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Cholecystectomy At the Time of Roux-EN-Y Gastric Bypass Does Not Alter the One Year Rate of Type 2 Diabetes Mellitus Resolution or Excess Weight Loss
Tammy L. Kindel*, Vishal Kothari, Jon S. Thompson
Surgery, University of Nebraska Medical Center, Omaha, NE
Introduction: Post-prandial bile acids have a role in glucose homeostasis, lipid metabolism, and energy expenditure. Recent studies suggest that increases in the bile acid pool may be a mechanism for restriction-independent weight loss and improvements in glucose homeostasis following roux-en-y gastric bypass (RYGB). While cholecystectomy alone does not alter the bile acid pool long-term, there are detriments in glucose homeostasis for up to six months post-operatively. We hypothesized that due to reduced post-prandial flow of bile acids after cholecystectomy, patients undergoing RYGB with a concomitant cholecystectomy (CC) would have lower excess weight loss and worse rates of resolution of type two diabetes mellitus (T2DM) at one year compared to patients who had a prior history of cholecystectomy (PC) or who had never undergone a cholecystectomy (NC).
Methods: An electronic bariatric database was reviewed from 1998-2012 for patients who underwent RYGB as a primary bariatric procedure and had follow-up data available at 12 months post-operatively. Patients were excluded if they required a cholecystectomy during the 12 months pre or post-operatively. Patient charts were reviewed and categorized as CC, PC, or NC. Patients from each group were identified as T2DM pre-operatively. Patient data was reassessed at the one year follow-up visit for resolution (no anti-hyperglycemic medications), improvement (insulin to oral agents), or unchanged pharmacotherapy (still on insulin or oral agents as compared to pre-op). Data are expressed as the mean ± standard deviation. Association of diabetes improvement to CC was assessed by chi-square analysis, with significance set at p<0.05.
Results: 599 patients underwent a primary RYGB (CC n=142, PC n=189, NC n=268). The average pre-operative BMI was 53.1 ± 9.1 for CC, 50.8 ± 8.1 for PC, and 49.1 ± 8.1 for NC. The average BMI loss at one year was 17.5 ± 7.7 for CC, 17.1 ± 5.7 for PC, and 16.3 ± 4.9 for NC. 15.5% of patients had a pre-operative diagnosis of T2DM (n=93). 91.6% (n=11) of CC patients had improved or resolved T2DM at one year post-operatively (p=0.17 vs NC). This is compared to 63.3% of PC patients (n=23; p=0.31 vs NC) and 72.7% of NC patients who had improved/resolved T2DM.
Conclusions: Contrary to our hypothesis, cholecystectomy at time of RYGB did not adversely impact weight loss outcomes at one year. Intra-operative cholecystectomy did not have a detrimental impact on post-operative glucose homeostasis. Further, there was a non-significant positive trend for cholecystectomy on the rate of T2DM improvement/resolution. Further prospective studies are needed to determine the effect of intra-operative cholecystectomy at the time of RYGB on the post-prandial bile acid pool and whether cholecystectomy might offer a novel adjunct at the time of RYGB to augment the metabolic improvement of T2DM.
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