Gallstones

Gallstones are very common in the United States, but occur even more frequently after weight loss surgery.  The most common explanation for the increased rate after a gastric bypass is that rapid weight loss triggers a change in the makeup of your bile that causes the stones to form in your gallbladder.  Your gallbladder is a relatively useless organ that stores bile that we use in digestion.  As I’ve pointed out many times, our body’s physiology evolved in response to our prehistoric environment and is not particularly well suited for today’s modern environment.  It’s like that the gallbladder evolved to aid in digesting the large amount of meat and animal fat that cavemen would consume after a successful hunt.  Most cavemen ate meat at most once or twice per week, and when they did, it was very large portions because the meat rotted very quickly.  The gallbladder allows for a large amount of bile to be released at one time which would likely be useful for a caveman after a big hunt.

Today’s modern diet typically does not consist of several pounds of raw or poorly cooked meat in a single sitting, so the gallbladder is now longer mandatory for digestion.  When stones develop in the gallbladder, patients typically experience pain in the upper abdomen or on their right side, particularly after eating a fatty meal.  Even foods like nuts and avocados can trigger the pain.  An ultrasound examination of the abdomen can successfully make, or rule out the presence of gallstones, 99% of the time.  Successful treatment of gallstones requires that the entire gallbladder is removed.  Any attempts to dissolve the stones through diet or sonic waves are ineffective, and even if they do help, the stones will re-form within weeks.  A cholecystectomy, or removal of the gallbladder, can be performed as an outpatient procedure most of the time and typically requires just a few days off work.  The risks of complications of removal of the gallbladder typically runs between 1%-2%.

Gallstones do pose a particular risk to gastric bypass patients because of the changes in anatomy that are made during the surgery.  Around 5% of gallstones travel out of the gallbladder and into the main liver duct where they can get stuck.  When this happens in a patient who has not had gastric bypass surgery, we can place a camera through your mouth, and into your intestines and retrieve the gallstones through the scope.  While these patients still have to have their gallbladder removed, they avoid a major surgery to retrieve the stones directly from the main liver duct.

After a gastric bypass, it is no longer feasible to remove the stones by performing an endoscopy through your mouth since the main part of your stomach is separated during the surgery.  In my practice, I’ve managed to avoid the need for a major surgery by going to the operating room and removing the gallbladder and making a small hole in the old stomach and having the endoscopist remove the stones through the hole in the stomach,.  While this requires a little longer recovery than a straightforward removal of the gallbladder, it is still not nearly as risky or difficult as when the stones are removed directly from the main liver duct.  Sleeve Gastrectomy patients are just as prone to the development of gallstones after surgery, however because they do not have any disruption in the arrangement of their intestines, they can still undergo an endoscopic removal of gallstones if they get stuck in the main liver duct.

For this reason, I recommend that patients who have had a gastric bypass undergo a gallbladder removal if they ever develop gallstones, rather than taking a “wait and see” approach.  Occasionally, I will remove a patient’s gallbladder at the same time as I perform a gastric bypass procedure, or even a few months before to prevent this problem.  In the early days of gastric bypass surgery, the gallbladder was removed routinely, however this practice is no longer advised since it results in the unnecessary removal of many normal gallbladders.

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