Comparison of Cholecystectomy Cases / Surgery for Obesity and Related Diseases 10 (2014) 64–70
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Editorial comment
Comment on: Comparison of cholecystectomy cases after Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding Received July 3, 2013; accepted July 4, 2013
It is undeniable that bariatric surgery has remodeled the landscape related to the care of obese patients. The weight loss and metabolic benefits derived from surgery are unparalleled and, for the vast majority patients, signal a complete reordering of health and quality of life. As more patients undergo bariatric operations each year and as the scope of available procedures broadens, it will continue to be important to revisit surgical outcomes in light of new evidence and new procedures. Rapid weight loss after bariatric surgery has long been associated with a risk of developing cholelithiasis. Although there is no absolute consensus regarding management of the gallbladder at the time of surgery, many programs seem to advocate only selected cholecystectomy concomitant to a bariatric operation [1–3]. In this issue of SOARD, Jawad et al. have reexamined the postoperative occurrence of cholelithiasis requiring cholecystectomy in the context of a comparison among Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and adjustable gastric banding (AGB). The authors found that patients developed postoperative symptomatic cholelithiasis at rates of 5.7% after RYGB, 6.1% after VSG, and 0% after AGB. This group was plagued by the same loss to follow-up issues that affects most bariatric surgery studies. The authors defined loss to follow-up as not reaching 2 months of postoperative evaluation. However, they reported that mean time between the primary bariatric operation and cholecystectomy to be 14 months for RYGB and 8 months for VSG. Thus the number of patients in whom symptomatic cholelithiasis developed may indeed be greater than reported. In any event, the authors’ point that cholecystectomy-requiring gallbladder disease is not uncommon after bariatric surgery is reasonable and corroborates many other studies. The authors reported their preference to perform cholecystectomy concomitant to bariatric surgery for patients with noted preoperative cholelithiasis. Simultaneous cholecystectomy at the time of bariatric surgery is not universally advocated. In the era of open bariatric surgery, routine concomitant cholecystectomy was initially championed but then amended to include only patients with known gallstones. This change followed clear evidence that
chemoprophylaxis with ursodeoxycholic acid (URSO) in the postoperative period dramatically reduces the risk of cholelithiasis during rapid weight loss [4]. In the era of laparoscopic surgery, the prevailing notion seems to support only selective removal of the gallbladder at the time of bariatric surgery. Although URSO can be effective, there is evidence that patient compliance with this medication may be low [5]. The authors did not use prophylactic URSO in their postoperative patient management. Although this study may have had some limitations, it provides some important information. Jawad et al. have given us a glimpse into the natural history of development of symptomatic cholelithiasis after bariatric surgery. Although I suspect that the frequency is higher than reported because of follow-up loss, the study provides data to guide discussions with patients. Specifically, surgeons can inform patients that symptomatic cholelithiasis develops in at least 6% of patients who undergo RYGB and VSG and that the frequency after AGB is very low. Furthermore, we can infer that the frequency between RYGB and VSG likely will be similar. The authors are also to be congratulated on the outcomes of cholecystectomy whether during bariatric surgery or separately in postoperative follow-up. The absence of complications despite some challenging cases in patients with ascending cholangitis supports the safety of performing laparoscopic cholecystectomy after bariatric surgery.
Mohamed R. Ali University of California, Davis Medical Center Sacramento, California References [1] Fuller W, Rasmussen JJ, Ghosh J, Ali MR. Is routine cholecystectomy indicated for asymptomatic cholelithiasis in patients undergoing gastric bypass? Obes Surg 2007;17:747–51. [2] Portenier DD, Grant JP, Blackwood HS, Pryor A, McMahon RL, DeMaria E. Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:476–9. [3] Swartz DE, Felix EL. Elective cholecystectomy after Roux-en-Y gastric bypass: why should asymptomatic gallstones be treated differently in morbidly obese patients? Surg Obes Relat Dis 2005;1:555–60.
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R. C. Moon et al. / Surgery for Obesity and Related Diseases 10 (2014) 64–70
[4] Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 1995;169:91–6; discussion 6–7.
[5] Wudel LJ Jr., Wright JK, Debelak JP, Allos TM, Shyr Y, Chapman WC. Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study. J Surg Res 2002;102:50–6.
