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Mohanned-Al-Haddad316
claim. Therefore, in the opinion of these authors, further studies with strong evidence are still needed to substantiate the association of omentopexy with reduced
GE.
6 Conclusion
Surgical technique is one of the main factors in the postoperative outcome of gastrointestinal symptoms. Reattaching the omentum to the new greater curvature of
the sleeved stomach in an effort to restore the natural anatomic position is becoming increasingly popular among bariatric surgeons to address this issue. Although,
the impact of omentopexy on food tolerance, GE, and GERD was observed in
various studies, further randomised studies are needed to draw a definitive conclusion. Therefore, we recommend the use of omentopexy for select patients undergoing LSG who are at higher risk of developing gastric coiling or gastric twist as
observed interaoperatively.
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317
Sleeve Gastrectomy and Gallstones Disease
Hanan M. Alghamdi
1 Introduction
Obesity is an established risk factor for gallstone formation, furthermore, rapid
weight loss increases the likelihood of developing gallbladder stone. Both risks
contribute to biliary disease complications in bariatric surgery. Laparoscopic
Sleeve Gastrectomy (SG) is the most common bariatric surgery performed worldwide, hence the increased gravity of any complication that may occur post operatively, moreover, the possible cumulative risk of biliary complications related to
rapid weight loss [1]. However, there is relative scarcity of published data on SG
and gallstones, with most of the research on this topic coming from the earlier bariatric procedures, namely gastric bypass and adjustable gastric band.
2 Obesity and the Risk of Gallstone
Obesity is a worldwide health problem which causes serious diseases including
the risk of developing gallstone (Cholelithiasis risk) [2, 4]. The risk is more established in the female population than male patients, especially with higher body
mass index (BMI) [5]. It has been proven that women with a BMI of 30 kg/m2 or
more have at least double the risk as those of normal BMI for gallstone formation
[6–12].
In a large cohort study that included nearly 90,000 women followed for a
period of 8 years, it was able find that a significant increase in the incidence of
H. M. Alghamdi (*)
HBP & Bariatric Surgeon, Imam Abdulrhman Bin Faisal University, Dammam, Saudi Arabia
e-mail: hmalghamdi@iau.edu.sa
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_32
319
H. M. Alghamdi320
gallstone disease was established with increasing BMI, particularly in women with
a BMI of 30 kg/m2 or more, with an exponential increase in the incidence of gallstones from a rate of 3.7 to 7.4 times with higher BMI in women as compared to
women with normal BMI [12].
3 Rapid Weight Loss and the Risk of Gallstone
Strong evidence of an increased risk for gallstones among the obese came from
clinical studies of individuals subjected to very low-calorie diets and having rapid
weight loss with an estimated risk of 10–25% [13–17]. The rationale behind this
is rapid mobilization of cholesterol from adipose tissue stores and excess cholesterol excretion from the liver leading to bile supersaturation with cholesterol.
Furthermore, fasting has been associated with reduced gallbladder contractility, a
sequala of dietary fat restriction, leading to gallbladder stasis and favoring gallstone formation. In contrast, increasing the dietary fat by a small amount induces
better gallbladder emptying and may reduce the risk of gallstone formation in
patients undergoing rapid weight loss [18]. Fluctuation of BMI due to repeated
dieting may also play an added role in gallstone formation [19, 20].
During follow-up, the Nurses’ Health Study cohort found an increased risk of
gallstone formation, with a 44% increase in women who lost 4 to 10 kg and a 94%
increase in women who lost more than 10 kg, compared to those whose weight
loss was less than 4 kg [12].
In the first U.S. National Health and Nutrition Examination Survey, a history of
dieting (however unknown degree of weight loss) among women was associated
with a raised incidence of hospitalization with gallstones during a 10 year followup (67%; P = 0.001) [21].
An association of gallstone disease and obesity in men has been more difficult
to establish, probably due to the fact that gallstone disease is generally more rare
in men. In an ultrasonographic study from Copenhagen County, Denmark, men
with a history of more than one weight loss treatment (with weight loss of more
than 5 kg) had a statistically significant increased prevalence of gallstone disease
(11.0% compared with 5.2% in normal diet) [9].
4 Pathophysiology and Type of Gallstones Formation
in Obesity
Cholesterol gallstones comprise 80% of all gallbladder stones in Western countries
[22]. More specifically, obesity related gallstones are predominantly of the cholesterol type and are formed when there is a disproportion in substance composing bile, partly due to the increase in the activity of 3-hydroxy-3-mthylglutaryl
coenzyme A reductase (HMGCoA), leading to increased secretion of biliary cholesterol [23]. Generally, there are three physical conditions described that contribute to the formation of cholesterol gallstones, however, they do not necessarily all
Sleeve Gastrectomy and Gallstones Disease
321
exist at the same time [Table 1] [24, 25]. Cholesterol crystal formation (visible by
microscopy) followed by sludge formation (visible by gallbladder ultrasonography) are thought to be necessary precursors for cholesterol gallstone formation.
