Effectiveness of Ursodeoxycholic Acid in the Prevention of Cholelithiasis After Sleeve Gastrectomy

Ursodeoxycholic acid for the prevention of gall stones after laparoscopic sleeve gastrectomy: a prospective controlled study

BACKGROUND

Obesity is a risk factor for cholelithiasis. Besides, rapid weight loss after bariatric surgery upsurges the rate of cholelithiasis and acute cholecystitis. This study aimed to compare gallstone development frequency after LSG under ursodeoxycholic acid (UDCA) prophylaxis.

METHODS

This prospective controlled study included 332 patients scheduled for LSG randomized to receive 500 mg UDCA daily for 12 months (UDCA Group) or no treatment (Control Group). Ultrasonography was done 6 and 12 months after surgery to detect gallstones. Cholecystectomy was done for complicated cases of cholelithiasis.

RESULTS

Seventy-one patients were lost to follow-up, and 3 developed severe adverse effects of UDCA and excluded. Data are presented for 130 patients in the UDCA group and 128 in the Control group. Collectively, 11 patients (8.5%) of the UDCA group and 41 (32.0%) of the Control group developed gall stones during the first postoperative year (p < 0.001). Cholecystectomy was indicated in 3 patients (2.3%) of the UDCA group and 9 (7.0%) of the Control group (p = 0.072). On multivariate analysis, higher BMI, dyslipidemia, and lacking UDCA prophylaxis were the independent factors significantly associated with stone development. Also, stone development was associated with higher weight loss after 6 and 12 months.

CONCLUSION

UDCA 500 mg once daily for 12 months after LSG is effective in reducing gallstone formation at 1 year. UDCA administration reduced the frequency of cholecystectomies from 7 to 2.3%. High BMI and dyslipidemia are the independent preoperative factors significantly associated with stone development.

Incidence of Symptomatic Cholelithiasis Following Laparoscopic Roux-en-Y Gastric Bypass Is Comparable to Laparoscopic Sleeve Gastrectomy: A Cohort Study

BACKGROUND

A few comparative studies have assessed the incidence of symptomatic cholelithiasis after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). However, they have shown inconsistent results. The present study has been designed based on comparing LSG and LRYGB regarding the incidence of symptomatic cholelithiasis and determining factors related to symptomatic cholelithiasis development after these procedures.

METHODS

This retrospective cohort study was conducted on 1163 patients aged ≥ 18 years old who underwent LRYGB (n = 377) or LSG (n = 786) from July 2006 to November 2019. The participants had no previous history of gallstones. A Cox-proportional hazard regression was used to assess associations between the types of procedures and the risk of symptomatic cholelithiasis. The univariable and then multivariable analysis were used to reveal the predictors of symptomatic cholelithiasis.

RESULTS

The mean person-time follow-up was 34 months (95% CI: 32.2 to 36.1 months). The incidence of symptomatic cholelithiasis was 8.3% over the follow-up period. There was no significant association between the risk of symptomatic cholelithiasis development and the type of surgical procedure (HR: 1.35, 95% CI: 0.75 to 2.41). Females had a 2.3-fold higher risk of symptomatic cholelithiasis than males, according to the multivariable Cox regression (HR: 2.31, 95% CI: 1.23 to 4.33). In addition, there was an inverse association between the administration of UDCA and the incidence of symptomatic cholelithiasis (HR: 0.13, 95% CI: 0.01 to 0.99). Our findings indicated that age, baseline body mass index (BMI), percentage of weight loss (%WL) after three and six months following surgery, postoperative pregnancy, and obesity-related comorbidities did not predict the risk of symptomatic cholelithiasis.

CONCLUSION

The present study illustrates no significant differences between LRYGB and LSG regarding symptomatic cholelithiasis occurrence. Our findings indicate that administration of UDCA has a protective effect against symptomatic cholelithiasis while, female gender is the main predictor of symptomatic cholelithiasis.

Ursodeoxycholic acid for the prevention of gallstones and subsequent cholecystectomy after bariatric surgery: a meta-analysis of randomized controlled trials

BACKGROUND

This meta-analysis aimed to compare the incidence of gallstone formation, subsequent biliary disease and the need for cholecystectomy in untreated patients and patients treated with ursodeoxycholic acid (UDCA) following bariatric surgery.

