Prevalence of Cholelithiasis and Choledocholithiasis in Morbidly Obese South Indian Patients and the Further Development of Biliary Calculus Disease After Sleeve Gastrectomy, Gastric Bypass and Mini Gastric Bypass

Endoscopic Biliary Drainage in Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the preferred method for managing biliary obstructions. However, the prevalence of surgically modified anatomies often poses challenges, making the standard side-viewing duodenoscope unable to reach the papilla in most cases. The increasing instances of surgically altered anatomies (SAAs) result from higher rates of bariatric procedures and surgical interventions for pancreatic malignancies. Conventional ERCP with a side-viewing endoscope remains effective when there is continuity between the stomach and duodenum. Nonetheless, percutaneous transhepatic biliary drainage (PTBD) or surgery has historically been used as an alternative for biliary drainage in malignant or benign conditions. The evolving landscape has seen various endoscopic approaches tailored to anatomical variations. Innovative methodologies such as cap-assisted forward-viewing endoscopy and enteroscopy have enabled the performance of ERCP. Despite their utilization, procedural complexities, prolonged durations, and accessibility challenges have emerged. As a result, there is a growing interest in novel enteroscopy and endoscopic ultrasound (EUS) techniques to ensure the overall success of endoscopic biliary drainage. Notably, EUS has revolutionized this domain, particularly through several techniques detailed in the review. The rendezvous approach has been pivotal in this field. The antegrade approach, involving biliary tree puncturing, allows for the validation and treatment of strictures in an antegrade fashion. The EUS-transmural approach involves connecting a tract of the biliary system with the GI tract lumen. Moreover, the EUS-directed transgastric ERCP (EDGE) procedure, combining EUS and ERCP, presents a promising solution after gastric bypass. These advancements hold promise for expanding the horizons of comprehensive and successful biliary drainage interventions, laying the groundwork for further advancements in endoscopic procedures.

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP. Methods: A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs). Results: Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3–89.4); I2: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4–99.4; I2: 0%) and 99.1% (95%CI: 98.6–99.7; I2: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3–78.0; I2: 86.9%) and 69.1% (95%CI: 65.3–72.9; I2: 91.8%) after EA-ERCP, 98% (95%CI: 96.5–99.6; I2: 0%) and 97.9% (95%CI: 96.3–99.4) after EDGE, and 98.6% (95%CI: 97.9–99.2; I2: 0%) and 98.5% (95%CI: 97.8–99.2; I2: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40–20.8); I2: 87.1%], and EDGE [13.1% (95%CI: 7.50–18.8); I2: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50–6.80); p ≤ 0.04; I2: 64.2%]. Conclusions: LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transcystic Choledochoscopy Utilizing a Disposable Choledochoscope: How We Do It

BACKGROUND

Biliary disease is common occurrence and can make up a large portion of the practice of a general surgeon. Choledocholithasis is a common entity amongst those with biliary disease. Although modern trends favor endoscopic retrograde cholangiopancreatography (ERCP) and other imaging modalities for the diagnosis and management of choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is likely underutilized.

METHODS

A literature summary utilizing a PUBMED search was performed to provide an up-to-date account regarding the latest data on LCBDE. A video identifying and explaining the critical components of a LBCDE procedure is provided.

RESULTS

LCBDE is an underutilized procedure which offers equivalent clinical outcomes compared with ERCP along with a shorter length of stay and reduced costs. LCBDE is also noted to be an effective option for common bile duct stones in the setting of altered anatomy, such as a Roux-en-Y gastric bypass.

CONCLUSION

Although modern trends favor ERCP and other imaging modalities for the diagnosis and management of choledocholithiasis, LCBDE is likely underutilized by surgeons. LCBDE can provide many benefits to patients including avoidance of additional procedures, shorter length of stay, higher success rates, and less costs. Out video should act is a guide for those surgeons interested in implementation LCBDE in their practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Experience of endoscopic retrograde cholangiopancreatography with side-viewing duodenoscope in patients with previous gastric surgery

OBJECTIVES

Endoscopic Retrograde Cholangiopancreatography (ERCP) with conventional side-viewing duodenoscope can be challenging and unsuccessful at altered anatomy in the gastrointestinal tract. This study aimed to evaluate our experience with ERCP in patients with previous gastric surgery.

