Weight gain after laparoscopic cholecystectomy

The bile-gut axis and metabolic consequences of cholecystectomy

Cholelithiasis and cholecystitis affect individuals of all ages and are often treated by surgical removal of the gallbladder (cholecystectomy), which is considered a safe, low-risk procedure. Nevertheless, recent findings show that bile and its regulated storage and excretion may have important metabolic effects and that cholecystectomy is associated with several metabolic diseases postoperatively. Bile acids have long been known as emulsifiers essential to the assimilation of lipids and absorption of lipid-soluble vitamins, but more recently, they have also been reported to act as metabolic signaling agents. The nuclear receptor, farnesoid X receptor (FXR), and the G protein-coupled membrane receptor, Takeda G protein-coupled receptor 5 (TGR5), are specific to bile acids. Through activation of these receptors, bile acids control numerous metabolic functions. Cholecystectomy affects the storage and excretion of bile acids, which in turn may influence the activation of FXR and TGR5 and their effects on metabolism including processes leading to metabolic conditions such as metabolic dysfunction-associated steatotic liver disease and metabolic syndrome. Here, with the aim of elucidating mechanisms behind cholecystectomy-associated dysmetabolism, we review studies potentially linking cholecystectomy and bile acid-mediated metabolic effects and discuss possible pathophysiological mechanisms behind cholecystectomy-associated dysmetabolism.

Cholecystectomy as a risk factor for metabolic dysfunction-associated fatty liver disease: unveiling the metabolic and chronobiologic clues behind the bile acid enterohepatic circulation

Metabolic dysfunction-associated fatty liver disease (MAFLD) is highly prevalent worldwide. Recent clinical and experimental studies have addressed the association between cholecystectomy and MAFLD, confirming that cholecystectomy is an independent risk factor for MAFLD. In this review, we describe the epidemiologic evidence that links cholecystectomy to MAFLD, and discuss the possible mechanisms behind these connections, in order to unveil the metabolic and chronobiologic signals conveyed by the waves of the bile acid enterohepatic circulation.

Development of a novel model of cholecystectomy in subsequently ovariectomized mice and characterization of metabolic and gastrointestinal phenotypes: a pilot study

Background

Cholecystectomy (XGB) is the most common abdominal surgery performed in the United States and is associated with an increased post-surgery incidence of metabolic and gastrointestinal (GI) diseases. Two main risk factors for XGB are sex (female) and age (40–50 yr), corresponding with onset of menopause. Post-menopausal estrogen loss alone facilitates metabolic dysfunction, but the effects of XGB on metabolic and GI health have yet to be investigated in this population. Study objectives were to (1) identify possible short-term effects of XGB and (2) develop a novel murine model of XGB in human menopause via subsequent ovariectomy (OVX) and assess longitudinal effects of OVX on metabolism, GI physiology, and GI microbiota in XGB mice.

Methods

Female C57BL/6 mice were utilized in two parallel studies (S1&S2). In S1, XGB mice were compared to a non-XGB baseline group after six wk. In S2, mice were XGB at wk0, either sham (SHM) or OVX at wk6, and sacrificed at wk12, wk18, and wk24. Body composition assessment and fresh fecal collections were conducted periodically. Serum and tissues were collected at sacrifice for metabolic and GI health endpoints.

Results

Compared to baseline, XGB increased hepatic CYP7A1 and decreased HMGCR relative expression, but did not influence BW, fat mass, or hepatic triglycerides after six wk. In S2, XGB/OVX mice had greater BW and fat mass than XGB/SHM. Cecal microbiota alpha diversity metrics were lower in XGB/OVX mice at wk24 compared the XGB/SHM. No consistent longitudinal patterns in fasting serum lipids, fecal microbial diversity, and GI gene expression were observed between S2 groups.

Conclusions

In addition to developing a novel, clinically-representative model of XGB and subsequent OVX, our results suggest that OVX resulted in the expected phenotype to some extent, but that XGB may modify or mask some responses and requires further investigation.

Prevalence of biopsy-proven nonalcoholic fatty liver among patients with gallstone disease

BACKGROUND/AIM

Gallstone disease (GD) and nonalcoholic fatty liver disease (NAFLD) are associated with metabolic syndrome. Despite the benign nature of NAFLD, 10% of patients may develop advanced fibrosis and cirrhosis. We aimed to identify the prevalence and factors associated with NAFLD among GD patients in the Saudi population.

