Ursodeoxycholic acid for the prevention of symptomatic gallstone disease after bariatric surgery: study protocol for a randomized controlled trial (UPGRADE trial)

The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey

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.

Prevalence of elevated alkaline phosphatase levels among post-bariatric surgery patients

INTRODUCTION

Little is known about the prevalence of elevated alkaline phosphatase in post-bariatric surgery patients due to under-utilization of this test after surgery. Elevated alkaline phosphatase levels are caused by hepatobiliary disease or bone resorption, which can lead to gallstones and osteoporosis. Early, post-operative measurement of alkaline phosphatase can prevent complications, thus reducing morbidity and overall healthcare costs. The purpose of this study was to determine the prevalence of elevated alkaline phosphatase levels among post-operative bariatric surgery patients.

METHODS

This was a retrospective study of patients 18 years or older, who underwent laparoscopic sleeve gastrectomy (LSG) at a Midwestern Weight Management Clinic between January 1, 2002 and December 31, 2020. Alkaline phosphatase levels, weight, body mass index (BMI), gamma-glutamyl transferase (GGT), parathyroid hormone (PTH), calcitriol, and calcitonin, vitamin D and multivitamin supplementation were measured at baseline, 3, 6, and 12 months post-surgery.

RESULTS

Two hundred thirty patients with mean age of 47 years and BMI of 44.6 were included with 80.9% (n = 186) female. Alkaline phosphatase was elevated relative to baseline for 36.1% of patients (n = 52) at 3 months post-surgery, 42.4% of patients (n = 56) at 6 months, and 43.3% of patients (n = 45) at 12 months (p < 0.001). There were six cases of documented cholelithiasis post-surgery.

CONCLUSION

A significant proportion of participants experienced elevations in alkaline phosphatase following surgery, indicating that the prevalence of gallbladder pathology and bone resorption may be higher than previously thought. This merits additional investigation into these complications post-operatively to determine prevalence and avoid excess morbidity.

Ursodeoxycholic acid for prevention of gallstone disease after laparoscopic sleeve gastrectomy: an Atlantic Canada perspective

BACKGROUND

Prophylactic ursodeoxycholic acid (UDCA) may be beneficial in reducing gallstone disease after bariatric surgery. The American Society for Metabolic and Bariatric Surgery (ASMBS) 2019 guidelines recommend a 6-month course of UDCA for patients undergoing laparoscopic sleeve gastrectomy (LSG). This has not been adopted broadly. This study intends to assess the effect of routine UDCA administration following LSG on symptomatic gallstone disease.

METHODS

We performed a retrospective chart review of patients who underwent LSG, between 2009 and 2019, at two tertiary care centers in Atlantic Canada. At one center, UDCA 250 mg oral twice daily was routinely prescribed following LSG for 6 months to patients with an intact gallbladder. At the other center, UDCA was not prescribed. Primary and secondary outcomes were cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) rates. Compliance with and side effects of UDCA therapy were analyzed.

RESULTS

A total of 751 patients were included in the study. Patients who had prior cholecystectomy or were lost to follow up were excluded. After exclusion criteria were applied, 461 patients were included for analysis: 303 in the UDCA group and 158 in the group who did not receive UDCA. Cholecystectomy rate was not significantly associated with UDCA administration, however there was a trend towards less cholecystectomy in patients who received UDCA (8.3% vs. 13.9%, p = 0.056). ERCP rate was significantly lower in patients who received UDCA (0.3% vs 2.5%, p = 0.031). Rate of gallstone disease requiring intervention, either cholecystectomy or ERCP, was significantly decreased in patients who received UDCA (8.9% vs 15.8%, p = 0.022). The most common barriers to compliance with UDCA were cost (45.4%) and nausea (18.1%).

CONCLUSION

This is the first study to demonstrate lower rates of ERCP in patients receiving routine UDCA following LSG. Our findings support the ASMBS 2019 guidelines for administering UDCA after LSG for preventing gallstone disease.

