Is Prophylactic Cholecystectomy Useful in Obese Patients Undergoing Gastric Bypass?

Background: Obesity constitutes a clear risk factor for cholelithiasis, especially if it is associated with a rapid weight loss, as is the case of patients following bariatric surgery. Prophylactic cholecystectomy is indicated in biliopancreatic diversions due to the high incidence of postoperative cholelithiasis. However, there is no agreement on gastric bypass. This study was conducted to establish the incidence of cholecystopathy demonstrated by histology and to assess the indication for prophylactic cholecystectomy in a systematic way on patients undergoing gastric bypass. Methods: The evaluation is based on 100 consecutive morbidly obese patients undergoing open gastric bypass surgery with concomitant prophylactic cholecystectomy. Variables studied were: age, gender, body mass index, preoperative ultrasound and the anatomopathologic analysis of the gallbladder that was removed. Results: Of the 100 patients who took part in the trial, 11 had had a previous cholecystectomy. Among the 89 patients remaining, preoperative ultrasound diagnosis of cholelithiasis was 16.8%, and the actual postoperative incidence was 24.7%. Other histologic alterations were: cholesterolosis 46.1%, chronic unspecified cholecystitis 22.5%, and granulomatous cholecystitis 1.1%. The total incidence of cholecystopathy was 93.3%. The morbi-mortality related to cholecystectomy was 0%. Conclusions: Based on these results and given the absence of morbidity, we believe that prophylactic cholecystectomy is suitable during open gastric bypass.     

Routine cholecystectomy is not mandatory during morbid obesity surgery

BACKGROUND: Controversy exists concerning the utility of routine cholecystectomy during bariatric surgery. We report our series of bariatric surgical procedures at our institution without concurrent cholecystectomy. METHODS: From October 2003 to August 2005, 621 morbidly obese patients underwent a weight loss operation. Preoperatively, each patient had undergone abdominal ultrasound (AUS) to evaluate for abnormal gallbladder findings. Patients with previous cholecystectomy were excluded. Symptomatic patients with AUS findings consistent with gallbladder disease underwent concomitant cholecystectomy and bariatric surgery. Asymptomatic patients, despite AUS findings, did not undergo cholecystectomy with their bariatric operation. A comparison between the preoperative AUS-positive and AUS-negative, asymptomatic patients after bariatric surgery was performed. RESULTS: Of the 621 patients who underwent bariatric surgery, 170 (27%) had undergone previous cholecystectomy and were excluded. Of the remaining 451 patients, 17 with positive AUS findings and symptoms underwent cholecystectomy during bariatric surgery. The range of follow-up was 4-25 months. Of the 451 patients, 324 were asymptomatic and had negative AUS findings and 102 were asymptomatic and had positive AUS findings for gallbladder abnormalities. Postoperatively, 29 asymptomatic/AUS-negative patients (9%) developed symptoms and had positive AUS findings. Nine asymptomatic patients with AUS positive findings (9%) developed symptoms. Finally, 38 patients (8.4%) went on to undergo elective cholecystectomy. These 2 groups were not signficantly different statistically. CONCLUSIONS: In this study, the development of symptomatic/AUS-positive gallbladder abnormalities was low after obesity surgery, suggesting that mandatory cholecystectomy is not required at bariatric surgery.     

Routine gallbladder screening not necessary in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Management of the gallbladder in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) is controversial. We reviewed our experience in patients undergoing LRYGBP without routine gallbladder screening. METHODS: The data of 644 patients who underwent LRYGBP at our institution were analyzed. Preoperative ultrasonography was routinely obtained early in our series and selectively thereafter in patients with suspected symptomatic biliary disease. Cholecystectomy at LRYGBP was performed in symptomatic patients with positive ultrasound findings. Postoperatively, patients with intact gallbladders were prescribed ursodiol for 6 months. RESULTS: Of the 644 patients, 155 (24%) had history of cholecystectomy. A total of 104 patients underwent preoperative ultrasonography. Of the 104 patients, 20 had positive ultrasound findings and symptoms consistent with biliary disease and underwent concomitant cholecystectomy. Twelve patients had positive ultrasound findings and no biliary symptoms and did not undergo cholecystectomy. At a mean follow-up of 26.4 months, only 1 (8.3%) of the 12 patients had required cholecystectomy. Of the 104 patients, 72 had negative ultrasound findings. At a mean follow-up of 21.2 months, 5 of them (6.9%) had required cholecystectomy. The remaining 385 patients did not undergo any gallbladder screening. At a mean follow-up of 14 months, 32 (8.3%) of 385 patients had required cholecystectomy. Compliance with ursodiol for >4 months was only 39%. A time-to-event analysis did not reveal a significant difference in the cholecystectomy rate between asymptomatic patients with preoperative gallbladder screening and patients with no screening. CONCLUSION: Omission of gallbladder screening in asymptomatic patients undergoing LRYGBP is a reasonable approach that spares the patient a potentially unnecessary procedure with all its associated risks.     

