Yolsuriyanwong K, Jubprang S, Winiyakul N, Cheewatanakornkul S, Wangkulangkul P, Promchan D. Incidence and predictors of gallstone disease after bariatric surgery in a Thai population. World J Gastrointest Surg 2026; 18(3): 116602 [DOI: 10.4240/wjgs.v18.i3.116602]
Corresponding Author of This Article
Kamthorn Yolsuriyanwong, MD, Assistant Professor, Department of Surgery, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Kho Hong, HatYai 90110, Songkhla, Thailand. kamthorn.y@psu.ac.th
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Surgery
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Retrospective Cohort Study
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Mar 27, 2026 (publication date) through Mar 30, 2026
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World Journal of Gastrointestinal Surgery
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Yolsuriyanwong K, Jubprang S, Winiyakul N, Cheewatanakornkul S, Wangkulangkul P, Promchan D. Incidence and predictors of gallstone disease after bariatric surgery in a Thai population. World J Gastrointest Surg 2026; 18(3): 116602 [DOI: 10.4240/wjgs.v18.i3.116602]
Kamthorn Yolsuriyanwong, Sireetorn Jubprang, Nichakan Winiyakul, Siripong Cheewatanakornkul, Piyanun Wangkulangkul, Department of Surgery, Faculty of Medicine, Prince of Songkla University, HatYai 90110, Songkhla, Thailand
Darawan Promchan, Department of Surgical Nursing, Faculty of Nursing, Prince of Songkla University, HatYai 90110, Songkhla, Thailand
Author contributions: Yolsuriyanwong K, Jubprang S, Winiyakul N, Cheewatanakornkul S, and Wangkulangkul P conceived and designed the study. Yolsuriyanwong K, Jubprang S, and Promchan D acquired and analyzed the data acquisition and analysis. Yolsuriyanwong K and Jubprang S contributed to the interpretation of data and critical revision of the manuscript for intellectual content. Yolsuriyanwong K, Jubprang S, and Winiyakul N drafted the manuscript. Cheewatanakornkul S and Wangkulangkul P reviewed and revised the manuscript. All the authors approved the final version for publication and agreed to be accountable for all aspects of the work, thus ensuring the accuracy and integrity of the study.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of the Faculty of Medicine, Prince of Songkla University. (No. 62-270-10-4).
Informed consent statement: The need for informed consent was waived.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: Data sharing is not applicable because the datasets contain protected patient information and cannot be released under institutional and ethical regulations.
Corresponding author: Kamthorn Yolsuriyanwong, MD, Assistant Professor, Department of Surgery, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Rd, Kho Hong, HatYai 90110, Songkhla, Thailand. kamthorn.y@psu.ac.th
Received: November 18, 2025 Revised: December 6, 2025 Accepted: January 12, 2026 Published online: March 27, 2026 Processing time: 132 Days and 17.8 Hours
Abstract
BACKGROUND
Several prior studies have reported a high incidence of gallstone disease post-bariatric surgery. However, its incidence and predictive factors in Asian populations have not been adequately studied.
AIM
To evaluate the incidence and predictive factors of gallstone disease post-bariatric surgery in a Thai population.
METHODS
We retrospectively evaluated patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass at a University Hospital in Thailand between July 2012 and December 2019. All patients underwent annual imaging studies for gallstones both before and after surgery. The predictive factors for postoperative gallstone disease were analyzed using univariate and multivariate analyses.
RESULTS
A total of 243 patients who underwent laparoscopic sleeve gastrectomy (70.8%) or laparoscopic Roux-en-Y gastric bypass (29.2%) were included in the analysis, with a mean age of 36.4 years. The incidence of postoperative gallstone disease was 19.3%, comprising 1.2% symptomatic and 18.1% asymptomatic cases, with a median follow-up of 24.6 (range: 6.1-98.4 months). Preoperative body mass index (BMI) was the only factor significantly associated with postoperative gallstone disease (P = 0.004). Patients with a BMI ≥ 50 kg/m2 were three times more likely to develop postoperative gallstone disease post-bariatric surgery compared to those with a BMI < 50 kg/m2 (P = 0.013).
