APPROACH TO GALL STONE DISEASE IN OBESITY Dr Girish juneja Head of surgery deptt. Specialist laparobariatric surgeon Al Noor Hospital, abu dhabi, uae

PREVALENCE IN GENERAL POPULATION Low(<0.05)in Africa & Asia Intermediate(10-30 %)in Europe & north America very high rates(30-70%) in native Americans. Gender F: M >1 Age women >50yrs times

GALL STONE DISEASE IN OBESITY There is higher incidence of gall stones disease in obese people as compared to general population BMI > 40 RR ratio 5-6 times of that background population Almost always cholesterol stones Lapbariatric surgery 2005(36)

Predisposing Factors Greater production of cholesterol Increased saturation index Decreased cholecystoskinin secretion & resistance

Predisposing Factors in obese Cholesterol super saturation Increased cholesterol, decreased bile acids & phospholipids Nucleating factors Increased glycoprotein increased mucin Gall bladder hypo motility Increased fasting & residual volume

Gall stones & RAPID WEIGHT LOSS Wt loss > 1.5 kgs or 1.5 % body weight / week VLCD <600kcal/day Low fat 1-3 g/d Incidence about 28% in 16 weeks *Band– 6.8% after 42 months *RYGB % within 1 yr obesity surgery2010

Predisposing Factors in obese *Dieting decreases bile salt secretion but not cholesterol secretion *Greater production of cholesterol * Decreased cholecystoskinin secretion & resistance *Duodenal loop bypass *Possible severing of hepatic branch of the vagus nerve during surgery

Cholesterol gall stones Unilamellar cholesterol micelles mutilamellar vesicles crystal nucleation Microcrystals overt gall stones

Management approach Symptomatic gall stones Concomittant cholecystectomy Normal gall bladder & asymptomatic gall stones controversial

Management approach 1. Do not let problems arise Protocols of fobi et al 2. Do not look for problems 3. Treat to test

Management I.The most aggressive is the concomitant cholecystectomy for all patients this prevents the potential complication of future gallstones and a second surgery, Recent reports shows no significant increase in-- morbidity It may reduce cost Poor sensitivity of USG in obese people Biliary causes may be difficult to diagnose after RYGB

Routine cholecystectomy (85.1%) abnormal histologic findings (14.7%)- normal gall bladder Gall bladder disease more frequent than reported(91.3%) Diagnostic studies are frequently inaccurate Postop Gall stone disease (28.7%) Amaral Am j surg1985apr;149

Management II. Concomitant cholycestectomy only for patients who have gallstones

Management III. Treat bariatric patients in the same manner as the general population

ASMBS Survey 32.5% - Surgeons perform concomitant cholecystectomy 7% - For gastric restrictive procedures 100% - For combined restrictive – malabsorptive procedure

procedure specific risk RYGB Rapid weight loss Median likelihood of forming new gallstones is 40% High incidence of new gall stones development after surgery No option of routine ERCP 40% of these have symptomatic disease 70 % failure of full compliance with preventive ursodiol tr. paul obrien arch surg.2003;138

procedure specific risk GASTRIC BAND Only 6.8 % at risk of syptomatic disease at a median follow up of 42 months paul obrien arch surg.2003;138

Factors to consider Surgical approach is also relevant. Open & laparoscopic Additional time 30 – 50 mts of operating time Length of stay increased from 2.7 days to 4.4 days Potential for the full range of complications that may occur with cholecystectomy paul obrien arch surg.2003;138

Risk factors during weight loss Relative weight loss greater than 1.5 kg/week Very low calorie diet with no fat Very long overnight fast period High serum triglyceride levels Eur j gastroenterol 2000dec12(12)

Preventive measures Ursodeoxycholic acid Control of weight loss Reduction of length of overnight fast period maintenance of small amount of fat in the diet Eur j gastroenterol 2000dec12(12) Haptology 1996sep;544

Ursodeoxycholic Acid (URSODIOL) 300 mg BID x 6 months Decreasing biliary cholesterol and glycoprotein secretion Mildly increased induction and bile acid R. studies have shown decrease in risk of sypmtpmatic cholecystitis from 40% to 4%

OWN RESULTS 129 cases (jan 2009nov 2012) Lap band- 24 LSG-48 GASTRIC BYPASS-57

our Own results PREOP GALL STONES 3 POSTOP GALL STONES symptomatic 3 Asymptomatic

Morbidly obese with intact gall bladder Purely restrictive procedure Combined restrictive- malabsorptive procedure Without concomitant cholecystectomy With concomitant cholecystectomy Normal gallbladder Observe for biliary pain Cholecystectomy Asymtomatic radiolucent gallstone Ursodeoxycholic acid Observe for biliary pain Cholecystectomy Without concomitant cholycestectomy Ursodeoxycholic acid Observe for biliary pain Cholecystectomy With concomitant cholycestectomy

In formulating policy regarding the investigations & management of the gallbladder in obesity we must incorporate recognition of the likelihood of disease in the future & the health consequences of that disease balanced against the cost & risk of the treatment conclusions

CONCLUSIONS There is significantly increased risk of gallstone disease in obese people compared with that in the general population. There are different approaches for managment the type of bariatric procedure chosen affects these approaches Prospective randomized trials about these approaches needed to determine superiority.

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