Gallbladder disease in patients undergoing laparoscopic adjustable gastric banding

BACKGROUND: Patients undergoing weight loss surgery may have an increased incidence of subsequent gallbladder disease. Management options include treatment of symptomatic disease only, preoperative ultrasonography and concurrent cholecystectomy in presence of stones, routine concurrent cholecystectomy, and choleretic therapy postoperatively. Here we report our approach to patients undergoing laparoscopic adjustable gastric banding (LAGB) and subsequent outcomes. METHODS: A retrospective review of all consecutive patients undergoing LAGB at our institution was performed. Only symptomatic patients were preoperatively evaluated for cholelithiasis and underwent concurrent cholecystectomy. No choleretics were used postoperatively. Weight loss data were collected when patients returned for band adjustments. All band adjustments were patient-driven and performed under fluoroscopic guidance. RESULTS: Between November 2001 and July 2004, 324 patients underwent LAGB. Mean starting weight was 143.6 kg (range, 92.3 to 250.5 kg), and mean body mass index was 50.5 kg/m(2) (range, 35.6 to 80 kg/m(2)). Fifty-six patients had undergone previous cholecystectomy, and 7 other patients underwent concurrent cholecystectomy. Average follow-up was 12.5 months (range, 1.3 to 31 months). Absolute weight loss for all patients ranged from - 2.7 to 102.3 kg. Of the remaining patients, 3 underwent subsequent uneventful laparoscopic cholecystectomy for symptomatic cholelithiasis. No independent predictors for post-LAGB gallbladder disease were identified. CONCLUSION: Despite significant weight loss, few patients require cholecystectomy after LAGB. Routine preoperative ultrasonography, empiric cholecystectomy, and choleretic therapy are of questionable value in LAGB patients. Considering the magnitude of weight loss in our patients, empiric cholecystectomy for all bariatric procedures may merit further investigation.     

Prophylactic Cholecystectomy with Open Gastric Bypass Operation

Background: There has been controversy regarding prophylactic cholecystectomy with Roux-en Y gastric bypass. The results reported in open cases showed no significant increase in morbidity by the addition of cholecystectomy. A series of open cases were reviewed to evaluate the propriety of prophylactic cholecystectomy. Method: The records of 141 patients undergoing cholecystectomy during open gastric bypass were reviewed, documenting age, ultrasound findings and pathology. Results: Of the 141 cases analyzed, the incidence of gall-bladder pathology was 80%. 24 (17%) of the 141 patients were noted to have gallstones on preoperative ultrasound examination, and 3 (2%) showed polyps. 9 patients (6%) had gallstones at surgery with normal ultrasound. Cholesterolosis was present in 52 cases (37%) and chronic cholecystitis in 25 cases (18%). Conclusion: In view of the high incidence of gall-bladder disease (80%) already present in morbidity obese patients undergoing gastric bypass and the lack of significant morbidity in open surgery with prophylactic cholecystectomy, the addition of prophylactic cholecystectomy appears appropriate.     

Systematic review of management of gallbladder disease in patients undergoing minimally invasive bariatric surgery

The introduction and subsequent widespread adaptation of minimally invasive approaches for bariatric surgery have not only changed the outcomes of bariatric surgery but also called into question the management of co-morbid surgical conditions, in particular gallbladder disease. The American Society for Metabolic and Bariatric Surgery Foregut Committee performed a systematic review of the published literature from 1995–2018 on management of gallbladder disease in patients undergoing bariatric surgery. The papers reviewed generated the following results. (1) Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended. (2) In symptomatic patients who are undergoing bariatric surgery, concomitant cholecystectomy is acceptable and safe. (3) Ursodeoxycholic acid may be considered for gallstone formation prophylaxis during the period of rapid weight loss. (4) Routine preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients. In the era of minimally invasive surgery, the management of gallbladder disease in patients undergoing bariatric surgery continues to evolve.     