Gallbladder hypomotility is measured by increased fasting volume, decreased
ejection fraction, and increased contracted volume [27–29].
Several prenucleation and antinucleating proteins (mechanism 2), perhaps derivatives of gallbladder mucin, have been implicated as kinetic factors.
Interestingly, Gustafsson et al. found that, by obtaining gallbladder bile during
bariatric surgery and percutaneous aspiration postoperatively after weight loss,
crystallization promoting compound like “Mucin” are of great importance in the
development of cholesterol Crystals. Patients are therefore transiently at risk for
gallbladder stones during the active weight reduction phase, which usually consists of the first 6–12 months, after which the risk diminishes after 2 years [30].
5 Incidence of Cholecystectomy in Sleeve Gastrectomy
Routine bariatric surgery is generally associated with a low frequency of postoperative cholecystectomy, however, it is highest early after surgery and is mainly
determined by the amount of excess weight loss within the first 3 months. As a
sequalae, several studies discouraged routine prophylactic cholecystectomy at the
time of bariatric surgery in asymptomatic patients [31].
In the largest retrospective series to date, with a 5 year follow-up period, Altieri
et al. found that cholecystectomy was required postoperatively, most prominently
following LSG in 167 (10.1%) of 1650 patients, with lower numbers seen following RYGB (Roux-en-Y Gastric Bypass) making up 1931 (9.7%) patients out
of 19,996, as well as LAGB (laparoscopic adjustable Gastric Band) compromising 989 (6.5%) patients from 15,301. Based on a multivariable Cox proportional
hazard mode, risk factors for subsequent cholecystectomy included younger age,
female sex, race, and some co-morbidities and complications (P < 0.05). Further,
they concluded that patients should be counseled preoperatively about this risk and
contemplate the use of Ursodiol biliary prophylaxis [32].
Table 1 Mechanism of cholesterol gallbladder formation in obesity and weight loss
Physical mechanism
The first physical mechanism: cholesterol
supersaturation of bile
The second physical mechanism: the presence
of a kinetic defect
The third physical mechanism: hypomotility of
gallbladder
Affect
Leading to preconditioning of cholesterol
crystallization
Causing acceleration of cholesterol crystal
nucleation and increase in supersaturated bile
Bile increased cholesterol supersaturation,
stasis in the gallbladder, and cholesterol crystallization leading to gallstone formation
H. M. Alghamdi322
6 Biliary Complications Post LSG
Most research on biliary complications have come from large studies on RYGB.
In a study of 3765 patients who underwent bariatric surgery, around 138 (3.6%)
patients developed postoperative biliary complications. The mean time from
surgery to biliary complication was seen to be 1.8 ± 1.4 years. The main biliary
complications were chronic cholecystitis (70.2%) and to a lesser extent, acute
cholecystitis (18.1%), acute pancreatitis (9.4%), choledocholithiasis (5.7%), and
jaundice (2.8%). The interventions were laparoscopic (n = 134, 97.0%) and open
(n = 1, 0.7%) cholecystectomy [33]. Similar studies with longer prospective follow
up (3 years) post open RYGB included 40 morbidly obese patients free of gallbladder disease preoperatively. Eleven of these patients (28.9%) developed cholelithiasis, four (10.5%) experienced biliary pain, and 2 suffered from acute biliary
pancreatitis (5.3%). The treatment for these patients involved laparoscopic cholecystectomy. There were no deaths encountered post-op, which makes it a reasonable conclusion to perform a cholecystectomy during RYGB in the presence of
cholelithiasis, or following this procedure if gallstones develop [34].
The most recent systematic review and meta-analysis of 42 studies with a
cumulative sample size of 729,642 patients was able to show an incidence rate of
biliary complications to be 5.54 cases/1000 patient year: SD = ± 6.87 (Table 2).
Sleeve gastrectomy had the highest complications rate equal to 5.66 cases/1000
patient year; SD = ± 9.06 compared to all other procedures. This was prob-
ably because none of the SG studies included ursodiol use. The most common
biliary complications encountered were biliary colic or biliary dyskinesia with
3.04 cases/1000 patient year: (SD = ± 2.67). Acute cholecystitis made up 1.44
cases/1000 patient year (SD = ± 2.13), acute pancreatitis was 0.11 cases/1000
patient year (SD = ± 0.2), and common bile duct stones showed an incidence of
0.34 cases/1000 patient year (SD = ± 0.53). The complication rate tended to be
exponential to the severity of weight loss [Table 2] [35].
