The Incidence and Risk Factors of Cholelithiasis Development After Bariatric Surgery in Saudi Arabia: A Two-Center Retrospective Cohort Study

A Review of the Management of Cholelithiasis at Buraydah Central Hospital in the Qassim Region, Saudi Arabia: A Cross-Sectional Study

Cholelithiasis is the most common cause of gastroenterological hospitalization. Given this significant risk, perfectly managing cholelithiasis is crucial to reduce hospitalization. Unfortunately, we have not found a study on a review of the management of cholelithiasis in Saudi Arabia. Therefore, we aim to evaluate cholelithiasis concerning demographic features, presentation symptoms, predisposing risk factors, laboratory features, complications, and outcomes in the Qassim region. This cross-sectional study of all patients with a radiological diagnosis of gallstones, whether symptomatic or not, was diagnostic in 2022. The researchers fielded a preformed data collection sheet for each patient from the hospital system. Data obtained were entered into a spreadsheet and analyzed using SPSS Statistics version 23.0 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). A total of 526 patients were included in the study. Most patients (116, 22.1%), were aged 38-42. The finding also indicated that most patients were females (397, 75.5%), while males were only 129 (24.5%). The study also found that the difference between women and men presenting complaints of fat intolerance and right shoulder pain was statistically significant. Women were 100 (84%) and men were 19 (16%) for fat intolerance, while for right shoulder pain, women were 50 (89.3%) and men were six (10.7%). The p-values were 0.014 and 0.011, respectively. Further, there was a statistically significant difference in terms of the complaints presented by the patients between the complicated and non-complicated cases of abdominal pain (p=0.001), nausea (p=0.001), vomiting (p=0.001), change in urine and stool color (p=0.001), and right shoulder pain (p=0.001), among other complaints (p=0.001). The study concludes that most patients affected by cholelithiasis are individuals in the middle age group, with women being more affected by the disease than men. Further, among the individuals affected by the disease, the majority of them were overweight and obese. On the other hand, the study concludes that the majority of patients who suffer more from cholelithiasis are affected mainly by other associated diseases such as hypertension, hypothyroidism, and diabetes mellitus. In conclusion, many factors may contribute to gallstone formation and the outcome of the disease and surgery. Therefore, the study recommends that health workers offer tailored education, especially targeting the highlighted factors found in this study, to create awareness of disease control measures in the general population. Also, keep in mind these factors when dealing with patients who complain of abdominal pain.

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.

Factors influencing body weight one year after bariatric surgery

The significant outcome of bariatric surgery (BS) is weight loss, which may be affected by many factors, such as initial body weight before surgery, sex, and dietary intake. Moreover, rapid weight loss is associated with an increased incidence of postsurgical cholelithiasis. To investigate the observed weight loss outcomes during the first year after BS, we investigated the factors that may influence weight loss and to detect the efficacy of prophylactic ursodeoxycholic acid against gallstone formation. This was a retrospective cohort study of all patients with morbid obesity who underwent BS in the hospital and completed a 1-year follow up. Patients with a previous BS or a history of cholecystectomy before BS were excluded. Data were extracted from the medical records at multiple postoperative intervals. There was significant weight loss in terms of percentage of excess weight loss and reduction in body mass index postoperative. A significant correlation was found between the percent of excess weight loss and age, initial body mass index, and initial weight, but there was no significant correlation with sex or type of surgery. The incidence of postoperative cholecystectomy is almost negligible. A significant association was found between age and weight loss after BS. ursodeoxycholic acid is an effective prophylaxis to decrease the incidence of cholecystectomy after BS.

Eight-Centimeter Gallbladder Stone Post-Roux-en-Y Gastric Bypass: A Case Report

Cholelithiasis occurs when a stone forms in the gallbladder; when symptoms develop, the condition is termed symptomatic cholelithiasis. The correlation between bariatric surgery and post-operative symptomatic cholelithiasis has long been established. Presented is a case of a 56-year-old female status post-Roux-en-Y gastric bypass who developed symptomatic cholelithiasis and subsequently underwent cholecystectomy with the removal of an 8-centimeter (cm) gallbladder stone. This case report explores the benefits and limitations of watchful waiting versus prophylactic concomitant cholecystectomy among bariatric surgery patients, noting the difference between the bariatric sleeve and bypass anatomy for managing biliary complications.

Risk and Prophylactic Management of Gallstone Disease in Bariatric Surgery: a Systematic Review and A Bayesian meta-analysis

BACKGROUND

The frequency and management of gallstone disease (GD) in bariatric patients, including the role of routine prophylactic concomitant cholecystectomy (CCY), are still a matter of debate. This study aims to assess the risk of de novo GD in patients undergoing bariatric surgery (BS) and their predictive factors, as well as mortality and morbidity in prophylactic CCY compared to BS alone.

METHODS

We performed a systematic review, searching PubMed, EMBASE, and Web of Science until April 2021. We performed a Bayesian meta-analysis to estimate the risk of GD development after BS and the morbidity and mortality associated with BS alone versus BS + prophylactic CCY. Sources of heterogeneity were explored by meta-regression analysis.

RESULTS

The risk of de novo post bariatric GD was 20.7% (95% credible interval [95% CrI] = 13.0-29.7%; I² = 75.4%), and that of symptomatic GD was 8.2% ([95% CrI] = 5.9-11.1%; I² = 66.9%). Pre-operative average BMI (OR = 1.04; 95% CrI = 0.92-1.17) and female patients' proportion (OR = 1.00; 95% CrI = 0.98-1.04) were not associated with increased risk of symptomatic GD. BS + prophylactic CCY was associated with a 97% probability of a higher number of postoperative major complications compared to BS alone (OR = 1.74, 95% CrI = 0.97-3.55; I² = 56.5%). Mortality was not substantially different between the two approaches (OR = 0.79; 95% CrI = 0.03-3.02; I² = 20.7%).

