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Bariatric Surgery and Gallstone Problems

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Bariatric Surgery and Gallstone Problems Central JSM Gastroenterology and Hepatology Bringing Excellence in Open Access Review Article *Corresponding author Volkan Genc, Ankara Üniversitesi Tıp Fakültesi, AkademikYerleske K4, 06100, Sıhhiye/Ankara / Bariatric Surgery and Gallstone Turkey, Tel: 903125082676; Fax: 903124909028; Email: Submitted: 16 December 2016 Problems Accepted: 22 February 2017 Gül Bora1, Bilgehan Çağdaş Sonbahar1, and Volkan Genç2* Published: 24 February 2017 aDepartment of Surgery, Medical Park Batıkent Private Hospital, Turkey Copyright 2Department of Surgery, Ankara University, Turkey © 2017 Genç et al. Abstract OPEN ACCESS The incidence of obesity has been increasing day after day, worldwide. Hence Keywords bariatric surgery has recently become one of the most common treatment modality • Bariatric surgery in maintaining long-term weight reduction and improving obesity-related conditions. • Gallstone problems Gallstones and bariatric surgery is an important issue because both obesity and • Cholecystectomy bariatric surgery resulting with rapid weight loss are risk factors for the formation of gallstones. It can cause acute cholecystitis and acute pancreatitis. There are some contradictions about diagnosis, treatment and preventing of gallstones in obese patients who undergo bariatric surgery. In our article, we have discussed usage of routine ultrasonography in perioperative period, timing of cholecystectomy and preventing cholelithiasis after bariatric surgery in company with literature. INTRODUCTION INCIDENCE OF CHOLELITHIASIS IN BARIATRIC The worldwide prevalence of obesity has been increasing SURGERY PATIENTS day after day. Obesity is related with many chronic diseases such Theoretically, cholelithiasis expected to be less common after as hypertension, type 2 diabetes, dyslipidemia, cardiovascular laparoscopic sleeve gastrectomy (LSG) or laparoscopic gastric diseases, sleep apnea etc. Other modalities for weight reduction banding (LGB) than laparoscopic Roux-en-Y gastric bypass (diet, exercise etc.) usually result in regaining weight differently (LRYGB), because the nutrients continue to follow the normal from bariatric surgery. Obesity related morbidities both shorten gastrointestinal tractus [11,12]. Nevertheless, Li et al., reported life time and cost expensive. Bariatric surgery has recently become no difference in gallstone formation between LSG and LRYGB [11]. one of the most common treatment modality in maintaining long- Likewise, the highest frequency of cholelithiasis was reported as term weight reduction and improving obesity-related conditions. 71% in patients who underwent LRYGB [13].Controversially, Hence bariatric surgery is a cost-effective treatment modality [1- only 3-16 % of these patients turn into symptomatic cases [14- 3]. 16]. Gallstone diseases are closely related to obesity and Melmer et al., observed 109 patients who underwent bariatric this topic is very important due to increase risk of acute surgery (gastric banding, gastric bypass, or sleeve gastrectomy) cholecystitis and acute pancreatitis. Acute pancreatitis is very over 10 years and gallstone formation after surgery was detected serious situation which can be fatal. Kumarevel et al., reported a as 17.4% and it was detected more frequent in gastric bypass 50-fold higher risk of acute pancreatitis after bariatric surgery [4]. and sleeve groups (42.9%) than gastric banding group (16.3%). The incidence of cholelithiasis ranges from 2% to 15%. Obesity, This result was correlated with the amount of weight loss. They female gender, age more than 40 years, and white ethnicity increase the incidence of cholelithiasis. Other risk factors are also reported that need for cholecystectomy was higher in bypass rapid weight gain or weight loss (as seen after bariatric surgery), and sleeve group [17]. Similarly, in a retrospective analyze of pregnancy, use of oral contraceptives, estrogen replacement 937 patients who underwent bariatric surgery, symptomatic therapy, diabetes, and family history [5,6].While the risk of cholelithiasis rates were similar in LRYGB and LSG and much gallstone formation increases 8-fold in patients with BMI >40 higher than gastric banding. There was no detected gallstone kg/m2[7], it also increases 5-fold in patients who underwent formation in the gastric banding group 24 months after surgery bariatric surgery compared with normal population [8]. Bariatric because of slow and less weight loss [18]. In another retrospective surgery causes rapid weight loss and multiple physiologic factors analyze of 1397 bariatric surgery patients (32-month mean actively affect the occurrence of gallstones. Hyper saturation of follow-up), the incidence of post-bariatric surgery development