MATERIAL AND METHODS

Patients on whom ERCP was performed from January 2017 to August 2021 and who had previous gastric surgery were included into the study. Age, sex, comorbidity, Charlson's Comorbidity Index (CCI), ERCP indication, previous gastric surgery (indication, type of resection and reconstruction), history of cholecystectomy, and MRCP results were evaluated retrospectively. The results were compared as successful ERCP (SERCP) or unsuccessful ERCP (USERCP). Also, odds ratio ERCP failure was also evaluated.

RESULTS

Forty-three patients were included into study. Mean age was 68.8 ± 13.6 years. The most common sex was female (51.2%). The most common ERCP indication was choledocholithiasis with 44.2%, gastric surgery indication was peptic ulcer with 72.1%, gastric resection was subtotal with 67.4%, and reconstruction was gastrojejunostomy with 58.1%. The success rate of ERCP was 44.2%. Mean CCI was 4.16 ± 2.28. Only malignancy history was significantly higher in the USERCP group (p= 0.026). Male sex, non-choledocholithiasis indication, history of malignancy, CCI> 4, total gastrectomy, Roux-NY (RNY) reconstruction, history of cholecystectomy, and intercalarily to the bile duct dilatation in MRCP were likelihood for USERCP.

CONCLUSION

While history of malignancy and cholecystectomy were the only significant factor for unsuccessful ERCP, male sex, total gastrectomy, RNY anastomosis result in a higher likelihood of ERCP failure in patients with previous gastric surgery. Alternative devices to side-viewing duodenoscope will increase success in selected patients.

Management of biliary stones in bariatric surgery

Morbidly obese and post-bariatric surgery patients are at increased risk for biliary stones formation. The complications related to biliary stones may impose complexity on their management. This study aimed to review the management of biliary conditions in obese and bariatric patients. In this study, a narrative review was performed of the medical, surgical, and endoscopic procedures for the management of biliary stones and their related complications. Knowing the main prophylactic and therapeutic interventions options is essential for clinicians to properly manage the biliary stones in patients candidates or submitted to bariatric surgery.

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.

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.

Utility of the Novel SpyGlass^TM DS II System and Laser Lithotripsy for Choledocholithiasis in Pregnancy

<b><i>Background and Aim:</i></b> Endoscopic retrograde cholangiopancreatography (ERCP) is considered a safe therapeutic modality even in pregnant women; however, adequate care needs to be taken. The utility of the SpyGlass^TM DS II system in choledocholithiasis among pregnant women is unexplored. <b><i>Methods:</i></b> We retrospectively analyzed patients who underwent<b><i></i></b>ERCP for choledocholithiasis in the absence of fluoroscopy using the SpyGlass DS II system from October 2019 to November 2020. Depending on the size and location of the stones, we used laser lithotripsy (LL) for large impacted stones, the balloon extraction technique for multiple stones, and the SpyGlass retrieval basket for single solitary stones. <b><i>Results:</i></b> A total of 10 (100% female) patients with a mean (±SD) age of 29.5 (±2.5) years underwent ERCP. Abdominal pain was the commonest presenting symptom in all patients. Four (40%) patients had cholangitis and 3 (30%) had pancreatitis. The majority of the patients (9; 90%) were in the second trimester. MRCP was the commonest radiological entity, used in 9 (90%) patients. ERCP was technically successful and the stones were removed from all of the patients in a mean (±SD) time of 30 (±3.5) min. LL was used successfully in 4 (40%) patients, balloon extraction in 3 (30%) patients, and the SpyGlass retrieval basket in 3 (30%) patients. There were no pre- or post-procedural complications. All of the patients had an uneventful childbirth, after which they underwent cholecystectomy and subsequent stent removal 2 weeks later. <b><i>Conclusions:</i></b> Use of the SpyGlass DS II system and LL during ERCP appears safe and effective for the treatment of choledocholithiasis among pregnant women.