The Incidence of Cholelithiasis After Bariatric Surgery in Saudi Arabia and Its Associated Risk Factors

INTRODUCTION

Saudi Arabia has one of the highest obesity rates (35.4%) in the world, and bariatric surgery (BS) has emerged as the most effective treatment for obesity and its comorbidities. Despite its effectiveness, it is a known risk factor for cholelithiasis. The aim of this study is to identify the incidence and risk factors that contribute to the development of symptomatic cholelithiasis after different types of bariatric surgery in Saudi Arabia.

METHODS

This is a cross-sectional study conducted among the Saudi adult population. The sample size was 706 participants who underwent bariatric surgery from all over Saudi Arabia. Data collection was done through a validated online self-reported survey.

RESULTS

Out of 706 participants who fulfilled the inclusion criteria, it was found that the incidence of gallstones (GS) after bariatric surgery was 18.8%. The most incidence was during the first year of surgery, where the number of individuals reached 80.4%. The majority were in females (22.9%) and those who underwent Roux-en-Y gastric bypass (RYGB) surgery (51.2%). Patients who had a body mass index (BMI) of >25 kg/m² significantly had a higher incidence of gallstones (23.1%) compared to those who had a lesser BMI (15.8%). As the analysis showed, the medication used to prevent the occurrence of gallstones can be considered one of the protective factors, where 85.4% of individuals who used these medications did not develop cholelithiasis.

CONCLUSION

 The incidence of gallstones after bariatric surgery was high, particularly within the first year of surgery. The increase in postoperative gallstone formation is correlated with hyperlipidemia and Roux-en-Y gastric bypass as basic predictive factors. On the contrary, the medication used to prevent the occurrence of gallstones is considered a protective factor.

Ursodeoxycholic Acid Use After Bariatric Surgery: Effects on Metabolic and Inflammatory Blood Markers

BACKGROUND

In addition to the reduction of symptomatic gallstone disease, ursodeoxycholic acid (UDCA) might also have beneficial metabolic effects after bariatric surgery. We examined the impact of UDCA on liver enzymes, hemoglobin A1c (HbA1c), lipids, and inflammation markers.

METHODS

Patients in the UPGRADE trial (placebo-controlled, double-blind) were randomized between UDCA 900 mg daily or placebo pills for 6 months after bariatric surgery. Patients without blood measurements pre- or 6 months postoperatively were excluded. The change in liver enzymes, Hba1c, lipids, and inflammation markers after surgery were compared between the UDCA and placebo group, followed by a postoperative cross-sectional comparison.

RESULTS

In total, 513 patients were included (age [mean ± SD] 45.6 ± 10.7 years; 79% female). Preoperative blood values did not differ between UDCA (n = 266) and placebo (n = 247) groups. Increase of alkaline phosphatase (ALP) was greater in the UDCA group (mean difference 3.81 U/l [95%CI 0.50 7.12]). Change in other liver enzymes, HbA1c, lipids, and CRP levels did not differ. Postoperative cross-sectional comparison in 316 adherent patients also revealed a higher total cholesterol (mean difference 0.25 mg/dl [95%CI 0.07-0.42]), lower aspartate aminotransferase (mean difference -3.12 U/l [-5.16 - -1.08]), and lower alanine aminotransferase level (mean difference -5.89 U/l [-9.41 - -2.37]) in the UDCA group.

CONCLUSION

UDCA treatment leads to a higher, but clinically irrelevant increase in ALP level in patients 6 months after bariatric surgery. No other changes in metabolic or inflammatory markers were observed. Except for the reduction of gallstone formation, UDCA has no effects after bariatric surgery.

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean gastrointestinal patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The present practical guideline is intended for clinicians and practitioners in general medicine, gastroenterology, surgery and other obesity management, including dietitians and focuses on obesity care in patients with chronic gastrointestinal diseases.

METHODS

The present practical guideline is the shortened version of a previously published scientific guideline developed according to the standard operating procedure for ESPEN guidelines. The content has been re-structured and transformed into flow-charts that allow a quick navigation through the text.

