This debate highlights on management of gallbladder or gallbladder pathology during bariatric surgery. Dr. Naif AlEnazi (Riyadh, KSA) is against removing gallbladders during weight loss surgeries while Dr. Christian Perez (Illinois, USA) is with. They both explain their point of views and present their reasons and indications. Prof. Mujjahid Abbas (Ohio, USA) added a commentary as an expert opinion.
Dr. Naif AlEnazi
Bariatric surgery is a fast and effective way to reduce the weight of severely obese patients. (Hamad, Ikramuddin, Gourash, & Schauer, 2003; Villegas et al., 2004) However, post-operative patients are at risk of gallbladder stones after surgery. This is due to an absence of cholecystokinin secretion, amongst other factors.(De Oliveira, Chaim, & Da Silva, 2003). For this reason, some researchers advocate routinely removing the gall bladder (cholecystectomy) during bariatric surgery, to eliminate the risk of kidney complications. (Fobi et al., 2002; Kim & Schirmer, 2009)
However, there are good reasons not to perform cholecystectomy during bariatric surgery. These reasons are patient safety, the technical difficulty of performing both procedures in the same operation, and the fact that cholecystectomies are unnecessary for most bariatric patients.
Reasons Not To Perform Cholecystectomy At The Same Time As Bariatric Surgery:
Reason #1: Patient safety
Patient safety is the main reason not to perform bariatric surgery and cholecystectomy together. After all, bariatric surgery and cholecystectomy are both major surgical procedures. Performing both procedures at the same time adds greater stress to the patient’s body and increases the risk of postoperative complications and mortality, as well as increase the time of anasthesia will expose the patient for un necessarily risk (Warschkow et al., 2013; Worni et al., 2012) Many studies have shown this fact. For example, a recent systematic literature review found that patients have a higher risk of anastomotic leak/stricture after receiving a cholecystectomy and gastric bypass together, compared to patients who only receive a gastric bypass alone.(Doulamis et al., 2019) Another study found that cholecystectomy increases the risk of infection when performed at the same time as a sleeve gastrectomy.(Wood, Kumar, Dewey, Lin, & Carter, 2019)
Reason #2: Technical difficulty
Another reason not to perform cholecystectomy during bariatric surgery is that it is difficult to perform both procedure in the same operation. Performing a cholecystectomy during laparoscopic bariatric surgery, for example, is difficult because of sub-optimal port placement, visceral obesity, and the fact that the large liver often engulfs the gallbladder.(De Oliveira et al., 2003) It is unsurprising therefore that performing a cholecystectomy and bariatric surgery during the same operation leads to much longer operation times(Baron & Garg, 2013).
Reason #3: Cholecystectomy is unnecessary in many bariatric patients
Another reason not to perform cholecystectomy during bariatric surgery is that many or even most bariatric patients do not actually need a cholecystectomy. This is because many patients, after receiving bariatric surgery, do not suffer from gallstones afterwards.Only 25-30% post bariatric surgery they get gallbladder stones .(Yardimci, Coskun, Demircioglu, Erdim, & Cingi, 2018) In fact, the risk of choledocholithiasis or biliary pancreatitis after bariatric surgery is low.(Warschkow et al., 2013) For most bariatric patients, therefore, it is unnecessary to remove their gallbladder. In fact, it would even advised not to remove their gallbladder, since cholecystectomy is an invasive procedure and comes with a risk of complications.
Alternatives to performing cholecystectomy during bariatric patients:
There are better alternatives to routinely performing cholecystectomy during bariatric surgery. One alternative is to wait to see if the post-surgery patient develops symptoms of a cute cholecystitis , then treatment can be given, whether in the form of cholecystectomy or another treatment - conservative treatment . If the patient does not develop gallstones, then the gallbladder does not need to be removed.
Another option is to only perform a cholecystectomy during bariatric surgery on patients who have biliary disease. Studies show that the patients most at risk of gall stones after bariatric surgery are those who already have gallbladder issues.(Wood et al., 2019) Cholecystectomy should therefore be performed as solo surgery on these patients and bariatric procedure to be done later.
References
Baron, T. H., & Garg, S. K. (2013). Routine cholecystectomy during Roux-en-Y gastric bypass with or without choledocholithiasis. Cochrane Database of Systematic Reviews, (8).
