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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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Nogueiro J, Santos-Sousa H, Ribeiro M, Cruz F, Pereira A, Resende F, Costa-Pinho A, Preto J, Sousa-Pinto B, Lima-da-Costa E, Carneiro S. Incidence of symptomatic gallstones after bariatric surgery: the impact of expectant management. Langenbecks Arch Surg 2023; 408:160. [PMID: 37093281 PMCID: PMC10124697 DOI: 10.1007/s00423-023-02904-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/19/2023] [Indexed: 04/25/2023]
Abstract
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.
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Affiliation(s)
- Jorge Nogueiro
- Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery Department, São João University Medical Center, Porto, Portugal
| | - Hugo Santos-Sousa
- Faculty of Medicine, University of Porto, Porto, Portugal.
- Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Porto, Portugal.
| | - Miguel Ribeiro
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Filipe Cruz
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - André Pereira
- Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery Department, São João University Medical Center, Porto, Portugal
| | - Fernando Resende
- Faculty of Medicine, University of Porto, Porto, Portugal
- Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Porto, Portugal
| | - André Costa-Pinho
- Faculty of Medicine, University of Porto, Porto, Portugal
- Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Porto, Portugal
| | - John Preto
- Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, 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
| | - Eduardo Lima-da-Costa
- Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, Porto, Portugal
| | - Silvestre Carneiro
- Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery Department, São João University Medical Center, Porto, Portugal
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Han ML, Lee MH, Lee WJ, Chen SC, Almalki OM, Chen JC, Wu CC. Probiotics for gallstones prevention in bariatric surgery patients: A prospective randomized trial. Asian J Surg 2022; 45:2664-2669. [PMID: 35232647 DOI: 10.1016/j.asjsur.2022.01.120] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/27/2021] [Accepted: 01/07/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Gall stone disease was known to increase after bariatric surgery. Ursodeoxycholic acid (UDCA) might reduce the gallstone formation rate after bariatric surgery. However, other option for gallstone prevention was unclear. We reported the result of a randomized trial comparing the gallstone prevention efficacy of probiotics and digestive enzyme versus UDCA. METHODS This prospective, randomized trial was held in an institute of Taiwan. Patients were eligible for inclusion if their body-mass index (BMI) was 32.5 kg/m2 or higher with the presence of comorbidity, or 27.5 kg/mw or higher with not-well controlled type 2 diabetes, and were aged 18-65 years. Participant were randomized assigned (1:1:1) to probiotic, digestive enzyme or UDCA. The primary endpoint was assessed in the incidence of gallstone disease at 6 months after surgery. This study is registered with ClinicalTrials.gov. number NCT03247101, and is now completed. RESULTS From January 2016 to December 2018, of 186 patients screened for eligibility, 152 were randomly assigned to probiotic (52) or digestive enzyme (52) or UDCA (52). In the per-protocol population, mean age was 35.9 years (SD 10.6), mean BMI was 40.3 kg/m2 (SD 6.9), 57(58.2%) were female. After 6 months, the incidence of gall bladder diseased was 15.2%, in the probiotics group, 17.6% in UDCA group and 29.1% in digestive enzyme groups, confirming non-inferiority of probiotic (p = 0.38). Female gender was identified as a risk factor for gall bladder disease after bariatric surgery (odds ratio = 4.61, 95% confidence interval = 1.05, 20.3, p = 0.04). The poor drug compliance rate was 19.5%, 22.7% and 26.2% in probiotics, UDCA and digestive enzyme group respectively. UDCA group had a higher drug adverse effect than probiotic group (15.9% vs. 2.4%, p = 0.03). CONCLUSION Probiotic is not inferior to UDCA regarding gall bladder disease prevention after bariatric surgery at 6 months.
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Affiliation(s)
- Ming-Lun Han
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Hsien Lee
- Metabolic & Bariatric Surgical Department, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan
| | - Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan.
