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 to 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 that 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 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 fully 30 percent of gastric bypass patients will develop gallstones, and 10 percent of patients will develop symptoms requiring surgical gall bladder removal (cholecystectomy). Conversely, 70 percent will have not develop gallstones.

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 above. Actigall taken during the weigh loss phase usually prevents gallstone formation. There still is a chance that stones could develop at some distant time in the future and that the gallbladder might need to be remove.

One group of patients who may be at particularly high risk for gallstones are young women, particularly of American Indian or Central American Indian ancestry who have multiple older female relatives who have had gallstone problems.

 

BACKGROUND: An increased risk of large bowel cancer, especially of the right colon, following cholecystectomy has been reported in some studies but contradicted in others. The aim of this study was to settle this question by creating a cohort of cholecystectomy patients that was large enough and with a sufficient follow-up time to detect even weak associations. METHODS: A population-based cohort consisting of 62,615 patients who underwent cholecystectomy was followed up for the occurrence of colorectal cancer up to 23 years. RESULTS: There were 633 colorectal cancers versus 637.9 expected (standardized incidence ratio [SIR] = 0.99; 95% confidence interval [CI] = 0.92-1.07). Analyses of an extensive number of subgroups including sex, age at operation, duration of follow-up, underlying diagnosis, type of operation, and different cancer sites did not show any association. However, for cancer of the right colon among women, the risk was increased (SIR = 1.24; 95% CI = 1.03-1.48) most prominent 15 years or more after operation (SIR = 1.54; 95% CI = 1.03-2.22). CONCLUSIONS: Overall, there is no excess risk of colorectal cancer following cholecystectomy, but consistent with some earlier reports, we observed an increased risk among women for right-sided colon cancer 15 years or more after operation

 2.  Intestinal cancer after cholecystectomy: is bile involved in carcinogenesis?

Lagergren J, Ye W, Ekbom A.

Gastroenterology 2001 Sep;121(3):542-7


BACKGROUND & AIMS: Results concerning an association between cholecystectomy and right-sided colon cancer are inconsistent. Little is known about the relation between cholecystectomy and small bowel cancer. Therefore, we evaluated cholecystectomy and risk of bowel cancer. METHODS: Cholecystectomized patients, identified through the Swedish Inpatient Register, from 1965 through 1997, were followed up for subsequent cancer. The standardized incidence ratio (SIR) estimated relative risk. RESULTS: In total, 278,460 cholecystectomized patients, contributing 3,519,682 person-years, were followed up for a maximum of 33 years after surgery. Cholecystectomized patients had an increased risk of proximal intestinal adenocarcinoma, which gradually declined with increasing distance from the common bile duct. The risk was significantly increased for adenocarcinoma (SIR, 1.77; 95% confidence interval [CI], 1.37-2.24) and carcinoids of the small bowel (SIR, 1.71; 95% CI, 1.39-2.08), and right-sided colon cancer (SIR, 1.16; 95% CI, 1.08-1.24). No association was found with more distal bowel cancer. The gradient was further pronounced when surgery of the common bile duct was included. The associations remained increased up to 33 years after cholecystectomy. No differences between sexes were found. CONCLUSIONS: Cholecystectomy increases the risk of intestinal cancer, a risk that declines with increasing distance from the common bile duct. Changes in the intestinal exposure to bile might be the underlying biological mechanism.

3. 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, Brolin RE, Fobi MA, Linner JH, MacDonald KG, MacGregor AM, Martin LF, Oram-Smith JC, et al.

Am J Surg 1995 Jan;169(1):91-6; discussion 96-7

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 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