DOI: 10.1111/obr.13725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 05/14/2024]
Abstract
In this meta-analysis, we aim to evaluate the risk of gallbladder and biliary disease of weight management strategies and investigate the association between weight reduction and risk of gallbladder or biliary disease. Randomized controlled trials (RCTs) with a duration of at least 12 weeks that compare antiobesity medications (AOMs) with placebo or bariatric surgery with less intensive weight management strategy were concluded. Weight management strategy was associated with a significant increased risk of gallbladder or biliary disease (OR 1.361, 95% CI 1.147 to 1.614, P < 0.001, I2 = 3.5%), cholelithiasis, cholecystitis, and cholecystectomy compared with placebo or controls. The increased risk of gallbladder or biliary disease was observed both in pharmacotherapies subgroup and bariatric surgery subgroup. With regards of specific pharmacotherapies, an increased risk of gallbladder or biliary disease was observed in trials with glucagon-like peptide 1 receptor agonist (GLP-1 RA) treatments. In addition, trials with indication of obesity and overweight treatment and trials with higher doses showed significant higher risk of gallbladder or biliary disease compared with placebo or controls. In conclusion, weight management strategy was associated with an increased risk of gallbladder or biliary disease when compared with placebo or control groups.
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Affiliation(s)
- Wenjia Yang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Han Wu
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xiaoling Cai
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Chu Lin
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Yingying Luo
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Suiyuan Hu
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Zonglin Li
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Ruoyang Jiao
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Shuzhen Bai
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Geling Liu
- Department of Endocrinology and Metabolism (Section 1), Tangshan Gongren Hospital, Tangshan, Hebei, China
| | - Xiaolin Yang
- Department of Endocrinology and Metabolism (Section 1), Tangshan Gongren Hospital, Tangshan, Hebei, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
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Kermansaravi M, Shikora S, Dillemans B, Kurian M, LaMasters T, Vilallonga R, Prager G, Chiappetta S. The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey. Obes Surg 2024; 34:1086-1096. [PMID: 38400945 DOI: 10.1007/s11695-024-07101-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS. BACKGROUND Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist. METHODS An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023. RESULTS Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB. CONCLUSION Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.
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Affiliation(s)
- Mohammad Kermansaravi
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Hazrat-E Fatemeh Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Scott Shikora
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruno Dillemans
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Brugge, Belgium
| | - Marina Kurian
- Department of Surgery, NYU Langone Medical Center, New York, NY, 10016, USA
| | - Teresa LaMasters
- UnityPoint Clinic Weight Loss Specialists, West Des Moines, IA, USA
| | - Ramon Vilallonga
- Endocrine, Bariatric and Metabolic Surgery Department, University Hospital Vall Hebron, Barcelona, Spain
| | - Gerhard Prager
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Sonja Chiappetta
- Bariatric and Metabolic Surgery Unit, Department of General and Laparoscopic Surgery, Ospedale Evangelico Betania, Via Argine 604, 80147, Naples, Italy.
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Al-Huniti M, Alsardia Y, Odeh A, Bdour B, Hassanat R, Aloun A, Sha'ban BW, Nseirat SM. Ursodeoxycholic Acid Prophylaxis and the Reduction of Gallstone Formation After Bariatric Surgery: An Updated Meta-Analysis of Randomized Controlled Trials. Cureus 2023; 15:e50649. [PMID: 38229797 PMCID: PMC10790195 DOI: 10.7759/cureus.50649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 01/18/2024] Open
Abstract
Gallstone formation following bariatric surgery poses a significant clinical concern, prompting various preventive strategies, including ursodeoxycholic acid (UDCA) prophylaxis. This systematic review and meta-analysis aimed to assess the efficacy of UDCA in preventing gallstone formation after bariatric surgery. A comprehensive literature search was conducted in major databases up to September 2023, identifying 12 randomized controlled trials (RCTs) meeting the inclusion criteria. The studies, spanning from 1993 to 2022, involved 2,767 patients who underwent diverse bariatric procedures. The primary outcome was the overall incidence of cholelithiasis, with secondary outcomes encompassing gallstone occurrences at three, six, and 12 months; symptomatic cholelithiasis; and rates of cholecystectomy. The Cochrane risk-of-bias tool was utilized for evaluating study quality, and statistical analyses were conducted using the RevMan software (Cochrane Collaboration, London, UK). Patients receiving UDCA demonstrated a significantly lower overall incidence of gallstones post-bariatric surgery (risk ratio [RR] 0.13; P < 0.0001). Subgroup analyses confirmed reduced gallstone incidence at three months (P = 0.04), six months (P < 0.00001), and one year (P < 0.00001) with UDCA prophylaxis. Symptomatic cholelithiasis incidence was also lower in the UDCA group (RR 5.70; P < 0.00001), and cholecystectomy rates were significantly reduced (RR 3.05; P = 0.002). This meta-analysis supports the efficacy of UDCA prophylaxis in preventing gallstone formation after bariatric surgery. The findings suggest that UDCA administration not only lowers overall gallstone incidence but also reduces the occurrence of symptomatic cholelithiasis and mitigates the need for cholecystectomy. However, caution is warranted due to heterogeneity, diverse surgical procedures, and limited long-term follow-up in the included studies. Further research with standardized protocols and extended observational periods is recommended to strengthen the evidence base and guide clinical practice.