CONCLUSION
The incidence of gallstone disease after bariatric surgery was relatively high. Preoperative BMI was the only predictive factor in this study. As only a few patients developed symptomatic gallstones post-bariatric surgery, the necessity of routine gallstone screening and prophylactic treatment in this population requires further evaluation.
Core Tip: Incidence of gallstone disease after bariatric surgery was 19.3% in Thai patients. There were 1.2% of bariatric surgery patients developed symptomatic gallstones. Preoperative body mass index was the only significant predictive factor. Patients with a body mass index ≥ 50 kg/m2 had a 3-time higher risk of gallstones post-surgery. To assess the factors associated with post-bariatric surgery gallstone disease, a univariate analysis was performed, comparing demographic and patient characteristics, including the type of bariatric surgery, between those with and without gallstones.
Citation: Yolsuriyanwong K, Jubprang S, Winiyakul N, Cheewatanakornkul S, Wangkulangkul P, Promchan D. Incidence and predictors of gallstone disease after bariatric surgery in a Thai population. World J Gastrointest Surg 2026; 18(3): 116602
Gallstone diseases are common worldwide, with varying incidence rates across each continent. In North and South America, the incidence is reported to be as high as 15%-16%. In contrast, lower rates have been observed in other regions, ranging from 8.3%-15% in Europe, 9.3%-10.7% in Asia, and 4.4% in Africa[1]. Gallstone diseases, such as acute cholecystitis and acute pancreatitis, can present without symptoms or complications. There are several risk factors that contribute to gallstone formation, including obesity, especially body mass index (BMI) > 40 kg/m2, rapid weight loss (1.5 kg) within a week, female, age > 40 years, and Caucasian ethnicity[2-4].
The emergence of bariatric surgery worldwide, including in Asia, has led to an increase in the incidence of gallstone diseases[4]. Among post-bariatric surgery patients, the incidence of gallstone disease ranges from 6.5% to 55%[5-9]. In theory, bile acids help emulsify fats and neutralize acids in the gut, which helps prevent gallstone formation. However, in post-bariatric surgery patients, alterations in gastrointestinal anatomy, reduced food intake, and gut microbiota dysbiosis result in decreased bile acid secretion and oversaturated cholesterol in the bile. The bile becomes more viscous, and when combined with reduced gallbladder motility, this leads to an increased risk of gallstone formation[10]. Due to this high risk, ursodeoxycholic acid (UDCA) is commonly used to prevent gallstone formation. However, the cost-effectiveness remains unexplored, and its side effects, including diarrhea, abdominal discomfort, or nausea/vomiting, can lead to poor compliance[11].
Most studies on gallstone formation after bariatric surgery have been conducted in Caucasian populations, with reported incidence rates ranging from 3.3% to 47.9%[6,8,12-14]. For instance, 26.5% of patients who underwent gastric banding in the Netherlands developed gallstones, whereas 5.4% of patients who underwent sleeve gastrectomy in Turkey developed gallstones[15,16]. In Asian populations, post-bariatric surgery gallstone incidence has been reported at 10.5% in India and 27.5% in Singapore[17,18]. However, studies in Asian populations, including Thailand, remain limited. Understanding the incidence of gallstone disease after bariatric surgery can help evaluate the cost-effectiveness of UDCA for gallstone prevention. This study aimed to determine the incidence of gallstone disease after bariatric surgery in Thailand and identify factors associated with gallstone formation following bariatric surgery. The findings may contribute to improving the management and prevention of gallstone disease in this population.
