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Kermansaravi M, Shikora S, Dillemans B, Kurian M, LaMasters T, Vilallonga R, Prager G, Chiappetta S. The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey. Obes Surg 2024; 34:1086-1096. [PMID: 38400945 DOI: 10.1007/s11695-024-07101-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS. BACKGROUND Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist. METHODS An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023. RESULTS Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB. CONCLUSION Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.
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Affiliation(s)
- Mohammad Kermansaravi
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Hazrat-E Fatemeh Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Scott Shikora
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruno Dillemans
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Brugge, Belgium
| | - Marina Kurian
- Department of Surgery, NYU Langone Medical Center, New York, NY, 10016, USA
| | - Teresa LaMasters
- UnityPoint Clinic Weight Loss Specialists, West Des Moines, IA, USA
| | - Ramon Vilallonga
- Endocrine, Bariatric and Metabolic Surgery Department, University Hospital Vall Hebron, Barcelona, Spain
| | - Gerhard Prager
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Sonja Chiappetta
- Bariatric and Metabolic Surgery Unit, Department of General and Laparoscopic Surgery, Ospedale Evangelico Betania, Via Argine 604, 80147, Naples, Italy.
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Malaussena Z, Mhaskar R, Richmond N, Diab ARF, Sujka J, DuCoin C, Docimo S. Hernia repair in the bariatric patient: a systematic review and meta-analysis. Surg Obes Relat Dis 2024; 20:184-201. [PMID: 37973424 DOI: 10.1016/j.soard.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/03/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Repair options for ventral hernias in bariatric patients include performing a staged approach in which bariatric surgery is performed before definitive hernia repair (BS-first), a staged approach in which hernia repair is performed before bariatric surgery (HR-first), or a concomitant approach. OBJECTIVES This meta-analysis aims to determine which surgical approach is best for bariatric patients with hernias. SETTING PubMed, CENTRAL, and Embase databases. METHODS A comprehensive search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to screen for all studies that focused on outcomes of patients who underwent both hernia repair and bariatric surgery, either simultaneously or separately. Exclusion criteria included hiatal and inguinal hernia studies, case reports, and case series. RESULTS 27 studies fit our inclusion criteria after identifying 1584 studies initially. Seven comparative studies were included, enrolling 8548 staged patients (6458 BS-first) and 3528 concomitant patients. A total of 7 single-arm staged studies and 13 single-arm concomitant studies were also included. Data on hernia recurrence, mesh infection, reoperation, surgical site infections, seroma, bowel complications, and mortality were abstracted. The concomitant approach was associated with decreased odds of experiencing surgical site infections, reoperation, and seromas. The staged approach (BS-first) was associated with decreased odds of mesh infection. The single-arm studies suggest a lower incidence of hernia recurrence in a staged BS-first approach than in a concomitant approach. CONCLUSIONS The data suggest a concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, while the staged (BS-first) approach is more appropriate if the hernia requires mesh placement.
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Affiliation(s)
- Zachary Malaussena
- University of South Florida Morsani College of Medicine, Tampa, Florida.
| | - Rahul Mhaskar
- University of South Florida Morsani College of Medicine, Tampa, Florida; Department of Medical Education, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Noah Richmond
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Abdul-Rahman F Diab
- University of South Florida Morsani College of Medicine, Tampa, Florida; Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Joseph Sujka
- University of South Florida Morsani College of Medicine, Tampa, Florida; Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Christopher DuCoin
- University of South Florida Morsani College of Medicine, Tampa, Florida; Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Salvatore Docimo
- University of South Florida Morsani College of Medicine, Tampa, Florida; Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida
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Marciniak C, Lenne X, Bruandet A, Hamroun A, Génin M, Baud G, Theis D, Pattou F, Caiazzo R. Risk-Benefit Balance of Simultaneous Gastric Bypass or Sleeve Gastrectomy and Concomitant Cholecystectomy: A Comprehensive Nationwide Cohort of 289,627 Patients. Ann Surg 2023; 278:725-731. [PMID: 37476980 DOI: 10.1097/sla.0000000000006039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To assess the relevance of concomitant laparoscopic metabolic bariatric surgery (MBS) and cholecystectomy. BACKGROUND Because of the massive weight loss it induces, MBS is associated with an increase in the frequency of gallstones. However, no consensus yet exists on the risk-to-benefit ratio of a concomitant cholecystectomy (CC) during MBS to prevent long-term biliary complications. METHODS This nationwide retrospective cohort research was conducted in 2 parts using information from a national administrative database (PMSI). The 90-day morbidity of MBS with or without CC was first compared in a matched trial (propensity score). Second, we observed medium-term biliary complication following MBS when no CC had been performed during MBS up to 9 years after MBS (minimum 18 months). RESULTS Between 2013 and 2020, 289,627 patients had a sleeve gastrectomy (SG: 70%) or a gastric bypass (GBP: 30%). The principal indications of CC were symptomatic cholelithiasis (79.5%) or acute cholecystitis (3.6%). Prophylactic CC occurred only in 15.5% of the cases. In our matched-group analysis, we included 9323 patients in each arm. The complication rate at day 90 after surgery was greater in the CC arm [odds ratio=1.3 (1.2-1.5), P <0.001], independently of the reason of the CC. At 18 months, there was a 0.1% risk of symptomatic gallstone migration and a 0.08% risk of biliary pancreatitis. At 9 years, 20.5±0.52% of patients underwent an interval cholecystectomy. The likelihood of interval cholecystectomy decreased from 5.4% per year to 1.7% per year after the first 18 months the whole cohort, risk at 18 months of symptomatic gallstone migration was 0.1%, of pancreatitis 0.08%, and of angiocholitis 0.1%. CONCLUSION CC during SG and GBP should be avoided. In the case of asymptomatic gallstones after MBS, prophylactic cholecystectomy should not be recommended.