Role of ultrasound screening for gallbladder disease in pretransplant patients

There is no uniform data regarding prophylactic cholecystectomy in patients undergoing renal transplantation with gallbladder disease. Data analyses suggest that posttransplant patients on cyclosporine have a higher incidence of gallbladder calcifications compared with nonimmunosuppressed patients. Laparoscopic cholecystectomy is a relatively safe procedure in modern-day surgery. Taking these facts into consideration, we attempted to compare risks and complications associated with gallbladder disease and eventual cholecystectomy in pretransplant versus posttransplant patients. Between June 1999 and December 2005, 210 renal transplants were performed at our institution. One hundred four patients who had transplants before April 2003 were not screened for gallbladder disease and nine of these patients developed gallbladder disease. These patients form our control group. One hundred six patients who had transplants after April 2003 had pretransplant screening for gallbladder disease and 11 patients were identified with gallbladder disease. These patients form our study group. Nine patients who developed gallbladder disease after renal transplant underwent laparoscopic cholecystectomy with three resulting morbidities (33%), two graft losses (22%), and one mortality (11%). There was one mortality (11%) in this group. One patient in the study group died of acute gallstone pancreatitis. Of the 11 patients who were found to have gallbladder disease on screening, nine patients underwent laparoscopic cholecystectomy with one morbidity and no mortality or graft loss. Given the relative rarity of the critical events in this study (morbidity, mortality, and graft loss), the definitive statistical value of prescreening for gallbladder disease cannot be established. However, our results are suggestive of clinical value and thus we tentatively recommend ultrasound screening for gallbladder disease for all pretransplant patients and laparoscopic cholecystectomy for those identified to have gallbladder disease.     

Gallstone Formation after Weight Loss following Gastric Banding in Morbidly Obese Dutch Patients

Background: Obesity is a risk factor for the development of gallstones. Rapid weight loss may be an even stronger risk factor. We retrospectively assessed the prevalence and risk factors of gallstone formation after adjustable gastric banding (AGB) in a Dutch population. Methods: All patients who underwent AGB between Jan 1992 and Dec 2000 for morbid obesity were invited to take part in this study. Transabdominal ultrasonography of the gallbladder was performed in those patients without a prior history of cholecystectomy (Group A). Additionally, 45 morbidly obese patients underwent ultrasonography of the gallbladder before weight reduction surgery (Group B). Results: 120 patients were enrolled in the study (Group A). Prior history of cholecystectomy was present in 21 patients: 16 before and 5 after AGB. Ultrasonography was performed in 98 patients: gallstones were present in 26 (26.5%). On multivariate analysis, neither preoperative weight, nor maximum weight loss, nor the interval between operation and the postoperative ultrasonography were determinants of the risk for developing gallstone disease. Prevalence of gallstones was significantly lower in the morbidly obese patients who had not yet undergone weight reduction surgery (Group B). Conclusions: Rapid weight loss induced by AGB, is an important risk factor for the development of gallstones. No additional determinants were found. Every morbidly obese patient undergoing bariatric surgery must be considered at risk for developing gallstone disease.     

Is Routine Cholecystectomy Necessary at the Time of Roux-en-Y Gastric Bypass?

Background: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, as occurs after Roux-en-Y gastric bypass (RYGBP) may also increase gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult following RYGBP. Controversy still exists whether prophylactic cholecystectomy is indicated at the time of RYGBP. Methods: Retrospective analysis was performed on a database of 535 patients who underwent RYGBP for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid was not prescribed following surgery. Results: 8% of patients had had cholecystectomy before the RYGBP. 75 of 492 patients (15%) were found to have gallstones at RYGBP, and cholecystectomy was performed at the same time. 3 of these patients had bile leaks but only 1 required further intervention (percutaneous transhepatic drainage for 3 weeks). Following RYGBP, 14 patients (3%) have required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Symptomatic gallbladder disease after RYGBP has not been frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of RYGBP. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of an RYGBP operation, concomitant cholecystectomy should be considered.     

