Ursodeoxycholic acid (UDCA) is a promising option for reducing the need for cholecystectomy in patients with post-laparoscopic sleeve gastrectomy (LSG) gallstones, however it appears ineffective for pre-existing gallstones, researchers from Turkey have reported. Therefore, they recommended that LSG patients with pre-existing asymptomatic gallstones should be managed conservatively as UDCA treatment in the first six months postoperatively did not reduce the necessity for cholecystectomy in LSG patients with pre-existing gallstones.
They authors noted that gallstone formation is more prevalent among individuals living with obesity compared to those without (10–20% in patients without obesity vs 30–50% with obesity). In addition, the rapid weight loss associated with bariatric and metabolic surgery (BMS) may further increase the risk of cholesterol gallstone formation in these patients leading to complications such as pancreatitis and cholecystitis, potentially necessitating cholecystectomy.
There is currently no consensus regarding the routine performance of concomitant cholecystectomy (CC) during LSG in patients with obesity and asymptomatic gallstones. There is also a lack of sufficient studies addressing the management of gallstones that develop postoperatively. UDCA is believed to prevent gallstone formation by reducing both the intestinal absorption and bile secretion of cholesterol. In addition, the investigators stated UDCA has been reported to inhibit gallstone formation related to weight loss following LSG and has also demonstrated efficacy as a gallstone dissolving agent.
For their study, they sought to evaluate the efficacy of UDCA in reducing the need for cholecystectomy in patients with asymptomatic gallstones, whether pre-existing or developed post-LSG.
Between July 2020 and November 2022, patients who underwent LSG for obesity at the General Surgery Clinic of Health Sciences University Umraniye Training and Research Hospital and had at least two years of clinical follow-up were retrospectively analysed.
Patients were divided into two groups according to both preoperative and postoperative gallbladder status. For patients with pre-existing asymptomatic gallstones during preoperative evaluation:
Those with UDCA treatment (group 1), patients with pre-existing gallstones preoperatively after September 2021.
Those without UDCA treatment (group 2), patients with pre-existing gallstones preoperatively in September 2021 and before.
For patients with newly formed gallstones in postoperative follow-up:
Those with UDCA treatment (group A), patients with newly Formed gallstones after September 2021.
Those without UDCA treatment (group B), patients with newly Formed gallstones in September 2021 and before.
Therefore, the patient groups compared represented different time periods. Group 2 and group B consisted of patients in whom thye performed the previous treatment protocol, while group 1 and group A consisted of patients after a change of the treatment protocol.
Outcomes
In this retrospective cohort study, 425 patients were included in the final analysis (from 476 patients). The flowchart (Figure 1) shows both the included-excluded patients and the management of LSG patients diagnosed with gallstones at preoperative and postoperative clinical follow-ups.

Of 476 patients, 34 (7.1%) were performed concomitant cholecystectomy (CC). Of 442 patients, 115 (25,1%) had preoperative gallstones but 13 of them underwent CC for symptomatic gallstones, and two were excluded because their gallstones were >1cm. Of the 98 patients with preoperative asymptomatic <1cm gallstones, 9 (9.1%) patients required cholecystectomy due to progression to symptomatic gallstones during follow-up. Three of these nine patients were in group 1, and six were in group 2. There was no significant difference in comparison of the groups (p=0.631).
During the follow-up period, 97 out of 329 patients (29.4%) developed gallstones postoperatively – two were excluded because their gallstones were >1cm. Comparison of patients who developed gallstones with those who did not showed no significant differences in terms of age, gender, height, preoperative weight, and preoperative BMI. However, a significant difference was observed in TWL%, weight at the end of the first year, and BMI at the end of the first year.
At the end of the first year, patients who newly developed gallstones following LSG had a higher TWL% (39.8±6.1), lower weight (73.4±11.5) and lower BMI (27.3±3.9) vs. those who did not develop gallstones (37.9±7.4, 77.3±13.9 and 28.7±4.4), which were statistically significant (p=0.004, p=0.028, p=0.006, respectively). Additionally, among patients with new-onset postoperative gallstones, those who received UDCA showed a significantly lower rate of cholecystectomy compared to those who did not (p=0.025).
Using ROC analysis, a cut-off value of 25.0% was identified as the optimal threshold, providing a balance between sensitivity and specificity. At this cut-off, the sensitivity was 37.3%, and the specificity was 81.4%, with a Youden’s Index of 18.7. The area under the curve (AUC) for the Receiver Operating Characteristics (ROC) analysis was 0.602 (95%CI =0.536-0.668), with an asymptotic significance (p-value) of 0.004, indicating the model’s discriminatory ability was statistically significant.
“These findings suggest that a TWL% cut-off of 25.0% offers the most clinically relevant balance, enabling effective discrimination between patients at risk of developing gallstones postoperatively and those who are not”, they authors noted.
The findings were reported in the paper, ' Efficacy of ursodeoxycholic acid in reducing the necessity of cholecystectomy due to pre-existing and subsequently formed gallstones in patients who underwent laparoscopic sleeve gastrectomy', published in BMC Surgery. To access this paper, please click here
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