| | - Shu-Chun Chen
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Owaid M Almalki
- Department of Surgery, College of Medicine, Taif University, Saudi Arabia
| | - Jung-Chien Chen
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Chun-Chi Wu
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
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Complications of Endoscopic Retrograde Cholangiopancreatography in Patients With Previous Bariatric Surgery: A National Inpatient Sample Analysis, 2007-2013. J Clin Gastroenterol 2022; 56:81-87. [PMID: 33405433 DOI: 10.1097/mcg.0000000000001483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/22/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND Bariatric surgery (BS) has been proven to be effective in the treatment of obesity and weight-related diseases, but the anatomic changes after BS make endoscopic retrograde cholangiopancreatography (ERCP) technically challenging. This study aims to assess the safety and clinical outcomes of ERCP in patients with previous BS. MATERIALS AND METHODS The National Inpatient Sample from 2007 to 2013 was queried for hospitalizations of adults over 18 years of age with procedure diagnoses of ERCP. Those with prior BS were selected as cases and those without BS as controls. Case-control matching at a ratio of 1 case to 2 controls was performed based on sex, age, race, comorbidities, and obesity. The primary outcomes were inpatient mortality and ERCP-related complications. Multivariate regression analysis was used to identify independent risk factors associated to the primary outcomes. RESULTS A total of 1,068,862 weighted hospitalizations with ERCP procedure codes were identified. Of these, 6689 with BS were selected as cases, and 13,246 were matched as controls. The reason for hospital admission was most often biliary stone disease (60.7% vs. 55.5%), followed by malignancy (3.5% vs. 12.1%) and cholangitis (7.7% vs. 4.5%) with and without BS, P<0.05. The BS group had lower rates of post-ERCP pancreatitis (0.1% vs. 1.3%), cholecystitis (0.1% vs. 0.3%), bleeding (1.0% vs. 1.4%), and inpatient mortality (0.2% vs. 0.5%), but had higher rates of cholangitis (5.0% vs. 3.7%) and systemic infections (6.2% vs. 4.8%), all P<0.05. CONCLUSIONS BS group had lower post-ERCP pancreatitis, cholecystitis and bleeding while had more cholangitis, and systemic infection compared with those without BS. Also, BS was independently associated with reduced inpatient mortality after adjusted for age, race, and comorbidity.
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Tustumi F, Pinheiro Filho JEL, Stolzemburg LCP, Serigiolle LC, Costa TN, Pajecki D, Santo MA, Nahas SC. Management of biliary stones in bariatric surgery. Ther Adv Gastrointest Endosc 2022; 15:26317745221105087. [PMID: 36388729 PMCID: PMC9664186 DOI: 10.1177/26317745221105087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 05/16/2022] [Indexed: 11/25/2022] Open
Abstract
Morbidly obese and post-bariatric surgery patients are at increased risk for
biliary stones formation. The complications related to biliary stones may impose
complexity on their management. This study aimed to review the management of
biliary conditions in obese and bariatric patients. In this study, a narrative
review was performed of the medical, surgical, and endoscopic procedures for the
management of biliary stones and their related complications. Knowing the main
prophylactic and therapeutic interventions options is essential for clinicians
to properly manage the biliary stones in patients candidates or submitted to
bariatric surgery.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Universidade de São Paulo, Av. Dr Eneas de Carvalho Aguiar, 255, Cerqueira Cesar, São Paulo 05403-000, SP, Brazil
- Department of Surgery, Faculdade de Medicina do ABC, Santo André, Brazil
| | | | | | | | | | - Denis Pajecki
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Marco Aurélio Santo
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio Carlos Nahas
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
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Concomitant Cholecystectomy for Asymptomatic Gallstones in Bariatric Surgery-Safety Profile and Feasibility in a Large Tertiary Referral Bariatric Center. Obes Surg 2021; 32:295-301. [PMID: 34791618 DOI: 10.1007/s11695-021-05798-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
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.
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Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm. Obes Surg 2021; 31:4993-5004. [PMID: 34350533 DOI: 10.1007/s11695-021-05627-z] [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: 04/07/2021] [Revised: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 01/22/2023]
Abstract
Choledocholithiasis in post-surgical bariatric Roux-en-Y gastric bypass patients presents a significant challenge secondary to altered anatomy. We aim to review the existing management options including either endoscopic, surgical, percutaneous or hybrid means. Current literature suggests reasonably successful cannulation rates for single- or double-balloon ERCP ranging from 50 to 70% and 63-83%, respectively. The hybrid technique of laparoscopic transgastric ERCP has gained popularity with success rates ranging from 90 to 100%. Conventional laparoscopic techniques like transcystic duct and transcholedochal bile duct exploration are still useful options (i.e. high success rates of 81-100% and 83-96%, respectively). The role of percutaneous transhepatic choledochography remains limited although it can help with rapid bile duct decompression. If feasible, treatment pathways should progress from least to more invasive options as required.