PATIENTS AND METHODS

This is a single-center, observational cohort study that included patients seen in general surgery clinics at our institution from 2011 to 2017. All liver biopsies were taken at the same time as the cholecystectomy. Demographical and clinical data were prospectively collected from the study population.

RESULTS

Of the 301 GD patients in the study, 15% had a normal body mass index (BMI), 29% were overweight, and 56% were obese. There were 143 (47.8%) patients with NAFLD, of which 125 (41.8%) showed steatosis and 18 (6%) had nonalcoholic steatohepatitis. There was a significant positive correlation between NAFLD and age (r = 0.243; P < 0.0001), and BMI (r = 0.242; P < 0.0001). Obese patients with BMI 30-40 kg/m[2] were 2.403 (P = 0.039) more likely to have NAFLD compared with normal BMI patients, and this value increased to 6.145 (P = 0.002) in patients with BMI >40 kg/m[2]. Additionally, patients with T2DM were 2.839 times (P = 0.015) more likely to have NAFLD compared with those who did not.

CONCLUSIONS

The prevalence of NAFLD among GD patients is high. High BMI and diabetes are independent factors associated with NAFLD in GD patients. The results suggest that there may be a need for routine liver biopsy in selected patients during cholecystectomy.

Is Cholecystectomy in Patients with Symptomatic Uncomplicated Cholelithiasis Beneficial in Improving the Lipid Profile?

Introduction

Gallstone disease is an emerging health issue worldwide with its incidence on the rise. The development of gallstone disease is multifactorial, with risk factors including increased age, female sex, obesity, and the use of oral contraceptive pills. It has been established that more than 50% of patients with gallstone disease have a coexisting lipid disorder. Cholecystectomy, the definitive management of gallstones, may improve the lipid profiles of some patients.

Objectives

This study aims to examine the postoperative changes in the lipid profiles of patients who underwent cholecystectomy. These lipid profiles include levels of low-density lipoprotein (LDL), triglycerides (TG), high-density lipoprotein (HDL), total cholesterol (TC), and the Chol/HDL ratio.

Methods

This retrospective study included 55 patients who underwent cholecystectomy between 2013 and 2017. Biochemical parameters, which include LDL, TG, HDL, and TC levels, were collected using the hospital’s recording system, in addition to the calculation of the Chol/HDL ratio.

Results

Statistically significant changes included a reduction in the mean LDL values in the two-, four-, and six-month postoperative periods (P = 0.029, 0.000, and 0.008, respectively), increased mean TG levels one-week postoperatively (P = 0.034), decreased mean TC levels at four (P = 0.049) and six months (P = 0.026) after cholecystectomy, and increased Chol/HDL ratio at two and 12 months postoperatively (P = 0.03, and 0.022, respectively).

Conclusions

From the results, it can be concluded that cholelithiasis is associated with abnormal lipid profiles and that undergoing cholecystectomy may improve them and reduce the future risk of developing coronary artery disease. However, further research is needed to confirm this association.

The Role of Diabetes Mellitus in Diseases of the Gallbladder and Biliary Tract

BACKGROUND

The increasing prevalence of diabetes mellitus worldwide continues to pose a heavy burden. Though its gastrointestinal impact is appropriately recognized, the lesser known associations may be overlooked.

OBJECTIVE

We aim to review the negative implications of diabetes on the gallbladder and the biliary tract.

METHODS

A MEDLINE® database search of literature was conducted with emphasis on the previous five years, combining keywords such as "diabetes," "gallbladder," and "biliary".

RESULTS

The association of diabetes to the formation of gallstones, gallbladder cancer, and cancer of the biliary tract are discussed along with diagnosis and treatment.

CONCLUSION

Though we uncover the role of diabetic neuropathy in gallbladder and biliary complications, the specific individual diabetic risk factors behind these developments is unclear. Also, in addition to diabetes control and surgical gallbladder management, the treatment approach also requires further focus.

