468203

7232019 468203

httpslidepdfcomreaderfull468203 16

Research ArticleComplicated Gallstones after Laparoscopic Sleeve Gastrectomy

Eleni Sioka Dimitris Zacharoulis Eleni Zachari Dimitris Papamargaritis

Ourania Pinaka Georgia Katsogridaki and George Tzovaras

Department of Surgery University Hospital of Larissa Viopolis 983092983089983089983089983088 Larissa Greece

Correspondence should be addressed to Dimitris Zacharoulis zachadimyahoocom

Received 983090 March 983090983088983089983092 Revised 983089983090 June 983090983088983089983092 Accepted 983089983094 June 983090983088983089983092 Published 983091 July 983090983088983089983092

Academic Editor R Prager

Copyright copy 983090983088983089983092 Eleni Sioka et al Tis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background Te natural history o gallstone ormation afer laparoscopic sleeve gastrectomy (LSG) the incidence o symptomaticgallstones and timing o cholecystectomy are not well established Methods A retrospective review o prospectively collecteddatabase o 983089983093983088 patients that underwent LSG was reviewed Results Preoperatively gallbladder disease was identi1047297ed in 983091983090 o the patients (983090983091983090) Postoperatively eight o 983089983091983096 patients (983093983096) became symptomatic Namely three o 983090983091 patients (983089983091) whohad evident cholelithiasis preoperatively developed complicated cholelithiasis From the cohort o patients without preoperativecholelithiasis 1047297ve o 983089983088983094 patients (983092983095) experienced complicated gallstones afer LSG otal cumulative incidence o complicatedgallstones was 983092983095 (983097983093 CI 983089983091ndash983096983089) Te gallbladder disease-ree survival rate was 983097983090983090 at 983090 years No patient underwentcholecystectomy earlier than 983097 months or later than 983090983091 months indicating the post-LSG effect Conclusion A signi1047297cant proportiono bariatric patients compared to the general population became symptomatic and soon developed complications afer LSG thusearly cholecystectomy is warranted Routine concomitant cholecystectomy could be considered because the proportion o patientswho developed complications especially those with potentially signi1047297cant morbidities is high and the time to develop complicationsis short and because o the real technical difficulties during subsequent cholecystectomy

1 Introduction

Te incidence o cholelithiasis has been reported to be 983093 inthe general population while it is signi1047297cantly increased inobese population reaching 983092983093 [983089ndash983091] Afer bariatric surgeryweight loss o more than 983090983093 o the original weight is

considered to be the only predictive actor to postoperativegallstone ormation [983092 983093]

Te incidence o gallstone ormation differs betweenthe various types o bariatric procedures Asymptomaticgallstones are reported in 983090983094983093 in gastric banding patients[983094] though only 983094983096 o patients become symptomatic post-operatively [983095] In addition asymptomatic gallstones rangedrom 983091983088 to 983093983090983096 afer 983094 to 983089983090 months postoperatively [983096ndash983089983088]whilst symptomatic gallstones occurred by 983095ndash983089983094 in gastricRoux-en-Y by pass (RYGB) patients [983096 983089983088ndash983089983090] Despite thatcholecystectomy aferRYGB was necessary only or 983091983097ndash983089983095983094o the patients whether or not stones were present beorebariatric surgery [983089983091]

Laparoscopic cholecystectomy (LC) in bariatric patientsmay be technically challenging due to suboptimal port place-ment and difficult body habitus Furthermore it is accompa-nied by potential risks such as lengthening o operative timeincreased morbidity and prolonged hospitalization Seriouscomplicationshave been reported as high as983090 to 983091 o cases

[983089983092]Te published data are not illuminating in laparoscopic

sleeve gastrectomy (LSG) o the best o our knowledgeonly ew case series exist in the literature Moreoverthere is lack o protocols concerning the managemento gallstones afer LSG It seems that current policy isrelied on local institution practice Besides the setting o cholecystectomy in relation to LSG as routine selectivesimultaneous or delayed remains an ongoing therapeuticdilemma

Te aim o this study was a retrospective analysis o our prospectively collected data in order to determine theincidence o complicated gallstone disease afer LSG

Hindawi Publishing CorporationJournal of Obesity Volume 2014 Article ID 468203 5 pageshttpdxdoiorg1011552014468203

7232019 468203


983090 Journal o Obesity

2 Materials and Methods

Te prospectively collected database o the morbidly obesepatients who underwent LSG between August 983090983088983088983094 andDecember 983090983088983089983089 in our academic centrewas reviewed Medicalrecords and histopathologic data were also reviewed

