Gallbladder Management During LRYGB Surgery

Abstract & Commentary

By Richard M. Peterson, MD, MPH, Clinical Instructor of Surgery, Department of Surgery, USC. Dr. Peterson reports no financial relationships relevant to this field of study.

Synopsis: The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low.

Source: Patel KR, et al. Gallbladder management during laparoscopic Roux-en-Y gastric bypass surgery: Routine preoperative screening for gallstones and postoperative prophylactic medical treatment are not necessary. Am Surg. 2006;72:857-861.

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.

In the field of bariatric surgery, the approach to dealing with gallstones is varied and controversial. Patel and colleagues reviewed their experience at UCLA and used their conclusions to propose a means for a more selective, and possibly more cost-effective, approach to gallbladder disease as it relates to the bariatric surgery patient and surgeon. The approaches that are utilized range from no evaluation of gallbladder symptomotology, simple history taking, ultrasound evaluation, concomitant cholecystectomy at time of bypass surgery for asymptomatic and acalculous gallbladder disease, and cholecystectomy for asymptomatic and symptomatic gallstone disease. Additionally, those not performing pre-emptive cholecystectomy may choose to use an agent such as Ursodeoxycholic acid (ursodiol) in order to reduce stone formation. Patel et al found that the studies evaluating the use of ursodiol discovered a low rate of biliary disease in compliant patients. However, contrary to that, those studies highlighting poor compliance cited rates as high as 28% stone formation.

In the series by Patel et al, 193 patients were included in their evaluation from January 2003 to January 2005. Only 12 patients (6%) required cholecystectomy. The reasons for surgery were acute cholecystitis (5 patients, 2.5%), biliary colic (5 patients, 2.5%), and gallstone pancreatitis (2 patients, 1%). In their analysis and review they found that the incidence of patients requiring cholecystectomy following laparoscopic gastric bypass was similar to the studies where patients were treated with bile salts and were poorly compliant. The rate of symptomatic gallbladder disease was essentially the same.

Patel et al point out that the addition of a cholecystectomy in this patient population can add operative time, increase length of stay, and add to the complexity of the operation. "Routine prophylactic cholecystectomy in this group can be technically demanding secondary to body habits, hepatomegaly, and the large amount of intra-abdominal fat, potentially increasing the incidence of complications." This addition, then, may be putting patients at increased risk for a problem that may never develop.

In our series of laparoscopic gastric bypass procedures at USC, we employ a similar approach to evaluation and postoperative treatment of the gallbladder as Patel et al. We have seen a similar low rate of symptomatic gallbladder disease, necessitating surgical intervention. Additionally, we do not routinely utilize bile salts in our patients for gallstone formation prophylaxis. I would agree with Patel et al's conclusions that routine preoperative screening or medical prophylaxis may not be necessary, but further studies to support this and make the information more generalizable are needed.