approach to gall stone disease in obesity dr girish juneja head of surgery deptt. specialist...
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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