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB)

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

Laparoscopic assisted ERCP in patient with Roux-en-Y gastric bypass. A case report

INTRODUCTION

Choledocholithiasis in Roux-en-Y patients is a therapeutic challenge for both surgeons and endoscopists. In fact, typical procedures, such as ERCP, can't be performed due to the altered anatomy of the patient. Nowadays, procedures on this kind of patient are performed not only in specialized bariatric centers, but, due to the increasing number of patients undergoing bariatric surgery, are starting to become more common even in smaller and non-specialized centers that don't possess the same expertise and technology.

CASE PRESENTATION

We present the case of a 33-year-old patient, who had already undergone bariatric surgery, and presented to our department with a diagnosis of choledocholithiasis. Due to the altered anatomy the patient was treated through a laparoscopic assisted ERCP.

DISCUSSION

A review of the need and proper timing for a cholecystectomy in this kind of patient, in order to prevent choledocholithiasis, is discussed. Moreover, a review of the literature regarding the possible treatments of this pathology in bariatric patients underlines the presence of other treatments, beyond the one performed in our department, that can be performed even in small non-specialized centers.

CONCLUSIONS

Prophylactic cholecystectomy is not recommended in bariatric surgery. Laparoscopic assisted-ERCP is a safe and feasible intervention which is to be preferred, even if B-ERCP and EDGE are two valid alternatives.

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.

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass

BACKGROUND

Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB.

METHODS

This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE.

RESULTS

Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004).

CONCLUSIONS

LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

The use of ursodeoxycholic acid (UDCA) to prevent gallstone formation after sleeve gastrectomy (SG) is still debated. Furthermore, no study has assessed the effectiveness of UDCA on gallstone formation after the first postoperative year. Our aim was to compare the incidence of cholelithiasis (CL) at 1 and 3 years after SG between patients treated or not treated with UDCA.

MATERIALS AND METHODS

From January 2008, a postoperative ultrasound monitoring was scheduled for all patients who underwent SG in our institution. Patients with a preoperative intact gallbladder who performed at least one ultrasound at 1 year after SG were included. We compared the incidence of CL between patients operated before October 2013 who did not receive UDCA and those operated from October 2013 who received UDCA 500 mg once daily for 6 months postoperatively.

RESULTS

The incidence of CL at 1 year after SG was 28% in the 46 non-treated and 3.5% in the 143 treated patients (p < 0.001). UDCA reduced the proportion of cholecystectomies from 11% to 1.4% (p = 0.012). Thus, the number of patients needed to treat to avoid a cholecystectomy was about 10. Only 2 patients (1.4%) stopped UDCA for adverse effects. No gallstone appeared at 3 postoperative years in the 61 patients who performed an ultrasound at this time.

CONCLUSION

UDCA 500 mg once daily for 6 months postoperatively is effective and well tolerated to prevent CL at midterm after SG. We recommend UDCA treatment in all patients after SG with an intact preoperative gallbladder. However, large randomized studies are needed to establish guidelines for prevention of gallstone formation after SG.