Gall bladder: The metabolic orchestrator

It is commonly held that the gall bladder (GB) is not indispensable for life. However, recent studies strongly suggest that GB removal can lead to the development of metabolic syndrome (MetS). With the recent recognition of the role of bile acids (BAs) in systemic metabolic regulation, it is worthwhile to re-examine the function of the GB, which can be regarded as the physiological "pacemaker" of BA flow. Thus, in the present study, we review the role of the GB in BA flow regulation, describe the epidemiologic evidence that associates cholecystectomy with various components of MetS, and discuss the possible mechanism behind these connections in order to demonstrate the pivotal role that GB plays in metabolic regulation.

Cholecystectomy and risk of metabolic syndrome

The gallbladder physiologically concentrates and stores bile during fasting and provides rhythmic bile secretion both during fasting and in the postprandial phase to solubilize dietary lipids and fat-soluble vitamins. Bile acids (BAs), major lipid components of bile, play a key role as signaling molecules in modulating gene expression related to cholesterol, BA, glucose and energy metabolism. Cholecystectomy is the most commonly performed surgical procedure worldwide in patients who develop symptoms and/or complications of cholelithiasis of any type. Cholecystectomy per se, however, might cause abnormal metabolic consequences, i.e., alterations in glucose, insulin (and insulin-resistance), lipid and lipoprotein levels, liver steatosis and the metabolic syndrome. Mechanisms are likely mediated by the abnormal transintestinal flow of BAs, producing metabolic signaling that acts without gallbladder rhythmic function and involves the BAs/farnesoid X receptor (FXR) and the BA/G protein-coupled BA receptor 1 (GPBAR-1) axes in the liver, intestine, brown adipose tissue and muscle. Alterations of intestinal microbiota leading to distorted homeostatic processes are also possible. According to this view, cholecystectomy, via BA-induced changes in the enterohepatic circulation, is a risk factor for the metabolic abnormalities and becomes another “fellow traveler” with, or another risk factor for the metabolic syndrome.

Cholecystectomy as a risk factor of metabolic syndrome: from epidemiologic clues to biochemical mechanisms

Cholecystectomy has long been regarded as a safe procedure with no deleterious influence on the body. However, recent studies provide clues that link cholecystectomy to a high risk for metabolic syndrome (MetS). In the present review, we describe the epidemiologic evidence that links cholecystectomy to MetS. Various components of MetS are investigated, including visceral obesity, dyslipidemia, elevated blood pressure, impaired fasting glucose, and insulin resistance. The possible mechanisms that associate cholecystectomy with MetS are discussed on the basis of experimental studies.

Effect of cholecystectomy on hepatic fat accumulation and insulin resistance in non-obese Hispanic patients: a pilot study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is highly prevalent worldwide. Experimental studies have shown that cholecystectomy (XGB) increases hepatic fat content in mice and appears associated to NAFLD in large retrospective population-based studies. The aim of this study was to prospectively assess the effects of XGB on hepatic fat content (HFC) and insulin resistance (IR) in non-obese, middle aged Hispanic subjects.

METHODS

Twenty-six gallstone patients undergoing elective XGB and 16 control subjects with normal livers and gallbladders at ultrasonography were prospectively followed 24 months for changes in HFC and IR. Clinical, biochemical determinations and hepatic imaging were performed at baseline and 24 months after surgery. MRI technique quantified HFC in four hepatic segments. IR was assessed by the Homeostasis Model Assessment (HOMA_-IR) index.

RESULTS

Initial body mass index (BMI) was 25.6 ± 0.4 and 24.3 ± 1.0 in the control and XGB groups of subjects, respectively. Serum insulin level increased from 8.1 ± 0.7 to 10.0 ± 1.9 (μU/ml) 24 months after surgery in XGB patients (p < 0.05); no significant changes were detected in control individuals. Median HOMA_-IR index increased from 1.31 (interquartile range, 1.01-1.68) to 2.20 (interquartile range, 1.57 - 2.60) 24 months after XGB, (p < 0.003). Median HOMA_-IR index of control subjects remained unchanged at the end of the study. Serum apoB concentration increased from 61.5 ± 3.4 to 79.0 ± 7.8 (μg/ml) in XGB patients (p < 0.03). Serum apoB levels remained within normal ranges in both periods of the study in control subjects. HFC significantly increased in 2 of the 4 segments 24 months after XGB: right posterior hepatic lobe (from 5.3 ± 0.2% to 6.0 ± 0.2%, p > 0.04) and right anterior hepatic lobe (from 5.8 ± 0.2% to 6.6 ± 0.3%, p < 0.02). The average HFC of the four hepatic segments studied slightly increased from 5.4 ± 0.2 to 5.8 ± 0.3 2 years after XGB (p < 0.03). No significant changes were found in HFC in the control subjects at the end of the study.