METHODS

Randomized controlled trials (RCTs) comparing UDCA and controls for the prevention of gallstone formation after bariatric surgery published until February 2022 were selected and subjected to a systematic review and meta-analysis. Articles were searched in the MEDLINE, Web of Science and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Eleven randomized controlled studies were included, with a total of 2363 randomized patients and 2217 patients analysed in the UDCA group versus 1415 randomized patients and 1257 patients analysed in the control group. Considering analysed patients, prophylactic use of UDCA was significantly associated with decreased (i) gallstone formation (OR = 0.25, 95% CI = 0.21-0.31), (ii) symptomatic gallstone disease (GD) (OR = 0.29, 95% CI = 0.20-0.42) and consequently (iii) cholecystectomy rate (OR = 0.33, 95% CI = 0.20-0.55). The results were similar in ITT analysis, in the subgroup of patients undergoing sleeve gastrectomy or considering only randomized versus placebo studies.

CONCLUSIONS

Prophylactic use of UDCA after bariatric surgery prevents both gallstone formation and symptomatic GD and reduces the need for cholecystectomy.

Roles of ursodeoxycholic acid in the bile biochemistry and metabolomics in patients with choledocholithiasis: a prospective study

INTRODUCTION

Recurrence after the endoscopic treatment of common bile duct stones (CBDS) is related to bile metabolism and bile compositions. Ursodeoxycholic acid (UDCA) has been proved effective in reducing the recurrence of CBDS. However, the detailed effects of UDCA on bile metabolism are still not extensively explored.

OBJECTIVES

This study aimed to analyze the role of UDCA in patients with choledocholithiasis (CDC) from the perspective of biochemistry and metabolomics.

METHODS

A total of 89 patients with CDC who underwent endoscopic retrograde cholangiopancreatography were prospectively examined and randomly assigned to control and UDCA groups. The biochemical detections (cholesterol, bilirubin, and so on) were performed on the collected bile. Moreover, the metabolomics analysis was conducted based on bile from 20 patients in the UDCA group.

RESULTS

The bile levels of cholesterol and endotoxins significantly decreased after UDCA treatment. Regarding bile metabolomics, the levels of 25 metabolites changed significantly after UDCA treatment. The pathway enrichment analysis showed that the UDCA addition evoked a common response related to phenylalanine, tyrosine, and tryptophan biosynthesis; phenylalanine metabolism; arachidonic acid metabolism; and terpenoid backbone biosynthesis.

CONCLUSIONS

UDCA treatment within a short time interval (7 days) did not improve the circulating laboratory values in patients with CDC who had undergone endoscopy surgery. However, relevant decreases in the bile levels of cholesterol and endotoxin were observed. UDCA evoked a common response related to lipid metabolism and amino acid metabolism, which probably reduced the bile level of cholesterol, protected hepatocytes, and corrected the abnormality of lipid metabolism caused by CDC.

Effect of ursodeoxycholic acid on gallstone formation after bariatric surgery: An updated meta-analysis

OBJECTIVE

Bariatric surgery increases the risk of postoperative gallstone formation. Many studies have proposed ursodeoxycholic acid (UDCA) as a preventive agent for postoperative gallstone formation. This study aimed to investigate the effect of UDCA on gallstone formation after bariatric surgery in patients without preoperative gallstones.

METHODS

PubMed, the Web of Science, the Cochrane Library, and EBSCO were searched for articles assessing the effect of UDCA on gallstone formation after bariatric surgery. The outcome was the incidence of postoperative gallstones. Odds ratios were used to assess dichotomous variables, and random-effects models were used for statistical analyses.

RESULTS

A total of 18 studies including 4,827 participants met the inclusion criteria. The statistical results showed that the incidence of gallstones in the UDCA group was significantly lower than in the control group. Furthermore, the occurrence of symptomatic gallstones and cholecystectomy was significantly reduced.

CONCLUSIONS

In patients without preoperative gallstones, UDCA can effectively prevent the formation of gallstones after bariatric surgery. In addition, UDCA can significantly reduce the occurrence of symptomatic gallstones and the risk of postoperative cholecystectomy. Doses of 500 to 600 mg/d can be used as a measure to prevent postoperative gallstone formation.

Risk Factors for Symptomatic Gallstone Disease and Gallstone Formation After Bariatric Surgery

PURPOSE

Patients who undergo bariatric surgery are at risk for developing cholesterol gallstones. We aimed to identify risk factors that are associated with symptomatic gallstone disease and gallstone formation after bariatric surgery.

MATERIALS AND METHODS

We included participants of the UPGRADE trial, a multicenter randomized placebo-controlled trial on the prevention of symptomatic gallstone disease with ursodeoxycholic acid (UDCA) after bariatric surgery. The association between patient characteristics and symptomatic gallstone disease, and gallstone formation was evaluated using logistic regression analysis.

