Updated panel report: best practices for the surgical treatment of obesity.

BACKGROUND: During the 2004 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on best practices in bariatric surgery. The rapid evolution of endoluminal technologies, surgical indications, and training in bariatric surgery since 2004 has led to new questions and concerns about optimal treatment algorithms, patient selection, and the preparation of our current and future bariatric workforce. METHODS: An expert panel was convened at the SAGES 2017 annual meeting to provide a summative update on current practice patterns, techniques, and training in bariatric surgery in order to review and establish best practices. This was a joint effort by SAGES, International Society for the Perioperative Care of the Obese Patient, and the American Society for Metabolic and Bariatric Surgery. RESULTS: On March 23, 2017, seven expert faculty convened to address current areas of controversy in bariatric surgery and provide updated guidelines and practice recommendations. Areas addressed included the expanded indications for use of metabolic surgery in the treatment of diabetes, the safety and efficacy of new and investigational endoluminal procedures, updates on new guidelines for the management of airway and sleep apnea in the obese patient, the development of clinical pathways to reduce variation in the management of the bariatric patient, and new guidelines for training, credentialing, and bariatric program accreditation. The following article is a summary of this panel. CONCLUSION: Bariatric surgery is a field that continues to evolve. A timely, systematic approach, such as described here, that coalesces data and establishes best practices on the current body of available evidence is imperative for optimal patient care and to inform provider, insurer, and policy decisions.

Tris-bipyridine based dinuclear ruthenium(ii)-osmium(iii) complex dyads grafted onto TiO2 nanoparticles for mimicking the artificial photosynthetic Z-scheme.

The Z-Scheme function within molecular systems has been rarely reported for solar energy conversion although it offers the possibility to achieve higher efficiency than single photon absorber photosystems due to the use of a wider range of visible light. In this study, we synthesized and investigated the electrochemical and spectroscopic properties of two new dyads based on ruthenium and osmium tris-bipyridine complexes covalently linked via a butane bridge to explore their ability to realize the Z-scheme function once immobilized on TiO2. These dyads can be grafted onto a nanocrystalline TiO2 film via the osmium complex bearing two dicarboxylic acid bipyridine ligands, while the ruthenium complex contains either two unsubstituted bipyridine ancillary ligands (RuH-Os) or two (4,4'-bis-trifluoromethyl-bipyridine) ancillary ligands (RuCF3-Os). Transient absorption spectroscopy studies of the Ru(ii)-Os(iii) dyads with femtosecond and nanosecond lasers were conducted both in solution and on TiO2. For both conditions, the photophysical studies revealed that the MLCT excited state of the ruthenium complex is strongly quenched and predominantly decays by energy transfer to the LMCT of the adjacent Os(iii) complex, in spite of the high driving force for electron transfer. This unexpected result, which is in sharp contrast to previously reported Ru(ii)-Os(iii) dyads, precluded us to achieve the expected Z-scheme function. However, the above results may be a guide for designing new artificial molecular systems reproducing the complex function of a Z-scheme with molecular systems grafted onto a TiO2 mesoporous film.

Lessons learned from the metabolic and bariatric surgery accreditation and quality improvement program site surveys: common deficiencies and corrective actions.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a joint program between the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS). On-site surveys of the applicant programs to determine adherence to the MBSAQIP standards are a hallmark of the accreditation process. OBJECTIVES: A retrospective review of 619 site surveys completed over 2 years was performed to include analysis of reviewer decisions, tabulation and cross-reference of identified deficiencies to the MBSAQIP standards and determine final disposition of corrective actions and overall accreditation rates. SETTING: Accredited Hospitals (Community and Academic) within MBSAQIP. METHODS: This is a retrospective review of site surveys by expert panel. RESULTS: ≥1 MBSAQIP Standards deficiencies were present at 149 of the 619 program site surveys (24.07%). The 3 leading Standards in Deficiency were in order: Commitment to Quality Care, Continuous Quality Improvement Process, and Data Collection. Within a year following initial site survey of the149 programs with Standards deficiencies, 59 programs demonstrated compliance, 83 programs were placed on probation (with a specific time-frame to demonstrate compliance) and 7 programs were denied accreditation. Ultimately, 98.9% of programs were able to gain or maintain MBSAQIP accreditation. CONCLUSIONS: The MBSAQIP accreditation through on-site surveys can identify and improve program adherence to MBSAQIP standards.