Impact of Rapid Weight Reduction on Risk of Cholelithiasis after Bariatric Surgery

Background: Obesity alone and rapid weight loss induced by bariatric surgery are recognized risk factors for the development of cholelithiasis. The decision to perform prophylactic cholecystectomy at the time of bariatric operations remains controversial and at the surgeon's discretion. Methods: From June 1998 to April 2001, 103 patients underwent Roux-en-Y gastric bypass (RYGBP) in Hospital das Clinicas/Unicamp (SP). 88 of these 103 patients had their preoperative ultrasonography of gallbladder recovered. 19 of these 88 patients showed gallstones before RYGBP, and the remaining 69 did not have ultrasonographic evidence of cholelithiasis. 36 of these 69 patients were followed with ultrasonography during the 12 postoperative months. They were divided into 2 groups: those who formed gallstones (n=19) and those who did not (n=17), to evaluate the importance of sex, age, preoperative BMI, preoperative excess weight and postoperative percent excess weight loss as risk factors in the gallstone formation. Results: Preoperative incidence of cholelithiasis in the 88 operated patients was 21.6% and postoperative incidence in the 36 patients followed by ultrasonograph was 52.8%. There was no statistical evidence that postoperative gallstone formation is associated significantly with the variables studied. Conclusion: This study confirms the high correlation between morbid obesity, rapid weight loss and gallbladder disease. Predictive risk factors for gallstone formation were not found.     

The porcelain gallbladder-laparoscopic approach

A long time porcelain gallbladder was considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer. From 12,000 patients underwent cholecystectomy in First Surgical Clinic of Iasi, 5 (0.04%) patients had porcelain gallbladder. All patients underwent ultrasound examen. Patients with porcelain gallbladder were classified as Type I to II according to preoperative ultrasound findings: three cases with porcelain gallbladder type I and two cases with porcelain gallbladder type II (in one case we found associated gallbladder carcinoma). We describe a three cases with porcelain gallbladder type I (complete calcification of gallbladder wall) treated by laparoscopic approach. Laparoscopic cholecystectomy was difficult because of adhesions and problems with grasping the thick gallbladder wall, but the postoperative course was uneventful. The histopathologic result of the specimen established the diagnosis of porcelain gallbladder type I and no cancer in the calcified wall of the gallbladder. We conclude based on cases presented and the literature review, although there is a high conversion rate, that patients with a type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.     

Coexistence of gallbladder disease and morbid obesity

To further investigate the relationship between gallbladder disease and morbid obesity, 92 morbidly obese patients underwent routine cholecystectomy at the time of their bariatric procedures. The preoperative ultrasonographic findings were positive in only 20 patients. Of the 92 patients who underwent cholecystectomy, 87 (95 percent) had pathologic evidence of gallbladder disease. This included cholecystitis, cholesterolosis, cholelithiasis, or some combination of the three. The incidence of postoperative cholecystitis, the technical difficulty of reoperation, the unnecessary expense and exposure to a second hospitalization and a second operation are all completely eliminated when routine cholecystectomy is performed in concert with elective bariatric procedures.     

Intraoperative ultrasonography evaluation of the gallbladder in morbidly obese patients.

Intraoperative ultrasound evaluation of the gallbladder was performed in 55 morbidly obese patients undergoing gastric bariatric surgery. Cholecystectomy was performed in the presence of any physical or ultrasonographic abnormality. Eighteen patients (33%) had cholecystectomy. Nine patients had palpable gallbladder disease confirmed by ultrasound. Nine patients had abnormalities detected by ultrasonography only. There was no false-negative ultrasonographic exam compared to physical exam. Pathologically, all specimens but one showed evidence of disease, thus there was a false-positive incidence of 1.8%. None of the 37 patients with normal physical and ultrasonographic examination have returned with gallbladder disease following the bariatric surgery. Intraoperative ultrasonography shows promise in detecting nonpalpable gallbladder disease and decreasing the incidence of delayed cholecystectomy.     