RESULTS

In 100 recommendations (3× A, 33× B, 24 × 0, 40× GPP, all with a consensus grade of 90% or more) care of gastrointestinal patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially metabolic associated liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present practical guideline offers in a condensed way evidence-based advice how to care for patients with chronic gastrointestinal diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

Safety of concomitant cholecystectomy during one anastomosis gastric bypass compared with sleeve gastrectomy and Roux-en-Y gastric bypass

Candidates of metabolic and bariatric surgery (MBS) are prone for gallstone formation. Concomitant cholecystectomy (CC) during MBS is controversial. This study is first to examine the safety of CC during one anastomosis gastric bypass (OAGB), compared with sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Single-center retrospective comparative study of CC (2012-2021) during OAGB, to SG and RYGB. CC was performed in 115 patients during OAGB (n = 50), SG (n = 39), and RYGB (n = 26). All procedures were completed laparoscopically. Baseline characteristics were similar except age, body mass index, gastroesophageal reflux disease, obstructive sleep apnea, and previous MBS (p < 0.05). Intraoperative complications occurred in one OAGB patient (2% vs. 0%, 0%; p = 0.52), which was not cholecystectomy related. There were no differences in total (6% vs. 2.6%, 15.4%; p = 0.13) and major (2% vs. 0%, 3.8; p = 0.50) early-complication rates. Of them, cholecystectomy-related complications occurred in one OAGB, compared with none of SG and one RYGB (2% vs. 0%, 3.8%; p = 0.50). The former was major, and the latter was minor complication. None of the OAGB patients needed re-admission (0% vs. 0%, 11.5; p = 0.04). All CC outcome parameters were similar between asymptomatic and symptomatic gallstones. Previous bariatric procedures were found to be a significant risk for major complications and readmissions (OR = 16.87, p = 0.019). CC during OAGB for gallstones seems safe, as in SG and RYGB. No cholecystectomy-related intraoperative complications occurred, and postoperative complication rates were low and acceptable. Outcomes for asymptomatic gallstones were similar to symptomatic ones, and we cautiously support CC in the presence of gallstones.

Incidence and risk factors for cholelithiasis after bariatric surgery: a systematic review and meta-analysis

BACKGROUND

Obesity has been identified as an independent risk factor for cholelithiasis. As a treatment for obesity, bariatric surgery may increase the incidence of cholelithiasis. The risk factors for cholelithiasis after bariatric surgery remain uncertain. The purpose of this study was to explore the risk factors for postoperative cholelithiasis after weight-loss surgery and propose suggestions for clinical decision making.

METHODS

Four databases, PubMed, EMBASE, Web of Science and Cochrane, were systematically searched for all reports about cholelithiasis after bariatric surgery, and literature screening was performed following prespecified inclusion criteria. The included studies were all evaluated for quality according to the NOS scale. Data extraction was followed by analysis using Reviewer Manager 5.4 and StataSE 15.

RESULTS

A total of 19 articles were included in this meta-analysis, and all studies were of high quality. A total of 20,553 patients were included in this study. Sex [OR = 0.62, 95% CI (0.55, 0.71), P < 0.00001] and race [OR = 1.62, 95% CI (1.19, 2.19), P = 0.002] were risk factors for cholelithiasis after bariatric surgery. Surgical procedure, preoperative BMI, weight-loss ratio, smoking, hypertension, diabetes mellitus, and dyslipidemia were neither protective nor risk factors for cholelithiasis after bariatric surgery.

CONCLUSION

Caucasian race and female sex are risk factors for developing cholelithiasis after bariatric surgery; surgical procedure, BMI, weight loss ratio, hypertension, diabetes mellitus, dyslipidemia, and smoking are not risk factors for cholelithiasis after bariatric surgery.

Bariatric Surgery: Targeting pancreatic β cells to treat type II diabetes

Pancreatic β-cell function impairment and insulin resistance are central to the development of obesity-related type 2 diabetes mellitus (T2DM). Bariatric surgery (BS) is a practical treatment approach to treat morbid obesity and achieve lasting T2DM remission. Traditionally, sustained postoperative glycemic control was considered a direct result of decreased nutrient intake and weight loss. However, mounting evidence in recent years implicated a weight-independent mechanism that involves pancreatic islet reconstruction and improved β-cell function. In this article, we summarize the role of β-cell in the pathogenesis of T2DM, review recent research progress focusing on the impact of Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) on pancreatic β-cell pathophysiology, and finally discuss therapeutics that have the potential to assist in the treatment effect of surgery and prevent T2D relapse.