RESULTS

Of 959 patients, 78 (8%) developed symptomatic gallstone disease within 24 months. Risk factors were the presence of a pain syndrome (OR 2.07; 95% CI 1.03 to 4.17) and asymptomatic gallstones before surgery (OR 3.15; 95% CI 1.87 to 5.33). Advanced age (OR 0.95; 95% CI 0.93 to 0.97) was protective, and UDCA prophylaxis did not reach statistical significance (OR 0.64; 95% CI 0.39 to 1.03). No risk factors were identified for gallstone formation, whereas advanced age (OR 0.98; 95% CI 0.96 to 1.00), statin use (OR 0.42; 95% CI 0.20 to 0.90), and UDCA prophylaxis (OR 0.47; 95% CI 0.30 to 0.73) all reduced the risk.

CONCLUSION

Young patients with a preoperative pain syndrome and/or asymptomatic gallstones before bariatric surgery are at increased risk for symptomatic gallstone disease after surgery. Whether statins, either alone or in combination with UDCA prophylaxis, can further reduce the burden of gallstones after bariatric surgery should be investigated prospectively.

Predictive Factors of Cholelithiasis After Prophylactic Administration of Ursodeoxycholic Acid Following Laparoscopic Bariatric Surgery: Tehran Obesity Treatment Study

PURPOSE

Cholelithiasis is a well-known consequence of obesity as well as rapid weight loss especially after bariatric surgery. A routine postoperative course of ursodeoxycholic acid (UDCA) is recommended as a prophylactic measure against gallstone formation. However, the efficacy of UDCA after bariatric surgery and predictors of cholelithiasis despite prophylaxis are not well understood. We assessed the incidence and predictors of de novo cholelithiasis after bariatric surgery in patients who received UDCA prophylaxis.

METHODS

Uniform data from 2629 consecutive patients who underwent either sleeve gastrectomy or gastric bypass between March 2013 and 2018 were collected prospectively. All patients received a 6-month course of UDCA 300 mg twice daily. Cholelithiasis was assessed with abdominal ultrasound at baseline as well as 6, 9, 12, 18, and 24 months postoperatively. The association between cholelithiasis and its predictors was examined by Cox proportional hazards models and restricted cubic spline regression.

RESULTS

The cumulative rate of cholelithiasis in 24 months after surgery was 10.8% (n = 283) with the greatest incidence within the first year. After multivariate analysis, 6-month body mass index (BMI) loss was found to be the only independent predictor for postoperative cholelithiasis (HR = 1.10 [95% CI: 1.04-1.16]). The concordance index for predicting cholelithiasis was 0.60 (0.56-0.64) for 6-month BMI loss.

CONCLUSION

Early postoperative rapid weight loss as represented by 6-month BMI loss is the main predictor of de novo cholelithiasis after bariatric surgery, although this parameter does not have enough power for discrimination of postoperative cholelithiasis.

Ursodeoxycholic acid for the prevention of symptomatic gallstone disease after bariatric surgery (UPGRADE): a multicentre, double-blind, randomised, placebo-controlled superiority trial

BACKGROUND

Rapid weight loss is a major risk factor for the formation of cholesterol gallstones. Consequently, patients with morbid obesity undergoing bariatric surgery frequently develop symptomatic gallstone disease. This trial assessed the efficacy of ursodeoxycholic acid versus placebo for the prevention of symptomatic gallstone disease after bariatric surgery.

METHODS

This multicentre, double-blind, randomised, placebo-controlled superiority trial enrolled patients with an intact gallbladder scheduled for laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy in three hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module to receive 900 mg ursodeoxycholic acid daily for 6 months or matched placebo. Randomisation was stratified by the presence of asymptomatic gallstones at baseline and type of surgery. Patients, clinicians, and study staff were masked to treatment allocation. The primary endpoint was symptomatic gallstone disease within 24 months, assessed in the modified intention-to-treat population (all randomly assigned eligible patients with any post-randomisation measurement). Prespecified subgroup analyses were done based on the stratification groups. Safety was assessed in all patients who took at least one dose of the study drug. This trial is registered with the Netherlands Trial Register, NL5954.

