Compression/palpation of gallbladder during WLS

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IBSR Newsletter

Winter 2000 Volume 15, number 4

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Concurrent Cholecystectomy with Obesity Surgery

by Eaton Mason MD, Ph.D.

Cholesterol is insoluble in water and depends upon sufficient bile

salt and phospholipid in bile to prevent stone formation. In the

morbidly obese, there is a higher concentration of cholesterol than

can be maintained in solution in bile.1 Such bile is called

lithogenic. Excessive production and secretion of cholesterol into

the bile is the cause of the lithogenicity in obese humans rather

than a depletion of the bile salt pool.2 Normal weight humans have

lithogenic bile only during periods of fasting but the morbidly obese

have lithogenic bile all of the time. During rapid weight loss there

is a further increase in cholesterol secretion into bile and an

increase in stone formation. It is possible to administer extra bile

salt to prevent gallstone formation during the period of rapid weight

loss following gastric reduction operations.3,4 Some surgeons have

recommended that the gallbladder be removed concurrent with an

operation for reducing weight.5

The most recent IBSR Pooled Report [14(2)] examined 8,097 primary

operation patient's records. It was found that cholecystectomy had

been performed prior to surgical treatment for obesity in 18.7 % of

patients, concurrent in 41% and no cholecystectomy in 40.3%. The

frequency of routine cholecystectomy varied in the different

surgeon's data sets. Five data sets showed 93.5% or more of their

patients undergoing cholecystectomy. This indicates that normal

appearing gallbladders were removed, i. e. prophylactic removal.

Five other sets showed less than 12%. Eight sets varied in the

frequency of cholecystectomy from 20 to 65.5%. There was an increase

in frequency of concurrent cholecystectomy during the years of 1997

to 1999, 54.7%, 57.5% and 60.3% respectively. An increase in more

complex procedures was also noted for that time period.

In order to increase the number of surgeons sampled, an e-mail

questionnaire was sent to 372 ASBS members. Over 30% responded

(n=123). Thirty-seven of the 123 surgeons (30%) remove all

gallbladders, whether or not stones are present. Eighty-three

surgeons (68%) only remove gallbladders when stones are present or

when there are other abnormalities such as adhesions or

cholesterolosis. One surgeon stated that he removed normal appearing

gallbladders if the patient was over 400 pounds because he did not

want to be faced with the need for an emergency cholecystectomy while

the patient was still morbidly obese.

The type of obesity operation has some influence upon the frequency

with which normal gallbladders are removed. Only one of 11 surgeons

using simple restrictive operations removes normal gallbladders. For

the most malabsorptive gastric reduction operations, prophylactic

cholecystectomy is a part of the operation. Scopinaro has always

recommended prophylactic cholecystectomy for patients undergoing

biliopancreatic diversion (BPD). Routine cholecystectomy is

practiced by all eight of the surgeons in our survey who indicated

that they were using the duodenal switch modification of BPD. Two

surgeons indicated that they perform distal gastric bypass, which is

similar to BPD and both remove all gall bladders.

Ninety-four surgeons indicated that they use RGB (33) or a complex

operation (61). Of these 94 surgeons, 28 (30%) remove all

gallbladders even if they appear normal. One surgeon, who uses

jejunoileal bypass (JIB) with drainage of the bypassed bowel into the

stomach, does not remove normal appearing gallbladders.

If " normal gall bladders " are to be left in place it is important to

determine whether or not there are small gallstones. Our

questionnaire asked whether compression of the gallbladder during the

operation was used to empty the bile, to make it possible to palpate

small stones that might otherwise be missed. Eighteen surgeons (15%)

indicated that they used intraoperative compression of the

gallbladder. Nineteen (15%) made a note in the operative report

regarding the absence of stones when they left a normal appearing

gallbladder. There were five surgeons who reported compression of

the gallbladder for the examination for stones but did not record

this in the operative note. There were six other surgeons who did

not empty the gallbladder by compression but recorded the absence of

palpable stones in the operative note. When stones are discovered

during the early postoperative period, the question is likely to be

asked, " were gallstones missed at the time of the operation for

obesity. " If there is documentation in the operative note that the

gallbladder was emptied by compression and no stones could be felt,

it is strong support for the conclusion that stones were formed

during rapid weight loss.

Questions about using preoperative and intraoperative ultrasound were

not asked but some surgeons volunteered information about such use.

Six surgeons indicated that they used preoperative ultrasound. Three

used intraoperative ultrasound. Two surgeons commented that they

ordered Ursodiol for 6 or 12 months if the gallbladder was left in

place. It was also suggested that a specific question about Ursodiol

use should have been included. This is under consideration for a

follow-up questionnaire.

A pattern has developed of removing normal gallbladders when the

obesity operation includes extensive bypass of small bowel or leaving

normal gallbladders in place when the operation is a simple

restriction procedure. When a standard RGB is performed, there is no

consensus regarding removal of normal appearing gallbladders. The

observations of what surgeons are doing does not provide the most

important information. That is - what is the consequence of

removing or leaving in place a normal appearing gallbladder. Mooney

and performed routine cholecystectomy concurrent with VBG.

They found that only 27% of the gallbladders removed were normal.6

The consequences of leaving a normal appearing gallbladder is

important to patients who are deciding about their operative consent.

1. Freeman JB, Meyer PD, Printen KJ, Mason EE, DenBesten L.

Analysis of gallbladder bile in morbid obesity. American Journal of

Obesity 129: 163-166, 1975.

2. Mabee TM, Meyer P, DenBesten L, Mason EE. The mechanism of

increased gallstone formation in obese human subjects. Surgery 79:

460-468, 1976.

3. Worobetz LJ, Inglis FG, Shaffer EA. The effect of

ursodeoxycholic acid therapy on gallstone formation in the morbidly

obese during rapid weight loss. American Journal of

Gastroenterology 88: 1705-1710, 1993.

4. Sugerman HJ, Brewer WH, Shiffman ML, etal. A multicenter,

placebo-controlled, randomized, double-blind, prospective trial of

prophylactic Ursodiol for the prevention of gallstone formation

following gastric-bypass-induced rapid weight loss. American Journal

of Surgery 169: 91-97, 1995

5. Schmidt JH, Hocking MP, Rout WR, Woodward ER. The case for

prophylactic cholecystectomy concomitant with gastric restriction for

morbid obesity. American Surgeon 54: 269-272, 1988.

6. Mooney MJ, PL. Routine cholecystectomy in the morbidly

obese. Military Medicine 154: 409-411, 1989.

WEB SITES

Web sites with information about obesity surgery are " cropping up

like weeds " on the Internet. But, what information is reliable and

accurate? When patients call the IBSR for clarification, we

recommend the following web sites:

www.asbs.org This is the official web page of the American Society

for Bariatric Surgery. It provides patients a summary of bariatric

surgery, has sections by noted authorities in the field and provides

a list of ASBS surgeons by state for patients to contact.

www.niddk.nih.gov/health/nutrit/win.htm The National Institute of

Diabetes and Digestive and Kidney Disease (NIDDK) " Weight-control

Information Network (WIN) " has information about surgical treatment

for obesity. Click on Weight Loss & Control, then Gastric Surgery

for Severe Obesity and you will find the 1994 version of the ASBS

booklet " Surgery for Severe Obesity, What Patient's Should Know. "

Original drawings were produced by Tom Weinzerl, MFA, at the

University of Iowa.