The gallbladder is a digestive organ located under the right side of the liver and connected to the common bile duct. Bile is a digestive juice secreted by the liver that helps digest fats and has other functions. Bile flows from the liver through the common bile duct down to the duodenum. The gallbladder which is attached to the common bile duct by the cystic duct acts as a reservoir. The gallbladder collects bile between meals and then squirts it out during meals to help digest food. Thus when you are not eating the bile is diverted into the gallbladder. When you eat bile is released into the intestine. When the gallbladder has been removed, the bile simply goes directly to the duodenum a little at a time, all day long. The reservoir function of the gallbladder makes the system more efficient. Bile is available when needed and it does not drip through the system when there is no food is present. The gallbladder was probably very important to primitive humans who ate large quantities of raw fat. Now we tend to cut away fat and cook our food, so fat intake is dramatically reduced. So having a large quantity of bile present at meal time is no longer critical. People by and large get along well without the gallbladder. Gallstones form when there is an imbalance in the bile causing a high ratio of cholesterol compared to bile salts. This type of imbalance often occurs when people are on very restrictive diets. Such is the case with liquid protein fast programs and during the first 6-18 months after gastric bypass. Studies have shown that 30 percent of gastric bypass patients will develop gallstones, and 10 percent of patients will develop symptoms requiring surgical gall bladder removal (cholecystectomy). Similarly, Weiner(1) and colleagues reported that 11% of Lab Band patients required later gall bladder removal. 1 / 5
Gallstone development following gastric bypass can be prevented two ways. First, the gallbladder can be removed at the time of surgery. Second, one can take a medication called Actigall. Actigall is a naturally occurring bile salt. Taking Actigall increases the ratio of bile salts to cholesterol in the bile and prevents cholesterol from crystallizing as gallstones. Actigall must be taken twice a day while one is losing weight. Once the weight is lost one can stop taking the Actigall. Actigall has infrequent side effects, occasionally causing diarrhea or other symptoms ( see Actigall information sheet ). Actigall prevents gallstone formation 98% of the time. The decision whether or not to remove a normal gallbladder at the time of gastric bypass is controversial with no "right" answer. Dr. Callery's general treatment philosophy is "if it isn't broken, don't fix it." While the gallbladder can generally be removed safely, there are definite disadvantages listed below. Actigall taken during the weight loss phase usually prevents gallstone formation. There is a chance that stones may develop in the future and that the gallbladder may need to be removed. Advantages of Cholecystectomy Disadvantages of Cholecystectomy Advantages of taking Actigall to prevent stone formation Disadvantages of taking Actigall 2 / 5
Decreases risk of developing gallstones from 32% to zero. Prolongs surgery, additional port sites or larger incision. Surgery quicker, fewer port sites or smaller incision. Must be taken twice a day until weight loss plateaus (min. 6 mo.) No need to take Actigall. Additional risk of complications. No risk of technical complications. Occasional diarrhea, other side effects. No worry about needing a future surgery for gallbladder stones. Some diarrhea in 10%-25% of patients; can be permanent. Gallbladder continues its digestive function. 3 / 5
Gallstones could occur later in life requiring another surgery. Possible small increased risk of intestinal cancer Reduces risk of developing gallstones from 32% to 2% during first 6 months post op. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Sugerman HJ, Brewer WH, Shiffman ML, et. al. Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298. BACKGROUND: Previous studies have documented a high incidence of gallstone formation following gastric-bypass (GBP)-induced rapid weight loss in morbidly obese patients. This study was designed to determine if a 6-month regimen of prophylactic ursodiol might prevent the development of gallstones. METHODS: A multicenter, randomized, double-blind, prospective trial evaluated 3 oral doses of ursodiol: 300, 600, and 1,200 mg versus placebo beginning within 10 days after surgery and continuing for 6 months or until gallstone development, for patients with a body mass index (BMI) > or = 40 kg/m2. All patients had normal intraoperative gallbladder sonography. Transabdominal sonography was obtained at 2, 4, and 6 months following surgery, or until gallstone formation. RESULTS: Of 233 patients with 4 / 5
at least one postoperative sonogram, 56 were randomized to placebo, 53 to 300 mg ursodiol, 61 to 600 mg ursodiol, and 63 to 1,200 mg ursodiol. Preoperative age, sex, race, weight, BMI, and postoperative weight loss were not significantly different between groups. Gallstone formation occurred at 6 months in 32%, 13%, 2%, and 6% of the patients on the respective doses. Gallstones were significantly (P < 0.001) less frequent with ursodiol 600 and 1,200 mg than with placebo. CONCLUSION: A daily dose of 600 mg ursodiol is effective prophylaxis for gallstone formation following GBP-induced rapid weight loss. Am J Surg. 1995 Jan;169(1):91-6; discussion 96-7. 5 / 5