Clinical Characteristics of Symptomatic Cholecystitis in Post-Gastrectomy Patients: 11 Years of Experience in a Single Center

Background and Objectives: Gallbladder (GB) stones, a major cause of symptomatic cholecystitis, are more likely to develop in post gastrectomy people. Our purpose is to evaluate characteristics of symptomatic cholecystitis after gastrectomy. Materials and Method: In January 2011−December 2021, total 1587 patients underwent operations for symptomatic cholecystitis at our hospital. We reviewed the patients’ general characteristics, operation results, pathologic results, and postoperative complications. We classified the patients into non-gastrectomy and gastrectomy groups, further divided into subtotal gastrectomy and total gastrectomy groups. Result: The patients’ ages, male proportion, and the open surgery rate were significantly higher (127/1543 (8.2%) vs. 17/44 (38.6%); p < 0.001), and the operation time was longer (102.51 ± 52.43 vs. 167.39 ± 82.95; p < 0.001) in the gastrectomy group. Extended surgery rates were significantly higher in the gastrectomy group (56/1543 (3.6%) vs. 12/44 (27.3%); p < 0.001). The period from gastrectomy to symptomatic cholecystitis was significantly shorter in the total gastrectomy group (12.72 ± 10.50 vs. 7.25 ± 4.80; p = 0.040). Conclusion: GB stones were more likely to develop in post-gastrectomy patients and extended surgery rates were higher. The period to cholecystitis was shorter in total gastrectomy. Efforts to prevent GB stones are considered in post-gastrectomy patients.

Cost-effectiveness of ursodeoxycholic acid in preventing new-onset symptomatic gallstone disease after Roux-en-Y gastric bypass surgery

BACKGROUND

The aim was to evaluate the cost-effectiveness and cost-utility of ursodeoxycholic acid (UDCA) prophylaxis for the prevention of symptomatic gallstone disease after Roux-en-Y gastric bypass (RYGB) in patients without gallstones before surgery.

METHODS

Data from a multicentre, double-blind, randomized placebo-controlled superiority trial were used. Patients scheduled for laparoscopic RYGB or sleeve gastrectomy were randomized to receive 900 mg UDCA or placebo for 6 months. Indicated by the clinical report, prophylactic prescription of UDCA was evaluated economically against placebo from a healthcare and societal perspective for the subgroup of patients without gallstones before surgery who underwent RYGB. Volumes and costs of in-hospital care, out-of-hospital care, out-of-pocket expenses, and productivity loss were assessed. Main outcomes were the costs per patient free from symptomatic gallstone disease and the costs per quality-adjusted life-year (QALY).

RESULTS

Patients receiving UDCA prophylaxis were more likely to remain free from symptomatic gallstone disease (relative risk 1.06, 95 per cent c.i. 1.02 to 1.11; P = 0.002) compared with patients in the placebo group. The gain in QALYs, corrected for a baseline difference in health utility, was 0.047 (95 per cent bias-corrected and accelerated (Bca) c.i. 0.007 to 0.088) higher (P = 0.022). Differences in costs were -€356 (95 per cent Bca c.i. €-1573 to 761) from a healthcare perspective and -€1392 (-3807 to 917) from a societal perspective including out-of-pocket expenses and productivity loss, both statistically non-significant, in favour of UDCA prophylaxis. The probability of UDCA prophylaxis being cost-effective was at least 0.872.

CONCLUSION

UDCA prophylaxis after RYGB in patients without gallstones before surgery was cost-effective.

European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal (GI) disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean GI patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The objective of the guideline is to give advice to all professionals working in the field of gastroenterology care including physicians, surgeons, dietitians and others how to handle patients with GI disease and obesity.

METHODS

The present guideline was developed according to the standard operating procedure for ESPEN guidelines, following the Scottish Intercollegiate Guidelines Network (SIGN) grading system (A, B, 0, and good practice point (GPP)). The procedure included an online voting (Delphi) and a final consensus conference.