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Affiliation(s)
- Mohammad Al-Huniti
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
| | - Yousef Alsardia
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
| | - Alaa Odeh
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
| | - Belal Bdour
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
| | - Ramadan Hassanat
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
| | - Ali Aloun
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
| | - Ban W Sha'ban
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
| | - Sara M Nseirat
- Department of General Surgery, Jordanian Royal Medical Services, Amman, JOR
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Coogan AC, Williams MD, Krishnan V, Skertich NJ, Becerra AZ, Sarran M, Schimpke S, Torquati A, Omotosho P. Ursodiol Prescriptions Following Bariatric Surgery: National Prescribing Trends and Outcomes. Obes Surg 2023; 33:2361-2367. [PMID: 37392353 DOI: 10.1007/s11695-023-06710-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Rapid weight loss after bariatric surgery is a risk factor for gallstone development. Numerous studies have shown that ursodiol after surgery decreases rates of gallstone formation and cholecystitis. Real-world prescribing practices are unknown. This study aimed to examine prescription patterns for ursodiol and reassess its impact on gallstone disease using a large administrative database. METHODS The Mariner database (PearlDiver, Inc.) was queried using Current Procedural Terminology codes for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2011 and 2020. Only patients with International Classification of Disease codes for obesity were included. Patients with pre-operative gallstone disease were excluded. The primary outcome was gallstone disease within 1 year, which was compared between patients who did and did not receive an ursodiol prescription. Prescription patterns were also analyzed. RESULTS Three hundred sixty-five thousand five hundred patients fulfilled inclusion criteria. Twenty-eight thousand seventy-five (7.7%) patients were prescribed ursodiol. There was a statistically significant difference in development of gallstones (p < 0.001), development of cholecystitis (p = .049), and undergoing cholecystectomy (p < 0.001). There was a statistically significant decrease in the adjusted odds ratio (aOR) for the development of gallstones (aOR 0.81, 95% CI: 0.74, 0.89), development of cholecystitis (aOR 0.59, 95% CI: 0.36, 0.91), and undergoing cholecystectomy (aOR 0.75, 95% CI: 0.69, 0.81). CONCLUSION Ursodiol significantly decreases the odds of development of gallstones, cholecystitis, or cholecystectomy within 1 year following bariatric surgery. These trends hold true when analyzing RYGB and SG separately. Despite the benefit of ursodiol, only 10% of patients received an ursodiol prescription postoperatively in 2020.
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Affiliation(s)
- Alison C Coogan
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA.
