OS16(6)articles 5/17/06 3:12 PM Page 759 Obesity Surgery, 16, 759-761 Is Routine Cholecystectomy Necessary at the Time of Roux-en-Y Gastric Bypass? Jerome Taylor, MD1; I. Michael Leitman, MD1; Michael Horowitz, MD2 1Department of Surgery, Beth Israel Medical Center, New York, NY, and 2Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA Background: Morbid obesity is associated with an Introduction increased incidence of gallstones. Rapid weight loss, as occurs after Roux-en-Y gastric bypass (RYGBP) may also increase gallstone development. Standard There continues to be a controversy over whether surgical treatments for gallbladder disease and its routine prophylactic cholecystectomy should be per- complications might be more difficult following formed during Roux-en-Y gastric bypass (RYGBP) RYGBP. Controversy still exists whether prophylactic surgery. Obese patients have an increased incidence cholecystectomy is indicated at the time of RYGBP. of biliary tract disease.1 Rapid weight loss, which Methods: Retrospective analysis was performed on occurs following RYGBP, further increases the risk a database of 535 patients who underwent RYGBP for of developing cholelithiasis.2,3 Prophylactic treat- morbid obesity during a 5.5-year period. Patients ® were followed and medical records were reviewed. ment with ursodeoxycholic acid (Actigall ) for at Ursodeoxycholic acid was not prescribed following least 6 months has been advocated by some investi- surgery. gators to prevent gallstone formation following Results: 8% of patients had had cholecystectomy bariatric surgery, but long-term compliance is diffi- before the RYGBP. 75 of 492 patients (15%) were cult.4,5 Others recommend that prophylactic chole- found to have gallstones at RYGBP, and cholecystec- cystectomy be performed at the time of RYGBP, tomy was performed at the same time. 3 of these given the high incidence of gallbladder disease patients had bile leaks but only 1 required further found at surgery and on pathologic evaluation.6-8 A intervention (percutaneous transhepatic drainage for selective approach using intra-operative ultrasound 3 weeks). Following RYGBP, 14 patients (3%) have required cholecystectomy for symptomatic cholelithi- and selective cholecystectomy followed by prophy- asis in the postoperative period. All were performed lactic ursodeoxycholic acid has been advocated by laparoscopically and without complication. some,9 but compliance with the ursodiol was only Conclusions: Symptomatic gallbladder disease 41%. Laparoscopic cholecystectomy in obese after RYGBP has not been frequent. Prophylactic patients typically enjoys a similar conversion rate, cholecystectomy for a normal gallbladder is not nec- complication rate and length of stay as in non-obese essary at the time of RYGBP. Patients without biliary patients10,11 and can be performed after RYGBP sur- tract symptoms may not require routine preoperative gery if clinically indicated. It does appear that com- sonogram. If an abnormal gallbladder or gallstones are found at the time of an RYGBP operation, con- bined laparoscopic RYGBP with cholecystectomy is comitant cholecystectomy should be considered. safe and feasible without altering port placement; however, it does increase operative time and hospital 12 Key words: Morbid obesity, bariatric surgery, gastric length of stay. The present study was designed to bypass, gallstones determine the prevalence of gallstones among patients, the incidence of the development of symp- Reprint requests to: I. Michael Leitman, MD, Department of tomatic gallstone disease, and the complications Surgery, Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, USA. Fax#: (212) 844-8440; related to the timing of the surgical therapy for bil- e-mail: [email protected] iary tract disease following RYGBP. © FD-Communications Inc. Obesity Surgery, 16, 2006 759 OS16(6)articles 5/17/06 3:12 PM Page 760 Taylor et al Patients and Methods opment of symptomatic gallstones following gastric bypass surgery was not related to age, gender, excess A total of 535 consecutive patients with indications weight lost or preoperative BMI. for bariatric surgery according to the National Institutes of Health criteria for Bariatric Surgery were evaluated.13 An additional 47 patients were excluded Discussion from the study due to incomplete data. The medical records of these patients were analyzed to determine prior gallbladder disease, biliary tract symptoms and Gallstone disease is prevalent in the morbidly obese 1 subsequent biliary surgery. All patients with a history patient. The incidence increases with rapid weight 2 of epigastric pain had a preoperative right upper loss. However, routine prophylactic cholecystectomy quadrant abdominal ultrasound. Open