RESULTS

In 100 recommendations (3x A, 33x B, 24x 0, 40x GPP, all with a consensus grade of 90% or more) care of GI patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially fatty liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present guideline offers for the first time evidence-based advice how to care for patients with chronic GI diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

The National Consensus statement on the management of adult patients with non-alcoholic fatty liver disease and main comorbidities

The National Consensus was prepared with the participation of the National Medical Association for the Study of the Multimorbidity, Russian Scientific Liver Society, Russian Association of Endocrinologists, Russian Association of Gerontologists and Geriatricians, National Society for Preventive Cardiology, Professional Foundation for the Promotion of Medicine Fund PROFMEDFORUM. The aim of the multidisciplinary consensus is a detailed analysis of the course of non-alcoholic fatty liver disease (NAFLD) and the main associated conditions. The definition of NAFLD is given, its prevalence is described, methods for diagnosing its components such as steatosis, inflammation and fibrosis are described. The association of NAFLD with a number of cardio-metabolic diseases (arterial hypertension, atherosclerosis, thrombotic complications, type 2 diabetes mellitus (T2DM), obesity, dyslipidemia, etc.), chronic kidney disease (CKD) and the risk of developing hepatocellular cancer (HCC) were analyzed. The review of non-drug methods of treatment of NAFLD and modern opportunities of pharmacotherapy are presented. The possibilities of new molecules in the treatment of NAFLD are considered: agonists of nuclear receptors, antagonists of pro-inflammatory molecules, etc. The positive properties and disadvantages of currently used drugs (vitamin E, thiazolidinediones, etc.) are described. Special attention is paid to the multi-target ursodeoxycholic acid (UDCA) molecule in the complex treatment of NAFLD as a multifactorial disease. Its anti-inflammatory, anti-oxidant and cytoprotective properties, the ability to reduce steatosis an independent risk factor for the development of cardiovascular pathology, reduce inflammation and hepatic fibrosis through the modulation of autophagy are considered. The ability of UDCA to influence glucose and lipid homeostasis and to have an anticarcinogenic effect has been demonstrated. The Consensus statement has advanced provisions for practitioners to optimize the diagnosis and treatment of NAFLD and related common pathogenetic links of cardio-metabolic diseases.

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.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

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.

Efficacy and Safety of Ursodeoxycholic Acid for the Prevention of Gallstone Formation After Gastrectomy in Patients With Gastric Cancer: The PEGASUS-D Randomized Clinical Trial

Importance

The incidence of gallstones has been reported to increase after gastrectomy. However, few studies have been conducted on the prevention of gallstone formation in patients who have undergone gastrectomy.

Objective

To evaluate the efficacy and safety of ursodeoxycholic acid (UDCA) in preventing gallstone formation after gastrectomy in patients with gastric cancer.

Design, Setting, and Participants

The PEGASUS-D study (Efficacy and Safety of DWJ1319 in the Prevention of Gallstone Formation after Gastrectomy in Patient with Gastric Cancer: A Multicenter, Randomized, Double-blind, Placebo-controlled Study) was a randomized, double-blind, placebo-controlled clinical trial conducted at 12 institutions in the Republic of Korea. Adults (aged ≥19 years) with a diagnosis of gastric cancer who underwent total, distal, or proximal gastrectomy were enrolled between May 26, 2015, and January 9, 2017; follow-up ended January 8, 2018. Efficacy was evaluated by both the full analysis set, based on the intention-to-treat principle, and the per-protocol set; full analysis set findings were interpreted as the main results.

Interventions

Eligible participants were randomly assigned to receive 300 mg of UDCA, 600 mg of UDCA, or placebo at a ratio of 1:1:1. Ursodeoxycholic acid and placebo were administered daily for 52 weeks.

Main Outcomes and Measures

Gallstone formation was assessed with abdominal ultrasonography every 3 months for 12 months. Randomization and allocation to trial groups were carried out by an interactive web-response system. The primary end point was the proportion of patients developing gallstones within 12 months after gastrectomy.

