Gallstones and Bariatric Surgery: To Treat or Not to Treat?

The relationship between the gall bladder and morbid obesity, and the strategy used by surgeons for its management can be passive-aggressive. Morbidly obese patients are more likely to develop cholelithiasis. On the other hand, bariatric surgery predisposes to gall bladder stone formation and potentially symptomatic cholelithiasis. The indication for cholecystectomy and its timing in relationship to bariatric surgery is a moving target. In this editorial, we review the current practice and what the literature has to say about it, particularly, what to do with the normal gall bladder and the asymptomatic cholelithiasis in anticipation of bariatric surgery. It seems that, based on the work done by Morais et al. [1], in this issue of the WJS, removing normal gall bladders or performing cholecystectomy for asymptomatic cholelithiasis is not justified when a bariatric procedure is done, a deep sigh of relief for bariatric surgeons. However, the evidence is hardly conclusive, and the debate will continue until prospective randomized trials are carried out. To close the loop on this surgical dilemma, we need to study the proper timing of intervention for one procedure in relationship to the other. Until then, the jury is out. Are you tired of politics and the 2016 political rallies of the US presidential race? Do you want to consider some other controvery for a change, like surgery? Well, do not hold your breath! Politics is everywhere. Voting for the right option in the management of gall bladder disease if you are contemplating a bariatric procedure is no exception. Should you be a liberal or a conservative? That is the question. In an attempt to answer this question, experts in bariatric surgery tried several options, ranging from one extreme to another. They relied on the limited available data sandwiched in space between expert opinions. Many issues of concern, some technical and other financial, dictated this indecision. Most bariatric surgeons, at least in the USA, leave the management of the gall bladder disease to general surgeons unless a decision is made to remove the gall bladder concomitantly. The general surgeons are faced with the technical difficulties of removing the gall bladder in the morbidly obese patient if cholecystectomy has to be done first. Having to go through a second (bariatric) procedure later is another concern for the patient. On the other hand, the bariatric surgeons do not want to add more variables that may complicate their outcomes if a concomitant procedure is to be done. Removing the gall bladder during a bariatric surgery prolongs the operative time and may require additional ports for optimal access. Data have even shown a higher morbidity and longer hospital stay if both procedures are combined [2]. Equally important, concomitant cholecystectomy is not reimbursed. On the hand, if the gall bladder acts up after the bariatric procedure, the general surgeon may have the advantage of operating when the extra weight is off, but is faced with possible lysis of adhesions, particularly, when the bariatric procedure was done open. We know that gall bladder disease is associated with morbid obesity [3]. The addition of a bariatric procedure complicates the matter even further. Rapid weight loss and its metabolic derangements add additional burden to the biliary system [4], leading to a higher incidence and prevalence of gallbladder disease. Every patient offered a bariatric procedure falls in one of the following categories & Samir Johna samir.johna@gmail.com