Safer Care Victoria’s Best Care resources support patients and healthcare providers to have conversations and make decisions together about the most appropriate pathways for care.
This resource, developed for clinicians, details a specific elective procedure that should now only be done for specific indications. Evidence-based recommendations that detail ‘best care’ pathways should be discussed with your patient to determine the most appropriate pathway of care.
This guidance specifically relates to the clinical decision pathway during bariatric surgery for intraoperative cholecystectomy.
It must be emphasised this clinical guidance is underpinned by the best evidence available at the time of publication but following guidance recommendations will not necessarily result in the best outcome. Guidance can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.
Gallstone diseases (cholelithiasis, choledocholithiasis, cholecystitis, ascending cholangitis) are associated with both obesity and weight loss (1).
Gallstones can develop in 30-50% of patients who undergo a bariatric procedure (2). Following bariatric surgery, patients are at increased risk of developing gallstone complications, such as biliary colic, acute cholecystitis, acute pancreatitis, and bile duct stones (3).
Whilst the formation of gallstones post bariatric surgery is common, symptomatic gallstone disease requiring cholecystectomy after bariatric surgery is less common with the highest rates after Roux-En-Y Gastric Bypass (6.1%- 10.6%) followed by Sleeve Gastrectomy (3.5% -6.1%) and the lowest rates after Adjustable Gastric Banding (0-2.9%) (3,4,5).
The incidence of cholecystectomy following bariatric surgery is highest within the first 3 months post operation and is usually related to weight loss during this period (3).
For patients with symptomatic gallstone disease at the time of bariatric procedure, prophylactic cholecystectomy concurrent with bariatric surgery has benefits such as avoiding gallstone formation and stone-related complications, therefore reducing costs and separate hospitalisation for each procedure (2). However, the increased risk for post-operative complications, longer operation time and technical difficulty may outweigh these benefits (2,6,7).
Current evidence does not support removing the gallbladder at the time of bariatric surgery unless the patient has symptomatic cholelithiasis.
Indications for procedure
Concurrent cholecystectomy could be considered for patients undergoing bariatric surgery who have symptomatic gallstone disease.
The benefit of concurrent cholecystectomy with symptomatic gallstone disease is that patients only require a singular surgery and hospital admission with minimal increased risk.
Alternative treatment pathway
- Cholecystectomy prior to bariatric surgery (usually in severe gallstone disease/symptoms)
- Deferring cholecystectomy for symptomatic gallstones until after bariatric surgery
Concurrent cholecystectomy for patients with asymptomatic gallstone disease may be considered for socioeconomically disadvantaged and geographically isolated patients where it may be difficult for the patient to access a second procedure if required. In this situation, the risk of not being able to access a second procedure if required needs to be balanced against the increased risk of concurrent cholecystectomy.
If cholecystectomy is not performed at the time of the bariatric surgery, patients and clinicians should remain aware of the potential for complications of biliary disease and undertake further investigations as appropriate (2).
Best Care recommendations
Best Care does not recommend concurrent cholecystectomy for patients with asymptomatic gallstones, as only a minority of these patients will develop symptoms requiring a cholecystectomy.
Concurrent cholecystectomy could be considered for people with socioeconomic disadvantage or in geographically isolated locations.
Download the guidance supplement for information about how this guidance was developed.
- Torgerson JS, Lindroos AK, Naslund I, Peltonen M. Gallstones, gallbladder disease, and pancreatitis: cross-sectional and 2-year data from the Swedish Obese Subjects (SOS) and SOS reference studies. Am J Gastroenterol 2003;98:1032-41
- Tsirline VB, Keilani ZM, El Djouzi S, et al. How frequently and when do patients undergo cholecystectomy after bariatric surgery? Surg Obes Relat Dis 2014;10:313-21.
- Tustumi, Francisco & Bernardo, Wanderley & Santo, Marco & Cecconello, Ivan. (2018). Cholecystectomy in Patients Submitted to Bariatric Procedure: A Systematic Review and Meta-analysis. Obesity Surgery. 28. 10.1007/s11695-018-3443-1.
- Moon RC, Teixeira AF, DuCoin C, Varnadore S, Jawad MA. Comparison of cholecystectomy cases after Roux-en-Y gastric bypass, sleeve gastrectomy, and gastric banding. Surg Obes Relat Dis 2014;10:64-8.
- Mishra T, Lakshmi KK, Peddi KK. Prevalence of Cholelithiasis and Choledocholithiasis in Morbidly Obese South Indian Patients and the Further Development of Biliary Calculus Disease After Sleeve Gastrectomy, Gastric Bypass and Mini Gastric Bypass. Obes Surg 2016;26:2411-7.
- D'Hondt M, Sergeant G, Deylgat B, et al. Prophylactic cholecystectomy, a mandatory step in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass? J Gastrointest Surg. 2011Sep;15(9):1532–6.19.
- Dakour-Aridi HN, El-Rayess HM, Abou-Abbass H, et al. Safety of concomitant cholecystectomy at the time of laparoscopic sleeve gastrectomy: analysis of the American College of Surgeons National Surgical Quality Improvement Program database. SurgObes Relat Dis. 2017 Jun;13(6):934–41.
Page last updated: 05 Jul 2022