Evaluation of the Effect of Laparoscopic Sleeve Gastrectomy on Gallstones in Shiraz

Abstract

Background:

Obesity can be associated with comorbidities such as hypertension, diabetes, and fatty liver. Cholelithiasis has a prevalence of 19–45% worldwide in obese individuals. This study was conducted to evaluate the effect of weight loss on gallstone formation.

Methods:

This is a retrospective review of prospectively collected database from 276 patients (220 females and 56 males) who underwent laparoscopic sleeve gastrectomy (LSG) from September 2009 until April 2014 in Shiraz, Iran.

Results:

The patients' mean age was 35.7 ± 0.6 years and mean body–mass index (BMI) was 44.3 ± 0.4 kg/m². Preoperatively, there were 171 (61.9%) patients with fatty liver and 15 (5.4%) patients with gallstone before weight loss. Postoperatively, 5 (1.8%) patients became symptomatic without preoperative cholelithiasis. Gallstone was seen with a higher percentage in female patients (95%). Weight loss after 1, 3, 6, and 12 months was similar in patients with gallstone and other patients.

Conclusions:

LSG leads to weight loss and resolution of comorbidities. Routine concomitant cholecystectomy could be considered in patients who have developed symptomatic gallstone. This study showed that there were fewer patients with cholelithiasis in comparison with other studies and it could be the effect of prophylactic consumption of ursodiol. In addition, time and amount of weight reduction are essential components of their management.

Introduction

In recent years, development of laparoscopic sleeve gastrectomy (LSG) as a bariatric surgery is more progressive, being applied to morbid obese patients and approved as an effective method for weight loss in the short term.¹ Obesity is linked to conditions such as type 2 diabetes, hypercholesterolemia, cardiopulmonary complications, hormonal disturbances, liver diseases, cholelithiasis, pancreatitis, cholecystitis, and cholecystectomies.² Gallstone rates were significantly increased in morbidly obese compared with normal body–mass index (BMI), particularly in women. In Iran, it was shown that obese women (BMI ≥30 kg/m²) had a twofold excess risk for gallstone and extremely obese women (BMI >45 kg/m²) had a sevenfold excess risk of symptomatic gallstones than normal ones.³

However, there is an increased risk of gallstone formation after bariatric surgery due to rapid weight loss, especially more than 25% of the original weight.^4,5 Cholelithiasis and sludge formation occur after bariatric procedures due to cholesterol oversaturation in the bile.² In addition, diminished dietary intake of cholesterol and changes in hepatic cholesterol synthesis and bile acid secretion may consequently result in gallstone formation.^6,7 Gallstones are reported in 6.8% of patients after gastric banding.² In addition, some investigations reported asymptomatic gallstones (30–52.8%) after 6–12 months and symptomatic gallstones (7–16%) after gastric Roux-en-Y bypass (RYGB) surgery.^4,8–11

A Swedish study demonstrated a fivefold increase in the possibility of gallstone after bariatric surgery in comparison with general population.⁸ The use of ursodeoxycholic acid has been proposed as a preventive factor for gallstone formation,^10–12 while cholecystectomy is another routine prophylactic performance.^13,14 Regarding the management of cholelithiasis at the time of bariatric surgery, concomitant cholecystectomy is the concern for postoperative biliary system access.¹⁵

However, there are few data on outcomes of LSG in obese patients with gallstone and the management of gallstones at the time of LSG is under debate. This is a retrospective study on prospectively collected data to determine the incidence of complicated gallstone disease after LSG and it is designed to show the outcomes of obese patients with gallstone before and after the surgery. In addition, we determined the impact of weight loss on the outcome of patients with metabolic or cardiovascular disorders and other comorbidities.

Methods

This is a retrospective analysis of data from 276 patients (220 females and 56 males) who underwent LSG in Shahid Faghihi and Madar-va-Kodak Hospitals, Shiraz, Iran. The patients were evaluated for bariatric surgery by a multidisciplinary team of psychologist, nutritionist, surgeons, and sport medicine physicians. Demographics, medical records, time from surgery, gallstone, and other comorbidities were reviewed.

Each patient was carefully evaluated in our multidisciplinary meeting and inclusion criteria were defined according to the NIH consensus: the patients were medically candidates for LSG and written informed consent was obtained.¹⁴ Exclusion criteria included age less than 18 years or more than 65 years, patients with 35 ≥ BMI ≥65 kg/m², patients with psychiatric disorders, history of substance abuse, and high operative risk.