Carbon nanotube heterogenization improves cobalt pyridyldiimine complex CO2 reduction activity in aqueous carbonate buffer.

We present two novel cobalt pyridyldiimine complexes functionalized with pyrene. Initially modest in homogeneous acetonitrile solution, their electrocatalytic CO2 reduction performance significantly improves upon immobilization on MWCNTs in an aqueous carbonate buffer. The complexes exhibit outstanding stability, with CO selectivity exceeding 97%, and TON and TOF values reaching up to 104 and above 1.2 s-1, respectively.

Marginal ulcers and associated risk factors after Roux-en-Y gastric bypass.

As the prevalence of morbid obesity continues to climb in America, so does the popularity of the Roux-en-Y gastric bypass (RYGB) to achieve weight loss goals; however, a long-term risk of RYGB is marginal ulceration, which requires urgent surgery if perforated. We sought to identify characteristics associated with elective vs urgent presentation for marginal ulcer following RYGB. Retrospective data for consecutive cases with marginal ulcers that required surgical intervention from May 2016 to February 2021 were queried from our institution's bariatric database, and differences in patient characteristics and clinical course were assessed according to presentation. Forty-three patients underwent surgery for marginal ulcer during the study timeframe. Twenty-four (56%) patients presented electively and were treated with resection of the gastroenterostomy and reanastomosis; the remaining 19 (44%) presented urgently with perforation and were treated with omental patch repair. Demographics, comorbidities, and medications were similar between groups. Patients with urgent presentations were less likely to have bleeds (0% vs. 33%, P = 0.0056) and strictures (16% vs. 46%, P = 0.0368), but were more likely to require admission to the intensive care unit (32% vs. 4%, P = 0.0325) and have a longer median length of stay (2 vs. 5 days, P < 0.0001). Bariatric surgeons must properly counsel patients about the risk of marginal ulcer development to prevent dangerous perforation, intensive care unit stays, and long hospitalizations.

Management of transmesenteric tunnel jejunal strictures with endoscopic dilation by using achalasia balloons (with videos).

BACKGROUND: Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Transmesenteric tunnel (TMT) or mesocolic jejunal stricture is an unusual postoperative complication that requires another operation. We hypothesize that endoscopic dilation by using achalasia dilatation balloons can be used to treat some TMT jejunal strictures. PATIENTS: This study involved 6 consecutive cases of TMT stricture. INTERVENTION: The TMT strictures were dilated by using achalasia balloons (30-40 mm) under fluoroscopic and endoscopic guidance. RESULTS: With endotherapy, 4 patients with late onset of symptoms (>3 weeks after Roux-en-Y gastric bypass) have not required another operation to date, with a follow-up of at least 5 to 12 months. Two patients with early onset of symptoms (<3 weeks after surgery) required operations, and 1 of these patients (symptoms onset <7 days after surgery) developed jejunal perforation within the stricture during dilation due to underlying jejunal ischemia within the stricture. LIMITATIONS: Small case number and limited follow-up period. CONCLUSION: Endoscopic dilation by using achalasia balloons can be used to treat some TMT jejunal strictures without another operation. Surgery should be considered in patients with early onset of obstructive symptoms and/or with jejunal ischemia within the stricture.

Variations of weight loss following gastric bypass and gastric band.