Results

A total of 521 patients (175 received 300 mg of UDCA, 178 received 600 mg of UDCA, and 168 received placebo) were randomized. The full analysis set included 465 patients (311 men; median age, 56.0 years [interquartile range, 48.0-64.0 years]), with 151 patients in the 300-mg group, 164 patients in the 600-mg group, and 150 patients in the placebo group. The proportion of patients developing gallstones within 12 months after gastrectomy was 8 of 151 (5.3%) in the 300-mg group, 7 of 164 (4.3%) in the 600-mg group, and 25 of 150 (16.7%) in the placebo group. Compared with the placebo group, odds ratios for gallstone formation were 0.27 (95% CI, 0.12-0.62; P = .002) in the 300-mg group and 0.20 (95% CI, 0.08-0.50; P < .001) in the 600-mg group. No significant adverse drug reactions were detected among the enrolled patients.

Conclusions and Relevance

Administration of UDCA for 12 months significantly reduced the incidence of gallstones after gastrectomy for gastric cancer. These findings suggest that UDCA administration prevents gallstone formation after gastrectomy in patients with gastric cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT02490111.

Global Variations in Practices Concerning Roux-en-Y Gastric Bypass-an Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures

INTRODUCTION

There is significant variation in practices concerning Roux-en-Y gastric bypass (RYGB) among bariatric surgeons, but there is currently a lack of robust data on the nature and extent of these variations. The purpose of this study was to understand global variations in practices concerning RYGB.

METHODS

A questionnaire-based survey on Survey Monkey® was created, and the link was shared freely on various social media platforms. The link was also distributed through a personnel email network of authors.

RESULTS

A total of 657 surgeons from 65 countries completed the survey. Crohn's disease and liver cirrhosis were considered absolute contraindications for RYGB by 427 surgeons (64.98%) and 347 surgeons (53.30%), respectively. More than 68.5% of surgeons performed routine upper GI endoscopy while 64.17% performed routine ultrasound of abdomen preoperatively. The majority of surgeons (77.70%) used the perigastric technique for Gastric pouch creation. Approximately, 79.5% used orogastric bougie. More than 70% of the respondents did not use any staple line reinforcement routinely. Only 17.67% of surgeons measured the whole small bowel length, and the majority of surgeons (86.5%) used constant length of BP limb. Approximately, 89% used constant length of alimentary limb. Approximately, 95% of surgeons preferred antecolic bypass, and more than 86% routinely closed the Petersen defect. Marginal ulcer prophylaxis was used by the majority (91.17%). Almost 95% of surgeons recommended lifelong vitamin and mineral supplements.

CONCLUSION

This survey identifies global variations in practices concerning RYGB. It identifies several areas for future research and consensus building.

The Role of Ursodeoxycholic Acid (UDCA) in Cholelithiasis Management After One Anastomosis Gastric Bypass (OAGB) for Morbid Obesity: Results of a Monocentric Randomized Controlled Trial

INTRODUCTION

Bariatric surgery leads to rapid weight loss, a well-known risk factor for gallstone formation. Postoperative biliary complication rate requiring cholecystectomy is between 0.9 and 7.5% after laparoscopic sleeve gastrectomy and between 6 and 50% after laparoscopic gastric bypass. Several authors recommended ursodeoxycholic acid (UDCA) administration to reduce gallstone formation after diet-induced weight reduction. The aim of this randomized monocentric study is to evaluate gallstone incidence after prophylactic administration of UDCA in patients undergoing one anastomosis gastric bypass (OAGB).

METHODS

Patients undergoing OAGB were prospectively randomized into 2 groups: the UDCA group receiving oral UDCA 600 mg/days for 6 months in the immediate postoperative days, and the control group not administered with UDCA. Each group included 95 patients. Abdominal ultrasound, clinical evaluation, and quality of life scoring with Gastrointestinal Quality of Life Index (GIQLI) were performed postoperatively in all patients at 3, 6, and 12 months.

RESULTS

At 12 months of postoperative follow-up, 4 (4.2%) and 24 patients (25.2%) showed gallstones in the UDCA group and control group, respectively (p < 0.05). Among those who developed gallstones, 8 (28.6%) cases were symptomatic whereas 20 (71.4%) did not show any symptom. No statistically significant difference in GIQLI score between the two groups was found.