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Sakran N, Dar R, Assalia A, Neeman Z, Farraj M, Sherf-Dagan S, Gralnek IM, Hazzan R, Mokary SE, Nevo-Aboody H, Dola T, Kaplan U, Hershko D. The use of Ursolit for gallstone prophylaxis following bariatric surgery: a randomized-controlled trial. Updates Surg 2020; 72:1125-1133. [PMID: 32666477 DOI: 10.1007/s13304-020-00850-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although bariatric surgery (BS) predisposes patients to development of gallstone formation, a preventive strategy is still in debate. AIM To compare the incidence of gallstone formation between patients treated with ursodeoxycholic acid (UDCA) vs. placebo for a duration of 6 months following BS. METHODS This multicenter randomized, double-blind controlled trial entails treatment with UDCA vs. an identical-looking placebo. The primary outcome was gallstone formation, as measured by abdominal ultrasound. RESULTS The data of 209 subjects were enrolled in the study, and 92 subjects completed the study and were analyzed (n = 46 for each study group). The high dropout rate was mainly due to difficulties in adding more medications and swallowing the pill. Among the subjects who completed the study, 77.2% were women, and their mean age and pre-surgery BMI were 42.2 ± 10.2 years and 44.4 ± 6.1 kg/m2, respectively. Gallstone formation was recorded in 45.7% (n = 21) vs. 23.9% (n = 11) of subjects among placebo vs. UDCA groups, respectively, p = 0.029. Subgroup-analysis, according to surgery type, found that the results were significant only for SG subjects (p = 0.041), although the same trend was observed for OAGB/RYGB. Excess Weight Loss percent (%EWL) at 6 months post-surgery was 66.0 ± 17.1% vs. 71.8 ± 19.5% for the placebo and UDCA groups, respectively; p = 0.136. A trend towards a reduction in prescribed comorbidity medications was noted within-groups during the follow-up period, as compared to baseline, with no between-group differences (p ≥ 0.246). Moreover, no between-group differences were found for blood test results (p ≥ 0.063 for all). CONCLUSION Administration of UDCA significantly decreased gallstone formation at 6 months at following BS. CLINICALTRIALS. GOV NUMBER NCT02319629.
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Affiliation(s)
- Nasser Sakran
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel. .,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Ron Dar
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ahmad Assalia
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ziv Neeman
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Medical Imaging Institute and Nuclear Medicine, Emek Medical Center, Afula, Israel
| | - Moaad Farraj
- Department of Surgery, Galilee Medical Center, Nahariya, Israel
| | - Shiri Sherf-Dagan
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel, Israel.,Department of Nutrition, Assuta Medical Center, Tel-Aviv, Israel
| | - Ian M Gralnek
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Ellen and Pinchas Mamber Institute of Gastroenterology, Hepatology, and Nutrition, Emek Medical Center, Afula, Israel
| | - Rawi Hazzan
- Ellen and Pinchas Mamber Institute of Gastroenterology, Hepatology, and Nutrition, Emek Medical Center, Afula, Israel
| | - Shams Eldin Mokary
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Hadar Nevo-Aboody
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tamar Dola
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel
| | - Uri Kaplan
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel
| | - Dan Hershko
- Department of Surgery, Emek Medical Center, 21 Izhak Rabin Blvd, 1834111, Afula, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Baimas-George M, Passeri MJ, Lyman WB, Dries A, Narang T, Deal S, Lewis J, Chauhan S, Martinie J, Vrochides D, Baker E, Iannitti D. A Single-Center Experience with Minimally Invasive Transgastric ERCP in Patients with Previous Gastric Bypass: Lessons Learned and Technical Considerations. Am Surg 2020. [DOI: 10.1177/000313482008600425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
As bariatric surgery increases, there is a growing population of patients with biliary obstruction and anatomy which precludes transoral access through endoscopic retrograde cholangiopancreatography (ERCP). Minimally invasive transgastric ERCP (TG-ERCP) offers a feasible alternative for the treatment. A retrospective review was performed of all patients who underwent laparoscopic or robotic-assisted TG-ERCP between 2010 and 2017. Chart abstraction collected demographics, procedural details, success rate, and postoperative outcomes. Forty patients were identified, of which 38 cases were performed laparoscopically and two robotically. Median operative time was 163 minutes, with an estimated blood loss of 50 cc. TG-ERCP was performed successfully in 36 cases (90%); sphincterotomy was completed in 35 patients (97%). Sixty per cent already had a cholecystectomy; in the remaining patients, it was performed concurrently. Major complications included stomach perforation (n = 1), pancreatitis (n = 3), and anemia requiring transfusion (n = 2). In patients with biliary obstruction and anatomy not suitable for ERCP, TG-ERCP can be performed in a minimally invasive fashion, with a high rate of technical success and low morbidity. We describe a stepwise, reproducible technique because it is an essential tool for the shared armamentarium of endoscopists and surgeons.
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Affiliation(s)
- Maria Baimas-George
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J. Passeri
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - William B. Lyman
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Andrew Dries
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Tarun Narang
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen Deal
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jason Lewis
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Shailendra Chauhan
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John Martinie
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin Baker
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David Iannitti
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
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10
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Does pregnancy increase the risk of cholecystectomy following bariatric surgery? A cross-sectional cohort study. Surg Obes Relat Dis 2019; 15:1822-1828. [PMID: 31466873 DOI: 10.1016/j.soard.2019.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/04/2019] [Accepted: 06/29/2019] [Indexed: 11/20/2022]
Abstract
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.
