Elective cholecystectomy after Roux-en-Y gastric bypass: why should asymptomatic gallstones be treated differently in morbidly obese patients?

BACKGROUND: Gallbladder management in bariatric surgery varies. Some surgeons perform routine cholecystectomy with bariatric surgery, and others selectively base that decision on routine preoperative ultrasound findings. Both approaches treat bariatric patients differently than the normal-weight population in whom cholecystectomy is not performed in asymptomatic patients. We hypothesized that it is possible to apply the commonly used indications for cholecystectomy in the nonobese population safely to a Roux-en-Y gastric bypass cohort.

METHODS: Data were collected prospectively and retrospectively on consecutive patients at our center undergoing Roux-en-Y gastric bypass from April 1, 2003 to March 31, 2004. Asymptomatic patients underwent neither preoperative gallbladder ultrasonography nor concomitant cholecystectomy. Age, body mass index, gender, length of follow-up, compliance to ursodiol therapy for 6 months, need for subsequent cholecystectomy, complications, and pathologic diagnoses were recorded.

RESULTS: A total of 692 primary Roux-en-Y gastric bypass procedures were performed, of which 661 (95.5%) were completed laparoscopically. Complete data were collected on 417 patients (60.3%). A total of 98 patients (23.5%) had had prior or concomitant cholecystectomy and were excluded from additional study. Of the remaining 319 patients, 47 (14.7%) required subsequent cholecystectomy and 272 (85.3%) did not. The risk of subsequent cholecystectomy correlated inversely with the duration of ursodiol prophylaxis. All pathologic specimens had cholecystitis but gallstones were present in only 48.8%. Two complications (abscess and port-site bleed) occurred, but no common duct stones developed and no patient died. The mean follow-up was 7.5 months (range 13-25).

CONCLUSION: Asymptomatic gallstones in bariatric patients may be treated safely with secondary cholecystectomy. After a 6-month regimen of ursodiol prophylaxis, 14.7% will require subsequent cholecystectomy. Asymptomatic gallstones in the bariatric patient may be safely managed identically to those in the nonobese population.