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The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery—An International Expert Survey

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Abstract

Objective

This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS.

Background

Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist.

Methods

An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023.

Results

Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6–12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB.

Conclusion

Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.

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Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

MBS:

Metabolic and bariatric surgery

CBD:

Common bile duct

ERCP:

Endoscopic retrograde cholangiopancreatography

SG:

Sleeve gastrectomy

SADI/S:

Single anastomosis duodenal-ileal bypass with sleeve

RYGB:

Roux-en-Y gastric bypass

OAGB:

One anastomosis gastric bypass

UDCA:

Ursodeoxycholic acid

US:

Ultrasonography

CCY:

Cholecystectomy

CCE:

Concomitant cholecystectomy

CBDS:

Common bile duct stones

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Acknowledgements

MOGIPSO Collaborators:

Collaborating authors:

1. Edo Aaarts

2. Imran Abbas

3. Ebrahim Aghajani

4. Luigi Angrisani

5. Luciano Antozzi

6. Jan Apers

7. Tanseer Asghar

8. Ahmad Bashir

9. Estuardo Behrens

10. Helmuth Billy

11. Daniel Caina

12. Miguel‑A. Carbajo

13. Benjamin Clapp

14. Ricardo Cohen

15. Jerome Dargent

16. Amirhossein Davarpanah Jazi

17. Maurizio De Luca

18. Mohamad Hayssam ElFawal

19. Daniel Moritz Felsenreich

20. Michael Gagner

21. Pierre Garneau

22. Khaled Gawdat

23. Tikfu GEE

24. Omar M Ghanem

25. Bijan Ghavami

26. Saber Ghiassi

27. Tamer A.A.M. Habeeb

28. Ashraf Haddad

29. Miguel F. Herrera

30. Farah Husain

31. Kazunori Kasama

32. Radwan Kassir

33. Nesreen Khidir

34. Mousa Khoursheed

35. Haris Khwaja

36. Lillian Kow

37. Jon Kristinsson

38. Matthew Kroh

39. Kuldeepak Singh Kular

40. Panagiotis Lainas

41. Laurant Layani

42. Ken Loi

43. Kamal Mahawar

44. Tarek Mahdy

45. John Melissas

46. Karl Miller

47. Hazem Almomani

48. Mario Musella

49. Alexandr Neimark

50. Abdelrahman Nimeri

51. Patrick Noel

52. Taryel Omarov

53. Mariano Palermo

54. Chetan Parmar

55. Abdolreza Pazouki

56. Ralph Peterli

57. Tadeja Pintar

58. Tigran Poghosyan

59. Jaime Ponce

60. Dimitri Pournaras

61. Arun Prasad

62. Aayad Alqahtani

63. Almino Ramos

64. Masoud Rezvani

65. Karl Rheinwalt

66. Rui Ribeiro

67. Elena Ruiz-Ucar

68. Bassem Safadi

69. Nasser Sakran

70. Alaa Sewafy

71. Asim Shabbir

72. Shahab Shahabi Shahmiri

73. Erik Stenberg

74. Halit Eren Taskin

75. Antonio Torres

76. Cunchuan Wang

77. Sylvia Weiner

78. Wah Yang

79. Natan Zundel

Author information

Authors and Affiliations

  1. Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Hazrat-E Fatemeh Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

    Mohammad Kermansaravi

  2. Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Scott Shikora

  3. Department of General Surgery, AZ Sint Jan Brugge-Oostende, Brugge, Belgium

    Bruno Dillemans

  4. Department of Surgery, NYU Langone Medical Center, New York, NY, 10016, USA

    Marina Kurian

  5. UnityPoint Clinic Weight Loss Specialists, West Des Moines, IA, USA

    Teresa LaMasters

  6. Endocrine, Bariatric and Metabolic Surgery Department, University Hospital Vall Hebron, Barcelona, Spain

    Ramon Vilallonga

  7. Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria

    Gerhard Prager

  8. Bariatric and Metabolic Surgery Unit, Department of General and Laparoscopic Surgery, Ospedale Evangelico Betania, Via Argine 604, 80147, Naples, Italy