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Doulamis IP, Michalopoulos G, Boikou V, Schizas D, Spartalis E, Menenakos E, Economopoulos KP. Concomitant cholecystectomy during bariatric surgery: The jury is still out. Am J Surg 2019; 218:401-410. [PMID: 30791992 DOI: 10.1016/j.amjsurg.2019.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 01/21/2019] [Accepted: 02/03/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND We sought to compare clinical outcomes of concomitant cholecystectomy during four different types of bariatric surgery vs. bariatric surgery alone. DATA SOURCES A systematic literature search of PubMed and Cochrane databases was conducted in accordance with the PRISMA guidelines. Thirty studies were included in this study, reporting data on 13,675 patients. Our findings suggest a higher rate of anastomotic leak/stricture in the case of concomitant cholecystectomy with gastric bypass compared to those who had gastric bypass alone. The scarcity of data concerning sleeve gastrectomy, adjustable gastric banding and biliopancreatic diversion prevented us from quantifying possible difference of outcomes between the examined treatment groups. CONCLUSIONS This study highlights the small number and poor quality of available studies referring to the role of simultaneous cholecystectomy during bariatric surgery.
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Affiliation(s)
- Ilias P Doulamis
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.
| | | | - Vasileios Boikou
- Surgery Working Group, Society of Junior Doctors, Athens, Greece; Athens University of Economics and Business, Athens, Greece
| | - Dimitrios Schizas
- Surgery Working Group, Society of Junior Doctors, Athens, Greece; First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Menenakos
- 1st Propaedeutic Surgical Department, "Evgenidion" Hospital of Athens, Medical School of Athens, National and Kapodistrian University of Athens, Greece
| | - Konstantinos P Economopoulos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Hasan MY, Lomanto D, Loh LL, So JBY, Shabbir A. Gallstone Disease After Laparoscopic Sleeve Gastrectomy in an Asian Population-What Proportion of Gallstones Actually Becomes Symptomatic? Obes Surg 2018; 27:2419-2423. [PMID: 28401383 DOI: 10.1007/s11695-017-2657-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite evidence on gallstone disease after laparoscopic sleeve gastrectomy (LSG), there is an existing lack of consensus on practice guidelines, i.e., surveillance and stone-lowering prophylaxis. Available evidence also has a racial bias as western reports predominate current data. Considering the growing popularity of LSG in Asia and the unique Asian anthropometrics, we have attempted to provide a regional perspective by reviewing our LSG database to investigate the epidemiology of this complication. METHODS One hundred two morbidly obese cases were retrospectively reviewed. Abdominal ultrasounds were conducted preoperatively and at 12-month post-op. No gallstone-lowering prophylaxis was used. Outcome measure was the incidence of new gallstone formation at 1 year and the rate of symptomatic stones during the follow-up period. RESULTS Mean age was 43 years (range 20-68) with average initial BMI of 41.68 kg/m2. Preoperative gallstones were present in 14 (13.7%) cases. At 12-month post-op, 24 (27.5%) patients with no previous gallstone disease developed new stones. Within the mean follow-up period of 28.4 months, only one case (0.9%) developed gallstone complication requiring a cholecystectomy. We found no statistical difference in demographics, BMI variables (initial BMI, ΔBMI at 6 months and 1 year), and comorbidities between patients with new gallstone and those without stones. CONCLUSION Our results match western data in that gallstone formation is common after LSG though incidence of complicated stones is small. This is despite not using gallstone-lowering prophylaxis. The low conversion rate also questions the relevance of surveillance screening, as most patients with new gallstones remain asymptomatic at least in the short-term follow-up.
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Affiliation(s)
- Muhammed Yaser Hasan
- Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
| | - Davide Lomanto
- Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
| | - Lee Leng Loh
- Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
| | - Jimmy Bok Yan So
- Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
| | - Asim Shabbir
- Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore.
