Abstract
Background Obesity and weight loss after bariatric surgery have a close association with gallbladder disease. The performance and proper timing of laparoscopic cholecystectomy (LC) with bariatric surgery remain a clinical question. Objective Evaluation of the outcome of LC during bariatric surgery whether done concomitantly or delayed according to the level of intraoperative difficulty. Methods The prospective study included patients with morbid obesity between December 2018 and December 2019 with preoperatively detected gallbladder stones. According to the level of difficulty, patients were allocated into 2 groups: group 1 included patients who underwent concomitant LC during bariatric surgery, and group 2 included patients who underwent delayed LC after 2 months. In group 1, patients were further divided into subgroups: LC either at the beginning (subgroup A) or after bariatric surgery (subgroup B). Results Operative time in group 1 vs. 2 was 92.63 ± 28.25 vs. 68.33 ± 17.49 (p < 0.001), and in subgroup A vs. B, it was 84.19 ± 19.62 vs. 130.0 ± 31.62 (p < 0.001). One patient in each group (2.6% and 8.3%) had obstructive jaundice, p > 0.001. In group 2, 33% of asymptomatic patients became symptomatic for biliary colic p > 0.001. LC difficulty score was 2.11 ± 0.70 vs. 5.66 ± 0.98 in groups 1 and 2, respectively, p < 0.001. LC difficulty score decreased in group 2 from 5.66 ± 0.98 to 2.26 ± 0.78 after 2 months of bariatric surgery, p < 0.001. Conclusion Timing for LC during bariatric surgery is challenging and should be optimized for each patient as scheduling difficult LC to be performed after 2 months may be an option.
Highlights
Obesity and weight loss after bariatric surgery have a close association with gallbladder disease. e performance and proper timing of laparoscopic cholecystectomy (LC) with bariatric surgery remain a clinical question
A clear liquid sip was started the second day of the operation, and intra-abdominal drains were removed after 24 hours if there is less than 50 ml serosanguinous fluid and it was left in place and removed at the first outpatient clinic (OPC) visit in patients with unusual operative bleeding, a higher risk for postoperative bleeding, and complex operative cases (ii) All patients without any complication were discharged on the second postoperative day after instructing on diet, activities, and medications including multivitamins (iii) In group 2: delayed LC was done after 2 months, and the intraoperative findings and postoperative outcomes were evaluated
The overall mean of LC difficulty score in the delayed group during bariatric surgery (BS) vs. after 2 months was 5.66 ± 0.98 vs. 2.26 ± 0.78, respectively, with significant improvement of adhesion at Calot’s triangle and to gall bladder (GB), p < 0.001 (Tables 4 and 5) (Figures 2 and 3)
Summary
Obesity and weight loss after bariatric surgery have a close association with gallbladder disease. e performance and proper timing of laparoscopic cholecystectomy (LC) with bariatric surgery remain a clinical question. A clear liquid sip was started the second day of the operation, and intra-abdominal drains were removed after 24 hours if there is less than 50 ml serosanguinous fluid and it was left in place and removed at the first outpatient clinic (OPC) visit in patients with unusual operative bleeding, a higher risk for postoperative bleeding, and complex operative cases (ii) All patients without any complication were discharged on the second postoperative day after instructing on diet, activities, and medications including multivitamins (iii) In group 2: delayed LC was done after 2 months, and the intraoperative findings and postoperative outcomes were evaluated During this waiting period, all the patients were screened for biliary symptoms (biliary colic, cholecystitis, acute cholangitis, obstructive jaundice, and biliary pancreatitis) by clinical examination and blood work (total leukocytic count and liver function test). (iv) Patients’ follow-up in OPC was weekly in the first month and at 2, 6, and 12 months after surgery (v) During the 12 months of follow-up, micromalnutrition was assessed if vitamin D was less than 30 g/ml, and macromalnutrition was assessed if hemoglobin was less than 10 g/dl or albumin was less than 3.5 g/dl
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