A rational approach to cholelithiasis in bariatric surgery: its application to the laparoscopically placed adjustable gastric band

BACKGROUND: Gallstones are more common in the obese population and may be formed during rapid weight loss. A rational approach to the management of the gallbladder should be incorporated into bariatric surgical practice. It has been recommended that patients undergoing Roux-en-Y gastric bypass have routine cholecystectomy regardless of gallstone status. We analyzed the outcomes of a noninterventionist policy on 1000 patients undergoing laparoscopic adjustable gastric banding. HYPOTHESIS: Patients scheduled for adjustable gastric banding should undergo investigation for and treatment of gallbladder disease regardless of symptoms. METHODS: Patients were screened preoperatively for symptoms of gallstones. Ultrasound examination was performed only in those with symptoms and, if stones were present, cholecystectomy was performed with gastric banding. The remaining patients were followed up clinically and outcomes were noted. RESULTS: A total of 1000 patients were followed up for 12 to 96 months, a total of approximately 3500 patient-years. Cholecystectomy was performed in 181 patients before and 10 at gastric banding surgery. Of the 809 patients at risk, 55 (6.8%) presented with symptomatic disease during follow-up and proceeded to undergo elective cholecystectomy without complications from the disease or the treatment. CONCLUSIONS: The incidence of cholecystectomy after gastric banding surgery was not different from the expected rate for a nonsurgical obese population. In contrast, after Roux-en-Y gastric bypass, a median of 40% of patients form stones in the postoperative period, and prophylactic cholecystectomy may be justified. Our data indicate that a noninterventionist approach to the gallbladder is appropriate for patients undergoing adjustable gastric banding surgery.     

Elective cholecystectomy after Roux-en-Y gastric bypass: why should asymptomatic gallstones be treated differently in morbidly obese patients?

BACKGROUND: Gallbladder management in bariatric surgery varies. Some surgeons perform routine cholecystectomy with bariatric surgery, and others selectively base that decision on routine preoperative ultrasound findings. Both approaches treat bariatric patients differently than the normal-weight population in whom cholecystectomy is not performed in asymptomatic patients. We hypothesized that it is possible to apply the commonly used indications for cholecystectomy in the nonobese population safely to a Roux-en-Y gastric bypass cohort. METHODS: Data were collected prospectively and retrospectively on consecutive patients at our center undergoing Roux-en-Y gastric bypass from April 1, 2003 to March 31, 2004. Asymptomatic patients underwent neither preoperative gallbladder ultrasonography nor concomitant cholecystectomy. Age, body mass index, gender, length of follow-up, compliance to ursodiol therapy for 6 months, need for subsequent cholecystectomy, complications, and pathologic diagnoses were recorded. RESULTS: A total of 692 primary Roux-en-Y gastric bypass procedures were performed, of which 661 (95.5%) were completed laparoscopically. Complete data were collected on 417 patients (60.3%). A total of 98 patients (23.5%) had had prior or concomitant cholecystectomy and were excluded from additional study. Of the remaining 319 patients, 47 (14.7%) required subsequent cholecystectomy and 272 (85.3%) did not. The risk of subsequent cholecystectomy correlated inversely with the duration of ursodiol prophylaxis. All pathologic specimens had cholecystitis but gallstones were present in only 48.8%. Two complications (abscess and port-site bleed) occurred, but no common duct stones developed and no patient died. The mean follow-up was 7.5 months (range 13-25). CONCLUSION: Asymptomatic gallstones in bariatric patients may be treated safely with secondary cholecystectomy. After a 6-month regimen of ursodiol prophylaxis, 14.7% will require subsequent cholecystectomy. Asymptomatic gallstones in the bariatric patient may be safely managed identically to those in the nonobese population.     

Significance of wall thickness in symptomatic gallbladder disease.

One hundred cases of patients who underwent urgent cholecystectomy after presenting with symptoms of acute or subacute gallbladder disease were retrospectively reviewed. Sixty patients had pathologically proved acute cholecystitis, and 40 had chronic cholecystitis alone. One patient had an incidental gallbladder carcinoma, and four had global gangrene of the gallbladder. Focal ischemia, transmural hemorrhage, or focal necrosis (indicating more severe disease) was present in 19 patients. Fifty-four percent of patients had thin-walled gallbladders. Among patients with more severe acute disease, 56% had thin walls. Conversely, 24% of thin-walled gallbladders and 22% of thick-walled gallbladders had evidence of focal necrosis or gangrene. We conclude that gallbladder wall thickness, although demonstrable on preoperative ultrasound examination in all patients, does not correlate directly with severity of disease or pathologic findings.     

