stones or the cholecystectomy compared with the general
population. Cholecystectomy concomitant with gastric
bypass is indicated when stones are detected by preop-
erative or intraoperative ultrasound examination or by
palpation when done by experienced hands. The risks and
costs of prophylactic treatment may outweigh any bene-
fit.
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Editorial Comment
Gallbladder management was less complicated in the era
of open gastric bypass. The belief that many morbidly obese
patients either had or would likely soon develop gallbladder
disease prompted the practice by some surgeons of routine
en passant cholecystectomy in conjunction with gastric by-
pass. This has been the long-standing practice for open
gastric bypass at our institution, where we have found that
with an adequate upper midline incision, access to the gall-
bladder is rarely difficult, even in super-obese patients. With
this approach, our program’s policy of routine incidental
cholecystectomy has been associated with a negligible
change in the patient’s overall risks and time of recovery
and an extremely low incidence of biliary-related compli-
cations. However, the era of laparoscopic Roux-en-Y gastric
bypass (RYGB) has led many surgeons to reconsider the
need for routine concomitant cholecystectomy. In a laparo-
scopic setting, routine cholecystectomy often may not be as
technically straightforward as it usually is in open surgery,
thus subjecting patients to significantly increased operating
times and potentially catastrophic additional risks. This so-
ber reality has led to advocates of other strategies for gall-
bladder management at RYGB. Among these are selective
concomitant cholecystectomy on the basis of the ultrasound
findings or palpation of the gallbladder; the use of ursodiol
to reduce the relative risk during the period of rapid weight
loss; and expectant treatment without preoperative biliary
workup in the absence of symptoms.
To muddy the water even further, it is generally accepted
that for patients undergoing laparoscopic gastric banding,
weight loss is more gradual than after RYGB. This gradual
weight loss, stretched out during 2–3 years, may create less
lithogenic bile and may decrease the risk of developing
early symptomatic cholelithiasis. If the data presented in the
report by Myers and associates hold true and only 1–2% of
patients will require cholecystectomy in the early years after
laparoscopic gastric banding, the additional laparoscopic
risks, operative time, possibly longer hospital stay, and
costs clearly do not justify a policy of routine cholecystec-
tomyinlaparoscopicgastricbandingpatients[1].Timewill
tell whether a substantial increase occurs in the incidence of
symptomatic cholelithiasis during the entire weight loss
period of 2–3 years. This information also calls into ques-
tion the surgical significance of known, but asymptomatic,
gallstones in preoperative bariatric patients. Also, what
should we make of the non-calculous gallbladder pathologic
features often found in obese patients undergoing routine
cholecystectomy during RYGB, if only a small fraction go
on to disease symptomatic enough to warrant later chole-
cystectomy?
In a cohort of open RYGB patients, Caruana reported a
9.9% incidence of symptomatic stones within 2 years in
patients with normal gallbladders by palpation at open
RYGB. Despite a prior midline incision, 80% of the sec-
ondary cholecystectomies were completed laparoscopically.
No choledocholithiasis developed. These data indicate that
567J.A. Caruana et al. / Surgery for Obesity and Related Diseases 1 (2005) 567–568