More Biliary Disease With Laparoscopic Bariatric Surgery

Megan Brooks

October 11, 2018

PHILADELPHIA — The shift from open bariatric surgery to laparoscopic surgery over the past decade has led to an increase in biliary disease, results from a retrospective study suggest.

"Obviously, we don't suggest switching back to open bariatric surgery — laparoscopic surgery is much safer for patients overall — but providers need to be cognizant that biliary complications can occur after laparoscopic bariatric surgery," said investigator Violeta Popov, MD, PHD, from the VA NY Harbor Healthcare System in New York City.

Rapid and dramatic weight loss of any kind, whether surgical or nonsurgical, is known to result in a predisposition for gallstones. Therefore, during the open surgery era, as a prophylactic measure, gallbladders were typically removed during the bariatric procedure. This required only minimal additional anesthesia time and exposed the patient to a minimal risk for additional complications.

However, with the advent of laparoscopic bariatric surgery, concomitant cholecystectomy with declined.

"Laparoscopic bariatric surgery became increasingly common from 2006 to 2014, and with this technique the gallbladder is left in place," said lead investigator Andrew Thompson, from NYU School of Medicine in New York City, who presented the study results here at the American College of Gastroenterology 2018 Annual Scientific Meeting.

"We hypothesized and showed that this is related to an increased risk of developing biliary disease," he told Medscape Medical News.

Using the National Inpatient Sample database, Thompson and Popov assessed the number of bariatric surgery patients admitted to the hospital for acute pancreatitis, acute cholecystitis, acute biliary cholangitis, or cholecystectomy in 2006 and 2014.

In those 2 years, 135,980 patients were admitted for acute cholecystitis, 98,098 for acute biliary cholangitis, and 782,395 for acute pancreatitis, and 861,549 underwent cholecystectomy.

Patients who had undergone bariatric surgery were 10- to 100-fold more likely to be admitted for any of the gallstone-related biliary diseases in 2014 than in 2006.

Table. Number of Cases of Biliary Disease After Bariatric Surgery
Condition 2006 2014
Acute cholecystitis 65 740
Acute cholangitis 36 530
Acute pancreatitis 380 4630
Cholecystectomy 738 6050

The researchers acknowledge that there could be other factors affecting the rate of biliary disease in bariatric surgery patients, and note that some of the increase seen from 2006 to 2014 might be related to the overall increase in the prevalence of obesity.

Limitations of the study include its retrospective design and its reliance on coding data. The ICD-9 code for bariatric surgery became available in 2006; thus, over time, the use and recognition of this code could have increased, the authors say. Also, the data only reflect index admissions, not readmissions.

"Of course, more research is needed and we hope our study will prompt further investigation," said Popov. "But we think that both physicians and patients should be aware that there is a risk of developing biliary disease after laparoscopic bariatric surgery."

"Gallstones typically develop in the first few months during the period of rapid weight loss," she added. "Patients should take the medication ursodiol, which is commonly prescribed after bariatric surgery to prevent gallstones and has been proven to decrease the frequency of gallstone formation." She acknowledged, however, that compliance with this medication "is an issue."

"Suspected and Expected"

"This is an interesting abstract that confirms what bariatric surgeons have suspected, and expected, for many years," said Samer Mattar, MD, from Swedish Weight Loss Services in Seattle, who is president of the American Society for Metabolic & Bariatric Surgery.

Once laparoscopic principles were adopted, "it became much more complex to perform concomitant cholecystectomy because standard trocar sites were not amenable to cholecystectomy," he explained. "Moreover, several studies highlighted the additional cost, increased risk of complications, and increased length of hospital stay associated with concomitant cholecystectomy, such that the overall risk–benefit ratio was not an advantage for concomitant cholecystectomy, especially as a prophylactic measure."

But "the more important findings of this study are the fact that [laparoscopic] bariatric surgery is associated with lower inpatient mortality, lower length of stay, and lower overall cost," said Mattar.

The study had no commercial funding. The authors and Dr Mattar have declared no relevant conflicts of interest.

American College of Gastroenterology (ACG) 2018 Annual Scientific Meeting: Poster 1610. Presented October 8, 2018.

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