Routine cholecystectomy during laparoscopic biliopancreatic diversion with duodenal switch is not necessary.

BACKGROUND: Similar to gastric bypass patients, a regimen of ursodeoxycholic acid in the immediate postoperative period might obviate the need for routine cholecystectomy. Routine cholecystectomy has been recommended for patients who undergo biliopancreatic diversion (BPD), because of the high prevalence of gallstones in the obese patient and presumed development of gallstones postoperatively. We have considered elective cholecystectomy only if gallbladder disease were present. The aim of this study was to assess the need for cholecystectomy in the postoperative period in such patients. METHODS: In this retrospective study, the data from 219 patients who had undergone BPD with duodenal switch (BPD/DS), from January 1999 to January 2003, were analyzed. We performed a 150-cm alimentary limb and 100-cm common channel BPD/DS. The patients received 600 mg ursodeoxycholic acid orally daily for 6 months. The following data were recorded: demographics, medical history, medication, weight loss, diagnostic evaluation, and operative and pathologic data. RESULTS: Of the 219 patients who underwent surgery, 59 were men (26.9%) and 160 women were (73.1%) (mean age 41.7 years, mean body mass index 55.7 kg/m(2)). The mean follow-up was 30 months (range 12-48). Of the 219 patients, 57 (19.6%) underwent cholecystectomy: 28 (12.7%) preoperatively, 10 (4.5%) simultaneously, and 19 (8.7%) postoperatively. Simultaneous cholecystectomy was performed when the patient had a history of colic episodes with gallbladder disease (disclosed by preoperative ultrasonography). The postoperative cholecystectomy pathology reports showed cholecystitis in only 7 patients. CONCLUSION: The results of our study have shown that the incidence of postoperative cholecystectomy in BPD/DS patients is low, and cholecystitis is rare. Routine cholecystectomy in BPD/DS patients is no longer recommended.     

Significance of preoperative ultrasound measurement of gallbladder wall thickness

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (> or =3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.     

Is concomitant cholecystectomy necessary in obese patients undergoing laparoscopic gastric bypass surgery?

Background  Morbid obesity is associated with a high prevalence of cholecystopathy, and there is an increased risk of cholelithiasis during rapid weight loss following gastric bypass. In the era of open gastric bypass prophylactic cholecystectomy was advocated. However, routine cholecystectomy at laparoscopic gastric bypass is controversial. Methods  We performed a retrospective review of a prospectively maintained database of morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) from February 2000 to August 2006. All had routine preoperative biliary ultrasonography. Concomitant cholecystectomy at LRYGB was planned in patients with proven cholelithiasis and/or gallbladder polyp ≥1 cm diameter. Results  1711 LRYGBs were performed. Forty-two patients (2.5%) had a previous cholecystectomy and were excluded from further analysis. Two hundred and five patients (12%) had gallbladder pathology: cholelithiasis in 190 (93%), sludge in 14 (6.8%), and a 2 cm polyp in 1 (0.5%). One hundred and twenty-three patients with cholelithiasis (65%) had a concomitant cholecystectomy at LRYGB, while 68 (35.7%) did not. Of these, 123 (99%) were completed laparoscopically. Concomitant cholecystectomy added a mean operative time of 18 min (range 15–23 min). One patient developed an accessory biliary radicle leak requiring diagnostic laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP). Of the 68 patients with cholelithiasis who did not undergo cholecystectomy 12 (17.6%) required subsequent cholecystectomy. A further 4 patients with preoperative gallbladder sludge required cholecystectomy. All procedures were completed laparoscopically. One patient required laparoscopic choledochotomy and common bile duct exploration (CBDE) with stone retrieval. Eighty-eight patients (6%) with absence of preoperative gallbladder pathology developed symptomatic cholelithiasis after LRYGB; 69 (78.4%) underwent laparoscopic cholecystectomy; 3 presented with gallstone pancreatitis and 2 with obstructive jaundice, requiring laparoscopic transcystic CBDE in 4 and LTG-ERCP in one. Conclusion  In our experience, concomitant cholecystectomy at LRYGB for ultrasonography-confirmed gallbladder pathology is feasible and safe. It reduces the potential for future gallbladder-related morbidity, and the need for further surgery. Competing Interests Declared: None