bile with cholesterol, raised mucin production and hypomotility of cholelithiasis was 10.53 % (8.42 % for LSG, 13.4% for LRYGB, of gallbladder contribute to gallstone formation [9,10]. Division and 12.7 % for mini gastric bypass) and the highest incidence of hepatic branch of the vagus nerve causes gallstone formation of symptomatic cholelithiasis requiring surgery was detected in as well [10]. LRYGB group (4.54%) [15]. The incidence of choledocholithiasis Cite this article: Bora G, Sonbahar BÇ, Genç V (2017) Bariatric Surgery and Gallstone Problems. JSM Gastroenterol Hepatol 5(1): 1078. Genç et al. (2017) Email: Central Bringing Excellence in Open Access after bariatric surgery was also reported from 0.7% to 2.09% Some authors mentioned that gallstone formation was more [15,16]. The question of “which bariatric procedure increases frequent after gastric bypass [11-13,15,17]. Wudel et al., also the cholelithiasis and/or choledocholithiasis risk more?” was reported this rate as high as 71%. Because of these high rates, analyzed in literature and Coupaye et al., reported that main concomitant cholecystectomy was suggested in patients who component leading to gallstone formation was rapid weight loss performed LRYGB [13]. Tucker et al., also suggested concomitant On the other hand, Manatsathit et al., reported that gallstone gallbladder pathology at preoperative or intraoperative period and formationespecially inwas the not first associated 6 months with rather amount than operationof weight typeloss [17].both theycholecystectomy also reported at this LRYGB surgery for is only feasible ultrasonography-confirmed and safe [23]. Especially during the early or late postoperative period [18]. after bypass surgery, it could be hard to perform cholecystectomy or other procedures like ERCP, due to altered gastrointestinal tract. Today, there is no consensus on the management of the incidence and what should be done for gallstone disease during gallbladder at the time of bariatric surgery. Some authors avoid andThus, after bariatricthere are surgery. many Therecontradictional are following findings three aboutquestions the concomitant cholecystectomy due to probability of postoperative about the bariatric surgery and gallstones. complications and long hospitalization [7]. Controversially, some 1. Should we practice routinely ultrasound (US) in also reported decreasing rate of postoperative complications perioperative period? and hospitalization time after concomitant cholecystectomy in patients with bypass surgery [24]. 2. If we diagnosed cholelithiasis preoperatively what will we do? Cholecystectomy or not? The effects of age, gender and preoperative BMI on postoperative gallstone formation analyzed in literature and 3. Should we use any drug preventing gallstone formation no relationship was found [25,26]. Chang et al., also reported after surgery? that excess weight loss (EWL)% was not a predictive factor for USE OF PERIOPERATIVE US was an independent predictive factor on the biliary complications Li et al., reported weight loss more than 25% of original postoperative complications. They also identified that elder age weight was main and only postoperative factor that can help selecting patients for postoperative ultrasound surveillance. predictor[27]. D’Hondt of delayed et al., symptomaticreported that cholelithiasis EWL during and first they 3 monthsdid not recommendpost-LRYGBP concomitant more than 50% cholecystectomy as the sole significant [28]. independent formation was 7.8% and mean time for its development was 10.2They months. also defined Therefore the theyoverall advised rate theof symptomatictiming of routine gallstone US as Three bariatric procedures (LRYGB, LSG, LGB) evaluated in terms of cholecystectomy rates in a prospective study and 109 of original weight [12]. Almazeedi et al., routinely performed (7.8%) patients of 1398 patients underwent cholecystectomy abdominalfirst 24 months ultrasound in patients before who LSG have in weight their study loss more including than 25%747 with a median follow-up 49 months. The highest cholecystectomy patients. The gallstone incidence was found as 11.1% and this rate was found in LRYGB group (10.6%) and the frequency was data did not correlated with degree of obesity. They reported that preoperative US did not alter the course of operation and they suggested that US should be applied to only symptomatic ofhighest cholecystectomy within the first after 6 monthsbariatric (3.7%). surgery They [29]. also Worni emphasized et al., patients [19]. analyzedthat EWL retrospectively>25% within the 70.287 first 3 adults months undergoing was strongest LRYGB predictor bypass patients’ data and due to increased postoperative complications, According to the actual clinic practice guidelines for the reinterventions, mortality, and longer hospital
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