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Choledocholithiasis after Bariatric Surgery-More than a Stone's Throw to Reach? J Gastrointest Surg 2018; 22:529-537. [PMID: 29192385 DOI: 10.1007/s11605-017-3634-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/06/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gallstone disease is common after bariatric surgery, and patients with bile duct stones in this cohort can be difficult to treat, due to the altered anatomy. This review aims to analyse the various management options available for choledocholithiasis in post-bariatric surgery patients. METHODS A literature search of PubMed, Medline and Cochrane library databases was carried out for studies on this subject, between January 1970 and March 2017. After initial screening and further full text review, suitable studies were identified after applying the inclusion criteria. RESULTS Twenty-nine studies were identified and analysed. Overtube-assisted endoscopy appears to be a popular technique, and 10 studies employing this technique were identified. Though there are minor variations between the three different types of overtube endoscopy, the success rate for ERCP with this approach is between 60 and 70%. Studies using a combination of radiological and endoscopic techniques report a success rate of 60-70%, though the endoscopic ultrasound-guided technique has been reported to have higher success rates (90-100%). Surgery-assisted ERCP also appears to be widely reported and has a consistently high ERCP success rate (80-100%), with an added advantage of the option to perform a concomitant cholecystectomy. There are very few reports on using surgery as the sole option in this scenario. CONCLUSION Both overtube-assisted endoscopy and laparoscopy-assisted ERCP appear to be safe, with good success rates. The other methods may be suitable for selected patients and centres with specific interest in such techniques.
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Wanjura V, Szabo E, Österberg J, Ottosson J, Enochsson L, Sandblom G. Morbidity of cholecystectomy and gastric bypass in a national database. Br J Surg 2017; 105:121-127. [DOI: 10.1002/bjs.10666] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/02/2017] [Accepted: 07/10/2017] [Indexed: 01/23/2023]
Abstract
Abstract
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.
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Affiliation(s)
- V Wanjura
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - E Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - J Österberg
- Department of Surgery, Mora Hospital, Mora, Sweden
| | - J Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Lindesberg, Sweden
| | - L Enochsson
- Department of Surgical and Perioperative Sciences, Division of Surgery, Sunderby Hospital, Umeå University, Umeå, Sweden
| | - G Sandblom
- Department of Surgical Gastroenterology, Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Dakour-Aridi HN, El-Rayess HM, Abou-Abbass H, Abu-Gheida I, Habib RH, Safadi BY. Safety of concomitant cholecystectomy at the time of laparoscopic sleeve gastrectomy: analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Surg Obes Relat Dis 2016; 13:934-941. [PMID: 28223091 DOI: 10.1016/j.soard.2016.12.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/23/2016] [Accepted: 12/14/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND The indication and safety of concomitant cholecystectomy (CC) during bariatric surgical procedures are topics of controversy. Studies on the outcomes of CC with laparoscopic sleeve gastrectomy (LSG) are scarce. OBJECTIVES To assess the safety and 30-day surgical outcomes of CC with LSG. METHODS A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database 2010 to 2013. Univariate and multivariate analyses were used. RESULTS Between 2010 and 2013, 21,137 patients underwent LSG; of those 422 (2.0%) underwent CC (LSG+CC), and the majority (20,715 [98%]) underwent LSG alone. Patients in both groups were similar in age, sex distribution, baseline weight, and body mass index. The average surgical time was significantly higher, by 33 minutes, in the LSG+CC cohort. No differences were noted between the groups with regard to overall 30-day mortality and length of hospital stay. CC increased the odds of any adverse event (5.7% versus 4.0%), but the difference did not reach statistical significance (odds ratio 1.49, P = .07). Two complications were noted to be significantly higher with LSG+CC, namely bleeding (P = .04) and pneumonia (P = .02). CONCLUSION CC during LSG appears to be a safe procedure with slightly increased risk of bleeding and pneumonia compared with LSG alone. When factoring the potential risk and cost of further hospitalization for deferred cholecystectomy, these data support CC for established gallbladder disease.
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Affiliation(s)
| | - Hebah M El-Rayess
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussein Abou-Abbass
- Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
| | - Ibrahim Abu-Gheida
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Robert H Habib
- Department of Internal Medicine and Outcomes Research Unit-Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Bassem Y Safadi
- Department of Surgery, American University of Beirut, Beirut, Lebanon.
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Coupaye M, Calabrese D, Sami O, Msika S, Ledoux S. Evaluation of incidence of cholelithiasis after bariatric surgery in subjects treated or not treated with ursodeoxycholic acid. Surg Obes Relat Dis 2016; 13:681-685. [PMID: 28089591 DOI: 10.1016/j.soard.2016.11.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/16/2016] [Accepted: 11/19/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND The use of ursodeoxycholic acid (UDCA) to prevent gallstone formation after gastric bypass (RYGB) is still debated. Furthermore, only 1 study has assessed the effectiveness of UDCA after sleeve gastrectomy (SG) with mitigated results. OBJECTIVES To compare the incidence of cholelithiasis (CL) between patients treated or not treated with UDCA after RYGB and SG. SETTING University hospital, France. METHODS Since January 2008, a postoperative ultrasound monitoring was scheduled for all patients without previous cholecystectomy who underwent bariatric surgery in our institution. Patients who underwent at least 1 ultrasound in the first postoperative year (±6 months) were included. We started to systematically prescribe UDCA (500 mg/d) for 6 months postoperatively, in February 2012 for RYGB (once or twice daily) and in October 2013 for SG (once daily). RESULTS Mean follow-up was 13.0±3.4 months. The incidence of CL was 32.5% in the 117 nontreated RYGB and 25.5% in the 51 nontreated SG. It was reduced to 2.4% in the 42 SG treated once daily (P = .005), to 5.7% in the 87 RYGB with 250 mg twice daily (P<.001), but only to 18.6% in the 102 RYGB with 500 mg once daily (P = .03). CONCLUSION UDCA 500 mg once daily for 6 months is efficient to prevent CL 1 year after SG, but the twice-daily doses seem to be more effective after RYGB. The effectiveness of UDCA once daily after SG and the superiority of the twice-daily doses after RYGB should be confirmed with more patients and longer follow-up.