Transabdominal ultrasound was performed in all patients preoperatively to find gallstones or sludge.

According to our protocol, ursodeoxycholic acid was used in all patients postoperatively for 6 months and patients with cholelithiasis underwent simultaneous laparoscopic cholecystectomy. The patients were interviewed in follow-up appointments and all signs and symptoms related to gallbladder disease were also recorded for at least 6 months postoperatively. The consent was obtained from the patients.

The study was approved by the ethics committee of Shiraz University of Medical Sciences, Shiraz, Iran. Statistical analysis was performed using the software, SPSS 16 (SPSS Inc., Chicago, IL). Quantitative variables are presented as mean ± standard error of means or range. Qualitative data are presented as absolute frequencies and proportions.

Results

All these patients had a mean age of 35.7 ± 0.6 years (range 18–64 years) and a mean BMI of 44.3 ± 0.4 kg/m² before surgery (Table 1). Patients in this study were predominantly female (80%). The median follow-up was 15 months (range 8–65 months).

Table 1.

Overall Outcome of Two Groups of Patients with Comorbidities and Characteristics (Mean ± SE of Mean)

Comorbidity	Patients without gallstone (n)	Patients with gallstone (n)	p-Value
Gender			0.075
Male	55	1
Female	201	19
Age (year)^a	35.6 ± 0.6 (range 18–64)	37.6 ± 2.0 (range 26–50)	0.385
BMI (kg/m²)^a	44.0 ± 0.5 (range 25.0–66.9)	46.6 ± 1.3 (range 39.6–62.0)	0.099
Sleep apnea	34 (13.3%)	6 (30%)	0.043
Fatty liver	159 (62.1%)	12 (60%)	0.687
COPD or asthma	13 (5.1%)	3 (15%)	0.057
Jaundice	9 (3.5%)	2 (10%)	0.147
Peptic ulcer	10 (3.9%)	3 (15%)	0.017
Thyroid disorders	27 (10.5%)	4 (20%)	0.170
PCO	20 (7.8%)	8 (40%)	0.002
Diabetes	13 (5.1%)	3 (15%)	0.04
Hypertension	36 (14.1%)	6 (30%)	0.025
Chronic constipation	50 (19.5%)	6 (30%)	0.249
Reoperation	12 (4.7%)	0	0.221
Smoker	50 (19.5%)	2 (10%)	0.927
Cholecystectomy while operation	0	3	<0.001
Bleeding during operation	11	1	0.897
Leakage	3	0	0.623
Conversion rate to open surgery	4	0	0.570
Wound infection	4	1	0.276
GBS after 6 months	0	3	<0.001

Mean and SD of mean.

Pearson chi-square test for qualitative data and t-test for quantitative data were used.

BMI, body–mass index; COPD, chronic obstructive pulmonary disease; GBS, gallbladder stone; PCO, polycystic ovaries; SE, standard error.

Of all patients, 15 females preoperatively were diagnosed as the patient with gallstone based on their clinical evaluation and sonography and five patients with no evidence of gallstone disease preoperatively presented with complicated cholelithiasis after surgery. Therefore, preoperative evidence of gallstone was shown in 5.4% of them. Prior cholecystectomy was performed in 12 patients and other patients used ursodiol as drug therapy. No patient underwent cholecystectomy indicating the post-LSG effect. Consequently, post-LSG cholecystectomy was performed in four patients due to symptoms of those with preoperative normal gallbladders.

Diabetes was detected in 16 patients based on their FBS before surgery and 100 patients had a family history of diabetes. Three patients with cholelithiasis had diabetes and seven of them had family history of diabetes. Diabetes was cured in five patients and dose of their drugs in most of them decreased after LSG. Hypertension was seen in 42 patients and 124 patients had a family history of hypertension. Six patients with cholelithiasis had hypertension and 12 of them had family history of hypertension. Hypertension was cured in four patients and became better in three more patients after LSG.