| | - Michael D Williams
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Vaishnavi Krishnan
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Nicholas J Skertich
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Marc Sarran
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Scott Schimpke
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Alfonso Torquati
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Philip Omotosho
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
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Hernández LA, Guilbert L, Sepúlveda EM, Rodríguez F, Peñuñuri F, García VH, Zerrweck C. Causes of revisional surgery, reoperations, and readmissions after bariatric surgery. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:232-237. [PMID: 34972678 DOI: 10.1016/j.rgmxen.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/25/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND OBJECTIVES Bariatric surgery is the most effective treatment for weight loss, with comorbidity control. With low complication rates, the reasons for reoperation are major complications or weight loss failure/weight regain. Nonsurgical problems can also present, such as anemia, dehydration, chronic pain, and malnutrition, among others. Our aim was to analyze the main causes of revisional surgery, reoperation, and hospital readmission, at a specialized bariatric center. METHODS A retrospective study was conducted on patients that underwent bariatric surgery within the time frame of 2012 and 2019. The baseline analysis included demographic, anthropometric, and perioperative data, as well as a sub-analysis of the main readmission causes and complications. RESULTS A total of 776 primary surgeries were performed (649 RYGBP, 127 SG, and 10 revisional surgeries), and 99 patients were identified for the study: 10 revisional surgeries, 44 reoperations, and 45 readmissions. The incidence of revisional surgery was 1.2%, reoperation was 5.6%, and readmission 5.8%. Fifty percent of the revisional surgeries were performed due to insufficient weight loss or weight regain; the most frequent causes of reoperation were cholecystitis (38.6%) and internal hernias (9.1%); and the most common causes of readmission were nonspecific abdominal pain (35.5%) and dehydration (24.4%). CONCLUSION The most frequent causes of postoperative readmission were nonsurgical events, followed by non-bariatric reoperations, and finally revisional surgeries. There was a low incidence of early reoperations. Knowledge of the abovementioned data is important for identifying higher-risk patients, to prevent major complications.
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Affiliation(s)
- L A Hernández
- Clínica Integral de Cirugía para la Obesidad y Enfermedades Metabólicas, Hospital General Tláhuac, Mexico City, Mexico
| | - L Guilbert
- Clínica Integral de Cirugía para la Obesidad y Enfermedades Metabólicas, Hospital General Tláhuac, Mexico City, Mexico
| | - E M Sepúlveda
- Clínica Integral de Cirugía para la Obesidad y Enfermedades Metabólicas, Hospital General Tláhuac, Mexico City, Mexico
| | - F Rodríguez
- Clínica Integral de Cirugía para la Obesidad y Enfermedades Metabólicas, Hospital General Tláhuac, Mexico City, Mexico
| | - F Peñuñuri
- Clínica Integral de Cirugía para la Obesidad y Enfermedades Metabólicas, Hospital General Tláhuac, Mexico City, Mexico
| | - V H García
- Servicio de Medicina Interna, Hospital General Tláhuac, Mexico City, Mexico
| | - C Zerrweck
- Clínica Integral de Cirugía para la Obesidad y Enfermedades Metabólicas, Hospital General Tláhuac, Mexico City, Mexico.
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Jiang T, Zhang H, Yin X, Cai Z, Zhao Z, Mu M, Liu B, Shen C, Zhang B, Yin Y. The necessity and safety of simultaneous cholecystectomy during gastric surgery for patients with asymptomatic cholelithiasis. Expert Rev Gastroenterol Hepatol 2023; 17:1053-1060. [PMID: 37795528 DOI: 10.1080/17474124.2023.2264782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/13/2023] [Indexed: 10/06/2023]
Abstract
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.
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Affiliation(s)
- Tianxiang Jiang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Haidong Zhang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Xiaonan Yin
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Zhaolun Cai
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Zhou Zhao
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Mingchun Mu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Baike Liu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Chaoyong Shen
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Bo Zhang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
| | - Yuan Yin
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan province, China
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9
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Virupaksha S, Bhandari M, Thulasiraman SV, YKS V, Mahane A. Role of Prophylactic Cholecystectomy for Patient Undergoing Laparoscopic Roux-en-Y Gastric Bypass for Weight Loss: a Systematic Review and Meta-analysis. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03671-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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10
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Amorim-Cruz F, Santos-Sousa H, Ribeiro M, Nogueiro J, Pereira A, Resende F, Costa-Pinho A, Preto J, Lima-da-Costa E, Sousa-Pinto B. Risk and Prophylactic Management of Gallstone Disease in Bariatric Surgery: a Systematic Review and A Bayesian meta-analysis. J Gastrointest Surg 2023; 27:433-448. [PMID: 36627465 PMCID: PMC9974690 DOI: 10.1007/s11605-022-05567-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/18/2022] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Filipe Amorim-Cruz
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Hugo Santos-Sousa
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal. .,Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Miguel Ribeiro
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Jorge Nogueiro
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Surgery Department, São João University Medical Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - André Pereira
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Surgery Department, São João University Medical Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Fernando Resende
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - André Costa-Pinho
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - John Preto
- Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Eduardo Lima-da-Costa
- Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Bernardo Sousa-Pinto
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal.,CINTESIS - Center for Health Technologies and Services Research, University of Porto, Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal
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11
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Asymptomatic cholelithiasis in bariatric practice. КЛИНИЧЕСКАЯ ПРАКТИКА 2023. [DOI: 10.17816/clinpract112390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background: The need for simultaneous cholecystectomy for asymptomatic cholelithiasis in patients undergoing bariatric intervention has not been proven. The experience of managing patients with obesity and concomitant disease cholelithiasis is presented.
