Review articleSystematic review of management of gallbladder disease in patients undergoing minimally invasive bariatric surgery
Section snippets
The link between obesity and gallbladder disease
Laparoscopic cholecystectomy in the morbidly obese may be associated with increased operative difficulty and morbidity compared with nonobese patients. Obesity itself is a factor for the development of gallstone disease, and periods of weight loss further increase the risk of gallstone formation. In the obese patient, the hypersecretion of cholesterol is considered to be the culprit that increases the risk of gallstone disease. Jonas et al. [1] described a 5-fold increased risk of symptomatic
Methods
Ovid MEDLINE was queried for articles published from 1998 to 2018 using the following terms: “bariatric surgery” or “gastric bypass” or “sleeve gastrectomy” or “gastric band*” (including “band” or “banding” or “banded) or “biliopancreatic diversion” or “duodenal switch” AND “cholelithiasis” or “cholecystectomy” or “choledocholithiasis” or “biliary” or “biliary tract diseases” or “gallbladder” or “gallbladder diseases” or “biliary tract disease” or “gallbladder diseases.” Articles were limited
Routine prophylactic cholecystectomy
Although safe, laparoscopic cholecystectomy performed concurrently with laparoscopic bariatric surgery has significant potential complications that can lengthen operative time, increase morbidity, and prolong hospitalization [10]. Prophylactic cholecystectomy during gastric bypass was historically recommended in the era of open surgery [11]. More recent studies show that concurrent cholecystectomy during laparoscopic bypass surgery should no longer be routinely performed due to higher rate of
Routine postoperative administration of ursodeoxycholic acid to prevent gallstone formation
Increased risk of gallstone development after rapid weight loss after bariatric surgery has been well-described and the incidence of gallstone formation ranges from 10% to 38% [28]. This is associated with a proportional increase in risk of developing biliary complications.
Several preventive measures in patients undergoing bariatric surgery have been proposed. One of the most studied medications to prevent cholelithiasis formation is UDCA, a secondary bile acid that increases cholesterol
No treatment for asymptomatic patients
Several studies, including a meta-analysis from 2013 [36], showed that the rate of subsequent cholecystectomy after LRYGB is low (6.8%), and the main cause for the subsequent cholecystectomy was uncomplicated biliary disease [37]. An advantage of delayed cholecystectomy is that the operation is technically easier to perform due to a reduction in intraabdominal fat after LRYGB [18]. In addition, the surgeon’s concern regarding the removal of a normal organ during the index bariatric procedure is
Choledocholithiasis
Small gallstones may easily migrate into the common bile duct (choledocholithiasis), where they may cause biliary obstruction and potentially biliary pancreatitis. Although migration of stones after LRYGB is infrequent (.2%–5.3% risk), migration and the possible development of cholangitis or biliary pancreatitis is a challenging problem. Endoscopic retrograde cholangiopancreatography (ERCP) may be necessary in patients who have undergone RYGB reconstruction (or other procedures preventing oral
Diagnosis and management of cholecystitis (updated 2018 Tokyo Guidelines)
The combination of clinical, laboratory, and imaging findings; as diagnostic criteria for acute cholecystitis, according to Tokyo Guidelines from 2018, have a sensitivity of 91.2% and a specificity of 96.9%. These criteria remain unchanged since the release of the initial 2013 Tokyo Guidelines Management of Cholecystitis—local signs of inflammation as Murphy’s sign and/or right upper quadrant mass, pain, or tenderness; laboratory findings are systemic signs, including fever, elevated C-reactive
Asymptomatic patients undergoing LAGB
LAGB has been decreasing in frequency in the United States, accounting for only 2.77% of all bariatric surgeries in 2017. Previous studies [47] demonstrated the safety of LAGB with concurrent cholecystectomy only for symptomatic patients, and others compared RYGB and SG with LAGB resulting in lower frequency of symptomatic gallstones for the LAGB group [48].
At this time, preoperative screening and prophylactic cholecystectomy is not recommended in asymptomatic patients undergoing LAGB.
Asymptomatic patients undergoing SG
SG in
Conclusions and recommendations
Gallstone formation remains a problem in obese patients. In the era of minimally invasive bariatric surgery, screening asymptomatic patients is not supported by the current literature. The exception are patients undergoing BPD where concomitant cholecystectomy is shown to be beneficial. Cholecystectomy after minimally invasive bariatric surgery in symptomatic patients is technically easier given less visceral fat and a reduction in hepatic steatosis. Choledocholithiasis can be challenging to
Acknowledgments
Kara Kallies - Gundersen Health (literature search).
Disclosures
The authors have no commercial associations that might be a conflict of interest in relation to this article.
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