CONCLUSION

OAGB, as other malabsorbent procedures, appears to have higher rate of cholelithiasis than purely restrictive procedures. In our prospective randomized controlled study, a regular postoperative UDCA intake during the first 6 months seems to significantly reduce cholelithiasis incidence after OAGB, with no case of intolerance reported. Further studies are needed to assess this issue.

An inverse association of weight and the occurrence of asymptomatic gallbladder stone disease in hypercholesterolemia patients: a case-control study

Background

Despite the fact that the majority of gallstones formed in the gallbladder are mainly composed of cholesterol, as they are formed from cholesterol-supersaturated bile, and hypercholesterolemia is a common metabolic disorder, which is closely related to cardiac, hepatic, renal and other oxidative damage inflammation and necrosis, there is still no consensus regarding the contribution of blood serum lipids in the pathogenesis of gallbladder stone disease (GSD). This study aimed to investigate the relationship between hypercholesterolemia and the risk of new-onset asymptomatic GSD, and to determine the prevalence of factors associated with new-onset asymptomatic GSD in patients with hypercholesterolemia.

Methods

In this study, 927 Chinese patients with new-onset asymptomatic gallstone disease and 845 healthy controls were enrolled starting from August 2012. Patients were matched for age, gender, race, occupation, systolic blood pressure, diastolic blood pressure, and fasting blood glucose levels (FBG). Body mass index (BMI), nonalcoholic fatty liver disease (NAFLD) and serum lipids indexes were compared and the relationships between BMI, blood lipid and gallbladder stone hazards were examined by logistic multivariate regression models.

Results

The result showed a significantly higher morbidity with GSD in hypercholesterolemia than non-hypercholesterolemia patients (Χ² = 17.211, P < 0.001). Of hypercholesterolemia patients, low density lipoprotein (OR = 1.493, P = 0.029) and NAFLD (OR = 2.723, P = 0.022) were significant risk factors for GSD, while being male (OR = 0.244, P = 0.033), weight (OR = 0.961, P = 0.022), high density lipoprotein (OR = 0.305, P < 0.001), and FBG (OR = 0.687, P = 0.034) were significantly negatively correlated with GSD in univariate analysis. Multivariate logistic regression indicated weakly positive correlations with NAFLD (OR = 3.284, P = 0.054), and significant negative correlations with weight (OR = 0.930, P = 0.018), HDL-c (OR = 0.144, P < 0.001), and GSD.

Conclusion

Hypercholesterolemia acts as an independent risk factor for new-onset asymptomatic GSD, while obesity and NAFLD are synergistic factors. Interestingly, it is first reported that elevated weight was inversely associated with GSD in patients with hypercholesterolemia. The results of this study suggest that effective control of hyperlipidemia is of greater significance than weight loss, which might make the situation worse, in the prevention of GSD in obese patients with hyperlipidemia.

Ursodeoxycholic acid for the prevention of symptomatic gallstone disease after bariatric surgery: statistical analysis plan for a randomised controlled trial (UPGRADE trial)

BACKGROUND

Approximately 8-15% of patients undergoing bariatric surgery develop symptomatic gallstone disease within 24 months after surgery. Ursodeoxycholic acid (UDCA) seems to effectively prevent the formation of gallstones detectable by ultrasound after bariatric surgery. The aim of the UPGRADE trial is to provide evidence on the prophylactic use of UDCA in preventing symptomatic gallstone disease postoperatively.

METHODS

The UPGRADE trial is designed as a randomised, placebo-controlled, double-blind multicentre trial in patients with morbid obesity undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Patients are randomly assigned to either UDCA 900 mg daily for 6 months or placebo treatment. This paper details the statistical analysis plan (SAP) of this trial and was submitted before outcome data were available.

RESULTS

The primary endpoint of this trial is symptomatic gallstone disease within 24 months after bariatric surgery, defined as admission or hospital visit for symptomatic gallstone disease. Secondary outcomes consist of the development of gallstones/sludge on ultrasound at 24 months in the gallstone-negative group at baseline, presence of gallstones/sludge on ultrasound at 24 months, number of cholecystectomies, side effects of UDCA, therapy compliance, quality of life, costs and revenues. Analyses will be completed according to this pre-specified SAP. The main analysis will be performed as a standard ITT analysis using the chi-squared test.