    Sonja Chiappetta

Authors
  1. Mohammad Kermansaravi
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  4. Marina Kurian
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  6. Ramon Vilallonga
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Consortia

MOGIPSO Collaborators

  • Edo Aaarts
  • , Imran Abbas
  • , Ebrahim Aghajani
  • , Luigi Angrisani
  • , Luciano Antozzi
  • , Jan Apers
  • , Tanseer Asghar
  • , Ahmad Bashir
  • , Estuardo Behrens
  • , Helmuth Billy
  • , Daniel Caina
  • , Miguel‑A. Carbajo
  • , Benjamin Clapp
  • , Ricardo Cohen
  • , Jerome Dargent
  • , Amirhossein Davarpanah Jazi
  • , Maurizio De Luca
  • , Mohamad Hayssam ElFawal
  • , Daniel Moritz Felsenreich
  • , Michael Gagner
  • , Pierre Garneau
  • , Khaled Gawdat
  • , Tikfu GEE
  • , Omar M Ghanem
  • , Bijan Ghavami
  • , Saber Ghiassi
  • , Tamer A. A. M. Habeeb
  • , Ashraf Haddad
  • , Miguel F. Herrera
  • , Farah Husain
  • , Kazunori Kasama
  • , Radwan Kassir
  • , Nesreen Khidir
  • , Mousa Khoursheed
  • , Haris Khwaja
  • , Lillian Kow
  • , Jon Kristinsson
  • , Matthew Kroh
  • , Kuldeepak Singh Kular
  • , Panagiotis Lainas
  • , Laurant Layani
  • , Ken Loi
  • , Kamal Mahawar
  • , Tarek Mahdy
  • , John Melissas
  • , Karl Miller
  • , Hazem Almomani
  • , Mario Musella
  • , Alexandr Neimark
  • , Abdelrahman Nimeri
  • , Patrick Noel
  • , Taryel Omarov
  • , Mariano Palermo
  • , Chetan Parmar
  • , Abdolreza Pazouki
  • , Ralph Peterli
  • , Tadeja Pintar
  • , Tigran Poghosyan
  • , Jaime Ponce
  • , Dimitri Pournaras
  • , Arun Prasad
  • , Aayad Alqahtani
  • , Almino Ramos
  • , Masoud Rezvani
  • , Karl Rheinwalt
  • , Rui Ribeiro
  • , Elena Ruiz-Ucar
  • , Bassem Safadi
  • , Nasser Sakran
  • , Alaa Sewafy
  • , Asim Shabbir
  • , Shahab Shahabi Shahmiri
  • , Erik Stenberg
  • , Halit Eren Taskin
  • , Antonio Torres
  • , Cunchuan Wang
  • , Sylvia Weiner
  • , Wah Yang
  •  & Natan Zundel

Corresponding authors

Correspondence to Mohammad Kermansaravi or Sonja Chiappetta.

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The authors declare no competing interests.

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Key Points

- Two-thirds of the experts preferred concomitant cholecystectomy in cases of symptomatic cholecystolithiasis. However, increased morbidity rates have been published in cases of performing concomitant procedures.

- Prophylactic ursodeoxycholic acid (UDCA) should be recommended for primary or secondary prophylaxis to patients undergoing metabolic and bariatric surgery (MBS) to reduce the risk of reforming new gallstones postoperatively or becoming symptomatic from preexisting gallstones.

- After Roux-en-Y gastric bypass (RYGB) or one anastomosis gastric bypass (OAGB), the preferred approach to access common bile duct stones is laparoscopic assisted transgastric endoscopic retrograde cholangiopancreatography.

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Kermansaravi, M., Shikora, S., Dillemans, B. et al. The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery—An International Expert Survey. OBES SURG 34, 1086–1096 (2024). https://doi.org/10.1007/s11695-024-07101-y

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