De Oliveira, C. I. B., Chaim, E. A., & Da Silva, B. B. (2003). Impact of rapid weight reduction on risk of cholelithiasis after bariatric surgery. Obesity Surgery, 13(4), 625–628.
Doulamis, I. P., Michalopoulos, G., Boikou, V., Schizas, D., Spartalis, E., Menenakos, E., & Economopoulos, K. P. (2019). Concomitant cholecystectomy during bariatric surgery: The jury is still out. The American Journal of Surgery.
Fobi, M. A. L., Lee, H., Igwe, D., Felahy, B., James, E., Stanczyk, M., & Fobi, N. (2002). Prophylactic cholecystectomy with gastric bypass operation: incidence of gallbladder disease. Obesity Surgery, 12(3), 350–353.
Hamad, G. G., Ikramuddin, S., Gourash, W. F., & Schauer, P. R. (2003). Elective cholecystectomy during laparoscopic Roux-en-Y gastric bypass: is it worth the wait? Obesity Surgery, 13(1), 76–81.
Kim, J.-J., & Schirmer, B. (2009). Safety and efficacy of simultaneous cholecystectomy at Roux-en-Y gastric bypass. Surgery for Obesity and Related Diseases, 5(1), 48–53.
Villegas, L., Schneider, B., Provost, D., Chang, C., Scott, D., Sims, T., … Jones, D. (2004). Is routine cholecystectomy required during laparoscopic gastric bypass? Obesity Surgery, 14(2), 206–211.
Warschkow, R., Tarantino, I., Ukegjini, K., Beutner, U., Güller, U., Schmied, B. M., … Thurnheer, M. (2013). Concomitant cholecystectomy during laparoscopic Roux-en-Y gastric bypass in obese patients is not justified: a meta-analysis. Obesity Surgery, 23(3), 397–407.
Wood, S. G., Kumar, S. B., Dewey, E., Lin, M. Y., & Carter, J. T. (2019). Safety of concomitant cholecystectomy with laparoscopic sleeve gastrectomy and gastric bypass: a MBSAQIP analysis. Surgery for Obesity and Related Diseases.
Worni, M., Guller, U., Shah, A., Gandhi, M., Shah, J., Rajgor, D., … Østbye, T. (2012). Cholecystectomy concomitant with laparoscopic gastric bypass: a trend analysis of the nationwide inpatient sample from 2001 to 2008. Obesity Surgery, 22(2), 220–229.
Yardimci, S., Coskun, M., Demircioglu, S., Erdim, A., & Cingi, A. (2018). Is concomitant cholecystectomy necessary for asymptomatic cholelithiasis during laparoscopic sleeve gastrectomy? Obesity Surgery, 28(2), 469–473.
Dr. Chirstian Perez:
My approach for patients with symptomatic cholelithiasis undergoing bariatric surgery is to perform cholecystectomy concomitantly.
The literature has shown that there is an increased risk of gallbladder disease after bariatric surgery. The incidence of symptomatic gallbladder disease peaks at 12-17 months after bariatric surgery with some studies reporting the peak incidence of up to 3 years.
More recently, the rate of prophylactic cholecystectomy has decreased as studies have shown that the incidence of future episodes of biliary colic or cholecystitis requiring cholecystectomy is between 2-11%. However, literature also shows that the rate of cholecystectomy after bariatric surgery is 6.5% with laparoscopic adjustable gastric band (LAGB), 9.7% with Roux-en-Y gastric bypass (RYGB) and 10.1% with sleeve gastrectomy (SG).
In my practice, indications for concomitant cholecystectomy include a patient with previous documented episodes of biliary colic and ultrasound with evidence of cholelithiasis.
Why should we perform a concomitant cholecystectomy during any bariatric procedure?
One major reason is the difficulty in accessing the biliary tree if a patient develops choledocholithiasis, which is more evident in patients who have undergone RYGB. Their “new anatomy “makes it more difficult to access/decompress the biliary system with endoscopic retrograde cholangio-pancreatography (ERCP), and usually requires advanced therapeutic endoscopy and/or another procedure to obtain trans-gastric access.
In addition, bariatric surgery patients have been shown to have a higher rate of common bile duct (CBD) injury (0.12%) when they have a cholecystectomy after their bariatric surgery. This is due to the fact that reports have shown that bariatric patients usually present with more severe biliary disease after their initial bariatric procedure. This rate is obviously higher when compared to the standard 0.08% reported CBD injury rate for the general population.