Discussion

Since the introduction of LSG into the bariatric armamentarium, it has become the most popular procedure in Iran, similar to worldwide trends. LSG is an effective procedure to reduce weight in obese patients and it improves comorbidities such as diabetes or hypertension.⁸ In our series, regarding preoperative evidence of diabetes and hypertension, some patients were cured or needed less medication after weight loss. The aim of our study was to find the effects of LSG on gallstone outcome. Prevalence of cholelithiasis varies between 19% and 45%, and 11–23% of patients have undergone cholecystectomy before bariatric surgery¹⁵; 5.4% of our patients were defined with preoperative gallstone and previous cholecystectomy was performed in 4.3% of our patients. These data show that the prevalence of cholelithiasis in our obese population is less than other studies. The main concerns after surgery are the interval between surgery and weight reduction. Following LSG, there is a rapid weight loss that typically continues for at least 1 year (Table 2). The mean percentage of excess weight loss after 6 months was 62.89% and patients with gallstone had a mean percentage of excess weight loss of 70.29%. Lakdawala et al. and Rosenthal et al. have reported a mean percentage of excess weight loss of 50.8% and 52.8% at the end of 6 months, respectively. Baltasar et al. have also reported a mean percentage of excess weight loss of 56.1% from 4 to 27 months after surgery.¹⁶

Table 2.

Mean WL (kg) After Sleeve Gastrectomy in Different Periods: Mean ± SE of Mean, No Significant Difference Between Groups Using T-Test

Parameter	Patients without gallstone	Patients with gallstone	p
Weight before	121.50 ± 1.57	127.05 ± 4.64	0.329
WL after 1 month	13.17 ± 0.67	13.43 ± 1.12	0.894
WL after 3 months	24.15 ± 1.29	23.25 ± 1.63	0.796
WL after 6 months	37.21 ± 2.18	39.77 ± 3.64	0.624
WL after 12 months	41.82 ± 3.17	45.14 ± 5.57	0.676

WL, weight loss.

In our study, preoperative transabdominal ultrasound was obtained from all patients. Elective cholecystectomy was performed in patients with preoperative evidence of symptomatic gallstone. In our study, four patients (1.8%) underwent subsequent cholecystectomy after LSG and just one patient with cholelithiasis did not undergo operation, which is not comparable with the rates seen in other studies.^2,4,17,18 Various studies have shown the rate of 20–52.8% asymptomatic gallstone formation 6–12 months after gastric bypass.^2,4,17,18 Arias et al. reported that 3.8% of patients developed symptomatic gallstones postoperatively, while 1.8% had symptoms of gallstones before surgery.⁶ Li et al. reported the same results for symptomatic gallstones after LSG, indicating that they required medical attention and surgical intervention.⁵

There have been many publications discussing the management of gallstone in RYGBP, but only a few have focused on LSG. The use of ursodeoxycholic acid has been accepted for prevention of the gallstone formation.¹⁹ It seems to be cost-effective, although it lessens the amounts of postoperative cholecystectomy and reduces the hospital stay; it was concluded that the prescription of ursodiol is preferred after bariatric surgeries.

Swartz and Felix followed the patients who used ursodeoxycholic acid prophylactically after bariatric surgery for 6 months and 14.7% of them required subsequent cholecystectomy. They reported that asymptomatic gallstones in bariatric patients were managed similar to the nonobese population by using ursodiol.¹² Compliance with this drug was associated with lower rates of gallstone or sludge formation. Our results showed that our patients received ursodiol for 6 months postoperatively and it was associated with significantly lower rates of gallstone development. However, in three patients with cholelithiasis, who used only drug before surgery, after the LSG, they had problem and it seems that they should have concomitant surgery for cholecystectomy because the drug just hid the symptoms. LSG permits unhindered access to the biliary system, allowing simple ERCP, when indicated for symptomatic gallstones.¹⁵ More studies are needed to establish a standard guideline for prevention of gallstones in LSG patients.

Limitations

Many patients had asymptomatic gallstones that would not have been discovered clinically if an ultrasound had not been ordered. Furthermore, although our follow-up rate is high for the first year (median follow-up was 15 months), it drops the number of patients as time progresses, perhaps causing underestimation of subsequent gallstone in our patients.

Conclusion

In conclusion, we believe that LSG is an effective procedure to achieve weight loss in the short term in the morbidly obese cases. The time interval between surgery and weight reduction is mandatory to prevent nutritional deficiencies and gallstone formation. Routine concomitant cholecystectomy could be considered when development of complications is short in symptomatic or nonsymptomatic gallstone. Ursodiol can prevent gallstone formation after LSG and it is recommended to be administered at least 6 months postoperatively.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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