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Affiliation(s)
- Camille Marciniak
- General and Endocrine Surgery Department, Lille University Hospital CHU Lille, Lille, France
- Inserm, U1190 Translational research on diabetes (EGID), Lille University Univ.Lille, Lille, France
| | - Xavier Lenne
- Medical Information Department, Lille University Hospital, Lille, France
| | - Amélie Bruandet
- Medical Information Department, Lille University Hospital, Lille, France
| | - Aghiles Hamroun
- Public health, Epidemiology - UMR 1167 Ridage, Institut Pasteur de Lille, Univ Lille, Chu Lille, Lille, France
| | - Michaël Génin
- University of Lille, CHU Lille, ULR 2694 - METRICS: Health technology and medical practice assessment, F-59000 Lille, France
| | - Grégory Baud
- General and Endocrine Surgery Department, Lille University Hospital CHU Lille, Lille, France
- Inserm, U1190 Translational research on diabetes (EGID), Lille University Univ.Lille, Lille, France
| | - Didier Theis
- Medical Information Department, Lille University Hospital, Lille, France
| | - François Pattou
- General and Endocrine Surgery Department, Lille University Hospital CHU Lille, Lille, France
- Inserm, U1190 Translational research on diabetes (EGID), Lille University Univ.Lille, Lille, France
| | - Robert Caiazzo
- General and Endocrine Surgery Department, Lille University Hospital CHU Lille, Lille, France
- Inserm, U1190 Translational research on diabetes (EGID), Lille University Univ.Lille, Lille, France
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Blank S, Otto M, Belle S. [Cholecystolithiasis and intestinal bypass procedures]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:512-517. [PMID: 36884048 DOI: 10.1007/s00104-023-01834-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 03/09/2023]
Abstract
With the increasing number of surgical interventions for obesity, the numbers of associated complications, such as gallstones after bariatric surgery are also increasing. The incidence of postbariatric symptomatic cholecystolithiasis is 5-10%; however, the numbers of severe complications due to gallstones and the probability of a necessary extraction of gallstones are low. For this reason, a simultaneous or preoperative cholecystectomy should only be carried out in symptomatic patients. Treatment with ursodeoxycholic acid reduced the risk of gallstone formation in randomized trials but not the risk of complications related to gallstones in cases of pre-existing gallstones. The most frequently used access route to bile ducts after intestinal bypass procedures is the laparoscopic approach via the stomach remnants. Other possible access routes are the enteroscopic approach as well as the endosonography-guided puncture of the stomach remnants.
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Affiliation(s)
- S Blank
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - M Otto
- Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - S Belle
- Medizinische Klinik II, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Clapp B, Janik M, Corbett J, Vahibe A, Ul Hassan O, Husain F, Pullat R, Ghanem OM. Duodenal switch without versus with laparoscopic cholecystectomy: a perioperative risk comparative analysis of the MBSAQIP database (2015-2019). Surg Endosc 2023; 37:219-224. [PMID: 35918551 DOI: 10.1007/s00464-022-09477-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/13/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The results of concurrent cholecystectomy with Roux-en Y gastric bypass and sleeve gastrectomy have been well elucidated. Large-scale data on the outcomes of concomitant cholecystectomy during biliopancreatic diversion with duodenal switch (BPD-DS) are still lacking. Our study aimed to explore whether simultaneous cholecystectomy with BPD-DS alters the 30-day postoperative outcomes. METHODS We conducted a retrospective analysis of the MBSAQIP database between 2015 and 2019. Propensity-score matching (PSM) in BPD-DS with cholecystectomy (Group 1) and BPD-DS without cholecystectomy (Group 2) cohorts was performed (PSM ratio 1:2). The two groups were matched for a total of 21 baseline variables including age, gender, BMI, ASA class, and other medical comorbidities and conditions. The 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions were obtained. RESULTS Initially, 568 patients in Group 1 and 5079 in Group 2 were identified. After performing PSM, 564 and 1128 patients respectively were compared. The BPD-DS with cholecystectomy group reported a higher rate of reoperation and reintervention compared to BPD-DS alone (3.9% versus 2.4% and 3.2% versus 2%, respectively), even though it did not reach statistical significance. The intervention time was significantly higher in Group 1 compared to Group 2 (192.4 ± 77.6 versus 126.4 ± 61.4 min). Clavien-Dindo complications (1-5) were similar between these two PSM cohorts. CONCLUSION Concomitant cholecystectomy during BPD-DS increases operative times but does not affect the other outcomes. Based on our results, the decision of cholecystectomy at the time of BPD-DS should be left to the surgeon's judgment.
