Concomitant laparoscopic cholecystectomy during bariatric surgery is safe and feasible

A prospective randomised controlled pilot study by researchers from Mansoura University, Mansoura, Egypt, has demonstrated that concomitant laparoscopic cholecystectomy (LC) during bariatric surgery in patients with morbidly obesity with pre-existing gallstones is safe and feasible. Although concomitant LC results in longer operative time (mean increase of 23.75 min) and higher immediate postoperative pain scores, the researchers noted that these differences do not translate into increased complications, major morbidity, or prolonged hospital stay.

“Concomitant LC during bariatric surgery in morbidly obese patients with pre-existing gallstones is demonstrated to be safe and feasible, with acceptable increases in operative time and postoperative pain,” they stated. “The high rate (79.3%) of symptomatic gallstone development in patients who did not undergo concomitant cholecystectomy supports adopting routine concomitant LC to prevent future morbidity, thereby influencing clinical decision-making and standard practice.”

The researchers noted that morbid obesity is strongly linked with gallbladder disease, especially gallstones (cholelithiasis). People with obesity are also more likely to develop complications, such as cholecystitis, obstructive jaundice and pancreatitis. Bariatric surgery is the most effective long-term treatment for morbid obesity, helping to lower the risks from related health problems.

However, rapid weight loss after surgery increases the risk of gallstones. This occurs due to increased bile cholesterol, increased mucin secretion, and weaker gallbladder contractions.

While symptomatic gallstones are an accepted indication for LC, management of asymptomatic gallstones during bariatric surgery remains controversial. Some surgeons advocate for prophylactic LC at the time of surgery to prevent future complications. Conversely, others recommend a delayed or selective approach due to concerns about increased operative complexity, longer operative times, and potential for additional complications.

Subsequently, they designed a pilot study to compare outcomes between bariatric surgery with concomitant LC versus bariatric surgery alone in morbidly obese patients with pre-existing gallstones. The primary objectives were to assess the safety and feasibility of concomitant cholecystectomy and to determine the incidence of symptomatic gallstone disease in patients who did not undergo prophylactic cholecystectomy. They hypothesised that concomitant LC would be safe and feasible, with acceptable increases in operative parameters, and would prevent the need for subsequent interval surgery in a substantial proportion of patients.

The study was conducted at the Department of General Surgery, Mansoura University Hospital, Egypt, from April 2021 to April 2024. In total, 58 patients were randomised (30 in Group I received bariatric surgery and LC and 28 in Group II received bariatric surgery only, with LC delayed for symptoms) into the study. All patients were followed prospectively according to a standardised protocol with scheduled clinic visits at one week, one month, three months, six months and 12 months postoperatively.

Outcomes

Baseline demographic and clinical characteristics revealed there were no significant differences in age, sex distribution, BMI, or prevalence of obesity-related comorbidities. Mean age was 38.4 ± 9.2 years in Group I and 39.1 ± 8.7 years in Group II (p=0.754). The majority of patients were female (73.3% in Group I and 71.4% in Group II, p=0.871). Mean BMI was similar between groups (46.2 ± 5.3 kg/m2 in Group I vs. 45.8 ± 4.9 kg/m2 in Group II, p=0.768).

Comorbidities were comparable between groups, including Type 2 diabetes mellitus (40.0% vs. 35.7%, p=0.733), hypertension (36.7% vs. 39.3%, p=0.835), dyslipidaemia (50.0% vs. 46.4%, p=0.784), obstructive sleep apnoea (26.7% vs. 28.6%, p=0.872) and gastroesophageal reflux disease (30.0% vs. 32.1%, p=0.862).

Gallstone characteristics were also similar between groups. Mean stone size was 12.3 ± 4.2 mm in Group I and 11.8 ± 3.9 mm in Group II (p=0.628). The proportion of patients with multiple stones (≥ 3 stones) was 53.3% in Group I and 50.0% in Group II (p=0.798). Gallbladder wall thickness was 3.2 ± 0.8 mm in Group I and 3.1 ± 0.7 mm in Group II (p=0.609).

Mean operative time was significantly longer in Group I compared to Group II (98.93 ± 11.58 min vs. 75.18 ± 11.26 min, p<0.001), representing a mean increase of 23.75 min (95% CI: 17.84–29.66 min) for the concomitant cholecystectomy. This difference was statistically significant and clinically relevant, reflecting the additional time required for the cholecystectomy procedure.

There were no major intraoperative complications in either group. Specifically, there were no bile duct injuries, bowel injuries, major vascular injuries, or splenic injuries. Minor bleeding requiring additional haemostatic measures (but not transfusion) occurred in 2 patients (6.7%) in Group I and 1 patient (3.6%) in Group II (p = 0.607). Pain scores assessed using the VAS were significantly higher in Group I than in Group II at all measured time points. Pain scores decreased over time in both groups, but remained consistently higher in Group I throughout the early postoperative period.

Mean hospital length of stay was similar between groups: 3.2 ± 0.8 days in Group I and 3.0 ± 0.7 days in Group II (p=0.284). The majority of patients in both groups were discharged on postoperative Day 3 after completion of the routine contrast study and confirmation of adequate oral intake.

All 58 patients completed a 12-month follow-up with no loss to follow-up. Weight loss outcomes were similar between groups at all time points. At 12 months, mean %EWL was 68.4 ± 12.3% in Group I and 66.8 ± 11.7% in Group II (p=0.596), indicating that concomitant cholecystectomy did not adversely affect weight loss outcomes.

“The most striking finding of this study was the high incidence of symptomatic gallstone disease in Group II (bariatric surgery alone). During the 12-month follow-up period, 22 of 28 patients (78.6%) in Group II developed symptomatic gallstone disease requiring subsequent cholecystectomy,” the noted. “When including one additional patient who developed symptoms at 13 months (just after the 12-month study endpoint), the rate was 23 of 28 patients (82.1%).”

The peak incidence of symptom development occurred between four and six months postoperatively, coinciding with the period of most rapid weight loss. The clinical presentations of symptomatic gallstone disease in Group II were as follows: biliary colic (uncomplicated): 15 patients (65.2%); acute cholecystitis: 5 patients (21.7%); choledocholithiasis: 2 patients (8.7%); and gallstone pancreatitis: 1 patient (4.3%). All 22 patients who developed symptoms during the 12-month study period underwent subsequent LC.

Only 6 patients (21.4%) in Group II remained asymptomatic throughout the 12-month follow-up period. These patients continued to have gallstones on follow-up ultrasound but did not develop symptoms requiring intervention.

“Based on our findings, we recommend routine concomitant cholecystectomy in morbidly obese patients with ultrasonographically confirmed gallstones undergoing bariatric surgery,” the researchers concluded. “The modest increases in operative time and postoperative pain are outweighed by the prevention of future gallstone-related morbidity in the majority of patients, the avoidance of interval surgery with its associated risks and costs, and the high likelihood of symptom development if cholecystectomy is deferred.”

The findings were reported in the paper, 'Bariatric Surgery With or Without Concomitant Laparoscopic Cholecystectomy in Morbidly Obese Patients With Gallbladder Stone Disease: A Prospective Randomized Controlled Pilot Study', published in the Journal of Obesity. To access this study, please click here