OBJECTIVE: To compare and describe the weight loss outcomes from gastric bypass and gastric band so as to define the variation of excess weight loss (EWL) among individual patients, the time to onset of effect, and the durability of weight loss in severely obese adults. SUMMARY BACKGROUND DATA: Gastric bypass and gastric band are the most common operations for obesity performed in the United States, but few reports have compared these 2 procedures. METHODS: Patients (N = 1733, aged 18-65 years) met National Institutes of Health criteria for obesity surgery and underwent either gastric bypass or gastric band between March 1997 and November 2006. The selection of bypass versus band was based on patient/surgeon discussion. The evaluable sample consisted of 1518 patients. The percentage of EWL was assessed over 2 years. Successful weight loss was defined a priori as > or = 40% EWL in each of four 6-month postoperative measurement periods. The analyses included a mixed model and generalized estimating equation (GEE) model with repeated measures. Odds ratios and descriptive analyses were also provided. RESULTS: Gastric bypass was associated with less individual variation in weight loss than gastric band. Both procedures were associated with a significant EWL benefit (Treatment Group effect P < 0.0001), but they differed in terms of time to effect (Treatment Group x Period interaction effect P < 0.0001). The mean EWL for gastric bypass was greater at each measurement period (6, 12, 18, 24 months) compared with gastric band (P < 0.0001). Furthermore, at each of the postoperative measurement periods within each treatment group (bypass and band), the mean EWL was greater for those who had preoperative body mass index (BMI) < or = 50 kg/m2 than for those who had preoperative BMI > 50 kg/m2 (P < 0.0001). Gastric bypass was consistently associated with a greater likelihood of at least a 40% EWL in each of the 6-month postoperative measurement periods (GEE, P < 0.0001). The odds ratio estimates at months 6, 12, 18, and 24 were 18.2, 20.6, 15.5, and 9.1, respectively. Despite these clinically meaningful outcome differences, nearly all (> or = 93%) bypass and band patients who had > or = 40% EWL at 6, 12, or 18 months postoperatively maintained at least this level of success at 2 years. CONCLUSIONS: Gastric bypass produced more rapid, greater, and more consistent EWL across individuals over a 2-year postoperative period than gastric band.

Endotherapy in unusual bariatric surgical complications (with videos).

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the USA. We hypothesize that therapeutic endoscopy can be used to treat some unusual post-operative complications. We report two cases of early post-operative complications: (1) gastrogastrotomy (GG) stricture and (2) "trans-mesenteric tunnel" or "mesocolic" jejunal stricture. Endoscopic strictureplasty/revision of the gastric pouch of a bypass after gastroplasty was performed. The mesocolic stricture was managed with endoscopic dilatation using the achalasia dilating balloon under fluoroscopic and endoscopic guidance. With endotherapy, the patient with the GG stricture did not require re-operation, and there were no complications or stricture recurrence. The patient with mesocolic stricture responded short-term to endotherapy but ultimately required surgical adhesion lysis. None of these patients developed any procedure-related complications. Thus, in patients with unusual post-operative complications after RYGBP, endotherapy may be useful when there is good collaboration between the endoscopist and the surgeon.

Gastrojejunal stomal reduction with the T-tag device in porcine models (with videos).

BACKGROUND: Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Gastrojejunal (GJ) stomal dilatation associated with weight regain is a late complication. Surgical revision is usually required for stomal or pouch reduction. OBJECTIVE: Our purpose was to evaluate the technical feasibility, efficacy, and safety of stomal reduction with endoscopic T-tag devices. DESIGN: Prospective nonsurvival studies were conducted in pigs (n = 2, 110 pounds each). INTERVENTIONS: Three GJ stomas were created in each pig through a midline laparotomy by using circular staplers. Endoscopic GJ stomal reduction/revision was performed on these newly created stomas with an Olympus T-tag device. Necropsy was performed to examine the deployed T-tag locations and procedure-related adjacent tissue/organ injury and to assess the effectiveness of stomal reduction. RESULTS: Endoscopic stomal revision was performed on 5 stomas with moderate stomal reduction. One GJ stoma could not be accessed easily by endoscopy because of the small size of the gastric pouch. An average of 4 T-tag devices was deployed around each stoma. The procedural time was about 61 +/- 12 minutes for each stomal reduction. Overall, 26 of 39 (66.7%) T-bars were deployed in accepted locations. The stomas were reduced from 1.60 +/- 0.21 mm x 1.44 +/- 0.14 mm to 1.28 +/- 0.29 mm x 0.98 +/- 0.17 mm and the percentage of stomal reduction was 27.3% +/- 13.3%. In the end, a therapeutic gastroscope could not be advanced through the reduced stomas. In 2 stomas, 5 of 39 (12.8%) T-bars injured or attached to the adjacent organs: isolated stomach and abdominal wall. LIMITATION: Nonsurvival pig studies. CONCLUSIONS: Endoscopic stomal reduction with T-tag device is technically feasible and effective in two thirds of trials. However, it is associated with a small risk of adjacent organ/tissue injury with the current prototype device and deployment method.

Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables.

BACKGROUND: Dexmedetomidine (Dex), an alpha(2) agonist, has well-known anesthetic and analgesic-sparing effects. We designed this prospective, randomized, double-blind, and placebo-controlled dose-ranging study to evaluate the effect of Dex on both early and late recovery after laparoscopic bariatric surgery. METHODS: Eighty consenting ASA II-III morbidly obese patients were randomly assigned to 1 of 4 treatment groups: (1) control group received a saline infusion during surgery, (2) Dex 0.2 group received an infusion of 0.2 microg x kg(-1) x h(-1) IV, (3) Dex 0.4 group received an infusion of 0.4 microg x kg(-1) x h(-1) IV, and (4) Dex 0.8 group received an infusion of 0.8 microg x kg(-1) x h(-1) IV. Mean arterial blood pressure values were maintained within +/-25% of the preinduction baseline values by varying the inspired desflurane concentration. Perioperative hemodynamic variables, postoperative pain scores, and the need for "rescue" analgesics and antiemetics were recorded at specific intervals. Follow-up evaluations were performed on postoperative days (PODs) 1, 2, and 7 to assess severity of pain, analgesic requirements, patient satisfaction with pain management, quality of recovery, as well as resumption of dietary intake and recovery of bowel function. RESULTS: Dex infusion, 0.2, 0.4, and 0.8 microg x kg(-1) x h(-1), reduced the average end-tidal desflurane concentration by 19, 20, and 22%, respectively. However, it failed to facilitate a significantly faster emergence from anesthesia. Although the intraoperative hemodynamic values were similar in the four groups, arterial blood pressure values were significantly reduced in the Dex 0.2, 0.4, and 0.8 groups compared with the control group on admission to the postanesthesia care unit (PACU) (P < 0.05). The length of the PACU stay was significantly reduced in the Dex groups (81 +/- 31 to 87 +/- 24 vs 104 +/- 33 min in the control group, P < 0.05). The amount of rescue fentanyl administered in the PACU was significantly less in the Dex 0.2, 0.4, and 0.8 groups versus control group (113 +/- 85, 108 +/- 67, and 120 +/- 78 vs 187 +/- 99 microg, respectively, P < 0.05). The percentage of patients requiring antiemetic therapy was also reduced in the Dex groups (30, 30, and 10% vs 70% in the control group). However, the patient-controlled analgesia morphine requirements on PODs 1 and 2 were not different among the four groups. Pain scores in the PACU, and on PODs 1, 2, and 7, in the three Dex groups were not different from the control group. Finally, quality of recovery scores and times to recovery of bowel function and hospital discharge did not differ among the four groups. CONCLUSIONS: Adjunctive use of an intraoperative Dex infusion (0.2-0.8 microg x kg(-1) x h(-1)) decreased fentanyl use, antiemetic therapy, and the length of stay in the PACU. However, it failed to facilitate late recovery (e.g., bowel function) or improve the patients' overall quality of recovery. When used during bariatric surgery, a Dex infusion rate of 0.2 microg x kg(-1) x h(-1) is recommended to minimize the risk of adverse cardiovascular side effects.

Revision of failed gastric restrictive operations to Roux-en-Y gastric bypass: impact of multiple prior bariatric operations on outcome.