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Affiliation(s)
- Ben Clapp
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Michal Janik
- Department of Surgery, Military Institute of Aviation Medicine, Warsaw, Poland
| | - John Corbett
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Ahmet Vahibe
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Omer Ul Hassan
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Farah Husain
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Rana Pullat
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
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Keshvedinova AA, Smirnov AV, Stankevich VR, Sharobaro VI, Ivanov YV. [Treatment of ventral hernias in patients with morbid obesity]. Khirurgiia (Mosk) 2023:95-102. [PMID: 37707338 DOI: 10.17116/hirurgia202309195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The review is devoted to the treatment of ventral hernias in patients with morbid obesity. This issue is important due to significant number of such patients and no unambiguous clinical recommendations. The advantages of simultaneous surgery (with bariatric intervention) are obvious, i.e. lower risk of postoperative hernia incarceration and no need for re-hospitalization with another intervention. High risk of bariatric population makes it necessary to minimize surgery time and surgical trauma. A staged approach with reducing body weight surgically or conservatively before hernia repair is often chosen. Hernia repair should be performed using laparoscopic or robotic techniques with obligatory use of mesh implants. Panniculectomy or abdominoplasty as the main surgery is a valid option. Currently, it is necessary to develop clear criteria for selecting patients with morbid obesity for staged and simultaneous treatment of ventral hernias.
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Affiliation(s)
- A A Keshvedinova
- Federal Research and Clinical Center for Specialized Types of Medical Care and Medical Technologies, Moscow, Russia
| | - A V Smirnov
- Federal Research and Clinical Center for Specialized Types of Medical Care and Medical Technologies, Moscow, Russia
| | - V R Stankevich
- Federal Research and Clinical Center for Specialized Types of Medical Care and Medical Technologies, Moscow, Russia
| | - V I Sharobaro
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - Yu V Ivanov
- Federal Research and Clinical Center for Specialized Types of Medical Care and Medical Technologies, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Vahibe A, Ghanem OM. Comment on: management of gallstone disease prior to and after metabolic surgery: a single-center observational study. Surg Obes Relat Dis 2021; 18:188-189. [PMID: 34903477 DOI: 10.1016/j.soard.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/07/2021] [Accepted: 11/14/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Ahmet Vahibe
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Dirnberger AS, Schneider R, Slawik M, Linke K, Kraljević M, Wölnerhanssen B, Peterli R. Management of gallstone disease prior to and after metabolic surgery: a single-center observational study. Surg Obes Relat Dis 2021; 18:182-188. [PMID: 34764040 DOI: 10.1016/j.soard.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/30/2021] [Accepted: 10/10/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Rapid weight loss after bariatric surgery is a risk factor for gallstone formation. There are different strategies regarding its management in bariatric patients, including prophylactic cholecystectomy (CCE) in all patients, concomitant CCE only in symptomatic patients, or concomitant CCE in all patients with known gallstones. We present the safety and long-term results of the last concept. METHOD Retrospective single-center analysis of a prospective database on perioperative and long-term results of patients with laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) over a 15-year period. The minimal follow-up was 24 months. Concomitant CCE was intended for all patients with gallstones detected by preoperative sonography. SETTING Academic teaching hospital in Switzerland. RESULTS After exclusion of patients with a history of CCE (11.5%), a total of 1174 patients (69.6% LRYGB, 30.4% LSG) were included in the final analysis. Preoperative gallbladder pathology was detected in 21.2% of patients, of whom 98.4%, or 20.9% of the total patients, received a concomitant CCE. The additional procedure prolonged the average operation time by 38 minutes (not significant) and did not increase the complication rate compared with bariatric procedure without CCE (3.7% versus 5.7%, P = .26). No complication was directly linked to the CCE. Postoperative symptomatic gallbladder disease was observed in 9.3% of patients (LRYGB 7.0% versus LSG 2.3%, P = .15), with 19.8% of those patients initially presenting with a complication. CONCLUSION The concept of concomitant CCE in primary bariatric patients with gallstones was feasible and safe. Nevertheless, 9.3% of primary gallstone-free patients developed postoperative symptomatic gallbladder disease and required subsequent CCE despite routine ursodeoxycholic acid prophylaxis.
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Affiliation(s)
- Amanda S Dirnberger
- Department of Visceral Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, Basel, Switzerland
| | - Romano Schneider
- Department of Visceral Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, Basel, Switzerland
| | - Marc Slawik
- Interdisciplinary Center of Nutritional and Metabolic Diseases, St. Claraspital, Basel, Switzerland
| | - Katja Linke
- Department of Visceral Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, Basel, Switzerland
| | - Marko Kraljević
- Department of Visceral Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, Basel, Switzerland
| | | | - Ralph Peterli
- Department of Visceral Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, St. Claraspital and University Hospital Basel, Basel, Switzerland.
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Abstract
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.
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