Eligibility or surgery was de1047297ned according to the 983089983097983097983089NIH consensus criteria or bariatric surgery [983089983093] Exclusioncriteria were heavy sweaters patients with suspected gastroe-sophageal re1047298ux disease as suggested by severe symptomsand endoscopic 1047297ndings patients with psychiatric disordersand addiction to either drugs or alcohol and patients withhigh operative risk Te operative technique has been previ-ously described [983089983094]

ransabdominal ultrasound (US) was perormed in allpatients preoperatively to rule out gallstones or sludgeAccording to the protocol patients with positive 1047297ndingson ultrasound were counselled or concomitant laparoscopiccholecystectomy Patients in the preoperative appointmentswere inormed o the evidence o cholelithiasis and the

potential risks and bene1047297ts o the arrangement o twoprocedures Te authors adopted the elective approachmeaning that simultaneous cholecystectomy was perormedin symptomatic patients Laparoscopic cholecystectomy wasperormed at the beginning o the procedure with theplacement o an extra trocar Postoperative prescription o ursodeoxycholic acid was not practiced in our managementprotocol

Postoperative ollow-up was perormed at 983090 weeks 983089month 983091 months 983094 months and 983089 year and then yearly post-operatively Patients were interviewed in ollow-up appoint-ments and complications related to gallbladder disease wererecorded Patients in this series were ollowed up or at least

six months postoperatively

3 Statistical Analysis

Statistical analyses were perormed using the sofware SPSS983089983097 (SPSS Inc Chicago IL USA) and Stata 983089983089 (StataCorp983090983088983088983097 College Station X USA) Quantitative variables werepresented as means plusmn standard deviation or median withinterquartile range or range Qualitative data were presentedas absolute requencies and proportions Prevalence cumula-tive incidence and corresponding con1047297dence interval (983097983093CI) were calculated Incidence per each interval was also

calculated using lie tables based on the actuarial methodKaplan-Meier estimator was used to estimate survival ratesand the corresponding 983097983093 con1047297dence intervals (type log-log) afer LSG operation providing a Kaplan-Meier survivalestimate plot

4 Results

During the entire study period one hundred sixty-1047297veconsecutive patients underwent LSG Gallbladder ollow-updata were obtained or 983089983093983088 patients (983097983090983094) Te medianage was 983092983088 years (range 983089983096ndash983094983090) and the median BMI was983092983094983089 (range 983091983093ndash983094983089) Patients in this study were predominantly

emale (983095983097) Te median ollow-up was 983090983094 months (range983089ndash983094983090)

Prior cholecystectomy was perormed in 983089983090 patients (983096)Preoperatively positive gallbladder disease was identi1047297edin 983091983090 patients (983090983091983090) In detail pathologic 1047297ndings weregallstones in 983090983097 patients and sludge in 983091 patients Tereore

preoperative evidence o gallbladder disease was shown in983091983089983090

Simultaneous cholecystectomy was perormed in 983097 o 983091983090patients who had preoperative gallstones and were symp-tomatic Eight operations were completed laparoscopicallywhile one open cholecystectomy was perormed due tomultiple adhesions rom previous laparotomy Neither peri-operative or postoperative complications occurred

Tus 983090983091 patients lef the operating room with intactgallstones O these three patients required cholecystectomy eventually Tese patients presented at 983097 983090983091 and 983089983093 monthsafer LSG with acute cholecystitis biliary colic and pancre-atitis respectively Te postoperative period was uneventul

o the contrary negative ultrasound 1047297ndings were observedin 983089983088983094 patientsFive patients o this group with no evidence o gallstone disease preoperatively presented with complicatedgallstones Tree patients presented with acute cholecystitisand two patients suffered rom choledocholithiasis Tusincidence o complicated gallstones postoperatively was esti-mated at 983093983096 (Figure 983089)

All patients were diagnosed at intervals speci1047297ed inable 983089 No late complications were noted All patientsexcept or one were managed with surgical interventionConsequent- ly post-LSG cholecystectomy was perormedin 983095 patients whether or not preoperative gallstones weredetected otal cumulative incidence o cholecystectomy was

983092983095 (983097983093 CI 983089983091ndash983096983089) Kaplan-Meier analysis detected thatthe biliary complication-ree survival rates were 983097983097983090 (983097983093CI 983097983092983092ndash983097983097983097) at 983089983090 months 983097983092983092 (983097983093 CI 983096983095983097ndash983097983095983092)at 983089983096 months and 983097983090983090 (983097983093 CI 983096983093983088ndash983097983094983088) at 983090983092 monthsafer LSG (Figure 983090)