Cholelithiasis After Sleeve Gastrectomy and Effectiveness of Ursodeoxycholic Acid Treatment

Aim: Few adverse effects may occur after bariatric surgery, one being the formation of gallstones. The aim of this study is to determine the incidence of cholelithiasis after laparoscopic sleeve gastrectomy (LSG) and whether ursodeoxycholic acid (UDCA) treatment reduces gallstone formation. Materials and Methods: Gall bladders of all patients planned for LSG were preoperatively checked by ultrasonography (USG). Patients who had no documented gallbladder pathology before LSG and who had USG at 12th month and 2 years follow-up after LSG were included in the study. The incidences of newly developed cholelithiasis, cholecystectomy, and endoscopic retrograde cholangiopancreatography (ERCP) requirement in patients who did not receive any UDCA treatment (pre-2015 protocol, n = 128) was compared with the corresponding numbers in patients who regularly used 500 mg/day oral UDCA for 6 months after the LSG (post-2015 protocol, n = 152). Results: Between January 2012 and October 2018, 717 LSGs were performed in two centers and after exclusions, 280 patients were eligible for evaluation. Sixty-four of 280 (23%) patients developed cholelithiasis after LSG and cholecystectomy was performed in 24 patients (8.6%) for symptomatic cholelithiasis. In the non-UDCA group, 48 patients developed cholelithiasis (n = 48/128, 37.5%) compared with 16 patients in the UDCA group (n = 16/152, 10.5%) (P < .001). Compared with 5 patients in the UDCA group, 19 patients underwent cholecystectomy (39.6%) in the non-UDCA group due to symptomatic cholelithiasis (P = .55) and 5 of these patients also required an ERCP. No ERCP became necessary in the UDCA group (P = .2). Conclusions: An almost fourfold decrease in the rate of new gall stone formation with 500 mg daily UDCA treatment was impressive and may suggest routine UDCA treatment after LSG. Given the rate of exclusions and follow-up differences among the groups, certainly, randomized trials, with less exclusion are needed to provide conclusive evidence.

The advantages and disadvantages of sleeve gastrectomy; clinical laboratory to bedside review

Sleeve gastrectomy is a surgical technique and a leading method in metabolic surgery. Sleeve gastrectomy gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery and has proved to be a successful method in achieving considerable weight loss in a short time. There are some disparate effects that patients may experience after sleeve gastrectomy including a reduction in BMI, weight, blood pressure, stroke, and cancer and also a significant remission in obesity-related diseases including type 2 diabetes (T2D), Non-alcoholic fatty liver (NAFLD), cardiovascular disease, obstructive sleep apnea, and craniopharyngioma-related hypothalamic obesity as well as non-obesity-related diseases such as gout, musculoskeletal problems, ovarian disorders and urinary incontinence. The most common complications of sleeve gastrectomy are bleeding, nutrient deficiencies, and leakage. There are several studies on the impact of gender and ethnic disparities on post-operative complications. This study collects state of the art of reports on sleeve gastrectomy. The aim of this study was to analyze recent studies and review the advantages and disadvantages of sleeve gastrectomy.

Systematic review of management of gallbladder disease in patients undergoing minimally invasive bariatric surgery

The introduction and subsequent widespread adaptation of minimally invasive approaches for bariatric surgery have not only changed the outcomes of bariatric surgery but also called into question the management of co-morbid surgical conditions, in particular gallbladder disease. The American Society for Metabolic and Bariatric Surgery Foregut Committee performed a systematic review of the published literature from 1995-2018 on management of gallbladder disease in patients undergoing bariatric surgery. The papers reviewed generated the following results. (1) Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended. (2) In symptomatic patients who are undergoing bariatric surgery, concomitant cholecystectomy is acceptable and safe. (3) Ursodeoxycholic acid may be considered for gallstone formation prophylaxis during the period of rapid weight loss. (4) Routine preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients. In the era of minimally invasive surgery, the management of gallbladder disease in patients undergoing bariatric surgery continues to evolve.

Trans-Gastric ERCP After Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis

BACKGROUND

Trans-oral endoscopic access to the pancreaticobiliary system is challenging after Roux-en-Y gastric bypass (RYGB). Trans-gastric ERCP (TG-ERCP) has emerged as a viable option to manage patients with symptomatic post-RYBG choledocolithiasis. The aim of this systematic review and meta-analysis was to examine the outcomes of TG-ERCP to better define the risk-benefit ratio of this procedure and to guide clinical decision-making.

