Incidence of symptomatic cholelithiasis after laparoscopic sleeve gastrectomy and its association with rapid weight loss

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.

Long-term Outcomes of Sleeve Gastrectomy in Adolescent Patients: The Effect of Weight Loss in Younger Years to Outcomes in Adulthood

BACKGROUND

Childhood obesity is associated with a variety of complications that see their light throughout adulthood. Due to the serious side effects of these morbidities, early intervention is essential. Laparoscopic sleeve gastrectomy (SG) is a safe and effective procedure for the treatment of obesity, however, the long-term data on its use in adolescents is lacking in the literature.

METHODS

A retrospective analysis was conducted on all patients that underwent SG aged between 12 and 21 years old at a public hospital in Kuwait. Data on their weight and comorbidities was collected and analyzed.

RESULTS

164 adolescent patients with a mean age of 19 underwent SG. 71% of the patients were female, while the mean weight at surgery was 128.6 kg, corresponding to a BMI of 47.8 Kg/m2. 32% of patients had a starting BMI more than 50, while 6.7% had a BMI over 60. The highest weight loss was achieved at 18 months post-op, corresponding to an EWL of 82.66%. On long-term follow-up, weight loss was maintained over the 13 years post-op. Obstructive sleep apnea resolved in 75% of the patients while hypertension persisted in the 2 patients who were diagnosed with it pre-op. 21 patients developed gastro-esophageal reflux disease 5.7 years post-op, while 20 patients were treated for gall bladder stones 4.4 years post-op.

CONCLUSION

It is of ample importance to tackle obesity during childhood before complications ensue later in life. Bariatric surgery, specifically SG, has been found to be an effective and safe weight loss tool, with sustained long-term weight maintenance and resolution of early comorbidities.

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.

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.

Childhood Obesity: Position Statement of Polish Society of Pediatrics, Polish Society for Pediatric Obesity, Polish Society of Pediatric Endocrinology and Diabetes, the College of Family Physicians in Poland and Polish Association for Study on Obesity

Childhood obesity is one of the most important problems of public health. Searching was conducted by using PubMed/MEDLINE, Cochrane Library, Science Direct, MEDLINE, and EBSCO databases, from January 2022 to June 2022, for English language meta-analyses, systematic reviews, randomized clinical trials, and observational studies from all over the world. Five main topics were defined in a consensus join statement of the Polish Society of Pediatrics, Polish Society for Pediatric Obesity, Polish Society of Pediatric Endocrinology and Diabetes and Polish Association for the Study on Obesity: (1) definition, causes, consequences of obesity; (2) treatment of obesity; (3) obesity prevention; (4) the role of primary care in the prevention of obesity; (5) Recommendations for general practitioners, parents, teachers, and regional authorities. The statement outlines the role of diet, physical activity in the prevention and treatment of overweight and obesity, and gives appropriate recommendations for interventions by schools, parents, and primary health care. A multisite approach to weight control in children is recommended, taking into account the age, the severity of obesity, and the presence of obesity-related diseases. Combined interventions consisting of dietary modification, physical activity, behavioral therapy, and education are effective in improving metabolic and anthropometric indices. More actions are needed to strengthen the role of primary care in the effective prevention and treatment of obesity because a comprehensive, multi-component intervention appears to yield the best results.

European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint European Society for Clinical Nutrition and Metabolism / United European Gastroenterology 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 European Society for Clinical Nutrition and Metabolism guidelines, following the Scottish Intercollegiate Guidelines Network 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.

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.

Symptomatic Gallstones in Young Patients Under the Age of 30 Years

Introduction

Gallstones are deposits of digestive fluid that is hardened into small pellets. Gallstones can be symptomatic or asymptomatic. The present study assessed the sociodemographic and clinical characteristics of patients under the age of 30 years old with symptomatic gallstones.

Methodology

A prospective, observational study was conducted at Surgical Unit-3, at Jinnah Postgraduate Medical Centre (JPMC), Pakistan, from July 2020 to July 2021. All patients suspected of having gallstone disease underwent ultrasonic examination. A diagnosis of gallstone disease was made if the gallbladder showed a hyperechoic mass casting a posterior acoustic shadow, with a change of position. All of the patients with gallstone disease were hospitalized. The patients were asked about their age, past history (with special emphasis on last pregnancy and years of oral contraceptive use, if any), socioeconomic status, and other demographic data. The patients were treated with a cholecystectomy, either laparoscopic or open. Postcholecystectomy complications, if any, were recorded.

Results

A total of 210 patients under the age of 30 years were included. The mean age of patients was 25 ± 3 years. The majority of the population were females, i.e., 170 (81%). Upon assessing the risk factors, it was found that 31.84% of the female patients had used oral contraceptives, 32.96% were pregnant at the time of presentation, 20.48% had diabetes mellitus, and 27.14% had a history of gallstones. Furthermore, it was found that about 114 (54.29%) patients were overweight with a body mass index (BMI) of 25-30 kg/m². High triglyceride levels and high cholesterol levels were found in 108 (51.43%) and 115 (54.76%) of the patients, respectively, indicating a link between symptomatic gallstones and younger age.