MATERIALS AND METHODS
We retrospectively reviewed patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) at an academic medical center between July 2012 and December 2019. This study received ethical approval from the Human Research Ethics Committee at our institute (No. 62-270-10-4). The exclusion criteria included: Previous cholecystectomy or bariatric surgery, preexisting gallstones, gallbladder polyps, lack of preoperative and postoperative gallstone imaging, use of prophylactic agents for gallstone prevention, follow-up period of less than 1 year, and undergoing bariatric procedures other than LSG and LRYGB.
Eligibility for bariatric surgery at our center included a BMI ≥ 37.5 kg/m2 or a BMI ≥ 32.5 kg/m2 with significant obesity-related comorbidities. All patients underwent routine preoperative ultrasonography of the upper abdomen to assess for gallstones, gallbladder diseases, and liver diseases. Patients with preoperative gallstones scheduled for LSG underwent simultaneous cholecystectomy, whereas those undergoing LRYGB had a cholecystectomy regardless of symptoms. All patients underwent ultrasonography one year after surgery to evaluate hepatobiliary disease. During the follow-up period, if patients had symptoms of gallstone disease, additional imaging studies were performed for diagnosis. Symptomatic gallstones required cholecystectomy. Imaging modalities, such as ultrasonography, computed tomography, and magnetic resonance imaging, were interpreted by a radiologist. Prophylactic agents for gallstone prevention were not routinely administered.
The primary outcomes of this study included the incidence of gallstone disease post-bariatric surgery and the factors associated with gallstone formation following the procedure. Data were collected using the Epidata program and analyzed with R (version 4.1.2; Comprehensive R Archive Network). Categorical and continuous variables were compared between the two groups. Categorical variables are presented as frequencies (percentages), whereas continuous variables are presented as means [standard deviation (SD)] or medians [interquartile range (IQR)]. Univariate and multivariate analyses were performed using logistic regression to assess the relationship between the risk factors and gallstone occurrence. The best model was selected using the Akaike Information Criterion technique[18], and both forward and backward selection methods were applied. Subgroup analysis was conducted using the Youden index method to determine the weight cutoff points significantly associated with gallstone occurrence[19]. Statistical significance was set at P < 0.05 for both analyses.
RESULTS
Of the 409 patients who underwent LSG or LRYGB, 59 were excluded for the following reasons: Seven had a previous cholecystectomy, four had undergone previous bariatric surgery, and 48 had preexisting gallstones or bile sludge detected on imaging. Therefore, the preoperative incidence of gallstone disease in patients with morbid obesity was 12.1%. After surgery, 243 patients underwent hepatobiliary imaging and were included in this study. The demographic and patient characteristics are shown in Table 1. Most were female (n = 151, 62.1%). The median age was 35 years (IQR: 28-43; range: 12-65 years). The median preoperative BMI was 46.2 kg/m2 (IQR: 42-54.2; range: 33.1-84.1 kg/m2). Seventy percent of patients (n = 172) underwent LSG. The median follow-up duration was 24.6 months (IQR: 17.9-47.6; range: 6.1-98.3 months).
Among the 243 included patients, postoperative gallstone disease was identified in 19.3% (n = 47) through imaging studies. Thirty-eight patients in this group underwent LSG. Whereas 9 patients developed gallstones after LRYGB (12.6% of all LRYGB patients). Only three patients (1.2%) developed symptomatic gallstones, all presenting with biliary colic. The remaining 44 patients (18.1%) were asymptomatic. The symptomatic patients underwent cholecystectomy at a median of 16.7 months (range: 7.1-68.6 months) after diagnosis. To assess the factors associated with post-bariatric surgery gallstone disease, a univariate analysis was performed, comparing demographic and patient characteristics, including the type of bariatric surgery, between those with and without gallstones. Age, preoperative body weight, preoperative BMI, and preoperative high-density lipoprotein levels were significantly associated with postoperative gallstone disease (Table 2). Multivariate analysis revealed that preoperative BMI was the only factor associated with gallstone disease after bariatric surgery [odds ratio (OR) = 1.07, P = 0.004]. Specifically, patients with a preoperative BMI ≥ 50 kg/m2 had a threefold higher risk of gallstone formation compared to those with a preoperative BMI < 50 kg/m2 (IQR: 1.26-7.13; P value = 0.013) (Table 3).