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Affiliation(s)
- Muriel Coupaye
- Service des Explorations Fonctionnelles, Centre Intégré Nord Francilien de prise en charge de l'Obésité (CINFO), Hôpital Louis Mourier (AP-HP), Université Paris Diderot, Sorbonne Paris Cité, France.
| | - Daniela Calabrese
- Service de Chirurgie, Centre Intégré Nord Francilien de prise en charge de l'Obésité (CINFO), Hôpital Louis Mourier (AP-HP), Université Paris Diderot, Sorbonne Paris Cité, France
| | - Ouidad Sami
- Service des Explorations Fonctionnelles, Centre Intégré Nord Francilien de prise en charge de l'Obésité (CINFO), Hôpital Louis Mourier (AP-HP), Université Paris Diderot, Sorbonne Paris Cité, France
| | - Simon Msika
- Service de Chirurgie, Centre Intégré Nord Francilien de prise en charge de l'Obésité (CINFO), Hôpital Louis Mourier (AP-HP), Université Paris Diderot, Sorbonne Paris Cité, France
| | - Séverine Ledoux
- Service des Explorations Fonctionnelles, Centre Intégré Nord Francilien de prise en charge de l'Obésité (CINFO), Hôpital Louis Mourier (AP-HP), Université Paris Diderot, Sorbonne Paris Cité, France
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EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65:146-181. [PMID: 27085810 DOI: 10.1016/j.jhep.2016.03.005] [Citation(s) in RCA: 282] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
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18
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Dakour Aridi H, Sultanem S, Abtar H, Safadi BY, Fawal H, Alami RS. Management of gallbladder disease after sleeve gastrectomy in a selected Lebanese population. Surg Obes Relat Dis 2016; 12:1300-1304. [PMID: 27178610 DOI: 10.1016/j.soard.2016.01.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with morbid obesity are at a higher risk of developing gallstones after bariatric surgery. Studies on the incidence of symptomatic gallstones necessitating cholecystectomy after laparoscopic sleeve gastrectomy (LSG) are limited in the Middle East. OBJECTIVES This study aims to assess the incidence of cholecystectomy after LSG during a 1-year follow-up and to evaluate potential risk factors and potential prophylactic measures. SETTING Two university hospitals in Lebanon. METHODS A prospectively maintained bariatric database of 361 patients who underwent primary LSG between January 2009 and December 2012 at the American University of Beirut Medical Center and Makassed General Hospital was reviewed. Data included demographics, preoperative weight, weight at 6 and 12 months postoperatively, and incidence of postoperative symptomatic cholelithiasis. RESULTS A total of 319 patients (88.4%) were followed up at 1 year. Twenty-four (7.5%) had symptomatic gallstones and underwent cholecystectomy after LSG. Mean postoperative time for the development of symptomatic gallstones was 426 days (range, 91-1234 days). Patients who developed symptomatic gallstones were significantly younger (29.8 versus 34.8, P = 0.008) but comparable to patients who did not undergo cholecystectomy in terms of other baseline characteristics and weight loss results at 1 year. Out of the obesity-related co-morbidities, hypertension was the only co-morbidity associated with post-LSG cholecystectomy (OR = 3.35, P = 0.036) after multivariate adjustment. CONCLUSION The incidence of symptomatic gallstones requiring cholecystectomy after LSG in our study cohort was higher than that of the general population (7.5%). This incidence does not warrant prophylactic cholecystectomy or routine pre- or postoperative ultrasounds.