5 Discussion

Tere is a paucity o data regarding preoperative evidenceo gallstones incidence o cholelithiasis with concomitantcomplications and gallstone ormation afer LSG In theliterature prior cholecystectomy in patients scheduled or

bariatric surgery was anticipated at percentages o 983089983089ndash983090983091[983089983091] In particular or LSG Li et al reported a percentage o 983091983090983095983097 [983089983095] Our results are similar with these studies since983090983091983090 o ourpatients were de1047297nedwith preoperative gallblad-der disease and previous cholecystectomy was perormed in983096 o our patients

In our series one patient experienced complicated gall-stones during the 1047297rst postoperative year while the othercases appeared during the second postoperative year Tatimplies what happened during the period o rapidweight lossOverall no patient underwent cholecystectomy earlier than 983097months or later than 983090983091 months afer LSG Tat indicates thepost-LSG effect regarding gallstones It seems that this effect

7232019 468203


Journal o Obesity 983091

Study population

Prior cholecystectomy Positive US 1047297ndings preoperatively

Negative US 1047297ndings preoperatively

Simultaneous cholecystectomy

Symptomatic

Symptomatic

Intact gallstones

Incidence o complicated gallstones afer LSG

n 12 (8)N 32 (232)

N 106 (768)

N 9

N 23

N 3

N 5

N 8 (58)

F983145983143983157983154983141 983089 Incidence o complicated gallstones afer LSG

983137983138983148983141 983089 Incidence o cholecystectomy at intervals afer LSG (laparoscopic sleeve gastrectomy)

Interval afer

LSG (months)

Number o patients

entering thisinterval

Number o patients

withdrawingduring interval

Number o patients with

postoperativeultrasounds

Number o patients exposed

to risk 983075

Number o patients who

underwentcholecystectomy

Incidence perinterval

(cumulativeincidence)

otal cumulativeincidence

(983097983093 CI)

983088 983089983091983096 983088 983088 983089983091983096 983088 983088983088

983095983089983091983096

983093983089(983089983092ndash983096983095)

lt983091 983089983091983096 983089983089 983088 983089983091983090983093 983088 983088983088

983091 to lt983094 983089983090983095 983089983089 983088 983089983090983089983093 983088 983088983088

983094 to lt983089983090 983089983089983094 983097 983089 983089983089983089983093 983089 983088983097

983089983090 to lt983090983092 983089983088983094 983090983095 983095 983097983090983093 983094 983094983093

983090983092+ 983095983091 983095983091 983088 983091983094983093 983088 983088983088Patients exposed to risk = Patients entering ndash (12 ) lowast Patients withdrawing

is similar to the effect o RYGB since the gallstones tend to

occur in the 1047297rst 983094ndash983089983090 months and rarely afer 983090 years [ 983089983096]Although 983090983091 patients were at risk or complicated gall-

stones due to preoperative evidence o gallstones only threepatients became symptomatic and required cholecystectomyTus the risk or this group was 983089983091983088983092 On the otherhand the risk or the patients without preoperative gallstoneswas 983092983095 In detail acute cholecystitis was diagnosed in 983092patients biliary colic in 983089 patient choledocholithiasis in 983090patients and pancreatitis in 983089 patient Our data are consistentwith other series More speci1047297cally ucker et al reportedsymptomatic cholelithiasis and choledocholithiasis in 983090 and983089 patients respectively in a total o 983089983094983092 patients (983089 983096)[983089983097] Arias et al reported that a percentage o 983091983096 o

patients developed symptomatic gallstones postoperatively

while 983089983096 had symptoms o gallstones prior to surgery [983090983088] Li et al showed that 983091983096 o patients afer LSGdeveloped symptomatic gallstones requiring medical atten-tion and surgical intervention [983089983095] Lalor et al mentionedcholedocholithiasis in 983088983095 [983090983089] Uglioni et al reported 983089 caseo acute cholecystitis and 983090 cases o cholelithiasis (983091983096) [983090983090]

Nowadays the conservative regimen o reserving chole-cystectomy or symptomatic disease in gastric bandingand RYGB serves as a sae modality o treatment [983095 983090983091]while asymptomatic gallstones (silent gallstones) represent adilemmatic approach Te natural history o asymptomaticgallstones suggests that many affected individuals will remainasymptomatic [983090983092 983090983093] Furthermore recent trend analysis

