*Kim

Preventing gallstones after gastric bypass surgery

Recommended Posts

Hi Dr Callery,

I haven't had surgery yet but I hear that a lot of people have had gallbladder problems afterwards. I was reading a lot about it and noticed that it talked about rapid weight loss being a cause for gallbladder disease and that doctor's can prescribe 2 different drugs to help the gallbladder process things better when someone is going to have a quick weight loss. The medicines were ursodiol and Orlistat. Do you recommend we take this medicine?

I found this information about Gallstones and Gallbladder Disease

"Preventing Gallstones during Weight Loss

Maintaining a normal weight and avoiding rapid weight loss are the keys to reducing the risk of gallstones. Taking the medication ursodiol (also called ursodeoxycholic acid, or Actigall) during weight loss may reduce the risk for people who are very overweight and need to lose weight quickly. This medication is ordinarily used to dissolve existing gallstones. Orlistat (Xenical), a drug for treating obesity, may protect against gallstone formation during weight loss. The drug appears to reduce bile acids and other components involved in gallstone production."

Share this post


Link to post
Share on other sites

Hi Dr Callery,

I haven't had surgery yet but I hear that a lot of people have had gallbladder problems afterwards. I was reading a lot about it and noticed that it talked about rapid weight loss being a cause for gallbladder disease and that doctor's can prescribe 2 different drugs to help the gallbladder process things better when someone is going to have a quick weight loss. The medicines were ursodiol and Orlistat. Do you recommend we take this medicine?

I found this information about Gallstones and Gallbladder Disease

"Preventing Gallstones during Weight Loss

Maintaining a normal weight and avoiding rapid weight loss are the keys to reducing the risk of gallstones. Taking the medication ursodiol (also called ursodeoxycholic acid, or Actigall) during weight loss may reduce the risk for people who are very overweight and need to lose weight quickly. This medication is ordinarily used to dissolve existing gallstones. Orlistat (Xenical), a drug for treating obesity, may protect against gallstone formation during weight loss. The drug appears to reduce bile acids and other components involved in gallstone production."

Many surgeons, myself included, place patients on Actigall 300 mg twice daily for at least 6 months after gastric bypass and sleeve gastrectomy. The indication is less clear for lap band since the weight loss is slower, although it's probably a good idea. A randomized prospective trial showed that 300 mg twice daily reduced the risks of stone formation after gastric bypass from about 30% to 2%. I wasn't aware of the use of orlistat for this purpose. When I searched Pub Med for orlistat and gallbladder with weight loss surgery, there were no trials that tested use of orlistat. Thus any use of orlistat for stone prevention after WLS is probably "off label" and not grounded in research. There are some disagreeable side effects of orlistat which would probably limit it's use, and Actigall works well. Even the use of Actigall is somewhat controversial. As you will see in the third reference below, while about 30% of patients may develop gallstones [reference 1] after GBP if left untreated, only about 9% develop sypmptomatic gallstones [reference3].

____________________________________________________________________________________________________

Am J Surg. 1995 Jan;169(1):91-6; discussion 96-7.

A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss.

Sugerman HJ, Brewer WH, Shiffman ML, Brolin RE, Fobi MA, Linner JH, MacDonald KG, MacGregor AM, Martin LF, Oram-Smith JC, et al.

Source

Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298.

Abstract

BACKGROUND:

Previous studies have documented a high incidence of gallstone formation following gastric-bypass (GBP)-induced rapid weight loss in morbidly obese patients. This study was designed to determine if a 6-month regimen of prophylactic ursodiol might prevent the development of gallstones.

METHODS:

A multicenter, randomized, double-blind, prospective trial evaluated 3 oral doses of ursodiol: 300, 600, and 1,200 mg versus placebo beginning within 10 days after surgery and continuing for 6 months or until gallstone development, for patients with a body mass index (BMI) > or = 40 kg/m2. All patients had normal intraoperative gallbladder sonography. Transabdominal sonography was obtained at 2, 4, and 6 months following surgery, or until gallstone formation.

RESULTS:

Of 233 patients with at least one postoperative sonogram, 56 were randomized to placebo, 53 to 300 mg ursodiol, 61 to 600 mg ursodiol, and 63 to 1,200 mg ursodiol. Preoperative age, sex, race, weight, BMI, and postoperative weight loss were not significantly different between groups. Gallstone formation occurred at 6 months in 32%, 13%, 2%, and 6% of the patients on the respective doses. Gallstones were significantly (P < 0.001) less frequent with ursodiol 600 and 1,200 mg than with placebo.