BACKGROUND: Morbid obesity is now an epidemic with considerable associated morbidity for which bariatric surgery has been the only effective treatment. Despite its success, occasional patients require revision because of weight regain or mechanical complications. The impact of multiple prior bariatric operations on complications and weight loss after revision to Roux-en-Y gastric bypass (RYGBP) was evaluated. METHODS: All patients undergoing revisional surgery to RYGBP by the senior author from 1997 through 2004 were retrospectively reviewed at a multi-center academic institution. Patients who had previously undergone multiple revisional operations (MR) were compared to patients who had undergone primary ("first-time") revision (PR). Demographics, indications for revision, complications, and weight loss were reviewed. RESULTS: 66 patients underwent open revision to RYGBP after failed bariatric operations, with 12 in the MR group and 54 in the PR group. Mean preoperative BMI was 46.1 and 45.2 (P=0.8), respectively. Operative time (227 vs 162 min, P=0.07), blood loss (517 vs 313 ml, P=0.09) and hospital length of stay (11.5 vs 6.7 days, P=0.2) were higher in the MR group. Major perioperative complications occurred in 16.7% of MR patients compared to 9.3% of PR patients (P=0.6). Percent of excess weight loss (%EWL) has been 54.3% in the MR group and 60.6% in the PR group (P=0.6). Average follow-up is 26 and 23 months, respectively. CONCLUSION: Although operative times, blood loss, and LOS were greater in MR patients, RYGBP can be performed in patients with multiple previous bariatric operations with acceptable weight loss and complication rates.

Regioselectivity in C-H activation: reagent control in cyclometallation of 2-(1-naphthyl)-pyridine.

2-(1-Naphthyl)-pyridine () possesses sp(2) C-H bonds in both the γ- and δ-positions and is therefore a suitable substrate for studying the cyclometallation selectivity with different reagents and conditions. Such selectivity studies are reported. Based on deuterium-exchange experiments it is concluded that cycloruthenation with RuCl2(p-cymene) dimer is reversible with kinetic and thermodynamic preference for γ-substitution. Electrophilic cycloborylation, on the other hand, shows unusual δ-substitution. The previously published cyclopalladation and cycloauration of the substrate was studied in detail and was shown to be irreversible; they proceed under kinetic control and give γ- and δ-substitution for palladium and gold, respectively.

Laparoscopic adjustable gastric banding: an attractive option.

Bariatric surgery is the only effective treatment producing sustained weight loss and reduction in comorbidities in the morbidly obese. Laparoscopic adjustable gastric banding (LAGB) has evolved considerably in techniques of insertion and band management since the initial descriptions in the early 1990s. Major advantages of LAGB include lower perioperative morbidity and mortality, adjust-ability, and reversibility. Although weight loss occurs more slowly than after gastric bypass, end results are comparable.

Heated and humidified insufflation during laparoscopic gastric bypass surgery: effect on temperature, postoperative pain, and recovery outcomes.

BACKGROUND: Controversy exists regarding the efficacy of heated and humidified intraperitoneal gases in maintaining core body temperature. We performed a sham-controlled study to test the hypothesis that active warming and humidification of the insufflation gas reduces intraoperative heat loss and improves recovery outcomes. PATIENTS AND METHODS: Fifty morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass procedures using a standardized anesthetic technique were randomly assigned to either a control (sham) group receiving room temperature insufflation gases with an inactive Insuflow (Lexion Medical, St. Paul, MN) device, or an active (Insuflow) group receiving warmed and humidified intraperitoneal gases. Esophageal and/or tympanic membrane temperature was measured perioperatively. Postoperative pain was assessed at 15 minute intervals using an 11-point verbal rating scale, with 0 = none to 10 = maximal. In addition, postoperative opioid requirements, incidence of nausea and vomiting, as well as the quality of recovery, were recorded. RESULTS: Use of the active Insuflow device was associated with significantly higher mean +/- standard deviation (SD) intraoperative core body temperatures (35.5 +/- 0.5 vs. 35.0 +/- 0.4 degrees C). Postoperative shivering (0 vs. 19%) and the requirement for morphine in the postanesthesia care unit (5 +/- 4 vs. 10 +/- 5 mg) were both significantly lower in the Insuflow vs. control groups. Patients in the Insuflow group also reported a higher quality of recovery 48 hours after surgery (15 vs. 13, P < 0.05). CONCLUSION: The Insuflow device modestly reduced shivering and heat loss, as well as the need for opioid analgesics in the early postoperative period. However, it failed to improve laparoscopic visualization due to fogging, and provided improvement in the quality of recovery only on postoperative day 2.

Gastro-clip gastroplasty: a very long-term complication.