69
Editorial comment
Comment on: Comparison of cholecystectomy cases after Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding Received July 3, 2013; accepted July 4, 2013
It is undeniable that bariatric surgery has remodeled the landscape related to the care of obese patients. The weight loss and metabolic benefits derived from surgery are unparalleled and, for the vast majority patients, signal a complete reordering of health and quality of life. As more patients undergo bariatric operations each year and as the scope of available procedures broadens, it will continue to be important to revisit surgical outcomes in light of new evidence and new procedures. Rapid weight loss after bariatric surgery has long been associated with a risk of developing cholelithiasis. Although there is no absolute consensus regarding management of the gallbladder at the time of surgery, many programs seem to advocate only selected cholecystectomy concomitant to a bariatric operation [1–3]. In this issue of SOARD, Jawad et al. have reexamined the postoperative occurrence of cholelithiasis requiring cholecystectomy in the context of a comparison among Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and adjustable gastric banding (AGB). The authors found that patients developed postoperative symptomatic cholelithiasis at rates of 5.7% after RYGB, 6.1% after VSG, and 0% after AGB. This group was plagued by the same loss to follow-up issues that affects most bariatric surgery studies. The authors defined loss to follow-up as not reaching 2 months of postoperative evaluation. However, they reported that mean time between the primary bariatric operation and cholecystectomy to be 14 months for RYGB and 8 months for VSG. Thus the number of patients in whom symptomatic cholelithiasis developed may indeed be greater than reported. In any event, the authors’ point that cholecystectomy-requiring gallbladder disease is not uncommon after bariatric surgery is reasonable and corroborates many other studies. The authors reported their preference to perform cholecystectomy concomitant to bariatric surgery for patients with noted preoperative cholelithiasis. Simultaneous cholecystectomy at the time of bariatric surgery is not universally advocated. In the era of open bariatric surgery, routine concomitant cholecystectomy was initially championed but then amended to include only patients with known gallstones. This change followed clear evidence that
chemoprophylaxis with ursodeoxycholic acid (URSO) in the postoperative period dramatically reduces the risk of cholelithiasis during rapid weight loss [4]. In the era of laparoscopic surgery, the prevailing notion seems to support only selective removal of the gallbladder at the time of bariatric surgery. Although URSO can be effective, there is evidence that patient compliance with this medication may be low [5]. The authors did not use prophylactic URSO in their postoperative patient management. Although this study may have had some limitations, it provides some important information. Jawad et al. have given us a glimpse into the natural history of development of symptomatic cholelithiasis after bariatric surgery. Although I suspect that the frequency is higher than reported because of follow-up loss, the study provides data to guide discussions with patients. Specifically, surgeons can inform patients that symptomatic cholelithiasis develops in at least 6% of patients who undergo RYGB and VSG and that the frequency after AGB is very low. Furthermore, we can infer that the frequency between RYGB and VSG likely will be similar. The authors are also to be congratulated on the outcomes of cholecystectomy whether during bariatric surgery or separately in postoperative follow-up. The absence of complications despite some challenging cases in patients with ascending cholangitis supports the safety of performing laparoscopic cholecystectomy after bariatric surgery.
Mohamed R. Ali University of California, Davis Medical Center Sacramento, California References [1] Fuller W, Rasmussen JJ, Ghosh J, Ali MR. Is routine cholecystectomy indicated for asymptomatic cholelithiasis in patients undergoing gastric bypass? Obes Surg 2007;17:747–51. [2] Portenier DD, Grant JP, Blackwood HS, Pryor A, McMahon RL, DeMaria E. Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3:476–9. [3] Swartz DE, Felix EL. Elective cholecystectomy after Roux-en-Y gastric bypass: why should asymptomatic gallstones be treated differently in morbidly obese patients? Surg Obes Relat Dis 2005;1:555–60.
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R. C. Moon et al. / Surgery for Obesity and Related Diseases 10 (2014) 64–70
[4] Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 1995;169:91–6; discussion 6–7.
[5] Wudel LJ Jr., Wright JK, Debelak JP, Allos TM, Shyr Y, Chapman WC. Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study. J Surg Res 2002;102:50–6.