Table 2 Univariate analysis of risk factors of gallstone diseases after bariatric surgery.
Obesity contributes to gallstone formation mainly through increased cholesterol metabolism, leading to higher cholesterol secretion and concentration in bile, a process linked to excessive calorie intake[20]. Additional mechanisms include changes in gut hormone levels and receptor function, which cause abnormal gallbladder contractility, gut microbiota dysbiosis, insulin resistance, and genetic predisposition[21]. In this study, the incidence of preoperative gallstones in patients with morbid obesity was 12.1%, which is relatively high. Similarly, studies by Karadeniz et al[22] in Turkey and Melmer et al[7] in Australia reported incidence rates of 13.3% and 22.2%, respectively. However, the exact pathophysiology of gallstone formation following bariatric surgery remains unclear. Studies suggest that rapid weight loss increases cholesterol secretion in bile, resulting in an elevated risk of gallstone formation[13]. Moreover, impaired gallbladder contractility due to factors such as duodenal bypass, decreased cholecystokinin levels after meals, or hepatic vagus nerve injury may also contribute to gallstone formation[13,14,23].
Many studies have examined the incidence of gallstones after bariatric surgery. Kiewiet et al[15] reported a 30.1% incidence of gallstone disease in patients who underwent adjustable gastric banding in the Netherlands. In Australia, Miller et al[2] found that the incidence of gallstones after vertical banded gastroplasty was 22% at 1 year and 30% at 2 years post-surgery. Similarly, Manatsathit et al[14] reported a 47.9% incidence of gallstone disease after sleeve gastrectomy in the United States. However, most of these studies focused on Caucasian populations.
Only a few studies have investigated this issue in Asia. Hasan et al[18] conducted a study in Singapore and found that 27.5% of patients who underwent sleeve gastrectomy developed gallstone disease, with a median follow-up time of 28.4 months. In India, Mishra et al[17] reported an incidence of 10.5% after bariatric surgery, with a median follow-up of 32.4 months. In our study, conducted in Thailand, the incidence of gallstone disease after bariatric surgery was 19.3%, with a median follow-up time of 24.6 months.
Compared with studies on Caucasian populations, Asians have a lower incidence of gallstone disease after bariatric surgery, which differs from the initial hypothesis. Sekine et al[24] indicated that visceral fat proportion is a key factor in gallstone formation. Given that Asians generally have a higher proportion of visceral fat than Caucasians, a higher incidence of gallstone disease would be expected[8,25]. However, our findings suggest otherwise. The results may be confounded by variations in median follow-up times and racial differences across studies. Race could be a contributing factor to gallstone formation after bariatric surgery, along with other unidentified risk factors that require further study.
Most patients who develop gallstone disease after bariatric surgery remain asymptomatic. In our study, only 1.2% of patients developed symptomatic gallstones, which is notably lower compared to the rates reported in other studies. For instance, Kiewiet et al[15] found that 4.9% of patients who underwent gastric banding developed symptomatic gallstones. Similarly, a study in Greece by Sioka et al[26] found the incidence of symptomatic gallstones after sleeve gastrectomy was 4.7%. In America, the incidence after sleeve gastrectomy was higher than that in Europe, reaching up to 8.2%[13]. In the Middle East, the incidence of symptomatic gallstones in patients who underwent bariatric surgery was reported to be 8.3% in Iran, Golzarand et al[27], and 6.2% in Israel, Sneineh et al[28]. Mishra et al[17] reported the incidence in India to be 3%. All the aforementioned studies reported a higher incidence than that observed in our study. However, another study in Singapore by Hasan et al[18] showed an incidence of only 0.9%, which is similar to our study in Thailand. It appears that the incidences in South Asia and Southeast Asia are lower than those in other continents. However, variations in follow-up duration and patient characteristics across studies may explain these differences in incidence rates.
