Sunday, September 23, 2007

Gallbladder, stones, sludge, and Gastric Bypass

Formation of gallstones or sludge in the gallbladder is known to increase with obesity and with rapid weight loss. According to one report, at 6 months, gallstones had developed in 36% and gallbladder sludge in additional 13% of patients

But another question is: What percentage of patients will actually develop symptoms or problems from gallstones or sludge after bariatric surgery? Well, reports quote anywhere from 3% to 30%.

There are different ways of dealing with the gallbladder, in relation to gastric bypass, and all of them are acceptable. A new trend in recent reports concluded no need to screen for gallbladder disease, based on the low incidence of patients who will actually have symptoms from gallstones after gastric bypass. Some reports will even not consider it necessary to remove a gallbladder with stones during a gastric bypass, because the majority of those with no symptoms before, will not develop symptoms after gastric bypass.

Many surgeons, however, still routinely order an ultrasound of the gallbladder before a gastric bypass. If abnormal, the gallbladder may be removed the same time of a gastric bypass. Surgical removal of the gallbladder is called "Cholecystectomy". Also, if a patient has symptoms of typical biliary pain, even if the ultrasound appears normal, a cholecystectomy may be considered.

Other surgeons routinely recommend the removal of the gallbladder at the time of a gastric bypass surgery, particularly with the open technique. If it is chosen that the gallbladder not be removed at the time of a gastric bypass, most will wait until symptomatic gallbladder disease develops, at which time the gallbladder would be removed (cholecystectomy). Some surgeons will ask patients to take a medication, Ursodiol (Brand Name: Actigall) to help lowering the chance of developing gallstones. One report documented a decrease in the incidence of development of gallstones from 32%, with no treatment to 2%. As you realize, there is no one unified approach.

The symptoms of gallstones or sludge after gastric bypass are not different from the general. In the most typical form, right upper quadrant pain in the abdomen, radiating to the back. However, there are so many variations of this typical picture.

Doing a cholecystectomy after a patient loses weight may be technically easier than during maximum obesity, and will almost always be covered by insurance companies when performed for symptoms. But, notice that treating gallstones, if they migrate to the common bile duct, is much more challenging after gastric bypass. The reason is that, after gastric bypass, patients can no longer have an endoscopic retrograde cholangiopancreatography (ERCP) performed in the usual manner. ERCP is a procedure performed using an endoscope, and allows the extraction of those migrating stones from the common duct, without a need to do surgical cutting into the abdomen. The procedure becomes much more difficult or impossible because the stomach has been completely divided, so the endoscope can no more be guided in the usual way from the stomach to the duodenum. Alternatives do exist, but none of them is that easy, nor the necessary set-up and expertise may be available. Therefore, after gastric bypass, a bigger operation, that is an open common bile duct exploration may be needed. Although the incidence of this particular challenging situation is low, it is still a significant occurrence for the individual unfortunate patient. This possibility needs also to be factored when deciding, weighing the benefits vs. the risks of removing the gallbladder along with a gastric bypass.