7232019 468203



0

1

025

075

05

09

D i s

e a s e -

f r e e s u r v i v a

l

0 606 12 24 3618 48

Months afer LSG operation

95 CI

Disease-ree survival

F983145983143983157983154983141 983090 Kaplan-Meier survival estimate plot Kaplan-Meier anal-ysis o patients subsequently requiring laparoscopic cholecystec-tomy afer LSG due to symptomatic cholelithiasis Te biliary complication-ree survival rates were 983097983097983090 (983097983093 CI 983097983092983092ndash983097983097983097)at 983089983090 months 983097983092983092 (983097983093 CI 983096983095983097ndash983097983095983092) at 983089983096 months and 983097983090983090

(983097983093 CI 983096983093983088ndash983097983094983088) at 983090983092 months

in RYGB patients suggests that concomitant cholecystectomy should be considered only in symptomatic gallstones [983090983094]

Te current statement o cholecystectomy and LSG hasnot been validated Tree options could be available Te1047297rst is the offer o laparoscopic cholecystectomy whethergallstones are identi1047297ed in the routine preoperative assess-ment even i they are asymptomatic (approach o Hamad)[983090983095] Tis prophylactic approach presupposes that naturalhistory o gallbladder disease in LSG patients is different thanthat in general population Te second is the simultaneousservice o cholecystectomy with LSG without preoperativeinvestigation (approach o Fobi) [983096] Te third is the treat-ment o the symptomatic patients only without preopera-tive screening (noninterventionist policy) [983095] However nostandard o care regarding the preoperative work-up or evenpostoperative care has been established In our practicepreoperative transabdominal ultrasound was obtained orall patients Furthermore the authorsrsquo philosophy was toperorm elective cholecystectomy in patients with preopera-tive evidence o gallbladder disease that were symptomaticHowever the act that eight o 983089983091983096 patients (983093983096) becamesymptomatic and soon developed complications warrants therecommendation or early cholecystectomy Furthermore a

signi1047297cant proportion o bariatric patients compared to thegeneral population developed complications in the absenceor not o preoperative gallstones As a consequence routineconcomitant cholecystectomy could be considered becausethe proportion o patients who developed complicationsespecially those with potentially signi1047297cant morbidities suchas choledocholithiasis cholangitis and pancreatitis are highand the time to develop complications is short and becauseo the real technical difficulties during subsequent cholecys-tectomy Nevertheless the ormulating policy regarding theinvestigation and management o cholelithiasis in LSG as apart o the routine assessment andcare o the bariatricpatientneeds to be urther evaluated

Regarding the management all cases except or one weresurgically managed From a technical point o view thecholecystectomy afer LSG is not technically straightorwarddue to trocar placement and body habitus Tus the positiono trocars made the perormance o cholecystectomy moredifficult than it would be expected Additional trocar was

inserted to improve access On the other hand the settingo cholecystectomy afer LSG has the advantage that thedifferent body habitus and the act that the patient had lostweight acilitated the cholecystectomy

Te use o ursodeoxycholic acid has been proposedas a preventive measure or the gallstone ormation Morespeci1047297cally Sugerman et al reported that the oral dose o 983094983088983088 mg ursodiol ollowing gastric bypass or 983094 months oreven until gallstone ormation was associated with decreasedrate o gallstone ormation [983090983096] Tese results are also incompliance with another study in vertical banded gastro-plasty and gastric banding which also supported that the rateo cholecystectomy was less requent in the group receiving

ursodiol compared to placebo group (983092983095 versus 983089983090) [983090983097]Mc et al in a meta-analysis concluded that rate o gallstoneormation was reduced by the protective use o ursodioltherapy [983091983088] However recent cost-effective analysis reportedthat even though the use o ursodeoxycholic acid lessened thecosts o concurrent cholecystectomy and reduced the hospitalstay along with logical cost raise in selective cholecystectomythe authors concluded that the prescription o ursodiol isunaffordable as an additional cost and proposed the nonuseo ursodiol afer bariatric surgery [983091983089]

Some limitations o our study should be acknowledgedTe retrospective nature o our study and the sample sizeshould be taken into account Additionally we did not

perorm postoperative ultrasound to evaluate the real rate o gallstone ormation afer LSG However we provide a serieswhich relies on prospectively collected data We also estimatetime-dependent gallbladder disease-ree survival rates Fur-thermore we describe the natural history o gallstones untilthe mid-term period Possibly these may change in the long-term evaluation

6 Conclusion

A signi1047297cant proportion o bariatric patients (983093983096) com-pared to the general population became symptomatic andsoon developed complications in the absence or not o preoperative gallstones afer LSG thus recommendation orearly cholecystectomy is warranted Routine concomitantcholecystectomy could be considered because the proportiono patients who developed complications especially thosewith potentially signi1047297cant morbidities are high and the timeto develop complications is short and because o the realtechnical difficulties during subsequent cholecystectomy