Concomitant cholecystectomy also has advantages on cost and resource utilization in the healthcare system. This avoids risks and costs of a second anesthesia event along with visits to the emergency room for repeated attacks of biliary colic. In fact, performing a cholecystectomy may eliminate the need to add additional work-up for gallbladder etiology in patients post bariatric surgery who present with postoperative pain, which may require costly, prolonged and extensive work-ups.
In reality, there is a lack of evidence on the best approach for bariatric patients who present with asymptomatic cholelithiasis. However, there has been evidence in literature to support the safety of these procedures during LAGB, RYGB and SG; some of these studies show an increase in surgical site infection and length of stay but no increase in rates of major complications. In fact, it has been uniformly recommended to perform cholecystectomy for patients with documented symptomatic cholelithiasis.
It is important to have an extensive discussion with the patient about the risks and possible complications when doing a concomitant cholecystectomy during their bariatric surgery, which includes the possibility of aborting the bariatric procedure altogether. It is not uncommon, that after this discussion, patients often choose to have both procedures perform concomitantly to avoid another surgery in the future.
In my practice, I adhere to the following principles when performing concomitant cholecystectomy. One, cholecystectomy should be completed with routine intraoperative cholangiogram before the actual bariatric procedure. Second, because cholecystectomy in obese patients is a challenging procedure, it is important to maintain the same tenets to achieve the critical view of safety during laparoscopic cholecystectomy. To avoid the fatty, enlarged, friable liver associated with obesity, patients follow a strict preoperative diet, which reduces the size of the liver, thus improving the visualization during the procedure. Adding extra port sites may be needed and placed to have the appropriate triangulation to perform the procedure in the safest possible way. A minimally invasive/bariatric surgeon should be, if at all possible, the one performing the cholecystectomy in patients after bariatric surgery because of their skill set and expertise with this patient population. However, as it has been shown in the literature, the reality is that most of the time, the subsequent cholecystectomy is performed in a different institution by a different surgeon.
To conclude, the management of gallbladder disease in patients with obesity should not differ from other patients in the general population. Patients with symptomatic gallbladder disease should have concomitant laparoscopic cholecystectomy during the time of their bariatric procedure as this has been demonstrated to be both, a safe and cost-effective approach to the overall care of bariatric patients.
References:
Tustumi F, et al. Cholecystectomy in Patients Submitted to Bariatric Procedure: A systematic Review and Meta-analysis. Obesity Surg(2018)28:3312
Altieri M, et al. Incidence of cholecystectomy after bariatric surgery. SOARD (2018)14:992-96.
Dakour-Aridi, H, et al. Safety of concomitant cholecystectomy at the time of laparoscopic sleeve gastrectomy: analysis of the American College of Surgeons National Surgical Quality Improvement Program database. SOARD(2017)13:934-941.
Obeid NR, Kurian MS, et al. Safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis. Surg Endosc (2015)5:1192-7.
Wood S, Kumar S, et al. Safety of concomitant cholecystectomy with laparoscopic sleeve gastrectomy and gastric bypass: a MBSAQIP analysis. SOARD 2019 in press.
Raziel A, Sakran N, et al. Concomitant cholecystectomy during laparoscopic sleeve gastrectomy. Surg Endosc(2015)29:2789-2793.
Dr. Mujjahid Abbas
Bariatric procedures and Cholecystectomy Conundrum!
Before we answer the question of whether concurrent cholecystectomy should be performed with index bariatric procedures, we have to answer few basic questions;
Is there need to perform concurrent cholecystectomy in asymptomatic patients with normal gallbladder or no gallbladder associated pathology?
I think there is a consensus on there being no need for such procedure in such patients.
Does every patient (morbidly obese or not) with cholelithiasis need cholecystectomy?
I think there is a consensus that not every patient with asymptomatic cholelithiasis needs cholecystectomy. Controversy obviously lies when such patients is undergoing a bariatric procedure and is found to have asymptomatic gallstones.
Are bariatric patients at higher risk of developing biliary disease after weight loss surgery?