FINDINGS

Between Jan 11, 2017, and Oct 22, 2018, 985 patients were randomly assigned to receive either ursodeoxycholic acid (n=492) or placebo (n=493). 967 patients were included in the modified intention-to-treat population, of whom 959 had data available for primary endpoint assessment. 189 (20%) patients had asymptomatic gallstones at baseline and 78 (8%) received a sleeve gastrectomy. Symptomatic gallstone disease occurred in 31 (6·5%) of 475 patients in the ursodeoxycholic acid group and in 47 (9·7%) of 484 patients in the placebo group (relative risk 0·67, 95% CI 0·43-1·04, p=0·071). Logistic regression showed a significant interaction between ursodeoxycholic acid and the presence of asymptomatic gallstones at baseline (p=0·046), with an effect of ursodeoxycholic acid in patients without (0·47, 0·27-0·84, p=0·0081), and no effect in patients with asymptomatic gallstones at baseline (1·22, 0·61-2·47, p=0·57). The effect was stronger in patients without gallstones at baseline undergoing RYGB (0·37, 0·20-0·71, p=0·0016), whereas the subgroup of patients undergoing sleeve gastrectomy was too small to draw clear conclusions. Adverse events were rare. In the ursodeoxycholic acid group, diarrhoea occurred in four (0·9%) of 444 patients and skin rash in two (0·5%) patients. In the placebo group, diarrhoea occurred in two (0·4%) of 453 patients and skin rash in two (0·4%) patients. The total number of serious adverse events did not significantly differ between the trial groups (75 [17%] in 444 patients in the ursodeoxycholic acid group and 102 [23%] in 453 patients in the placebo group). The most common serious adverse events were abdominal pain and internal hernia. No serious adverse event was attributed to the study drug.

INTERPRETATION

Ursodeoxycholic acid prophylaxis did not significantly reduce the occurrence of symptomatic gallstone disease in all patients after bariatric surgery. In patients without gallstones before RYGB surgery, ursodeoxycholic acid treatment reduced the occurrence of symptomatic gallstone disease compared with placebo. Further research is needed to assess the efficacy of ursodeoxycholic acid after sleeve gastrectomy.

FUNDING

The Netherlands Organization for Health Research and Development, Zambon Netherlands BV, Foundation for Clinical Research of the Slotervaart Hospital, the Spaarne Gasthuis Academy, and Amsterdam Gastroenterology Endocrinology Metabolism.

Common bile duct morphology is associated with recurrence of common bile duct stones in Billroth II anatomy patients

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary choice for removing common bile duct (CBD) stones in Billroth II anatomy patients. The recurrence of CBD stones is still a challenging problem.

AIM

To evaluate CBD morphology and other predictors affecting CBD stone recurrence.

METHODS

A retrospective case-control analysis was performed on 138 CBD stones patients with a history of Billroth II gastrectomy, who underwent therapeutic ERCP for stone extraction at our center from January 2011 to October 2020. CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis.

RESULTS

CBD morphology (P < 0.01) and CBD diameter ≥ 1.5 cm (odds ratio [OR] = 6.15, 95% confidence interval [CI]: 1.87-20.24, P < 0.01) were the two independent risk factors. In multivariate analysis, the recurrence rate of patients with S type was 16.79 times that of patients with straight type (OR = 16.79, 95%CI: 4.26-66.09, P < 0.01), the recurrence rate of patients with polyline type was 4.97 times that of patients with straight type (OR = 4.97, 95%CI: 1.42-17.38, P = 0.01), and the recurrence rate of S type patients was 3.38 times that of patients with polyline type (OR = 3.38, 95%CI: 1.07-10.72, P = 0.04).

CONCLUSION

CBD morphology, especially S type and polyline type, is associated with increased recurrence of CBD stones in Billroth II anatomy patients.

The Mid-Term Effects of Transit Bipartition with Sleeve Gastrectomy on Glycemic Control, Weight Loss, and Nutritional Status in Patients with Type 2 Diabetes Mellitus: a Retrospective Analysis of a 3-Year Follow-up

BACKGROUND

Metabolic surgery is an effective treatment method for glycemic control and weight loss in obese patients with type 2 diabetes mellitus (T2DM). This study aimed to present the mid-term metabolic effects and weight loss results of the patients with T2DM who underwent transit bipartition with sleeve gastrectomy (TB-SG).

METHODS

A total of 32 obese patients with T2DM who underwent TB-SG were included in the study. The T2DM remission status after surgery was evaluated. The postoperative glycemic variables, weight loss, lipid profile, and nutritional profile were also compared with the baseline values.

RESULTS

At 36 months after surgery, T2DM remission occurred in 27 patients (84.3%) and the mean BMI decreased from 44.70 ± 9.34 to 29.75 ± 2.19 kg/m². The percentage of total weight loss (TWL) and excess weight loss (EWL) was 33.84% and 77.19%, respectively. The mean LDL values significantly decreased compared to baseline; however, the mean HDL did not significantly differ. No significant difference was observed regarding the mean albumin, vitamin B12, and folic acid levels.