Aim: to determine the indications for simultaneous cholecystectomy and bariatric surgery in the combination of morbid obesity and a asymptomatic cholelithiasis.
Methods: The results of observation of 37 patients with initially asymptomatic cholelithiasis were analyzed: 27 patients underwent bariatric surgery and simultaneous cholecystectomy, and 10 patients underwent only bariatric surgery. The immediate and long-term results of the treatment, the quality of life of patients and the cost of the treatment were assessed.
Results: During 12 months of the follow-up, none of the patients who underwent simultaneous cholecystectomy developed any complications. Of the 10 patients in the observation group, 3 were operated on. Two patients underwent laparoscopic cholecystectomy for acute cholecystitis and one patient was operated on for choledocholithiasis with obstructive jaundice. The greatest improvement in the quality of life was observed in the gastric bypass group with simultaneous cholecystectomy. The treatment cost per patient was lower in that group, too.
Conclusion: In the presence of asymptomatic cholelithiasis in a patient with morbid obesity, bariatric intervention and simultaneous cholecystectomy prevents the development of complications of cholelithiasis and thereby potentially improves the quality of life and reduces the cost of medical care.
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12
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Clapp B, Janik M, Corbett J, Vahibe A, Ul Hassan O, Husain F, Pullat R, Ghanem OM. Duodenal switch without versus with laparoscopic cholecystectomy: a perioperative risk comparative analysis of the MBSAQIP database (2015-2019). Surg Endosc 2023; 37:219-224. [PMID: 35918551 DOI: 10.1007/s00464-022-09477-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/13/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The results of concurrent cholecystectomy with Roux-en Y gastric bypass and sleeve gastrectomy have been well elucidated. Large-scale data on the outcomes of concomitant cholecystectomy during biliopancreatic diversion with duodenal switch (BPD-DS) are still lacking. Our study aimed to explore whether simultaneous cholecystectomy with BPD-DS alters the 30-day postoperative outcomes. METHODS We conducted a retrospective analysis of the MBSAQIP database between 2015 and 2019. Propensity-score matching (PSM) in BPD-DS with cholecystectomy (Group 1) and BPD-DS without cholecystectomy (Group 2) cohorts was performed (PSM ratio 1:2). The two groups were matched for a total of 21 baseline variables including age, gender, BMI, ASA class, and other medical comorbidities and conditions. The 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions were obtained. RESULTS Initially, 568 patients in Group 1 and 5079 in Group 2 were identified. After performing PSM, 564 and 1128 patients respectively were compared. The BPD-DS with cholecystectomy group reported a higher rate of reoperation and reintervention compared to BPD-DS alone (3.9% versus 2.4% and 3.2% versus 2%, respectively), even though it did not reach statistical significance. The intervention time was significantly higher in Group 1 compared to Group 2 (192.4 ± 77.6 versus 126.4 ± 61.4 min). Clavien-Dindo complications (1-5) were similar between these two PSM cohorts. CONCLUSION Concomitant cholecystectomy during BPD-DS increases operative times but does not affect the other outcomes. Based on our results, the decision of cholecystectomy at the time of BPD-DS should be left to the surgeon's judgment.
