Concomitant versus Delayed Cholecystectomy in Bariatric Surgery

The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey

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.

Characterization and Risk Factors for Early Biliary Complications Following Elective Bariatric Surgery: an Mbsaqip Analysis

INTRODUCTION

Patients undergoing bariatric surgery are at risk of postoperative biliary complications. This study aims to characterize biliary complications occurring within 30 days of bariatric surgery and to determine factors associated with their occurrence.

METHODS AND PROCEDURES

The 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was analyzed comparing patients with early biliary complications to those without. Early biliary complications were defined by any reoperation, reintervention, or readmission due to gallstones within 30 days of surgery. Patients undergoing elective sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were included; patients with prior surgery were excluded. Bivariate analysis compared groups using chi-squared for categorical data and ANOVA for continuous data was performed. Multivariable modeling was performed to determine factors independently associated with early biliary complications.

RESULTS

We evaluated 750,498 patients with 691 (0.1%) experiencing early biliary complications. Patients with early biliary complications were more often female (87.7% vs 79.6%, p < 0.001). Patients with early biliary complications required significantly more reoperations (86.0% vs 1.1%, p < 0.001), readmissions (82.5% vs 3.6%, p < 0.001), and reinterventions (15.8% vs 1.2%, p < 0.001). Female gender (OR 1.89; CI 1.47-2.44; p < 0.001), postoperative weight loss (OR 1.08; CI 1.06-1.09, p < 0.001), and LRYGB (OR 1.51, CI 1.27-1.79; p < 0.001) were substantial independent predictors of early biliary complications.

CONCLUSIONS

Early post-bariatric surgery biliary complications occur uncommonly but confer substantial morbidity. Female gender, postoperative weight loss, and RYGB are the greatest predictors for early biliary complications. Evaluation of preventative measures in these high-risk groups is needed.