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Affiliation(s)
- Hanaa Dakour Aridi
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Serge Sultanem
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Houssam Abtar
- Department of Surgery, Makassed General Hospital, Beirut, Lebanon
| | - Bassem Y Safadi
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hayssam Fawal
- Department of Surgery, Makassed General Hospital, Beirut, Lebanon
| | - Ramzi S Alami
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Chang J, Corcelles R, Boules M, Jamal MH, Schauer PR, Kroh MD. Predictive factors of biliary complications after bariatric surgery. Surg Obes Relat Dis 2015; 12:1706-1710. [PMID: 26948453 DOI: 10.1016/j.soard.2015.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/26/2015] [Accepted: 11/11/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Obesity and rapid weight loss are risk factors for gallstone development. Bariatric surgery and significant postoperative weight loss are associated with postoperative biliary complications. OBJECTIVE We aim to identify predictive factors of biliary complications after bariatric surgery. SETTING University hospital. METHODS After Institutional Review Board approval, charts at a single institution were reviewed to identify patients with biliary complications after bariatric surgery from 2005 to 2012. Data collected included baseline patients demographic characteristics, perioperative parameters, and postoperative biliary complications. Parameters were analyzed using paired and unpaired Student t test for continuous variables and χ2 test for categorical variables. Univariate and multivariate analyses were used to assess risk factors for complications after bariatric surgery. All tests were 2 tailed; results with P<.05 were considered statistically significant. RESULTS One hundred thirty-eight (3.6%) of 3765 patients who underwent bariatric surgery developed postoperative biliary complications. Mean time from surgery to biliary complication was 1.8±1.4 years. Complications included acute cholecystitis (18.1%), chronic cholecystitis (70.2%), acute pancreatitis (9.4%), choledocholithiasis (5.7%), and jaundice (2.8%). Interventions were laparoscopic (n = 134, 97.0%) and open (n = 1, .7%) cholecystectomy. Forty patients (28.9%) had known cholelithiasis before surgery. There were no mortalities. Univariate analysis identified female gender, age>50, cholelithiasis at time of bariatric procedure, and Roux-en-Y gastric bypass independent of excess weight loss as predictive factors of biliary complications. Multivariate analysis confirmed advanced age as an independent predictive factor. CONCLUSION The results of our study suggest that patients of advanced age are at higher risk of biliary complications. However, the indications for prophylactic cholecystectomy at time of bariatric surgery remain unclear.
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Affiliation(s)
| | | | - Mena Boules
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mohammad H Jamal
- Kuwait Medical School and Mubarak Teaching Hospital, Kuwait City, Kuwait
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Abstract
ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates.
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Cazzo E, Gestic MA, Utrini MP, Machado RR, Jimenez LS, da Silva APC, Baracat J, Callejas-Neto F, Pareja JC, Chaim EA. Influence of Insulin Resistance Status on the Development of Gallstones Following Roux-En-Y Gastric Bypass: a Prospective Cohort Study. Obes Surg 2015. [DOI: 10.1007/s11695-015-1815-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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22
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Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass in obese patients: a prospective study. Surg Obes Relat Dis 2015; 11:779-84. [PMID: 25851775 DOI: 10.1016/j.soard.2014.10.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/09/2014] [Accepted: 10/13/2014] [Indexed: 02/02/2023]
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Potential Benefits of Prophylactic Cholecystectomy in Patients Undergoing Bariatric Bypass Surgery. Obes Surg 2015; 25:2054-60. [DOI: 10.1007/s11695-015-1650-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Stokes CS, Gluud LL, Casper M, Lammert F. Ursodeoxycholic acid and diets higher in fat prevent gallbladder stones during weight loss: a meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol 2014; 12:1090-1100.e2; quiz e61. [PMID: 24321208 DOI: 10.1016/j.cgh.2013.11.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 11/04/2013] [Accepted: 11/21/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The prevalence of gallstones is increasing in association with the obesity epidemic, but rapid weight loss also increases the risk of stone formation. We conducted a systematic review of the efficacy of strategies to prevent gallbladder stones in adults as they lose weight. METHODS Randomized controlled trials of nonsurgical strategies to prevent gallstones were identified by electronic and manual searches. Our final analysis included 13 trials, comprising 1836 participants undergoing weight loss through dieting (8 trials) or bariatric surgery (5 trials). The trials compared ursodeoxycholic acid (UDCA) or high-fat weight loss diets with control interventions. We performed random-effects meta-analyses and evaluated heterogeneity and bias with subgroup, sensitivity, regression, and sequential analysis. RESULTS UDCA reduced the risk of ultrasound-verified gallstones compared with control interventions (risk ratio, 0.33; 95% confidence interval [CI], 0.18-0.60; number needed to treat, 9). This effect was significantly larger in trials of diets alone (risk ratio, 0.17; 95% CI, 0.11-0.25) than in trials of patients who underwent bariatric surgery (risk ratio, 0.42; 95% CI, 0.21-0.83) (test for subgroup differences, P =.03). UDCA reduced the risk of cholecystectomy for symptomatic stones (risk ratio, 0.20; 95% CI, 0.07-0.53). Diets high in fat content also reduced gallstones, compared with those with low fat content (risk ratio, 0.09; 95% CI, 0.01-0.61). The meta-analyses were confirmed in trials with a low risk of bias but not in sequential analysis. No additional beneficial or harmful outcomes were identified. CONCLUSIONS On the basis of a meta-analysis of randomized controlled trials, during weight loss, UDCA and/or higher dietary fat content appear to prevent formation of gallstones.
