Cholecystectomy and bariatric surgery in asymptomatic patients with cholelithiasis?

Dear Editor,

The conclusions of the article published in your journal by Ainhoa Andrés-Imaz et al. on the appearance of cholelithiasis after bariatric surgery (BS)¹ recommend the postoperative use of ursodeoxycholic acid and concomitant cholecystectomy during bariatric surgery “regardless of symptomatology”. I believe that following their study of de novo cholelithiasis occurring in 10% of patients during the first postoperative year of BS, further use of ursodeoxycholic acid would be justified, although controversial². However, this finding may not be sufficient to promote cholecystectomy in all obese patients with cholelithiasis during BS.

For these patients, there is a clear consensus to perform cholecystectomy concomitant with BS when symptoms related to cholelithiasis are present^2–6, but in asymptomatic cases there are many doubts.

Firstly, the bariatric technique should be analysed, since performing cholecystectomy after vertical gastrectomy is not the same as after gastric bypass or another more complex technique⁵. There are articles that show a slight increase in complications in patients who undergo cholecystectomy after completing a gastric bypass^2,4,5. However, other authors obtain good results and propose performing both techniques at the same time⁶.

What happens in asymptomatic patients undergoing vertical gastrectomy? Vertical gastrectomy is a simpler procedure with a duration of about 60 min where cholecystectomy can increase the operation by 40–50 min. In this case, endoscopic access to the bile duct is still available and it is only the prevention of biliary complications together with the saving of a second operation that would support this double procedure.

In the SECO 2021 congress, we presented our experience in patients with symptomatic/asymptomatic cholelithiasis before BS and subsequent evolution with/without cholecystectomy. Of the 39 patients diagnosed with cholelithiasis by ultrasound over 10 years, the 10 symptomatic patients underwent surgery without incident, and vertical gastrectomy with cholecystectomy was successfully performed in 9 of the remaining 29. Most interestingly, 90% of the other 20 non-cholecystectomised patients remained asymptomatic for a long period of time (3–12 years).

To sum up, there are many factors to bear in mind when considering cholecystectomy during BS in asymptomatic patients with cholelithiasis. Perhaps the most important is the surgeons’ experience in complex cholecystectomy⁵. If the team performs well and does not increase morbidity, cholecystectomy can be considered by mutual agreement with the patient. If not, the most sensible approach would be to perform the bariatric procedure and consider cholecystectomy when symptoms appear.