Gallbladder management during laparoscopic Roux-en-Y gastric bypass surgery: routine preoperative screening for gallstones and postoperative prophylactic medical treatment are not necessary.
ABSTRACT In the bariatric surgery literature, the optimum approach to the gallbladder is controversial. Recommendations range from concomitant cholecystectomy to selective screening and postoperative medical prophylaxis. At our institution, we have taken a highly selective approach where patients are not routinely screened for gallstones, nor are they medically treated postoperatively with bile salts. We have reviewed our experience with this approach. From January 2003 to January 2005, 407 laparoscopic Roux en Y gastric bypasses were performed at UCLA and postoperative outcomes were collected into a prospective database. Exclusion criteria included previous cholecystectomy, a follow-up period less than 6 months, or incomplete records. One hundred ninety-nine patients were included in the study. With a mean follow up period of 17.8 months, 12 (6%) patients required cholecystectomy for gallstone-induced pathology. Laparoscopic removal was performed in 11 (92%) patients. Indications for surgery included acute cholecystitis in five (2.5%) patients, gallstone pancreatitis in two (1%) patients, and biliary colic alone in another five (2.5%) patients. The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low. These results are similar to those from institutions where routine preoperative screening and prophylactic postoperative medical therapy is used. Routine preoperative screening or medical prophylaxis may not be necessary.
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ABSTRACT: While LRYGB has become a cornerstone in the surgical treatment of morbidly obese patients, concomitant cholecystectomy during LRYGB remains a matter of debate. The aim of this meta-analysis was to estimate the rate and morbidity of subsequent cholecystectomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) in obese patients. A meta-analysis was performed analyzing the rate and morbidity of subsequent cholecystectomy in patients who underwent LRYGB without concomitant cholecystectomy. Thirteen studies met the inclusion criteria. The rate of subsequent cholecystectomy was 6.8 % (95 % CI, 5.0-8.7 %) based on 6,048 obese patients who underwent LRYGB without concomitant cholecystectomy. The rate of subsequent cholecystectomy due to biliary colic or gallbladder dyskinesia was 5.3 %; due to cholecystitis, 1.0 %; choledocholithiasis, 0.2 %; and biliary pancreatitis, 0.2 %. The mortality after subsequent cholecystectomy was 0 % (95 % CI, 0-0.1 %). The surgery-related complication rate after subsequent cholecystectomy was 1.8 % (95 % CI, 0.7-3.4 %) resulting in a risk of 0.1 % (95 % CI, 0.03-0.3 %) to suffer from a cholecystectomy-related complication in patients undergoing LRYGB without concomitant cholecystectomy. A prophylactic concomitant cholecystectomy during LRYGB should be avoided in patients without cholelithiasis and exclusively be performed in patients with symptomatic biliary disease.Obesity Surgery 01/2013; · 3.10 Impact Factor
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ABSTRACT: Background Rapid weight loss after bariatric surgery is associated with gallstone formation, and cholecystectomy is required in up to 15% of patients. Prophylactic cholecystectomy or prophylactic ursodiol administration in the postoperative period have been suggested to address this problem. The objectives of this study were to investigate the frequency and timing of cholecystectomies after bariatric surgery and to determine the associated risk factors in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric band (LAGB), or laparoscopic sleeve gastrectomy (LSG). Methods Data prospectively collected in an institutional database were analyzed. Differences among the 3 procedures and the effects of ursodiol administration, patient demographic characteristics, postoperative weight loss, and individual surgeon practices on cholecystectomy rates were examined. Survival analysis and proportional hazard models were used. Results Of 1398 patients, 109 (7.8%) underwent cholecystectomy with a median follow-up of 49 (range 12–103) months. Cholecystectomy frequency was 10.6% after LRYGB, significantly higher than 2.9% after LAGB (P<.001), and 3.5% after LSG (P = .004). The frequency was highest within the first 6 months (3.7%), but declined over time to<1% per year after 3 years. Ursodiol administration did not affect cholecystectomy rates (P = .97), and significant intersurgeon variability was noted. Excess weight loss (EWL)>25% within the first 3 months was the strongest predictor of postoperative cholecystectomy (P<.001). Cox hazards model revealed 1.25 odds ratio per 10% EWL within 3 months, and odds ratio .77 per decade of life. In addition, white patients had 1.45 times higher cholecystectomy rates than did black patients. Preoperative body mass index, gender, and surgeon did not affect cholecystectomy rates. Conclusion Bariatric surgery is associated with a low frequency of postoperative cholecystectomy, which is highest early after surgery and mainly determined by the amount of EWL within the first 3 months. The results of the present study do not support routine prophylactic cholecystectomy at the time of bariatric surgery in asymptomatic patients.Surgery for Obesity and Related Diseases 01/2013; · 4.12 Impact Factor
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ABSTRACT: BACKGROUND: Many studies have described the risk factors of gallstone formation in gastric cancer patients after gastrectomy, but few studies focus on the management of asymptomatic gallstones. Our goal is to examine the rationale of simultaneous cholecystectomy during gastric cancer surgery, and influence of surgical mortality, morbidity and overall survival after combined cholecystectomy and gastrectomy. METHODS: We retrospectively reviewed 445 gastric cancer patients and the gallbladders evaluated by abdominal ultrasound or computed tomography preoperatively and postoperatively. Clinicopathologic factors, including surgical morbidity, mortality and overall survival of combined surgery, were compared between patients receving gastrectomy with simultaneous cholecystectomy and patients receiving gastrectomy only. We also evaluated the risk factors of gallstone formation after gastrectomy and the probability of subsequent cholecystectomy after gastrectomy in gastric cancer patients with or without asymptomatic gallstones. RESULTS: Of 445 gastric cancer patients, 52 (11.7%) patients had asymptomatic gallstones upon diagnosis of gastric cancer. Among patients with healthy gallbladders, 15.2% developed gallstones after gastrectomy. Men and older patients (age over 60) had significantly higher risk of gallstone formation. Rate of subsequent cholecystectomy in patients with and without preoperative asymptomatic gallstones was 30.8% and 4.5%, respectively (p=0.005). The rates of mortality and morbidity were not significantly different between combined surgery (3.4%, 24.2%) and gastrectomy only (3.1%, 22%). There was also no significant difference in 5-year survival between combined surgery (61%) and gastrectomy only (63%) groups. CONCLUSION: Combined cholecystectomy for asymptomatic gallstone in gastric cancer surgery may be considered. It was not associated with increased surgical morbidity or mortality, and had no significant effect on overall survival.International Journal of Surgery (London, England) 02/2013; · 1.44 Impact Factor