7 Cholecystectomy: When to Operate?
Presently there is no consensus on the best timing to perform a cholecystectomy
for asymptomatic gallstones in individuals undergoing bariatric surgery, with
widespread variation in practice. This can be explained by a lack of high-quality
studies and the lack of randomized control trials, especially covering LSG. This
controversy is null when the patient presents with symptomatic gallstone given
that the standard practice would be to perform a cholecystectomy before or commitment to their bariatric procedure [36].
There are three possible approaches to deal with the risk of biliary complications and asymptomatic gallstones:
Sleeve Gastrectomy and Gallstones Disease
Table 2 Incidence of biliary complication post bariatric surgery
Bariatric Technique,
UDCA & Biliary
complications
RYGB 62,116.02 226,168.85 5.27 6.12
LSG 4771.36 5907.47 5.66 9.06
LAGB 2819.17 766.23 1.02 1.08
BPD/DS 6059.50 1908.48 5.53 2.11
UDCA 3176.17 2584.51 4.1 3.37
NO UDCA
URSODIOL
Global biliary
complications
Biliary colic or
dyskinesia
Acute cholecystitis 167,371.45 740,115.82 1.44 2.13
Acute pancreatitis 11,938.94 19,571.46 0.11 0.2
Mean total patient
year
10,912.36 17,963.78 5.67 9.82
135,581 598,964.17 5.54 6.87
61,952.22 232,429.74 3.04 2.67
(±SD) Mean number of
cases/1000 patient
year
(±SD)
1. Prophylactic (Routine) Cholecystectomy
2. Selective (Elective) Cholecystectomy
3. Conventional (expectant) Cholecystectomy
323
8 Prophylactic (Routine) Cholecystectomy
Refers to performing laparoscopic cholecystectomy in all patients at the time of
initial surgery, regardless of the presence or absence of gallstones. In earlier concerns, there has been an increased incidence of biliary complications after bariatric
surgery compared to the general population. Another important concern is that the
diagnosis of microlithiasis is difficult, while the incidence might be higher than
expected.
The risk for postoperative complications was lower when the procedure was
performed concomitantly with bariatric surgery compared to those performed
post- (RD = − 0.09; 95% CI − 0.13, − 0.05) or pre-bariatric surgery (RD = − 0.05;
95% CI − 0.08, − 0.01). Furthermore, the risk for reoperation was lower for
patients that underwent concomitant cholecystectomy (RD = − 0.02; 95%
CI − 0.05, − 0.00). The reason for cholecystectomy having a higher risk postopera-
tively is thought to be because 36.2% of the cholecystectomy indications following bariatric procedures were acute cholecystitis or involved choledochotomy for
common bile duct exploration [35]
H. M. Alghamdi324
Worni et al. retrospectively analyzed 70,287 adults that underwent RYGB
which reported only 9.1% of the patients had undergone concomitant cholecystectomy. However, the proportion of patients undergoing concomitant cholecystectomy decreased significantly from 26.3% in 2001 to 3.7% in 2008. Due to
increased postoperative complications, interventions, mortality, and longer hospital stay they did not recommend concomitant cholecystectomy [37–39].
This approach was challenged by the fact that patients submitted to bariatric surgery have a low incidence rate of biliary complications, and concomitant cholecystectomy increases the risk for postoperative complications, cost and operative time.
Subsequent reports and a major meta-analysis covered 13 studies analyzing the rate
and morbidity of subsequent cholecystectomy in 6,048 patients who underwent
RYGB without concomitant cholecystectomy. The rate of subsequent cholecystectomy was 6.8% (95% CI, 5.0–8.7%). 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 rate 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%)
while the risk of suffering from a cholecystectomy-related complication was 0.1%
(95% CI, 0.03–0.3%) in patients undergoing RYGB without concomitant cholecystectomy. An important recommendation was to avoid prophylactic concomitant
cholecystectomy during RYGB in patients without cholelithiasis, with the procedure exclusively reserved for patients with symptomatic biliary disease [36].
9 Elective (Selective) Cholecystectomy:
The approach involves performing concomitant laparoscopic cholecystectomy
only in patients with gallstones pre/intraoperatively, even if asymptomatic. Many
of the reasons that make it an appealing approach is that there is an assumed
higher incidence of symptomatic disease as compared to patients without
gallstones.
Hamed et al. performed cholecystectomy in 16.9% of patients during RYGB
and compared the outcomes to those who did not have concomitant surgery. The
result showed significantly longer operative time, longer hospital stays, and higher
major morbidity in those with concomitant cholecystectomy.
There was, however, no specific morbidities causally related to cholecystectomy [40].