Conflict of Interests

Te authors have no con1047298ict o interests or 1047297nancial ties todisclose

7232019 468203



References

[983089] G W Dittrick J S Tompson D Campos D Bremers andD Sudan ldquoGallbladder pathology in morbid obesityrdquo Obesity Surgery vol 983089983093 no 983090 pp 983090983091983096ndash983090983092983090 983090983088983088983093

[983090] M Fobi H Lee D Igwe et al ldquoProphylactic cholecystectomy with gastric bypass operation incidence o gallbladder diseaserdquo

Obesity Surgery vol 983089983090 no 983091 pp 983091983093983088ndash983091983093983091 983090983088983088983090[983091] C I B de Oliveira E A Chaim and B B da Silva ldquoImpact o

rapid weight reduction on risk o cholelithiasis afer bariatricsurgeryrdquo Obesity Surgery vol 983089983091 no 983092 pp 983094983090983093ndash983094983090983096 983090983088983088983091

[983092] V K Li N Pulido P Fajnwaks S Szomstein R Rosenthal andP Martinez-Duartez ldquoPredictors o gallstone ormation aferbariatric surgery a multivariate analysis o risk actors com-paring gastric bypass gastric banding and sleeve gastrectomyrdquoSurgical Endoscopy vol 983090983091 no 983095 pp 983089983094983092983088ndash983089983094983092983092 983090983088983088983097

[983093] V K Li N Pulido P Fajnwaks et al ldquoErratum to ldquoPredictors o gallstone ormation afer bariatric surgery a multivariate analy-sis o risk actors comparing gastric bypass gastric banding andsleeve gastrectomyrdquordquo Surgical Endoscopy vol 983090983091 no 983095 p 983089983094983092983093983090983088983088983097

[983094] R M Kiewiet M F Durian M Van Leersum F L E M Hespand A C M Van Vliet ldquoGallstone ormation afer weight lossollowing gastric banding in morbidly obese Dutch patientsrdquoObesity Surgery vol 983089983094 no 983093 pp 983093983097983090ndash983093983097983094 983090983088983088983094

[983095] P E OrsquoBrien and J B Dixon ldquoA rational approach to cholelithi-asis in bariatric surgery its application to the laparoscopically placed adjustable gastric bandrdquo Archives of Surgery vol 983089983091983096 no983096 pp 983097983088983096ndash983097983089983090 983090983088983088983091

[983096] L Villegas B Schneider D Provost et al ldquoIs routine cholecys-tectomy required during laparoscopic gastric bypassrdquo Obesity Surgery vol 983089983092 no 983090 pp 983090983088983094ndash983090983089983089 983090983088983088983092

[983097] C Iglezias Brandao de Oliveira E Adami Chaim and B Bda Silva ldquoImpact o rapid weight reduction on risk o bariatric

surgeryrdquo Obesity Surgery vol 983089983091 no 983092 pp 983094983090983093ndash983094983090983096 983090983088983088983091[983089983088] M L Shiffman H J Sugerman J M Kellum W H Brewer

andE W Moore ldquoGallstoneormation afer rapid weight loss aprospective study in patients undergoing gastric bypass surgery or treatment o morbid obesityrdquo Te American Journal of Gastroenterology vol 983096983094 no 983096 pp 983089983088983088983088ndash983089983088983088983093 983089983097983097983089

[983089983089] A Dhabuwala R J Cannan and R S Stubbs ldquoImprovementin co-morbidities ollowing weight loss rom gastric bypasssurgeryrdquo Obesity Surgery vol 983089983088 no 983093 pp 983092983090983096ndash983092983091983093 983090983088983088983088

[983089983090] D D Portenier J P Grant H S Blackwood A Pryor R LMcMahon and E DeMaria ldquoExpectant management o theasymptomatic gallbladder at Roux-en-Y gastric bypassrdquo Surgery for Obesity and Related Diseases vol 983091 no 983092 pp 983092983095983094ndash983092983095983097 983090983088983088983095

[983089983091] D E Swartz and E L Felix ldquoElective cholecystectomy aferRoux-en-Y gastric bypass why should asymptomatic gallstonesbe treated differently in morbidly obese patientsrdquo Surgery for Obesity and Related Diseases vol 983089 no 983094 pp 983093983093983093ndash983093983094983088 983090983088983088983093

[983089983092] W Fuller J J Rasmussen J Ghosh and M R Ali ldquoIs routinecholecystectomy indicated or asymptomatic cholelithiasis inpatientsundergoing gastric bypassrdquo Obesity Surgery vol 983089983095 no983094 pp 983095983092983095ndash983095983093983089 983090983088983088983095