Yes, there is higher incidence of developing cholelithiasis and symptomatic cholelithiasis after rapid weight loss in bariatric patients. Incidence of developing cholelithiasis in various studies is in single digits to even higher than 50% in some studies. Incidence of developing symptomatic cholelithiasis after bariatric surgery seems to be in single digit and incidence of laparoscopic cholecystectomy performed post bariatric surgery seems to be around 5%. Risk of developing cholelithiasis is highest in first six months to a year, it decreases significantly afterwards in line with decline in rapid weight loss.
Can we prevent gallstone formation in bariatric patients after surgery?
Yes, using Ursodeoxycholic acid is associated with significantly reduced risk of developing cholelithiasis. In our experience however, most patients do not continuously take the medicine because of cost, taste of the medication and pill aversion being few of the causes.
Is cholecystectomy in morbidly obese patients more difficult to perform than in nonobese patients?
Yes, it is technically more challenging and takes longer to perform laparoscopic cholecystectomy in morbidly obese patients however various studies have shown no statistical difference in post-operative morbidity and complications although a trend towards more complications and increased morbidity is reported by some studies.
Is management of complicated gallbladder disease in post bariatric patients more difficult?
Yes, in gastric bypass patients it is true although more recently endoscopists have become facile in reaching the duodenum in retrograde fashion via Roux to biliary limb rout. Other modalities to gain access to duodenum like laparoscopic trans-gastric remnant access, IR guides percutaneous access to remnant stomach and using that track for ERCP and more recently endoscopic access to gastric remnant via gastric pouch and using stent device like AXIOS between pouch and remnant( thus creating a gastrogastric fistula, which is closed afterwards) has made it possible to do so without need for surgical access to gastric remnant, hence I do not believe fear of a possible difficult endoscopic access to duodenum in future should make a case of concurrent cholecystectomy in patients with asymptomatic cholelithiasis who are planning to undergo gastric bypass.
What is your main argument against performing concurrent cholecystectomy in asymptomatic cholelithiasis patients?
Most of the patients with asymptomatic cholelithiasis will remain asymptomatic even after weight loss surgery hence performing cholecystectomy in those patients will be borderline unethical in my opinion.
My approach:
Do I get a preoperative abdominal ultrasound in all bariatric patients?
No, I do not believe it is indicated, as most of the patients with symptomatic cholelithiasis and other gallbladder pathology would have clinical history to suggest so. A gallbladder ultrasound should be obtained in patients where clinical suspicion arises.
Do I perform concurrent cholecystectomy with index bariatric procedures in asymptomatic patients?
No, I only perform concurrent cholecystectomy with index bariatric procedures in patients with symptomatic cholelithiasis.
However, I do consider performing concurrent cholecystectomy in patients with asymptomatic cholelithiasis or no gallstones in following scenarios;
gallstones larger than 2CM, gallbladder polyps, previous history of pancreatitis in nonalcoholic patient, previous abdominal pain thought secondary to gallbladder pathology with other etiology ruled out but lack of classic biliary colic history, biliary dyskinesia, sickle disease status etc.
Are there any technical considerations if I am performing a concurrent cholecystectomy?
Yes, I do cholecystectomy part first and only proceed with bariatric part if I am completely satisfied with cholecystectomy part.
I do place extra ports as needed and try not to change my port placement too much to reduce overall number of ports.
I do perform cholangiogram, intraoperative ultrasound or ICG cholangiography whichever is available.
I do consider leaving a drain if cholecystectomy part of surgery was more difficult than usual.
I do check LFTs postoperatively before patient is discharged.
I will have low threshold to do a partial cholecystectomy or leaving the posterior wall intact if it was not safe to proceed with Calot’s triangle dissection.
Dr. Naif AlEnazi
Head of General Surgery Department
Prince Mohammed Bin Abdulaziz Hospital
Riyadh, KSA
Christian Perez MD, FACS, FASMBS
Medical Director of Metabolic and Bariatric Surgery, Carle Foundation Hospital
Clinical Assistant Professor, University of Illinois College of Medicine
Champaign-Urbana, Illinois, USA
Mujjahid Abbas MD, DABS, FACS, FASMBS
Director of Bariatric and Metabolic Surgery University hospitals Parma Medical Center Co-Director for advance GI/bariatric surgery fellowship UH Cleveland medical center Associate Professor of surgery, Case Western reserve University school of medicine
Cleveland, Ohio, USA