Review article
Systematic review of management of gallbladder disease in patients undergoing minimally invasive bariatric surgery

https://doi.org/10.1016/j.soard.2019.10.016Get rights and content

Highlights

  • Gallbladder surgery is the most frequently performed procedure after bariatric surgery and may be more technically challenging.

  • Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended.

  • Mildly symptomatic patients with positive imaging studies may undergo concomitant cholecystectomy at the time of bariatric surgery, regardless of procedure.

  • Ursodeoxycholic acid can be used during the period of rapid weight loss to mitigate the development of symptomatic gallbladder disease after bariatric surgery.

  • Preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients.

Abstract

The introduction and subsequent widespread adaptation of minimally invasive approaches for bariatric surgery have not only changed the outcomes of bariatric surgery but also called into question the management of co-morbid surgical conditions, in particular gallbladder disease. The American Society for Metabolic and Bariatric Surgery Foregut Committee performed a systematic review of the published literature from 1995–2018 on management of gallbladder disease in patients undergoing bariatric surgery. The papers reviewed generated the following results. (1) Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended. (2) In symptomatic patients who are undergoing bariatric surgery, concomitant cholecystectomy is acceptable and safe. (3) Ursodeoxycholic acid may be considered for gallstone formation prophylaxis during the period of rapid weight loss. (4) Routine preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients. In the era of minimally invasive surgery, the management of gallbladder disease in patients undergoing bariatric surgery continues to evolve.

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.

References (59)

  • L.J. Wudel et al.

    Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study

    J Surg Res

    (2002)
  • M. Coupaye et al.

    Evaluation of incidence of cholelithiasis after bariatric surgery in subjects treated or not treated with ursodeoxycholic acid

    Surg Obes Relat Dis

    (2017)
  • M. Coupaye et al.

    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)
  • C.S. Stokes et al.

    Ursodeoxycholic acid and diets higher in fat prevent gallbladder stones during weight loss: a meta-analysis of randomized controlled trials

    Clin Gastroenterol Hepatol

    (2014)
  • J.I. Mechanick et al.

    Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

    Surg Obes Relat Dis

    (2013)
  • A. Lee et al.

    Endoscopic approach to the bile duct in the patient with surgically altered anatomy

    Gastrointest Endosc Clin North Am

    (2013)
  • T. Lopes et al.

    Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center

    Gastrointest Endosc

    (2009)
  • R.C. Moon et al.

    Comparison of cholecystectomy cases after Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding

    Surg Obes Relat Dis

    (2014)
  • V.B. Tsirline et al.

    How frequently and when do patients under cholecystectomy after bariatric surgery?

    Surg Obes Relat Dis

    (2014)
  • V. Wanjura et al.

    Cholecystectomy after gastric bypass-incidence and complications

    Surg Obes Relat Dis

    (2017)
  • P.K. Papasavas et al.

    Routine gallbladder screening not necessary in patients undergoing laparoscopic Roux-en-Y gastric bypass

    Surg Obes Relat Dis

    (2006)
  • U. Gustafsson et al.

    Changes in gallbladder bile composition and crystal detection time in morbidly obese subjects after bariatric surgery

    Hepatology

    (2005)
  • V.K. Li et al.

    Symptomatic gallstones after sleeve gastrectomy

    Surg Endosc

    (2009)
  • E. Cazzo et al.

    Influence of insulin resistance status on the development of gallstones following Roux-en-Y gastric bypass: a prospective cohort study

    Obes Surg

    (2016)
  • N. Sakran et al.

    Laparoscopic sleeve gastrectomy for morbid obesity in 3003 patients: results at a high-volume bariatric center

    Obes Surg

    (2016)
  • M.Y. Hasan et al.

    Gallstone disease after laparoscopic sleeve gastrectomy in an Asian population-what proportion of gallstones actually becomes symptomatic?

    Obes Surg

    (2017)
  • P.L. Liew et al.

    Gallbladder disease among obese patients in Taiwan

    Obes Surg

    (2007)
  • A. Wrzesinski et al.

    Complications requiring hospital management after bariatric surgery [in Portugese]

    Arq Bras Cir Dig

    (2015)
  • M. Morais et al.

    Gallstones and bariatric surgery: to treat or not to treat?

    World J Surg

    (2016)
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