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Affiliation(s)
- Ben Clapp
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Michal Janik
- Department of Surgery, Military Institute of Aviation Medicine, Warsaw, Poland
| | - John Corbett
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Ahmet Vahibe
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Omer Ul Hassan
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Farah Husain
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Rana Pullat
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
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13
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Son SY, Song JH, Shin HJ, Hur H, Han SU. Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2022; 11:30-38. [PMID: 36926672 PMCID: PMC10011673 DOI: 10.17476/jmbs.2022.11.2.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 03/11/2023]
Abstract
Obesity by itself is a factor in the development of gallstone disease, and periods of weight loss after bariatric surgery further increase the risk of gallstone formation. In patients with obesity, hypersecretion of cholesterol may increase the risk of gallstone formation, which is approximately five-fold higher than that in the general population. The incidence of gallstone formation after bariatric surgery is 10-38% and often associated with a proportional increase in the risk of developing biliary complications. Routine postoperative administration of ursodeoxycholic acid (UDCA) is recommended to prevent gallstone formation. Several randomized trials have indicated that UDCA can effectively prevent gallstones and reduce the risk of cholecystectomy after bariatric procedures. The effective daily dose of UDCA in each study ranged from 500 to 1,200 mg, and it may be considered at least during the period of rapid weight loss (first 3-6 months postoperatively) to decrease the incidence of symptomatic gallstones.
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Affiliation(s)
- Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jeong Ho Song
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Ho-Jung Shin
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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14
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Barclay RL, Jain A, Buteau Ferland AS, Chen YI, Donnellan F. Living on the EDGE: Canadian Experience With EUS-directed Transgastric ERCP (EDGE) in Patients With Roux-en-Y Gastric Bypass Anatomy. J Can Assoc Gastroenterol 2022; 5:116-120. [PMID: 35669842 PMCID: PMC9157288 DOI: 10.1093/jcag/gwab035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Roux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EDGE, is an endoscopic approach which involves accessing the excluded stomach to facilitate ERCP. Objective The objective of this study is to describe the results of EDGE procedures performed in Canada. Methods Data were collected from patient cases who had undergone an EDGE procedure across centers in Canada. All patients had a history of RYGB bariatric surgery. In each procedure, a 20-mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS guidance to allow access from the gastric remnant/proximal jejunum to the excluded stomach. Subsequently, during a separate procedure, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was replaced with a pigtail stent or APC was used to facilitate closure of the gastro-jejunal/gastro-gastric fistula. Results The indication for EDGE in the seven included cases was for the treatment of choledocholithiasis (six) or gallstone pancreatitis (one). The technical success rate of the EDGE procedure in these cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all cases. There were no adverse events reported. Conclusion The results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery.
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Affiliation(s)
- Robert L Barclay
- Department of Internal Medicine, Division of Gastroenterology, Victoria General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Avni Jain
- Department of Internal Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anne-Sophie Buteau Ferland
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Yen-I Chen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fergal Donnellan
- Department of Internal Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Ying J, Dai S, Fu R, Hong J, Dai C, Jin Q. Effect of ursodeoxycholic acid on gallstone formation after bariatric surgery: An updated meta-analysis. Obesity (Silver Spring) 2022; 30:1170-1180. [PMID: 35475596 DOI: 10.1002/oby.23427] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Bariatric surgery increases the risk of postoperative gallstone formation. Many studies have proposed ursodeoxycholic acid (UDCA) as a preventive agent for postoperative gallstone formation. This study aimed to investigate the effect of UDCA on gallstone formation after bariatric surgery in patients without preoperative gallstones. METHODS PubMed, the Web of Science, the Cochrane Library, and EBSCO were searched for articles assessing the effect of UDCA on gallstone formation after bariatric surgery. The outcome was the incidence of postoperative gallstones. Odds ratios were used to assess dichotomous variables, and random-effects models were used for statistical analyses. RESULTS A total of 18 studies including 4,827 participants met the inclusion criteria. The statistical results showed that the incidence of gallstones in the UDCA group was significantly lower than in the control group. Furthermore, the occurrence of symptomatic gallstones and cholecystectomy was significantly reduced. CONCLUSIONS In patients without preoperative gallstones, UDCA can effectively prevent the formation of gallstones after bariatric surgery. In addition, UDCA can significantly reduce the occurrence of symptomatic gallstones and the risk of postoperative cholecystectomy. Doses of 500 to 600 mg/d can be used as a measure to prevent postoperative gallstone formation.