[983089983093] ldquoNIH conerence Gastrointestinal surgery or severe obesityConsensus Development Conerence Panelrdquo Annals of Internal Medicine vol 983089983089983093 no 983089983090 pp 983097983093983094ndash983097983094983089 983089983097983097983089

[983089983094] D Zacharoulis E Sioka D Papamargaritis et al ldquoIn1047298uence o the learning curve on saety and efficiency o laparoscopic sleevegastrectomyrdquo Obesity Surgery vol 983090983090 no 983091 pp 983092983089983089ndash983092983089983093 983090983088983089983090

[983089983095] V K M Li N Pulido P Martinez-Suartez et al ldquoSymptomaticgallstones afer sleeve gastrectomyrdquo Surgical Endoscopy vol 983090983091no 983089983089 pp 983090983092983096983096ndash983090983092983097983090 983090983088983088983097

[983089983096] H JSugerman L G Wole DA Sica andJ N Clore ldquoDiabetesandhypertension in severeobesity and effects o gastricbypass-induced weight lossrdquo Annals of Surgery vol 983090983091983095 no 983094 pp 983095983093983089ndash983095983093983096 983090983088983088983091

[983089983097] O N ucker S Szomstein and R J Rosenthal ldquoIndications orsleevegastrectomy as a primary procedure or weightloss in themorbidly obeserdquo Journal of Gastrointestinal Surgery vol 983089983090 no983092 pp 983094983094983090ndash983094983094983095 983090983088983088983096

[983090983088] E Arias P R Martınez V Ka Ming Li S Szomstein and RJ Rosenthal ldquoMid-term ollow-up afer sleeve gastrectomy as a1047297nal approach or morbid obesityrdquo Obesity Surgery vol 983089983097 no983093 pp 983093983092983092ndash983093983092983096 983090983088983088983097

[983090983089] P F Lalor O N ucker S Szomstein and R J RosenthalldquoComplications afer laparoscopic sleeve gastrectomyrdquo Surgery for Obesity and Related Diseases vol 983092 no 983089 pp 983091983091ndash983091983096 983090983088983088983096

[983090983090] B Uglioni B Wolnerhanssen Peters C Christoffel-CourtinB Kern and R Peterli ldquoMidterm results o primary vs sec-

ondary Laparoscopic Sleeve Gastrectomy (LSG) as an isolatedoperationrdquo Obesity Surgery vol 983089983097 no 983092 pp 983092983088983089ndash983092983088983094 983090983088983088983097

[983090983091] J A Patel N A Patel G L Piper D E Smith III G Malhotraand J J Colella ldquoPerioperative management o cholelithiasis inpatients presenting or laparoscopic Roux-en-Y gastric bypasshave we reached a consensusrdquo American Surgeon vol983095983093no 983094pp 983092983095983088ndash983092983095983094 983090983088983088983097

[983090983092] D F Ransohoff and W A Gracie ldquoreatment o gallstonesrdquo Annals of Internal Medicine vol 983089983089983097 no 983095 part 983089 pp 983094983088983094ndash983094983089983097983089983097983097983091

[983090983093] E J Gibney ldquoAsymptomatic gallstonesrdquo British Journal of Sur- gery vol 983095983095 no 983092 pp 983091983094983096ndash983091983095983090 983089983097983097983088

[983090983094] M Worni U Guller A Shah et al ldquoCholecystectomy con-comitant with laparoscopic gastric bypass a trend analysis o

the nationwide inpatient sample rom 983090983088983088983089 to 983090983088983088983096rdquo Obesity Surgery vol 983090983090 no 983090 pp 983090983090983088ndash983090983090983097 983090983088983089983090

[983090983095] G G Hamad S Ikramuddin W F Gourash and P R Schau-er ldquoElective cholecystectomy during laparoscopic Roux-En-Ygastric bypass is it worth the waitrdquo Obesity Surgery vol 983089983091 no983089 pp 983095983094ndash983096983089 983090983088983088983091

[983090983096] H JSugerman W H Brewer M L Shiffman et al ldquoA multicen-ter placebo-controlled randomized double-blind prospectivetrial o prophylactic ursodiol or the prevention o gallstoneormation ollowing gastric-bypass-induced rapid weight lossrdquo American Journal of Surgery vol 983089983094983097 no 983089 pp 983097983089ndash983097983095 983089983097983097983093