METHODS

A literature search was conducted to identify all reports on ERCP after RYGB. Pubmed, MEDLINE, Embase, and Cochrane databases were thoroughly consulted matching the terms "ERCP" AND "gastric bypass." Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were calculated using Freeman-Tukey double arcsine transformation and DerSimonian-Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I²-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders.

RESULTS

Thirteen papers published between 2009 and 2017 matched the inclusion criteria. Eight hundred fifty patients undergoing 931 procedures were included. The most common clinical indications for TG-ERCP were biliary (90%) and pancreatic (10%). The majority of patients underwent an initial laparoscopic approach (90%). Same-day ERCP was successfully achieved in 703 cases (75.5%). Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were 99% (95% CI = 98-100%), 3.1% (95% CI = 1.0-5.8%), 3.4% (95% CI = 1.7-5.5%), and 14.2% (95% CI = 8.5-20.8%), respectively.

CONCLUSION

TG-ERCP is a safe and effective therapeutic option in patients with symptomatic post-RYGB choledocolithiasis.

Laparoscopic Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Results at 5-Year Follow-up

BACKGROUND

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard treatment for morbid obesity. After LRYGB, the endoscopic access to the gastric remnant and pancreaticobiliary system is challenging. The laparoscopic gastric bypass with fundectomy and exploration of the gastric remnant (LRYGBfse) was introduced in an attempt to overcome this limitation. The purpose of this study was to analyze the medium-term outcomes and safety of LRYGBfse.

METHODS

Observational prospective single-arm multicenter cohort study. Patients with BMI > 35 kg/m² were included. Previous open abdominal surgery was an exclusion criterion. Postoperative 1, 2, 3, and 5-year weight loss, BMI decrease, and percentage of excess weight loss (%EWL) were recorded. Wilcoxon signed rank sum test was used for paired data.

RESULTS

Among 653 enrolled patients, 229 completed the 5-year follow-up. Preoperative median body weight (kg) and BMI (kg/m²) were 133.4 kg (interquartile range (IQR) = 12.0) and 48.2 kg/m² (IQR = 10.1), respectively. Median 5-year body weight, BMI, and %EWL were 83.7 (IQR = 17.3), 31.2 (IQR = 7.7), and 74.8 (IQR = 23.4), respectively, all significantly improved compared to baseline (p = 0.002, p = 0.001, and p = 0.012, respectively). Comorbid improvement or resolution was observed in 88% of the patients. No major intraoperative complications were reported. Postoperative overall morbidity and mortality rates were 1 and 0%, respectively. Banding removal was necessary in one patient 62 months after the index operation.

CONCLUSIONS

The LRYGBfse seems safe and effective with durable results at 5-year follow-up. Endoscopic exploration of the gastric remnant is an additional valuable tool.

Mini Gastric Bypass-One Anastomosis Gastric Bypass (MGB-OAGB)-IFSO Position Statement

PREAMBLE

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and/or endoscopic interventions in treating adiposity-based chronic diseases.The mini gastric bypass is also known as the one anastomosis gastric bypass. The IFSO has agreed that the standard nomenclature should be the mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB). The IFSO commissioned a task force (Appendix 1) to determine if MGB-OAGB is an effective and safe procedure and if it should be considered a surgical option for the treatment of obesity and metabolic diseases.The following position statement is issued by the IFSO MGB-OAGB task force and approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed in 2 years.

Patients Remain at High Risk of Gallstones Development Late (10 y) After Sleeve Gastrectomy?

BACKGROUND

Sleeve gastrectomy (SG) is an established bariatric procedure which produces substantial and rapid weight loss and hence can lead to an increase in gallstones development.

OBJECTIVES

To demonstrate the early and late appearance of gallstones after SG.

MATERIALS AND METHODS

A prospective protocol was established in consecutive patients submitted to SG. Clinical and ultrasound evaluations were performed early (1 to 2 y) and late after surgery (over 6 y).

