Gallstones

Gallstone disease affect about 10-20% of adults

  • Obesity and T2DM are independently associated with gallstone disease
  • Rapid weight loss after bariatric surgery is also a risk factor where there is a change of cholesterol metabolism and consequently there is an increase in the cholesterol level in the bile and this can’t be dissolved by the bile salts

The risk of biliary pancreatitis may be increased by 50 fold after bariatric surgery

A recent systemic review and meta-analysis reported de novo post bariatric surgery gallstone disease as 20.7% and symptomatic gallstone disease as 8.2%

Symptomatic gallstone disease has been reported to be 7.5% (after RYGBP), 7.1% (after sleeve) and 22.7% (after BPD/DS)

After a gastric bypass an ERCP can’t be performed

  • Hence it is very difficult to manage common bile duct stones
  • A laparoscopic transgastric ERCP is difficult to perform

There are no uniform guidelines as to how to manage asymptomatic gallstone disease

  • Most surgeons may perform concomitant cholecystectomy during gastric bypass or sleeve gastrectomy for symptomatic gallstone disease, it is safe and feasible
  • There is a slightly higher risk when both procedures are done at the same time
  • ASMBS foregut committee does not recommend prophylactic cholecystectomy during bariatric surgery

Interval cholecystectomy

Some experts believe that the interval time between bariatric surgery and cholecystectomy is 6 months after significant weight loss has been achieved

Alternatively:

  • Cholecystectomy should be done 6 to 12 weeks after bariatric surgery
  • Or cholecystectomy should be done before bariatric surgery

Ursodeoxycholic acid

A recent published meta-analysis of 11 RCT suggest prophylactic use of ursodeoxycholic acid to decrease gallstone formation and cholecystectomy rate

  • It may decrease gallstone formation from 24.7 to 7.3% compared to placebo

However the Upgrade trial showed no significant effect of ursodeoxycholic acid on the occurrence of symptomatic gallstones in all patients after bariatric surgery

It is reported that only 57% of experts prescribe ursodeoyxcholic acid after bariatric surgery and the duration may be for 6 months