CONCLUSION

The risk of de novo symptomatic GD after BS is not substantially high. Although mortality is similar between groups, odds of major postoperative complications were higher in patients submitted to BS + prophylactic CCY. It is still arguable if prophylactic CCY is a fitting approach for patients with a preoperative lithiasic gallbladder.

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.

Frequency of cholelithiasis in need of surgical or endoscopic treatment a decade or more after Roux-en-Y gastric bypass

BACKGROUND

Symptomatic cholelithiasis requiring treatment is a known side effect after Roux-en-Y gastric bypass (RYGB), but reported rates vary greatly. The objectives for this study were to evaluate the long-term frequency of surgical or endoscopic treatment for symptomatic cholelithiasis 10-15 years after RYGB and its relation to self-reported abdominal pain.

METHODS

Observational data from 546 patients who underwent RYGB at public hospitals in Central Norway between March 2003 and December 2009 were analyzed.

RESULTS

Median follow-up was 11.5 (range 9.1-16.8) years. Sixty-five (11.9%) patients had undergone cholecystectomy prior to RYGB. Out of the 481 patients with intact gallbladder, 77 (16.0%) patients underwent cholecystectomy and six (1.2%) patients had treatment for choledocholithiasis during the observation period. Median time from RYGB to cholecystectomy or treatment of choledocholithiasis was 51 (range 1-160) and 109 (range 10-151) months, respectively. Female sex was associated with an increased risk of subsequent cholecystectomy [OR (95% CI) 2.88 (1.31-7.15)], p < 0.05. There was a higher frequency of self-reported abdominal pain at follow-up [OR (95% CI) 1.92 (1.25-2.93)] among patients who underwent cholecystectomy before or after RYGB.

CONCLUSION

With a median follow-up of more than 11 years after RYGB, one in six patients with an intact gallbladder at time of RYGB underwent cholecystectomy, and 1.1% of the patients needed surgical or endoscopic treatment for choledocholithiasis. Patients with a history of cholecystectomy reported a higher frequency of abdominal pain.

Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures

Obesity by itself is a factor in the development of gallstone disease, and periods of weight loss after bariatric surgery further increase the risk of gallstone formation. In patients with obesity, hypersecretion of cholesterol may increase the risk of gallstone formation, which is approximately five-fold higher than that in the general population. The incidence of gallstone formation after bariatric surgery is 10-38% and often associated with a proportional increase in the risk of developing biliary complications. Routine postoperative administration of ursodeoxycholic acid (UDCA) is recommended to prevent gallstone formation. Several randomized trials have indicated that UDCA can effectively prevent gallstones and reduce the risk of cholecystectomy after bariatric procedures. The effective daily dose of UDCA in each study ranged from 500 to 1,200 mg, and it may be considered at least during the period of rapid weight loss (first 3-6 months postoperatively) to decrease the incidence of symptomatic gallstones.

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.

A Case Report of Severe Osteomalacia in a Young Patient After Bariatric Surgery

Obesity can promote several metabolic, cardiovascular, and musculoskeletal complications and has been associated with poor quality of life. The treatment of obesity can range from simple lifestyle modifications or medications to complicated bariatric surgeries. Although bariatric surgery has been a proven treatment for morbid obesity, it has also been associated with multiple consequences and complications. Several reports and studies have revealed bone loss or decreased bone mineral density (BMD), fractures, or even several metabolic bone diseases, such as osteoporosis, following bariatric surgery. This case report aims to increase awareness on postoperative patient supplementation compliance and incorporation of early detection and intervention. This case report involves a 39-year-old male who underwent laparoscopic biliopancreatic diversion 10 years prior to presentation. The patient was not compliant with his supplements for over nine years, which lead to multiple fragility fractures, myopathy, and muscle atrophy due to hypocalcemia, vitamin D deficiency, hyperparathyroidism, and other electrolyte disturbances. He has since been treated with supplements and physiotherapy for 10 months and showed clinical improvement. This case report highlights the importance of pre- and postoperative screening of bone loss risks and any vitamin or mineral deficiencies with subsequent correction via supplements. Moreover, it emphasizes the need for more studies on the complications of late post-bariatric surgeries.

Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass: a meta-analysis

BACKGROUND

Bariatric surgery could increase the risk of cholelithiasis, although it is unclear whether the incidence rates of cholelithiasis are similar after different bariatric procedures.

OBJECTIVES

To compare the incidence rates of cholelithiasis after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in people with obesity.

SETTING

Meta-analysis of cohort studies.

METHODS

We searched the PubMed and Web of Science databases for relevant studies before December 2020, and estimated the summary odds ratios (OR) and 95% confidence intervals (CI) using a random-effects model or fixed-effects model, according to the heterogeneity.

RESULTS

In total, 8 cohort studies were included in this meta-analysis, and 94,855 and 106,844 participants received SG and RYGB, respectively. Compared with those receiving RYGB, the summary results showed that participants receiving SG had a 35% lower rate of cholelithiasis (OR, .65; 95% CI, .49-.86). Also, the participants receiving SG had a significantly lower incidence of cholecystectomy than those receiving RYGB (OR, .54; 95% CI, .30-.99). In a subgroup analysis, SG was associated with a significantly lower incidence of subsequent cholelithiasis than RYGB in both Western and non-Western countries. SG led to a significantly lower incidence of cholelithiasis than RYGB only when the follow-up was <2 years instead of over 2 years.

CONCLUSION

Participants receiving SG had a significantly lower incidence of cholelithiasis than those receiving RYGB, particularly within the first 2 years after the bariatric surgery.