RESULTS

From 109 patients included, 13 (13.1%) had a previous and 10 (10.1%) had simultaneous cholecystectomy at the time of SG. Therefore, 86 patients were submitted to surveillance. Seven patients were unreachable, leaving 79 patients for late follow-up. Forty-five patients (57%) had alithiasic gallbladder late after surgery, whereas 34 patients (43%) showed appearance of gallstone. From them, 53% developed gallstones late after surgery (mean, 7.5 y). Among the group with early development of stones, 69% were symptomatic and in the latter group only 17%.

CONCLUSIONS

Study with 92% of follow-up late after SG demonstrated a 43% development of gallstones: half earlier and half late after surgery. We emphasize the need for late control to detect the real appearance of gallstones after SG.

Management of complicated gallstones in the elderly: comparing surgical and non-surgical treatment options

Objective

The aim of this study was to evaluate the differences in clinical outcomes of endoscopic retrograde cholangiopancreatography (ERCP), ERCP followed by cholecystectomy (EC) and percutaneous aspiration (PA) in the elderly population with choledocholithiasis.

Methods

We included a total of 43 338 elderly patients aged 60 years or older and 45 295 patients younger than 60 years for comparison in our study. Data were obtained from the Nationwide Inpatient Sample (Healthcare Utilization Project) for years 2001–14 by identifying patients who were admitted for gallstone complications based on the ICD 9 diagnostic code. Multiple logistic regression was used to calculate the odds of in-hospital mortality and to detect statistical differences among the treatment groups, age groups and between male and female patients. Univariate ordinary linear regression was used to compare the length of hospital stay and readmission frequency among the different age groups.

Results

The age of the patient affected mortality and the length of hospital stay after any type of procedure of gallstones removal. In a manner independent of the patient’s age, PA was associated with the highest risk of death and length of stay, while the EC was characterized by lowest mortality and ERCP by the shortest length of stay. Neither age of the patient nor the type of procedure affected the likelihood of readmission. The odds of death and the probability of readmission were not affected by patient sex. However, in patients aged between 60 and 79 years, the female gender predicted a shorter duration of stay in the hospital.

Conclusions

A patient’s age negatively affects the treatment outcomes of cholelithiasis with associated complications. The EC procedure appears to be the method of choice for the management of complicated gallstones in patients of all ages.

First case report of bile leak from the duct of Luschka in a patient with mini-gastric bypass: The challenge of management

Introduction

The incidence of Bile duct injury after laparoscopic cholecystectomy approaches 0.11%–1.4%. Ducts of Luschka are the second most common site of bile leaks. The rarity of these ducts with cases of anatomical alterations in the gastrointestinal tract such as mini-gastric bypass makes the management a challenging option.

Presentation of case

Hereby we present a unique case of 28 year old female patient with mini-gastric bypass who had done uneventful cholecystectomy. Day 3 postoperatively patient complained of diffuse abdominal pain. Computed tomography showed free fluid in the abdomen. Liver enzymes were normal. Relaparoscopy showed leaking bile duct of Luschka, which was closed by surgical clips and drains left in the spaces. However bile leak continued for 4 weeks then stopped. Patient did well after all.

Discussion

Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. However no data were available using this method in a patient with Mini-gastric bypass procedure. Many authors have argued the role of relaparoscopy, but it is still an important way for adequate drainage and control of bile leakage. The only significant factor in determining clinical outcome in cases of non-surgical management is the type of bile duct injury.

Conclusion

To the best of our knowledge, this is the first case report of bile leak from duct of Luschka after mini-gastric bypass treated successfully with relaparoscopy and drainage. Herein we will discuss all the available options of treatment and the challenge of it.

•

The combination of Duct of Luschka in a patient with mini-gastric bypass is unique in the literature.

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The challenge of management especially endoscopic one puts a great pressure on both surgeons and gastroenterologists.

•

NO single data available in the literature in doing ERCP by any method in a patient with mini-gastric bypass.