[983090983097] K Miller E Hell B Lang and E Lengauer ldquoGallstone or-mation prophylaxis afer gastric restrictive procedures orweight loss a randomized double-blind placebo-controlledtrialrdquo Annals of Surgery vol 983090983091983096 no 983093 pp 983094983097983095ndash983095983088983090 983090983088983088983091

[983091983088] U MC M C alingdan-e W Z Espinosa M L Daez andJ P Ong ldquoUrsodeoxycholic acid the prevention o gallstoneormation afer surgery a meta-analysisrdquo Obesity Surgery vol983089983096 no 983089983090 pp 983089983093983091983090ndash983089983093983091983096 983090983088983088983096

[983091983089] JBenarroch-Gampel DR Lairson C A Boyd K M SheffieldV Ho and S Riall ldquoCost-effectiveness analysis o cholecys-tectomy during Roux-en-Y gastric bypass or morbid obesityrdquoSurgery vol 983089983093983090 no 983091 pp 983091983094983091ndash983091983095983093 983090983088983089983090

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7232019 468203



2 Materials and Methods

Te prospectively collected database o the morbidly obesepatients who underwent LSG between August 983090983088983088983094 andDecember 983090983088983089983089 in our academic centrewas reviewed Medicalrecords and histopathologic data were also reviewed

Eligibility or surgery was de1047297ned according to the 983089983097983097983089NIH consensus criteria or bariatric surgery [983089983093] Exclusioncriteria were heavy sweaters patients with suspected gastroe-sophageal re1047298ux disease as suggested by severe symptomsand endoscopic 1047297ndings patients with psychiatric disordersand addiction to either drugs or alcohol and patients withhigh operative risk Te operative technique has been previ-ously described [983089983094]

ransabdominal ultrasound (US) was perormed in allpatients preoperatively to rule out gallstones or sludgeAccording to the protocol patients with positive 1047297ndingson ultrasound were counselled or concomitant laparoscopiccholecystectomy Patients in the preoperative appointmentswere inormed o the evidence o cholelithiasis and the

potential risks and bene1047297ts o the arrangement o twoprocedures Te authors adopted the elective approachmeaning that simultaneous cholecystectomy was perormedin symptomatic patients Laparoscopic cholecystectomy wasperormed at the beginning o the procedure with theplacement o an extra trocar Postoperative prescription o ursodeoxycholic acid was not practiced in our managementprotocol

Postoperative ollow-up was perormed at 983090 weeks 983089month 983091 months 983094 months and 983089 year and then yearly post-operatively Patients were interviewed in ollow-up appoint-ments and complications related to gallbladder disease wererecorded Patients in this series were ollowed up or at least

six months postoperatively

3 Statistical Analysis

Statistical analyses were perormed using the sofware SPSS983089983097 (SPSS Inc Chicago IL USA) and Stata 983089983089 (StataCorp983090983088983088983097 College Station X USA) Quantitative variables werepresented as means plusmn standard deviation or median withinterquartile range or range Qualitative data were presentedas absolute requencies and proportions Prevalence cumula-tive incidence and corresponding con1047297dence interval (983097983093CI) were calculated Incidence per each interval was also

calculated using lie tables based on the actuarial methodKaplan-Meier estimator was used to estimate survival ratesand the corresponding 983097983093 con1047297dence intervals (type log-log) afer LSG operation providing a Kaplan-Meier survivalestimate plot

4 Results

During the entire study period one hundred sixty-1047297veconsecutive patients underwent LSG Gallbladder ollow-updata were obtained or 983089983093983088 patients (983097983090983094) Te medianage was 983092983088 years (range 983089983096ndash983094983090) and the median BMI was983092983094983089 (range 983091983093ndash983094983089) Patients in this study were predominantly

emale (983095983097) Te median ollow-up was 983090983094 months (range983089ndash983094983090)

Prior cholecystectomy was perormed in 983089983090 patients (983096)Preoperatively positive gallbladder disease was identi1047297edin 983091983090 patients (983090983091983090) In detail pathologic 1047297ndings weregallstones in 983090983097 patients and sludge in 983091 patients Tereore

preoperative evidence o gallbladder disease was shown in983091983089983090

Simultaneous cholecystectomy was perormed in 983097 o 983091983090patients who had preoperative gallstones and were symp-tomatic Eight operations were completed laparoscopicallywhile one open cholecystectomy was perormed due tomultiple adhesions rom previous laparotomy Neither peri-operative or postoperative complications occurred