CONCLUSION

TB-SG procedure seems promising in terms of T2DM remission and weight loss with less malnutrition and vitamin deficiency in treating obese patients with T2DM.

Ursodeoxycholic acid for the prevention of gallstone and subsequent cholecystectomy following gastric surgery: A systematic review and meta-analysis

BACKGROUND/PURPOSE

Patients who undergo gastric surgery are prone to form postsurgical gallstones. Debates still exist about the need for prevention and the selection of preventive methods. No studies had been reported comparing the efficacy of prophylactic ursodeoxycholic acid (UDCA) and prophylactic cholecystectomy (PC) for lowering postsurgical gallstone formation and subsequent cholecystectomy (SC) in patients who have undergone gastric surgery.

METHODS

We did a systematic review to identify studies from PUBMED, EMBASE, and the Cochrane database through 30 June 2020. We conducted direct and indirect comparisons of each prophylaxis using conventional and network meta-analysis. Studies with patients who have no history of cholecystectomy and who have not had preoperative gallstone were included.

RESULTS

The excellent preventive effects of PC and UDCA were demonstrated for gallstone formation (odds ratio [OR] 0.05, [95% CI 0.01, 0.22] and 0.20, [95% CI 0.16, 0.24], respectively) and the need for SC (OR 0.10, [95% CI 0.02, 0.57] and OR 0.22, [95% CI 0.14, 0.35], respectively) than control group. The UDCA group showed a tendency to generate more gallstones (OR 3.74, [95% CI 0.88, 15.82]) and a greater need for SC (OR 2.19, [95% CI 0.47-10.14]) than did the PC group without statistical significance.

CONCLUSIONS

Prophylaxis for gallstone formation may be needed for patients who undergo gastric surgery to reduce troublesome morbidities. Prophylactic UDCA seems to be a reasonable preventive method for postsurgical gallstone formation to ensure clinical benefit while reducing the burden of subsequent cholecystectomy for the patient as compared to a PC.

Simultaneous surgeries in bariatric surgery (literature review)

Based on the available publications, the article presents an analysis of the studies on the simultaneous implementation of cholecystectomy, ventral and paraesophageal hernia repair during a bariatric intervention. If there is a clinical picture of chronic calculous cholecystitis, simultaneous cholecystectomy is justified and does not lead to a significant increase in the number of complications. In the case of asymptomatic gallstones, the optimal tactics remains controversial, both a surgical treatment and observation are possible. In the absence of gallstone disease, all patients after the surgical correction of the excess weight are prescribed ursodeoxycholic acid, while performing preventive cholecystectomy is not recommended. A simultaneous ventral hernia repair is justified only for small defects ( 10 cm) of the anterior abdominal wall. If a paraesophageal hernia is detected in patients with morbid obesity, bariatric surgery may be combined with cruroraphy.

Is It Safe to Recommend Cholecystectomy Whenever Gallstones Develop After Bariatric Surgery?

BACKGROUND

Cholelithiasis (ChL) is common after bariatric surgery (BS). Laparoscopic cholecystectomy (LC), the preferential treatment, is usually recommended only to symptomatic patients. LC may be, however, beneficial to asymptomatic patients as well. A prerequisite to such a policy is that it must be safe. This study aimed to assess whether, in post-bariatric (Post-Bar) patients who develop gallstones, LC achieves the same results as those reported in the general population.

METHODS

A cohort of 376 patients undergoing elective LC had their medical records reviewed. Patients were divided into non-bariatric (Non-Bar) and Post-Bar groups, and then compared for characteristics and surgical outcomes.

RESULTS

The study included 367 patients, 292 Non-Bar and 75 Post-Bar. Considering characteristics, Post-Bar patients were younger (44.5 ± 11.8 vs 48.4 ± 14.1) and less symptomatic (2.4% vs 19.8%) and had a higher BMI (32.2 ± 4.8 vs 30.8 ± 4.4) than Non-Bar patients. Regarding surgical outcomes, mortality (none), morbidity (1%, only in Non-Bar patients), readmission (1%, only in Non-Bar patients), conversion to laparotomy (0.6%, only in Non-Bar patients) showed no difference between the groups. Operative time (42.6 ± 14.4 min in Non-Bar and 38.2 ± 12.6 min in Post-Bar patients) tended to be lower in Post-Bar patients, p = 0.054. Same-day discharge was higher in Post-Bar patients (98.6%) than in Non-Bar patients (90.4%), p = 0.03.

CONCLUSIONS

Compared with Non-Bar patients, LC in Post-Bar patients showed not only similar morbimortality, readmissions, and conversions but also even a higher same-day discharge rate and a trend to lower operative times.