CONCLUSION:

A daily dose of 600 mg ursodiol is effective prophylaxis for gallstone formation following GBP-induced rapid weight loss.

___________________________________________________

Am J Gastroenterol. 2001 Jun;96(6):1888-94.

Orlistat maintains biliary lipid composition and hepatobiliary function in obese subjects undergoing moderate weight loss.

Trouillot TE, Pace DG, McKinley C, Cockey L, Zhi J, Häeussler J, Guerciolini R, Showalter R, Everson GT.

Source

University of Colorado Health Sciences Center, Denver 80262, USA.

Abstract

OBJECTIVES:

Orlistat, an intestinal lipase inhibitor, has recently been approved by the US Food and Drug Administration for treatment of obesity. The effects of orlistat on hepatobiliary function have not been previously defined. A 4 wk study was performed involving modest weight loss in obese subjects to observe any short-term hepatobiliary responses that occur after initiating treatment with orlistat and a hypocaloric diet.

METHODS:

A total of 23 obese (BMI 30-41 kg/m2) subjects were randomized to a double blind t.i.d. treatment with 120 mg of orlistat or a placebo in conjunction with a hypocaloric diet (1200-1500 kcal/day). The study was designed to achieve similar modest weight loss in both groups in order to be able to directly assess the effects of orlistat. Cholesterol saturation, bile composition, and gallbladder motility were measured.

RESULTS:

At the end of the treatment period, mean weight loss of 3.8 kg was achieved in the orlistat group (vs 2.3 kg with placebo, p = NS). Total bile acid concentration decreased significantly with placebo (-18.57 +/- 6.99 mmol/L; 95% CI = -32.26 to -4.87), but not with orlistat. Biliary phospholipid concentration decreased significantly with placebo (-4.38 +/- 1.91 mmol/L; 95% CI = -8.13 to -0.64) but not with orlistat. Mean changes from the baseline in cholesterol saturation index and gallbladder motility were similar in both groups. Microscopy of bile failed to reveal cholesterol microcrystals before or after treatment in either group.

CONCLUSIONS:

Our findings indicate a primary initial effect of weight loss is a reduction in biliary bile acids and phospholipids. Orlistat blocks these adverse changes in biliary lipid composition and maintains hepatobiliary function. We speculate that the risk of formation of gallstones during weight loss may actually be lowered with orlistat.

____________________________________________________

Surg Obes Relat Dis. 2007 Jul-Aug;3(4):476-9. Epub 2007 Apr 18.

Expectant management [wait and see] of the asymptomatic gallbladder at Roux-en-Y gastric bypass.

Portenier DD, Grant JP, Blackwood HS, Pryor A, McMahon RL, DeMaria E.

Source

Department of Surgery, Duke University Medical Center, Durham, North Carolina 27704, USA. dana.portenier@duke.edu

Abstract

BACKGROUND:

Because of the claim that about one third of patients develop gallstones within 6 months of Roux-en-Y gastric bypass (RYGB), many have recommended preoperative ultrasonography for all patients and/or prophylactic cholecystectomy (CCY), or ursodiol to prevent stone formation.

METHODS:

Prospective data were collected from 1391 consecutive patients followed up for > or = 6 months after RYGB (2000-2005) to assess our practice of not routinely removing the gallbladder and not administering ursodiol.

RESULTS:

Of the 1391 patients, 334 (24%) had undergone CCY before RYGB. Of the remaining 1057 asymptomatic patients, 516 had undergone preoperative ultrasonography. Stones were identified in 99 (19%), sludge in 5 (0.97%), and polyps in 6 (1.1%). Of the 984 patients with gallbladders left in situ after RYGB, only 80 (8.1%) became symptomatic and required delayed CCY. The average excess weight loss at the delayed CCY was 65%. The risk of undergoing delayed CCY seemed to be restricted to the first 29 months after RYGB, because none of 165 patients followed up for 30-144 months required CCY.

CONCLUSION:

Although CCY should be performed whenever symptoms mandate, the value of routine preoperative ultrasonography and CCY was not apparent from the results of our study. Waiting until symptoms develop might simplify the operative procedure because of the significant weight loss that should have occurred after RYGB. Using an expectant approach, most patients undergoing RYGB will not require CCY.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now