Tus 983090983091 patients lef the operating room with intactgallstones O these three patients required cholecystectomy eventually Tese patients presented at 983097 983090983091 and 983089983093 monthsafer LSG with acute cholecystitis biliary colic and pancre-atitis respectively Te postoperative period was uneventul

o the contrary negative ultrasound 1047297ndings were observedin 983089983088983094 patientsFive patients o this group with no evidence o gallstone disease preoperatively presented with complicatedgallstones Tree patients presented with acute cholecystitisand two patients suffered rom choledocholithiasis Tusincidence o complicated gallstones postoperatively was esti-mated at 983093983096 (Figure 983089)

All patients were diagnosed at intervals speci1047297ed inable 983089 No late complications were noted All patientsexcept or one were managed with surgical interventionConsequent- ly post-LSG cholecystectomy was perormedin 983095 patients whether or not preoperative gallstones weredetected otal cumulative incidence o cholecystectomy was

983092983095 (983097983093 CI 983089983091ndash983096983089) Kaplan-Meier analysis detected thatthe biliary complication-ree survival rates were 983097983097983090 (983097983093CI 983097983092983092ndash983097983097983097) at 983089983090 months 983097983092983092 (983097983093 CI 983096983095983097ndash983097983095983092)at 983089983096 months and 983097983090983090 (983097983093 CI 983096983093983088ndash983097983094983088) at 983090983092 monthsafer LSG (Figure 983090)

5 Discussion

Tere is a paucity o data regarding preoperative evidenceo gallstones incidence o cholelithiasis with concomitantcomplications and gallstone ormation afer LSG In theliterature prior cholecystectomy in patients scheduled or

bariatric surgery was anticipated at percentages o 983089983089ndash983090983091[983089983091] In particular or LSG Li et al reported a percentage o 983091983090983095983097 [983089983095] Our results are similar with these studies since983090983091983090 o ourpatients were de1047297nedwith preoperative gallblad-der disease and previous cholecystectomy was perormed in983096 o our patients

In our series one patient experienced complicated gall-stones during the 1047297rst postoperative year while the othercases appeared during the second postoperative year Tatimplies what happened during the period o rapidweight lossOverall no patient underwent cholecystectomy earlier than 983097months or later than 983090983091 months afer LSG Tat indicates thepost-LSG effect regarding gallstones It seems that this effect

7232019 468203



Study population




Symptomatic

Symptomatic

Intact gallstones


n 12 (8)N 32 (232)

N 106 (768)

N 9

N 23

N 3

N 5

N 8 (58)



Interval afer

LSG (months)

Number o patients


Number o patients





to risk 983075






(983097983093 CI)

983088 983089983091983096 983088 983088 983089983091983096 983088 983088983088

983095983089983091983096

983093983089(983089983092ndash983096983095)

lt983091 983089983091983096 983089983089 983088 983089983091983090983093 983088 983088983088

983091 to lt983094 983089983090983095 983089983089 983088 983089983090983089983093 983088 983088983088

983094 to lt983089983090 983089983089983094 983097 983089 983089983089983089983093 983089 983088983097

983089983090 to lt983090983092 983089983088983094 983090983095 983095 983097983090983093 983094 983094983093








7232019 468203



0

1

025

075

05

09

D i s

e a s e -


l

0 606 12 24 3618 48


95 CI













6 Conclusion




7232019 468203



References




































7232019 468203



httpwwwhindawicom

7232019 468203



Study population




Symptomatic

Symptomatic

Intact gallstones


n 12 (8)N 32 (232)

N 106 (768)

N 9

N 23

N 3

N 5

N 8 (58)



Interval afer

LSG (months)

Number o patients


Number o patients





to risk 983075






(983097983093 CI)

983088 983089983091983096 983088 983088 983089983091983096 983088 983088983088

983095983089983091983096

983093983089(983089983092ndash983096983095)

lt983091 983089983091983096 983089983089 983088 983089983091983090983093 983088 983088983088

983091 to lt983094 983089983090983095 983089983089 983088 983089983090983089983093 983088 983088983088

983094 to lt983089983090 983089983089983094 983097 983089 983089983089983089983093 983089 983088983097

983089983090 to lt983090983092 983089983088983094 983090983095 983095 983097983090983093 983094 983094983093








7232019 468203



0

1

025

075

05

09

D i s

e a s e -


l

0 606 12 24 3618 48


95 CI













6 Conclusion




7232019 468203



References




































7232019 468203



httpwwwhindawicom

7232019 468203



0

1

025

075

05

09

D i s

e a s e -


l

0 606 12 24 3618 48


95 CI













6 Conclusion




7232019 468203



References




































7232019 468203



httpwwwhindawicom

7232019 468203



References




































7232019 468203



httpwwwhindawicom

7232019 468203



httpwwwhindawicom

468203

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