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.

The Type of Bariatric Surgery Impacts the Risk of Acute Pancreatitis: A Nationwide Study

“…RYGB and VSG led to a steep rise in AP rates in the first 6 months after surgery, ranging between 0.17% and 0.21%, but not after HR. These rates are slightly lower than the previously reported range of 0.2–1.04%, probably because of different designs, small sample sizes, and variable follow up in prior studies 22 , 23 , 25 , 26 , 28 – 33 . VSG led to a higher pre- to post-surgery AP risk when compared to RYGB and HR after adjusting for multiple covariates.…”

EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones

“…Based on such estimates, concurrent prophylactic cholecystectomy during RYGB has previously been recommended, based on the rationale that the conversion rate to open surgery is not increased, neither is operative time nor hospital stay [173]. Further studies, however, have suggested that most patients remain asymptomatic [156,157,160,168,169,[174][175][176][177][178] and never require further interventions following RYGB. Thus, concurrent (prophylactic) cholecystectomy during laparoscopic bypass surgery is no longer routinely performed [168,169,[174][175][176]179].…”

Key Points for Cholelithiasis and Gallstone Ileus Prevention Following Biliointestinal Bypass

“…The rate of weight loss is also considered an independent prognostic factor in gallstone formation [33] and is suggested to be directly correlated with cholecystectomy frequency [31]. Prophylactic cholecystectomy, during bariatric surgery, is not considered beneficial nowadays because it is associated with higher early complications rate [34,35], longer length of hospitalization [35], and longer operative time [36,37]. In a prospective study with 1398 patients who received bariatric surgery, only 7.8% of patients developed symptomatic gallbladder disease within 4 years [31].…”