CONCLUSIONS

Elective XGB increases HFC, HOMA_-IR index and serum apoB concentration. These results support the notion that XGB is a risk factor non-alcoholic fatty liver disease and other IR - associated disease conditions.

Diet After Cholecystectomy

Patients with gallstones are often affected by alimentary disorders contributing to the onset of gallstones disease. Cholecystectomy can have nutritional and metabolic consequences in the short-term (diarrhea, abdominal pain and bloating) and in the long-term (increased Body Mass Index with metabolic syndrome, gastritis, liposoluble vitamin deficiency). Pathogenic mechanisms behind these disturbances are reviewed and the need for an early post-operative nutritional intervention based on low-lipid, high-fibers diet, is highlighted.

Cholecystectomy and NAFLD: does gallbladder removal have metabolic consequences?

Pathogenesis of nonalcoholic fatty liver (NAFLD) disease and gallbladder (GB) disease secondary to cholesterol gallstones is complex, yet both conditions share similar associated risk factors, most of them related to the metabolic syndrome. Cholecystectomy, the best treatment for GB disease, is one of the most performed abdominal surgeries worldwide. In this issue of the American Journal of Gastroenterology, Ruhl and Everhart, using data from the Third United States National Health and Nutrition Examination Survey (1988-1994), show that NAFLD is associated with cholecystectomy (odds ratio (OR)=2.4; 1.8-3.3), but not with gallstones (OR=1.1; 0.84-1.4). This finding suggests that cholecystectomy may itself represent a risk factor for NAFLD, which is in line with the recently undisclosed role of the GB and bile acids in systemic metabolic regulation. Thus, cholecystectomy may not be innocuous and may have a major impact on public health by contributing to NAFLD development.

Measuring the rate of weight gain and the influential role of diet in patients undergoing elective laparoscopic cholecystectomy: a 6-month follow-up study

Weight gain after cholecystectomy is one of the major surgical problems consistent with morbidities and long-term mortalities. Here, we aimed to study the impact of palliative cholecystectomy on weight gain and nutritional status of the patients before and in 1, 4 and 6 months after surgery. We performed a prospective survey on a cohort of 48 patients undergoing elective cholecystectomy. The nutritional status of the patients was collected by nutrition nurse and analysed by NutriBase software. There were 13 (16%) females and 35 (84%) males with the mean age of 51.8 ± 1.97. In 6 months after surgery, patients had higher values of BMI, daily energy expenditure, carbohydrate and lipid consumption and a decreased level of protein consumption. Weight gain after surgery was caused by an increase in fat consumption which resulted in the weight gain and worsening of lipid profile. Dietary consultation, shortly after surgery, would improve patient outcome after cholecystectomy.

The metabolic syndrome is associated with complicated gallstone disease

An association between cholecystectomy and metabolic syndrome has not been fully established. Here we analyzed the association between cholecystectomy and metabolic syndrome in a Chinese population of 5672 subjects who undergone annual health checkups at the First Affiliated Hospital, College of Medicine, Zhejiang University between January 2011 and December 2012. The prevalences of gallstones, cholecystectomy and metabolic syndrome were 6.0%, 3.6%, and 32.5%, respectively. The prevalence of metabolic syndrome was significantly higher in subjects with a history of cholecystectomy (63.5%) than in those with gallstones (47.0%) or in those without gallstone disease (30.3%; P<0.01 for both). Multivariate logistic regression analysis showed that cholecystectomy was significantly associated with increased risk of metabolic syndrome (OR = 1.872; 95% CI: 1.193–2.937). However, the association of gallstones with metabolic syndrome was not statistically significant (OR = 1.267; 95% CI: 0.901–1.782). Altogether, our results suggest that cholecystectomy significantly increases the risk of metabolic syndrome.