Since there is a risk of gallstone formation after bariatric surgery in all races, prophylactic treatment is administered to reduce the likelihood of gallstone disease. A systematic review and meta-analysis of multiple randomized controlled trials by Magouliotis et al[29] found that administering UDCA for 6 months after bariatric surgery significantly reduced the risk of gallstone formation. However, poor compliance has been observed in some patients due to the side effects and cost of UDCA[30]. Identifying risk factors for gallstone formation after bariatric surgery could help target prophylactic treatment to high-risk patients, potentially improving outcomes.
Many studies have investigated risk factors for gallstone formation after bariatric surgery. Li et al[8] found that weight loss exceeding 25% was associated with an increased risk of symptomatic gallstones. Similarly, Abo-Ryia et al[31] identified excess weight loss as the only risk factor. Chen et al[32] found that being female and undergoing a gastric restrictive procedure were significantly associated with gallstone formation. The type of bariatric procedure has also been identified as a factor associated with gallstone formation. A prospective study reported gallstone incidences of 34% after LRYGB and 28% after LSG, with no statistically significant difference between the procedures[33]. In addition, a meta-analysis of eight cohort studies (94855 LSGs and 106844 LRYGBs) demonstrated that LSG was associated with a 35% lower rate of gallstone formation (OR = 0.65; 95% confidence interval: 0.49-0.86) and a significantly lower incidence of cholecystectomy (OR = 0.54; 95% confidence interval: 0.30-0.99) compared with LRYGB[34]. In contrast, our analysis did not reveal a statistically significant difference between LSG and LRYGB after multivariate adjustment, which may be related to the limited sample size and relatively short follow-up period. Preoperative BMI was the only factor associated with gallstone disease following bariatric surgery, particularly in patients with preoperative BMI greater than 50 kg/m2. This corresponds to the results of previous studies that identified high BMI and rapid weight loss as risk factors for gallstone disease[13,35,36]. However, some studies did not find any significant risk factors[4,37].
The incidence of gallstone disease varies by continent, ranging from approximately 3%-15%. For example, the average incidence in Europe and North America is approximately 15%[38]. In Asia, the incidence is lower, at approximately 3%-6%[39]. The incidence of symptomatic gallstones is approximately 2%[40]. Most patients with gallstone disease remain asymptomatic. However, approximately 10%-25% may develop symptoms within 5-15 years[41]. In this study, the incidence of gallstone disease post-bariatric surgery was 19.3%, which is higher than that of the general population, including populations in Asia. Despite this, only three out of 47 patients with gallstones developed symptoms. These findings suggest the need for further studies to evaluate the benefit of annual gallstone surveillance after bariatric surgery, as well as the role of gallstone prophylaxis in Asian populations. This study has some limitations. As a single-center retrospective chart review with a relatively short follow-up period, it may not fully capture the long-term incidence of gallstone disease after bariatric surgery. Nevertheless, as there is limited literature focusing on Asian populations, this study contributes valuable data to the existing body of research.
CONCLUSION
In our study, the incidence of gallstone formation following bariatric surgery was relatively high, while preoperative BMI was the only factor significantly associated with gallstone disease, particularly in patients with a BMI > 50 kg/m2. Despite the low incidence of symptomatic gallstones, further research is needed to clarify the role of routine surveillance and UDCA prophylaxis, particularly in Asian populations.
ACKNOWLEDGEMENTS
The authors would like to thank the staff of the Prince of Songkla University who helped to retrieve and collect essential information. We also thank Dr. Thammasin Ingviya and colleagues from the Department of Family Medicine and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, for their assistance.
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