DISCUSSION

The UPGRADE trial will show if prophylactic use of UDCA reduces the incidence of symptomatic gallstone disease after bariatric surgery. Unforeseen deviations from the SAP at the time of analysis will be motivated and discussed.

TRIAL REGISTRATION

The Netherlands Trial Register NL5954 . Registered on 21 November 2016.

The use of Ursolit for gallstone prophylaxis following bariatric surgery: a randomized-controlled trial

BACKGROUND

Although bariatric surgery (BS) predisposes patients to development of gallstone formation, a preventive strategy is still in debate.

AIM

To compare the incidence of gallstone formation between patients treated with ursodeoxycholic acid (UDCA) vs. placebo for a duration of 6 months following BS.

METHODS

This multicenter randomized, double-blind controlled trial entails treatment with UDCA vs. an identical-looking placebo. The primary outcome was gallstone formation, as measured by abdominal ultrasound.

RESULTS

The data of 209 subjects were enrolled in the study, and 92 subjects completed the study and were analyzed (n = 46 for each study group). The high dropout rate was mainly due to difficulties in adding more medications and swallowing the pill. Among the subjects who completed the study, 77.2% were women, and their mean age and pre-surgery BMI were 42.2 ± 10.2 years and 44.4 ± 6.1 kg/m², respectively. Gallstone formation was recorded in 45.7% (n = 21) vs. 23.9% (n = 11) of subjects among placebo vs. UDCA groups, respectively, p = 0.029. Subgroup-analysis, according to surgery type, found that the results were significant only for SG subjects (p = 0.041), although the same trend was observed for OAGB/RYGB. Excess Weight Loss percent (%EWL) at 6 months post-surgery was 66.0 ± 17.1% vs. 71.8 ± 19.5% for the placebo and UDCA groups, respectively; p = 0.136. A trend towards a reduction in prescribed comorbidity medications was noted within-groups during the follow-up period, as compared to baseline, with no between-group differences (p ≥ 0.246). Moreover, no between-group differences were found for blood test results (p ≥ 0.063 for all).

CONCLUSION

Administration of UDCA significantly decreased gallstone formation at 6 months at following BS. CLINICALTRIALS.

GOV NUMBER

NCT02319629.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Cholelithiasis after bariatric surgery, incidence, and prophylaxis: randomized controlled trial

BACKGROUND

Rapid weight loss is associated with a high incidence of cholelithiasis.

OBJECTIVES

To identify the incidence of gallstone formation after weight loss surgery and to detect the efficacy of 6 months regimen of prophylactic Ursodeoxycholic acid (UDCA).

METHODS

RCT included a total of 1530 morbid obese patients who were subjected to either laparoscopic one anastomosis gastric bypass (OAGB), sleeve gastrectomy (SG), or greater curve plication (GCP). Patients with previous or concomitant cholecystectomy and missed follow-up were excluded, leaving 1432 patients to analyze. They were randomly allocated into two groups receiving either UDCA or placebo with a minimum follow-up of one year for assessment of cholelithiasis and weight loss.

RESULTS

The overall incidence of cholelithiasis after surgery was 9.7%. There was a significant decrease in the incidence of gallstone formation from 22% in placebo to 6.5% in treated group with UDCA. The mean percentage of excess weight loss (%EWL) was significantly higher in those who develop gallstones than others. Of those developing gallstones, there was 64.7 % with SG versus 28.1% and 7.2% in OAGB and GCP, respectively, which is statistically significant. NNT to prevent cholelithiasis is six, AR% is 70.4%, and RR is 3.4%.

CONCLUSIONS

Cholelithiasis after SG and OAGB was higher than GCP. %EWL was rapid and higher in OAGB and SG contributing to the higher rate of symptomatic cholelithiasis and could be predictive for post-bariatric cholelithiasis. A 6-month use of UDCA is an effective prophylaxis decreasing gallstone formation after bariatric surgery at short-term follow-up.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Recent advances in understanding and managing cholesterol gallstones

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.