For most surgeons, the gastro-clip gastroplasty is an unfamiliar operation. It was performed during the mid 1980s as an alternative to more complex bariatric operations. However, the device had problems. Because of its rigid nature, it occasionally eroded into the stomach and chest. Many of these devices required removal. However, patients may occasionally present with delayed complications. We present a patient with a Gastro-clip gastroplasty, who presented years after the procedure with a functional gastric outlet obstruction.

Use of fibrin sealant in laparoscopic gastric bypass for the morbidly obese.

Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the USA. Anastomotic leak is one of the devastating complications in this operation. By using fibrin sealant around the anastomosis, surgeons can achieve better hemostasis around the suture-line and prevent or decrease the incidence of anastomotic leaks. This paper discusses the biological and clinical evidence for use of fibrin sealant in laparoscopic gastric bypass.

Acute post-gastric reduction surgery (APGARS) neuropathy.

BACKGROUND: A variety of neurologic complications have been reported after weight loss surgery. Recently, a new term was introduced to describe cases of postoperative polyneuropathy - acute post-gastric reduction surgery (APGARS) neuropathy, a polynutritional, multisystem disorder characterized by protracted postoperative vomiting, hyporeflexia, and muscular weakness. The incidence, associations, and prognosis of this disorder have not been precisely defined. METHODS: A questionnaire about features of APGARS was mailed to all members of the ASBS. Surgeons were asked about their surgical and bariatric experience. Respondents were asked to report on specific cases where APGARS may have been present. They were also asked to report the patient's diagnosis and which operation the patient had undergone. RESULTS: Of the 808 questionnaires, 257 were returned for a response-rate of 31.8%. The mean years in general surgical practice and in bariatric surgery were 15.3 +/- 10.3 and 7.5 +/- 7.4. A total of 168010 bariatric cases were performed by all respondents. 109 cases of neuropathy were described. 99 cases were believed to represent APGARS (weakness with hyporeflexia and/or vomiting). Vitamin B and/or thi12 amine deficiency were present in 40 (40%); 18 cases resolved. 9 of 17 cases with B(12) deficiency resolved; 12 of 29 cases with thiamine deficiency resolved; and 3 of 6 cases with both deficiencies resolved. Vitamin deficiencies were not noted in 59 (60%), of which 30 resolved. The most common diagnoses were Wernicke's encephalopathy, thiamine deficiency, and Guillain-Barré Syndrome. The most common operation performed was gastric bypass. CONCLUSIONS: The incidence of APGARS in this survey was 5.9 cases per 10000 operations. Given the potentially reversible nature of APGARS, surgeons should be aware of the findings and treatment.

Routine upper gastrointestinal Gastrografin swallow after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Upper gastrointestinal (UGI) swallow radiographs following laparoscopic Roux-en-Y gastric bypass (LRYGBP) may detect an obstruction or an anastomotic leak. The aim of our study was to determine the efficacy of routine imaging following LRYGBP. METHODS: Radiograph reports were reviewed for 201 consecutive LRYGBP operations between April 1999 and June 2001. UGI swallow used Gastrografin, static films, fluoroscopic video, and a delayed image at 10 minutes. Mean values with one standard deviation were tested for significance (P < 0.05) using the Mann-Whitney U test statistic. RESULTS: Of 198 available reports, UGI detected jejunal efferent (Roux) limb narrowing (n = 17), partial obstruction (n = 12), anastomotic leak (n = 3), complete bowel obstruction (n = 3), diverticulum (n = 1), hiatal hernia (n = 1), and proximal Roux limb narrowing (n = 1). A normal study was reported in 160 cases (81%). Partial obstruction resolved without intervention. Complete obstruction required re-operation. Compared to 6 patients who developed delayed leaks, early identification of a leak by routine UGI swallow resulted in a shorter hospital stay (mean 7.7 +/- 1.5 days vs 40.2 +/- 12.3 days, P < 0.03). CONCLUSIONS: Early intervention after UGI swallow may lessen morbidity. Routine UGI swallow following LRYGBP does not obviate the importance of close clinical follow-up.

Is routine cholecystectomy required during laparoscopic gastric bypass?

BACKGROUND: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of our study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). METHODS: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. RESULTS: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 39 patients developed gallstones (22%) and 12 developed sludge (8%), as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients developing stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). CONCLUSIONS: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.