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Affiliation(s)
- Jingjing Ying
- Department of Pharmacy, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Senjie Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Rongrong Fu
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Chenglong Dai
- School of Medical Imaging, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qiong Jin
- Emergency Medical Center, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
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16
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McCarty TR, Kumar N. Revision Bariatric Procedures and Management of Complications from Bariatric Surgery. Dig Dis Sci 2022; 67:1688-1701. [PMID: 35347535 DOI: 10.1007/s10620-022-07397-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
Abstract
Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Nitin Kumar
- HSHS Medical Group, Springfield, IL, 62704, USA.
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17
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Verhoeff K, Mocanu V, Dang J, Switzer NJ, Birch DW, Karmali S. Characterization and Risk Factors for Early Biliary Complications Following Elective Bariatric Surgery: an Mbsaqip Analysis. Obes Surg 2022; 32:1170-1177. [PMID: 35048248 DOI: 10.1007/s11695-022-05914-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Kevin Verhoeff
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom 2G2 Walter C. Mackenzie Health Sciences Centre, 8440112 ST NW, T6G 2B7, Edmonton, Alberta, Canada.
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Jerry Dang
- Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, T6G 2B7, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, T6G 2B7, Canada
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18
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Stenberg E, Dos Reis Falcão LF, O'Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg 2022; 46:729-751. [PMID: 34984504 PMCID: PMC8885505 DOI: 10.1007/s00268-021-06394-9] [Citation(s) in RCA: 139] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 02/08/2023]
Abstract
Background This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol. Methods A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations. Results The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries. Conclusion A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
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Affiliation(s)
- Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Mary O'Kane
- Dietetic Department, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Ronald Liem
- Department of Surgery, Groene Hart Hospital, Gouda, Netherlands.,Dutch Obesity Clinic, The Hague, Netherlands
| | - Dimitri J Pournaras
- Department of Upper GI and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, UK
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anupama Wadhwa
- Department of Anesthesiology, Outcomes Research Institute, Cleveland Clinic, University of Texas Southwestern, Dallas, USA
| | - Ulf O Gustafsson
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
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19
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Predictive Factors of Cholelithiasis After Prophylactic Administration of Ursodeoxycholic Acid Following Laparoscopic Bariatric Surgery: Tehran Obesity Treatment Study. Obes Surg 2021; 32:311-317. [PMID: 34816356 DOI: 10.1007/s11695-021-05777-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/14/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
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.
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20
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Qi L, Dai W, Kong J, Tian Y, Chen Y. Cholecystectomy as a risk factor for metabolic dysfunction-associated fatty liver disease: unveiling the metabolic and chronobiologic clues behind the bile acid enterohepatic circulation. J Physiol Biochem 2021; 77:497-510. [PMID: 34302623 DOI: 10.1007/s13105-020-00782-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/23/2020] [Indexed: 02/08/2023]
Abstract
Metabolic dysfunction-associated fatty liver disease (MAFLD) is highly prevalent worldwide. Recent clinical and experimental studies have addressed the association between cholecystectomy and MAFLD, confirming that cholecystectomy is an independent risk factor for MAFLD. In this review, we describe the epidemiologic evidence that links cholecystectomy to MAFLD, and discuss the possible mechanisms behind these connections, in order to unveil the metabolic and chronobiologic signals conveyed by the waves of the bile acid enterohepatic circulation.
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Affiliation(s)
- Li Qi
- Department of Rheumatology and Immunology, Shengjing Hospital of China Medical University, No. 39, Hua xiang Road, Tiexi District, Shenyang, 110022, Liaoning Province, China
| | - Wanlin Dai
- Innovation Institute of China Medical University, No. 77, Pu He Road, Shenbeixin District, Shenyang, 110004, Liaoning Province, China
| | - Jing Kong
- Department of General Surgery, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Heping District, Shenyang, 110004, Liaoning Province, China
| | - Yu Tian
- Department of General Surgery, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Heping District, Shenyang, 110004, Liaoning Province, China
| | - Yongsheng Chen
- Department of General Surgery, Shengjing Hospital of China Medical University, No. 36, San Hao Street, Heping District, Shenyang, 110004, Liaoning Province, China.
