SSAT - SIMULTANEOUS ROUX-EN-Y GASTRIC BYPASS AND CHOLECYSTECTOMY ARE ASSOCIATED WITH WORSE 5-YEAR CLINICAL OUTCOMES COMPARED TO ROUX-EN-Y GASTRIC BYPASS ALONE: RESULTS OF A MULTINATIONAL ANALYSIS

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SIMULTANEOUS ROUX-EN-Y GASTRIC BYPASS AND CHOLECYSTECTOMY ARE ASSOCIATED WITH WORSE 5-YEAR CLINICAL OUTCOMES COMPARED TO ROUX-EN-Y GASTRIC BYPASS ALONE: RESULTS OF A MULTINATIONAL ANALYSIS
Do Han Kim^*², Donghyun Ko³, Wilhelm S. Basegoda⁴, Jose A. Porres⁵, Paul T. Kr�ner⁶, Christopher C. Thompson¹
¹Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; ²Mount Sinai Morningside Hospital, New York, NY; ³Bridgeport Hospital, Bridgeport, CT; ⁴University of South Alabama, Mobile, AL; ⁵Universidad Francisco Marroquin Facultad de Medicina, Guatemala City, Guatemala Department, Guatemala; ⁶Riverside Health System, Newport News, VA

Introduction
Rapid weight loss from metabolic surgery is a known factor contributing to increased gallstone formation. Choledocholithiasis in patients with a Roux-en-Y gastric bypass (RYGB) anatomy poses a particular challenge to conventional biliary access with endoscopic retrograde cholangiopancreatography (ERCP), requiring advanced endoscopic techniques such as endoscopic ultrasound-directed transgastric ERCP (EDGE) or balloon enteroscope-assisted ERCP, among others. These techniques demand a high degree of technical expertise, for which they are not widely available. For this reason, some have argued in favor of simultaneous cholecystectomy (CCY) at the time of RYGB. However, simultaneous CCY at the time of RYGB has been noted to carry significantly higher immediate postoperative risks, which has suggested against the widespread implementation of this practice. The goal of this study is to explore the 5-year outcomes of patients undergoing simultaneous CCY at the time of RYBG using a large multinational dataset.

Methods
A retrospective cohort study was performed using large population-based data from the TriNetX platform. Patients who underwent RYGB and CCY since January 1, 2014, were identified. This group was matched with patients who underwent RYGB without CCY according to age, gender, demographics, comorbidities, and medication by using 1:1 propensity matching. To analyze 5-year outcomes, Cox regression was used to yield hazard ratios (HR) and 95% confidence intervals (95%CI). Outcomes were mortality, shock, mechanical ventilation, ICU admission, acute kidney injury (AKI), venous thromboembolism (VTE), ERCP, rehospitalization, recurrent biliary acute pancreatitis (BAP), acute cholecystitis, and choledocholithiasis.

Results
A total of 44,232 patients with RGYB were identified, out of which 2,072 underwent simultaneous CCY. 1,640 were matched 1:1 to patients who did not undergo simultaneous CCY. At 90 days, the RGYB and CCY group had higher risk of ICU admission (HR, 1.72; 95% CI, 1.00-2.94) and choledocholithiasis (HR, 4.99; 95% CI, 1.09-22.78). At 5 years, the RGYB and CCY group had lower risk of rehospitalization (HR, 0.88; 95% CI, 0.80-0.98) and acute cholecystitis (HR, 0.21; 95% CI, 0.08-0.56).

Discussion
While patients undergoing simultaneous weight loss RYGB and CCY not only had increased mortality odds at 5 years, but also displayed significantly increased odds of morbidity surrogate markers, suggesting greater longer-term effects associated with the simultaneous procedure. It is speculated that the increased rates of choledocholithiasis seen in the simultaneous RYGB and CCY cohort at 90-days may have influenced the decision of conducting not only the simultaneous procedure but also ERCP in that cohort. Findings of this study continue to support against performing simultaneous CCY at the time of RYGB.

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