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Affiliation(s)
- Caroline S Stokes
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Lise Lotte Gluud
- Diabetes Research Division, Department of Medicine, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Markus Casper
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany.
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Jayakrishnan TT, Groeschl RT, George B, Thomas JP, Pappas S, Gamblin TC, Turaga KK. Management of acute cholecystitis in cancer patients: a comparative effectiveness approach. Surg Endosc 2014; 28:1505-14. [DOI: 10.1007/s00464-013-3344-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 11/04/2013] [Indexed: 01/12/2023]
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Milella M, Alfa-Wali M, Leuratti L, McCall J, Bonanomi G. Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery. Int J Surg Case Rep 2014; 5:249-52. [PMID: 24705194 DOI: 10.1016/j.ijscr.2014.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/25/2014] [Accepted: 03/04/2014] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. PRESENTATION OF CASE We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. DISCUSSION Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. CONCLUSION Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.
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Sioka E, Zacharoulis D, Zachari E, Papamargaritis D, Pinaka O, Katsogridaki G, Tzovaras G. Complicated gallstones after laparoscopic sleeve gastrectomy. J Obes 2014; 2014:468203. [PMID: 25105023 PMCID: PMC4106056 DOI: 10.1155/2014/468203] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/12/2014] [Accepted: 06/16/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The natural history of gallstone formation after laparoscopic sleeve gastrectomy (LSG), the incidence of symptomatic gallstones, and timing of cholecystectomy are not well established. METHODS A retrospective review of prospectively collected database of 150 patients that underwent LSG was reviewed. RESULTS Preoperatively, gallbladder disease was identified in 32 of the patients (23.2%). Postoperatively, eight of 138 patients (5.8%) became symptomatic. Namely, three of 23 patients (13%) who had evident cholelithiasis preoperatively developed complicated cholelithiasis. From the cohort of patients without preoperative cholelithiasis, five of 106 patients (4.7%) experienced complicated gallstones after LSG. Total cumulative incidence of complicated gallstones was 4.7% (95% CI: 1.3-8.1%). The gallbladder disease-free survival rate was 92.2% at 2 years. No patient underwent cholecystectomy earlier than 9 months or later than 23 months indicating the post-LSG effect. CONCLUSION A significant proportion of bariatric patients compared to the general population became symptomatic and soon developed complications after LSG, thus early cholecystectomy is warranted. Routine concomitant cholecystectomy could be considered because the proportion of patients who developed complications especially those with potentially significant morbidities is high and the time to develop complications is short and because of the real technical difficulties during subsequent cholecystectomy.
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Affiliation(s)
- Eleni Sioka
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110 Larissa, Greece
| | - Dimitris Zacharoulis
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110 Larissa, Greece
- *Dimitris Zacharoulis:
| | - Eleni Zachari
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110 Larissa, Greece
| | | | - Ourania Pinaka
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110 Larissa, Greece
| | - Georgia Katsogridaki
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110 Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110 Larissa, Greece
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Modelling the long-term outcomes of bariatric surgery: A review of cost-effectiveness studies. Best Pract Res Clin Gastroenterol 2013; 27:987-95. [PMID: 24182616 DOI: 10.1016/j.bpg.2013.08.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 08/07/2013] [Accepted: 08/26/2013] [Indexed: 01/31/2023]
Abstract
Obesity, defined as BMI ≥30 kg/m(2), affects over 30% of the United States adult population and has been declared an epidemic by the Centers for Disease Control. Bariatric surgery is a treatment option to reduce excess weight and is available to individuals with BMI greater than 40 kg/m(2), or 35 kg/m(2) with obesity-related comorbidities. As surgical options have become more common, researchers have analysed the long-term cost-effectiveness of these procedures. However, the follow-up data on patients is limited, and modelers need to forecast lifetime costs and outcomes for this chronic disease. In this chapter, we conduct a systematic literature review of cost-effectiveness studies on bariatric surgery to understand the forecasting methods used in practice. We identified six unique studies, which used statistical models, Markov models, or assumptions to forecast lifetime outcomes. We discuss each of the approaches, so clinicians, policy-makers, and payers can make informed interpretations based on the models.
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