It is well known that obesity is a risk for gallstone formation and biliary sludge. Additionally, it has been clearly shown that rapid weight loss following bariatric surgery is a risk factor for cholesterol cholelithiasis. Multiple serious complications from gallstones such as cholecystitis, cholangitis, gallstone pancreatitis, and cholecystenteric fistulae may occur. Thus, it is necessary to employ medical or surgical methods to prevent or treat gallstones in this group. Therapy should be individualized. Although there is a high incidence of gallstones in this group, only a minority of individuals will develop symptomatic disease. When used in patients who are compliant, ursodeoxycholic acid therapy can be effective to prevent gallstone formation during rapid weight loss. The cost effectiveness of routine ursodeoxycholic acid therapy compared with the potential costs of complicated gallstone disease needs to be further investigated. Combined cholecystectomy with Roux-en-Y gastric bypass surgery is a safe and appropriate therapeutic option in those with preoperatively known gallstones, biliary sludge, and prior episodes of cholecystitis. However, routine cholecystectomy at the time of gastric bypass surgery is not warranted for all patients because of the increased time of operation and postoperative hospitalization, as well as all the potential complications after cholecystectomy. The approach of routine cholecystectomy in this setting subjects many patients to an unnecessary procedure because the majority will not develop symptoms or complications of gallstones. Furthermore, cholecystectomy is technically easier to perform after weight loss occurs.
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