10 Conventional (Expectant) Cholecystectomy
Approach
This involves expectant management with or without prophylactic administration
of UDCA until the symptoms develop. Thus, cholecystectomy is performed only
when symptoms arise. The advantage of this approach is that surgery is performed
Sleeve Gastrectomy and Gallstones Disease
after a significant weight loss is achieved allowing surgical risk and technical difficulties to subside after the weight loss procedure.
Several studies showed a low incidence rate (only 9.84%) of patients after
RYGB without prophylactic UDCA requiring subsequent cholecystectomy and
they concluded that the natural history of patients with asymptomatic gallstones
undergoing bypass is very much like the natural history of asymptomatic gallstones in the general population [41].
325
11 Ursodeoxycholic Acid (UDCA) Prophylaxis
The role of UDCA in prevention of gallstones is well established in the literature.
It works by acting at the cholesterol and mucin levels in the bile (decreasing bile
saturation) and improving gallbladder emptying.
In a randomized clinical trial, although a small sample was included, 51 obese
women and 17 obese men all received a 16-week, 520-kcal-per-day weight-loss
program. Gallstones formation was reported in 0 of 18 of the ursodeoxycholic
acid-treated group, 2 of 14 of the aspirin-treated group and significantly in 5 out of
19 of the placebo-treated group [14].
12 UDCA Efficacy in Post Bariatric Surgery
12.1 Dose, Frequency
The ideal dose of UDCA to markedly and significantly reduce gallstone formation
from 32 to 2% proved to be 600 per day, provided prophylactically twice daily
in divided doses for 6 months after RGBP-induced rapid weight loss. This intervention further decreases the morbidity of this potentially life-saving operation.
However, UDCA can reduce gallstone formation with no further risk reduction
when using higher doses of 1200 mg daily (6%) [42].
There was weak evidence that the duration of UDCA prophylaxis is proportional to the BMI preoperatively, with no strong evidence available and the best
recommendation to support 6 month prophylaxis period in all patients.
Consensus from an earlier systemic review of eight studies incorporating 1355
patients demonstrated lower incidence of gallstone formation in patients taking
UDCA in relation to different bariatric procedures, doses of administered UDCA,
and time from bariatric surgery. Adverse events were similar in both groups.
Fewer patients required cholecystectomy in the UDCA group and no deaths were
reported [43].
The only randomized clinical trial that has been published to date among SG
patients investigated gallstone prevention with UDCA in 37 patients randomized
to the UDCA treatment arm and 38 patients to no treatment. The results at
6 months demonstrated that the UDCA group had a statistically significant lower
incidence of gallstones (p = 0.032) while at 1 year no significant difference in
H. M. Alghamdi326
gallstones between the two groups was detected. The overall gallstone formation
rate was 29.8% [44].
13 Disadvantages of UDCA
Other than the higher cost inferred on patients, some side effects can be seen with
UDCA usage, e.g. diarrhea, skin rash and aggravation of liver diseases that the
patient needs to be informed about and could be a limiting factor in its use [43].
14 Summary
Obesity and rapid weight loss after LSG contribute to the risk of gallstone formation and the likelihood of developing biliary disease complications.
There is relative scarcity of published data on LSG and biliary disease and a
limitation of this review is that most of the included studies were a retrospective
cohort that mostly came from RYGB studies. These studies characteristics may
explain the high heterogeneity noted in some analysis.
Clearly the data showed low incidence of biliary complications after bariatric
surgery. Prophylactic cholecystectomy currently has no indications, even in the
presence of asymptomatic gallstones due to the fact that it may increase the risk of
postoperative complications and the mean operative time. However, if cholecystectomy is not performed before or at the time of the LSG, patients should be carefully
followed with special attention for biliary complications. Commonly, indication for
cholecystectomy post-bariatric surgery is due to acute biliary complications, which
despite being unusual, infer a higher risk for postoperative complications and reoperations. If a patient presents with biliary symptoms at the time of bariatric surgery,
surgeons should considerer cholecystectomy before or concomitantly.
Given the current popularity of the sleeve. Future controlled trials are required
for evidence of higher power. In addition, a standardized usage of ursodiol for
each type of bariatric technique should also be assessed in further studies. The
use of UDCA in a dose of 300 mg taken twice daily for 6 months significantly
reduces or prevents gallstone formation and is highly recommended in asymptomatic gallstones.
15 Conclusion
Sleeve gastrectomy is an increasingly performed procedure worldwide and is
viewed by many experts as a valid option for weight reduction and resolution of
metabolic comorbidity. Post-operative biliary disease is a serious risk, however
prophylactic cholecystectomy is not indicated while UDCA prophylaxis is indicated especially in asymptomatic gallstones. Longer term, and comparative data
are still needed.