RYGBP was concomitant with RYGBP for all patients exposes them performed over a 5.5-year period by an individual to increased operative time, hospital length of stay and surgeon (IML) at a single institution. Any patients potential complication. Cholecystectomy during open lost to follow-up were not included in the study. RYGBP can usually be done through the same incision. Ursodeoxycholic acid was not prescribed to any With laparoscopic RYGBP, an additional port may be patients throughout the study period. Patients found placed in order to facilitate a cholecystectomy.4 The to have evidence of chronic cholecystitis or gall- present study suggests that the vast majority of patients stones at the time of bariatric surgery had concomi- who come to bariatric surgery without gallbladder dis- tant cholecystectomy. Those patients who were ease will not develop symptomatic cholelithiasis. Those found to have gallstones from the work-up or epi- patients who do develop biliary tract disease, do not gastric or abdominal discomfort following RYGBP appear to have increased risks for the development of were subjected to laparoscopic cholecystectomy. complications should they require laparoscopic chole- Data were subjected to univariate and multivariate cystectomy at a future date, at a time when they have analysis. Chi-square analysis was utilized and a P- generally lost considerable weight. value <0.05 was considered statistically significant. Cholecystectomy following RYGBP surgery may present some technical challenges to the surgeon. Adhesions that occur following foregut surgery could Results make laparoscopic visualization of the anatomy more difficult. In addition, with RYGBP it is much less fea- sible or impossible to perform endoscopic pancreatic A total of 8% of the patients in the present study had had cholangiopancreatography (ERCP) if needed, fol- cholecystectomy before the RYGBP surgery. During the lowing the creation of the long Roux limb. RYGBP, 15% of the patients required cholecystectomy For these reasons, we advocate a selective approach because of the presence of gallstones and/or inflamma- tion of the gallbladder. Two of these patients had tran- to patients undergoing RYGBP. Patients who have sient bile leaks postoperatively that were managed with- evidence of biliary tract disease should undergo con- out further intervention. One additional patient devel- comitant cholecystectomy at the time of RYGBP, oped a cystic duct bile leak after the combined surgery even if asymptomatic. Prophylactic cholecystectomy that required transhepatic percutaneous drainage for 3 during RYGBP is not supported by the present study. weeks, and then recovered without problems. Patients may choose whether they wish to take urso- Patients were followed for a mean of 2.5 years diol for 6 months, but compliance with this has been (range 14-81 months). In the postoperative period, variable because many find that the pills are too large, 3% of the patients have required cholecystectomy. cost too much, have bad taste or that the gastroin- All had their gallbladder removed laparoscopically. testinal side-effects are unacceptable. The present One required a laparoscopic common bile duct study suggests that patients may be counseled that exploration. The patients tolerated their cholecystec- post-RYGBP their risk for requiring cholecystectomy tomy without any morbidity or mortality. The devel- is not high if they choose not to take ursodiol. 760 Obesity Surgery, 16, 2006 OS16(6)articles 5/17/06 3:12 PM Page 761 Routine Cholecystectomy During Gastric Bypass Conclusion trolled trial. Ann Surg 2003; 238: 697-702. 6. Liem RK, Niloff PH. Prophylactic cholecystectomy with open gastric bypass operation. Obes Surg 2004; Routine prophylactic cholecystectomy at the time of 14: 763-5. RYGBP appears to be unnecessary because risk of 7. Csendes A, Burdiles P, Smok G et al. Histologic find- symptomatic gallstone disease requiring cholecys- ings of gallbladder mucosa in 87 patients with morbid tectomy is low and can be performed laparoscopi- obesity without gallstones compared to 87 control cally without appreciable increase in morbidity. subjects. J Gastrointest Surg 2003; 7: 547-51. 8. Fobi M, Lee H, Igwe D et al. Prophylactic cholecys- tectomy with gastric bypass operation: incidence of References gallbladder disease. Obes Surg 2002; 12: 350-3. 9. Scott DJ, Villegas L, Sims TL et al. Intraoperative ultrasound and prophylactic ursodio for gallstone pre- 1. Dittrick GW, Thompson JS, Campos D et al. vention following laparoscopic gastric bypass. Surg Gallbladder pathology in morbid obesity. Obes Surg Endosc 2003; 17: 1796-802. 2005; 15: 238-42. 10.Simopoulos C, Polychronidis A, Botaitis S et al. 2. Iglezias Brandao de Oliveira C,