Conclusion

Our study indicated that young people are prone to symptomatic gallstones. The rate of disease was considerably high among females and in patients with high cholesterol and triglyceride levels and abnormal body mass index. Further exploratory studies are needed to determine the cause of gallstones.

Comparative analysis of postoperative pain after transvaginal hybrid NOTES versus traditional laparoscopic cholecystectomy in obese patients

Purpose

Even though obesity is a known risk factor for needing cholecystectomy, most research excludes patients with higher degrees of obesity. The aim of this retrospective study was to compare postoperative pain and analgesic consumption in obese patients, who underwent either transvaginal hybrid Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy (NC) or traditional laparoscopic cholecystectomy (LC).

Methods

Between 12/2008 and 01/2017, 237 NC were performed, of which 35 (14.8%) showed a body mass index (BMI) of 35 kg/m² or more (obesity II and III according to the World Health Organization). Of these, procedural time, postoperative pain, analgesic requirements, and other early postoperative parameters were collected and compared with 35 matched LC patients from the same time period.

Results

There were no differences in the baseline characteristics between the two groups, but we found significant benefits for the hybrid NOTES technique in terms of less pain (P = 0.006), coherent with significantly less intake of peripheral (paracetamol; P = 0.005), and of centrally acting analgesics (piritramide; P = 0.047) within the first two-day post-surgery. We also found that those in the NC group had shorter hospital stays (P < 0.001). The postoperative complication rates and the procedural time did not differ between the two groups.

Conclusion

With regard to postoperative pain and analgesic requirements and without an increase in postoperative complications, obese patients experience short-term benefits from the hybrid NOTES technique compared to traditional laparoscopic cholecystectomy.

Unexpected histopathology results following routine examination of cholecystectomy specimens: How big and how significant?

BACKGROUND

Routine histopathological examination (RHPE) of all gallbladder specimens is required to detect the presence of gallbladder carcinoma (GBC) or any other pathology. The work aims to study the incidence and the clinical significance of detecting unusual gallbladder findings upon the RHPE of the referred cholecystectomy specimens to a histopathology laboratory section at a referral hospital in Saudi Arabia during one year period.

MATERIALS AND METHODS

From May 2019 to May 2020, all histopathology reports of 444 consecutive gallbladder specimens after elective and emergency cholecystectomies were retrospectively analyzed and divided into two groups; usual findings and unusual findings which were reviewed blindly by two other pathology consultants. Frequencies, descriptive statistics, normality test, and correlations were run. The Interrater reliability between clinical and histopathological diagnosis was assessed statistically by kappa test.

RESULTS

The results of histopathological examination of these gallbladder specimens showed that chronic cholecystitis was found in 296 out of 444 total cases (66.7%), acute cholecystitis in 52 cases (11.7%), and other associated usual findings in 85 cases (19%). Three cases (0.7%) of incidental carcinomas and other three cases (0.7%) of dysplasia. Eosinophilic carcinomas were detected in two cases (0.45%), gallbladder complete septum was found in one case, and one case of Phrygian cap anomaly. All patients with gallbladder carcinoma were diagnosed incidentally during the histopathological examination.

CONCLUSIONS

RHPE of cholecystectomy materials are required to confirm the final diagnosis and document any other pathology. Failure to detect incidental occult carcinoma may be catastrophic, given the poor prognosis.

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

Background: Rapid weight loss after bariatric surgery is a known risk factor for cholelithiasis development. This study aimed to estimate the incidence of cholelithiasis following bariatric surgery among morbidly obese patients who underwent bariatric surgery. Methods: This is a retrospective cohort study of all morbidly obese patients who underwent bariatric surgery in King Abdulaziz Medical City (Riyadh, Saudi Arabia) or King Abdulaziz Hospital (Al Ahsa, Saudi Arabia) between January 2015 and December 2018. Patients with a history of cholecystectomy or previous bariatric surgery were excluded. We estimated the incidence rate of cholelithiasis among the cohort. We also examined the associated risk factors of cholelithiasis development. Results: The study cohort contained 490 patients (38.7% males; 61.43% females) with a mean age of 36.87 ± 11.44 years. Most patients (58.54%) were followed up for 12 months. The incidence of cholelithiasis post-operation was 6.53% (n = 32). The average period of cholelithiasis formation was 12-24 months. The percentage of total weight loss (TWL%) was significantly associated with the development of cholelithiasis post-operatively. Conclusion: A significant association was found between weight loss following bariatric surgery and the incidence of cholelithiasis. Gender, age, and comorbidities were not associated with the formation of cholelithiasis. We recommend regular follow-up appointments with thorough patient education about gradual weight loss to reduce the risk of developing cholelithiasis.