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

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 POPULATIONLow(<0.05)in Africa & AsiaIntermediate(10-30 %)in Europe &

north America very high rates(30-70%) in native

Americans.Gender F: M------------------ 2>1Age women >50yrs----------- 3times

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 obeseCholesterol super saturation

Increased cholesterol, decreased bile acids & phospholipids

Nucleating factors Increased glycoprotein increased mucin

Gall bladder hypo motilityIncreased 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/dIncidence about 28% in 16 weeks*Band– 6.8% after 42 months *RYGB--- 36 -53% 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 o’brien 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 o’brien 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

o’brien 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 2009—nov 2012)

Lap band- 24 LSG-48 GASTRIC BYPASS-57

our Own results

PREOP GALL STONES 3

POSTOP GALL STONES 4--- 1 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.

THANK YOU