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21
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Elgohary H, El Azawy M, Elbanna M, Elhossainy H, Omar W. Concomitant versus Delayed Cholecystectomy in Bariatric Surgery. J Obes 2021; 2021:9957834. [PMID: 34234964 PMCID: PMC8216831 DOI: 10.1155/2021/9957834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/01/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Obesity and weight loss after bariatric surgery have a close association with gallbladder disease. The performance and proper timing of laparoscopic cholecystectomy (LC) with bariatric surgery remain a clinical question. OBJECTIVE Evaluation of the outcome of LC during bariatric surgery whether done concomitantly or delayed according to the level of intraoperative difficulty. METHODS The prospective study included patients with morbid obesity between December 2018 and December 2019 with preoperatively detected gallbladder stones. According to the level of difficulty, patients were allocated into 2 groups: group 1 included patients who underwent concomitant LC during bariatric surgery, and group 2 included patients who underwent delayed LC after 2 months. In group 1, patients were further divided into subgroups: LC either at the beginning (subgroup A) or after bariatric surgery (subgroup B). RESULTS Operative time in group 1 vs. 2 was 92.63 ± 28.25 vs. 68.33 ± 17.49 (p < 0.001), and in subgroup A vs. B, it was 84.19 ± 19.62 vs. 130.0 ± 31.62 (p < 0.001). One patient in each group (2.6% and 8.3%) had obstructive jaundice, p > 0.001. In group 2, 33% of asymptomatic patients became symptomatic for biliary colic p > 0.001. LC difficulty score was 2.11 ± 0.70 vs. 5.66 ± 0.98 in groups 1 and 2, respectively, p < 0.001. LC difficulty score decreased in group 2 from 5.66 ± 0.98 to 2.26 ± 0.78 after 2 months of bariatric surgery, p < 0.001. CONCLUSION Timing for LC during bariatric surgery is challenging and should be optimized for each patient as scheduling difficult LC to be performed after 2 months may be an option.
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Affiliation(s)
- Hatem Elgohary
- General Surgery Department, Faculty of Medicine, Helwan University, Helwan, Egypt
| | - Mahmoud El Azawy
- General Surgery Department, Faculty of Medicine, Helwan University, Helwan, Egypt
| | - Mohey Elbanna
- Department of General Surgery, Faculty of Medicine, Ain-shams University, Cairo, Egypt
| | - Hossam Elhossainy
- General Surgery Department, Faculty of Medicine, Helwan University, Helwan, Egypt
| | - Wael Omar
- General Surgery Department, Faculty of Medicine, Helwan University, Helwan, Egypt
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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. Obes Surg 2020; 31:1249-1255. [PMID: 33230759 DOI: 10.1007/s11695-020-05125-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 01/01/2023]
Abstract
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.
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23
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Falvo AM, Vacharathit V, Dove J, Fluck M, Daouadi M, Gabrielsen J, Horsley R, Petrick A, Parker DM. A 3-Year MBSAQIP propensity-matched analysis of Roux-en-Y gastric bypass with concomitant cholecystectomy: Is the robotic or laparoscopic approach preferred? Surg Endosc 2020; 35:4712-4718. [PMID: 32959181 DOI: 10.1007/s00464-020-07939-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/25/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Alexandra M Falvo
- Geisinger Medical Center, 100 N Academy Drive, Danville, PA, 17822, USA
| | | | - James Dove
- Geisinger Medical Center, 100 N Academy Drive, Danville, PA, 17822, USA
| | - Marcus Fluck
- Geisinger Medical Center, 100 N Academy Drive, Danville, PA, 17822, USA
| | - Mustapha Daouadi
- Geisinger Medical Center, 100 N Academy Drive, Danville, PA, 17822, USA
| | - Jon Gabrielsen
- Geisinger Medical Center, 100 N Academy Drive, Danville, PA, 17822, USA
| | - Ryan Horsley
- Geisinger Commonwealth Medical Center, Scranton, USA
| | - Anthony Petrick
- Geisinger Medical Center, 100 N Academy Drive, Danville, PA, 17822, USA
| | - David M Parker
- Geisinger Medical Center, 100 N Academy Drive, Danville, PA, 17822, USA.
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