病態性肥胖病人,具有沒有症狀的膽結石,進行減重手術時,需要併行膽囊切除術嗎? 成大醫院之經驗分享 黃建璋 李國鼎 國立成功大學醫學院附設醫院 一般外科

GALLSTONE RISK FACTORS Fasting and rapid weight loss  Bile stasis Symptomatic cholelithiasis after bariatric surgery 7-15%, Difficulty in cholecystectomy after bariatric surgery Increased morbidity Hospital stay Bariatric surgery is a well-established risk factor for cholelithiasis, due to predisposition of cholesterol gallstone formation and neurohormonal regulation of gallbladder contractility in the obese population

Question Is it necessary to perform concomitant cholecystectomy with bariatric surgery when asymptomatic cholelithiasis preoperatively? Risk factors? Suggestion??

成大醫院代謝暨減重手術個案-人數統計 術前檢查 陽性：36人 陰性：257人 術中合併LC 是 17人 否 19人 0人 257人 手術日期：2009年1月~2017年12月; 男:女=137:167 (收案數) 術前檢查 陽性：36人 陰性：257人 術中合併LC 是 17人 否 19人 0人 257人 術後有症狀 1人 18人 24人 239人 術後檢查 陽性 23人 陰性 1人* 術後接受LC 10人 13人 術前接受腹部超音波或腹部電腦斷層檢查人數：293 術前檢查為陽性(有GB stone、sludge或polyp)人數共36人，其中17人於接受減重手術時合併進行膽囊切除手術。在未接受膽囊切除手術的19人中，僅1人於減重術後出現膽囊炎症狀並接受膽囊切除手術，其餘18人減重術後至今皆未出現症狀 術前檢查為陰性(無GB stone或sludge)人數共257， 18人於接受減重手術後出現腹痛(與GB stone或sludge相關)症狀，其中6人接受膽囊切除手術，12人觀察 *影像報告為正常，但有症狀反覆出現，術後檢體亦有發現

Adjustable gastric banding 術式 Adjustable gastric banding Sleeve gastrectomy Mini-gastric bypass 人數 (N) 1 M=1 F=0 11 M=2 F=9 12 M=10 F=2 術後症狀出現時間(M) 31 平均 14.0 中位數 10.5 (0.6~39.5) 平均 16.5 中位數 13.8(0.6~81) Weight loss ( Kg ) 44.4 平均 35.0 中位數 37.4 (9.7~59.5) 平均 40.7 中位數 47.8 (8.3~77.6) EBW loss ( % ) 36.1 平均 59.2 中位數 57 (17.6~109.8) 平均 59.4 中位數 69.3 (14~91.6) 減重術後 LC人數(N) 1 (100%) 7 (63.6%) 3 (25%)

LITERATURE REVIEW M. S. Altieri et al. (subsequent cholecystectomy) Female and younger age are more likely (35 y/o) AGB & RYGB are less likely CBD injury (0.12%) Symptomatic cholelithiasis  concurrent cholecystectomy Excess weight loss (EWL)>25% within the first 3 months was the strongest predictor of postoperative cholecystectomy 6.5% 9.7% 10.1% Concomitant cholecystectomy is highest in RYGB group  5.2%  Increased complication rate, operative time, hospital stay!!! Subsequent cholecystectomy is relatively low in risk!!!!! M. S. Altieri et al. / Surgery for Obesity and Related Diseases 14 (2018) 992–996

LITERATURE REVIEW Della PA et al. (retrospective analysis) 61 preoperative asymptomatic gallstones 1 developed symptoms 3 months after SG  Surgery(-) 1 developed chronic cholecystitis after SG  Surgery(+) 96.8% remained asymptomatic Urso x 6 months seemed to reduce incidence of gallstone-related morbidity Obes Surg. 2019 Jan 2. doi: 10.1007/s11695-018-03651-0

LITERATURE REVIEW Doulamis IP et al. (systemic review) Anastomosis leakage / stricture increased in RYGB + CC than RYGB alone Risk of GB formation after bariatric surgery (3.4-17.9%) Risk of complicated cholecystectomy (up to 26.3%) Surgery GB symptoms Subsequent CC RYGB 10% 6.4% LSG 3.5% 3.1% AGB 4.4% all Average time to subsequent Cholecystectomy 8.3~17.7 months The performance of cholecystectomy concomitantly with bariatric surgery remains a clinical question with no clear answer to date. CC  increased morbidity ; no CC  risk of GB stone the low sensitivity (50e75%) of the transabdominal ultrasound in obese populations, hinders the exact estimation of the incidence of gallbladder disease Consensus -Prophylactic CC, CC in the case of gallbladder disease and conservative management with ursodeoxycholic acid have been investigated. -Each approach presents with certain pros and cons, but the superiority of a specific approach has not been proved. -there is tendency towards a more conservative approach suggesting initial medical treatment and subsequent CC when indicated Consensus -Prophylactic CC, CC in GB disease, Urso administration -Tendency : conservative approach with subsequent CC Doulamis IP et al., Concomitant cholecystectomy during bariatric surgery: The jury is still out, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.02.006

LITERATURE REVIEW Chen JH et al. (cohort retrospective study) Subsequent biliary event Non-surgical vs bariatric vs general population = 2.79% vs 2.89% vs 1.15% Female and restrictive procedure were risk for gallstone Tustumi F et al. (systemic review and meta-anaslysis) Prophylactic cholecystectomy may be avoided Risk for complication and reoperation Bariatric group is lower than concomitantly cholecystectomy Risk for biliary complication Lower in concomitant cholecystectomy than that post bariatric surgery Obes Surg. 2019 Feb;29(2):464-473. Obes Surg. 2019 Jan 2. doi: 10.1007/s11695-018-03651-0

LITERATURE REVIEW Hunag H-H et al. Increased risk of cholecystectomy in morbidly obese undergoing bariatric surgery, esp. female and 30-64 years Nearly 50% of new GB stones after bariatric surgery needs emergent surgery The highest rate of cholecystectomy after bariatric surgery was 3.7% in the first six months after bariatric procedure Routine prophylactic cholecystectomy with bariatric surgery simultaneously is still not recommended. Huang HH (Taiwanese National Health Insurance Research Database)(Study: morbidly obese undergoing bariatric surgery ; compare: morbidly obese without bariatric surgery) -bariatric surgery is known for promising long-term body weight loss for morbid obesity patients but the increasing rate of gallstone formation owing to body weight loss was the adverse effect and a challenging problem -The highest rate of cholecystectomy after bariatric surgery was 3.7% in the first six months after bariatric procedure -Routine prophylactic cholecystectomy with bariatric surgery simultaneously is still not recommended. -Ursodeoxycholic acid administration was proposed as an alternative medical treatment to prevent gallstone formation after bariatric surgery but has a poor compliance -Female : 2-3 fold higher than male Huang H-H, et al. Risk of cholecystectomy in morbidly obese patients after bariatric surgery in Taiwan. Obes Res Clin Pract (2018), https://doi.org/10.1016/j.orcp.2019.01.001

Answer for Question Is it necessary to perform concomitant cholecystectomy with bariatric surgery when asymptomatic cholelithiasis preoperatively? Anastomosis complication in concomitant cholecystectomy in RYGB groups Biliary complication in subsequent cholecystectomy Risk factors? Female & younger population Sleeve gastrectomy Excess weight loss > 25% Suggestion Symptomatic cholelithiasis  concomitant cholecystectomy Asymptomatic cholelithiasis  follow up and subsequent cholecystectomy if indicated

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