The Type of Bariatric Surgery Impacts the Risk of Acute Pancreatitis: A Nationwide Study

Objective

We investigated whether vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass surgery (RYGB) have a differential impact on post-operative risk of acute pancreatitis (AP).

Methods

This retrospective study uses the 2012–2014 National Readmission Database. We compared morbidly obese patients who underwent VSG (n = 205,251), RYGB (n = 169,973), and hernia repair (HR) control (n = 16,845). Our main outcome was rates of AP within 6 months post- vs. 6 months pre-surgery in VSG, RYGB, and HR. We also investigated risk factors and outcomes of AP after bariatric surgery.

Results

The rates of AP increased post- vs. pre-VSG (0.21% vs. 0.04%; adjusted odds ratio [aOR] = 5.16, P < 0.05) and RYGB (0.17% vs. 0.07%; aOR = 2.26, P < 0.05) but not post-HR. VSG was associated with a significantly greater increase in AP risk compared to RYGB (aOR = 2.28; 95% CI: 1.10, 4.73). Furthermore, when compared to HR controls, only VSG was associated with a higher AP risk (aOR = 7.58; 95% CI: 2.09, 27.58). Developing AP within 6 months following bariatric surgery was mainly associated with younger age (18–29 years old: aOR = 3.76 for VSG and aOR: 6.40 for RYGB, P < 0.05) and gallstones (aOR = 85.1 for VSG and aOR = 46 for RYGB, P < 0.05). No patients developed “severe AP” following bariatric surgery.

Conclusions

More patients develop AP within 6 months after VSG compared to RYGB and controls. This risk is highest for younger patients and those with gallstones. Prospective studies examining mechanisms and prevention are warranted.

Morbidity of cholecystectomy and gastric bypass in a national database

Background

There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated.

Methods

Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored.

Results

There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1·35, 95 per cent c.i. 1·09 to 1·68; P = 0·006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2·02, 1·44 to 2·85; P &lt; 0·001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1·72, 1·14 to 2·60; P = 0·010). Simultaneous cholecystectomy added 61·7 (95 per cent c.i. 56·1 to 67·4) min (P &lt; 0·001) to the duration of surgery.

Conclusion

Cholecystectomy should be performed before, not during or after, RYGB.

Evaluation of incidence of cholelithiasis after bariatric surgery in subjects treated or not treated with ursodeoxycholic acid

BACKGROUND

The use of ursodeoxycholic acid (UDCA) to prevent gallstone formation after gastric bypass (RYGB) is still debated. Furthermore, only 1 study has assessed the effectiveness of UDCA after sleeve gastrectomy (SG) with mitigated results.

OBJECTIVES

To compare the incidence of cholelithiasis (CL) between patients treated or not treated with UDCA after RYGB and SG.

SETTING

University hospital, France.

METHODS

Since January 2008, a postoperative ultrasound monitoring was scheduled for all patients without previous cholecystectomy who underwent bariatric surgery in our institution. Patients who underwent at least 1 ultrasound in the first postoperative year (±6 months) were included. We started to systematically prescribe UDCA (500 mg/d) for 6 months postoperatively, in February 2012 for RYGB (once or twice daily) and in October 2013 for SG (once daily).

RESULTS

Mean follow-up was 13.0±3.4 months. The incidence of CL was 32.5% in the 117 nontreated RYGB and 25.5% in the 51 nontreated SG. It was reduced to 2.4% in the 42 SG treated once daily (P = .005), to 5.7% in the 87 RYGB with 250 mg twice daily (P<.001), but only to 18.6% in the 102 RYGB with 500 mg once daily (P = .03).

CONCLUSION

UDCA 500 mg once daily for 6 months is efficient to prevent CL 1 year after SG, but the twice-daily doses seem to be more effective after RYGB. The effectiveness of UDCA once daily after SG and the superiority of the twice-daily doses after RYGB should be confirmed with more patients and longer follow-up.