Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century?

The Type of Bariatric Surgery Impacts the Risk of Acute Pancreatitis: A Nationwide Study

OBJECTIVE

We investigated whether vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass surgery (RYGB) have a differential impact on post-operative risk of acute pancreatitis (AP).

METHODS

This retrospective study uses the 2012-2014 National Readmission Database. We compared morbidly obese patients who underwent VSG (n = 205,251), RYGB (n = 169,973), and hernia repair (HR) control (n = 16,845). Our main outcome was rates of AP within 6 months post- vs. 6 months pre-surgery in VSG, RYGB, and HR. We also investigated risk factors and outcomes of AP after bariatric surgery.

RESULTS

The rates of AP increased post- vs. pre-VSG (0.21% vs. 0.04%; adjusted odds ratio [aOR] = 5.16, P < 0.05) and RYGB (0.17% vs. 0.07%; aOR = 2.26, P < 0.05) but not post-HR. VSG was associated with a significantly greater increase in AP risk compared to RYGB (aOR = 2.28; 95% CI: 1.10, 4.73). Furthermore, when compared to HR controls, only VSG was associated with a higher AP risk (aOR = 7.58; 95% CI: 2.09, 27.58). Developing AP within 6 months following bariatric surgery was mainly associated with younger age (18-29 years old: aOR = 3.76 for VSG and aOR: 6.40 for RYGB, P < 0.05) and gallstones (aOR = 85.1 for VSG and aOR = 46 for RYGB, P < 0.05). No patients developed "severe AP" following bariatric surgery.

CONCLUSIONS

More patients develop AP within 6 months after VSG compared to RYGB and controls. This risk is highest for younger patients and those with gallstones. Prospective studies examining mechanisms and prevention are warranted.

Percutaneous Cholecystostomy in Acute Cholecystitis-Predictors of Recurrence and Interval Cholecystectomy

BACKGROUND

Percutaneous cholecystostomy (PC) tube is a preferred option in acute cholecystitis for patients who are high risk for cholecystectomy (CCY). There are no evidence-based guidelines for patient care after PC. We identified the predictors of disease recurrence and successful interval CCY.

METHODS

A retrospective review of 145 PC patients between 2008 and 2016 at a tertiary hospital was performed. Primary outcomes included mortality, readmissions, hospital and intensive care unit length of stay (LOS), disease recurrence, and interval CCY.

RESULTS

There were 96 (67%) calculous and 47 (33%) acalculous cholecystitis cases. Seventy-two (49%) had chronic and 73 (51%) had acute prohibitive risks as an indication for PC. There were 54 (37%) periprocedural complications, which most commonly were dislodgements. Twenty-six (18%) patients had a recurrence at a median time of 65 days. Calculous cholecystitis (odds ratio [OR] 3.44, P = 0.038) and purulence in the gallbladder (OR 3.77, P = 0.009) were predictors for recurrence. Forty-one (28%) patients underwent interval CCY. Patients with acute illness were likely to undergo interval CCY (OR 6.67, P = 0.0002). Patients with acalculous cholecystitis had longer hospital LOS (16 versus 8 days) and intensive care unit LOS (2 versus 0 days), and higher readmission rates (OR 2.42, P = 0.02). Thirty-day mortality after PC placement was 9%. Patients receiving interval CCY were noted to have increased survival compared to PC alone. However, this should not be attributed to interval CCY alone in absence of randomization in this study.

CONCLUSIONS

Calculous cholecystitis and purulence in the gallbladder are independent predictors of acute cholecystitis recurrence. Acute illness is a strong predictor of successful interval CCY. The association of interval CCY and prolonged survival in patients with PC as noted in this study should be further assessed in future prospective randomized trials.

Frequency of gallstones and mean BMI in decompensated cirrhosis

Introduction

The aim of the study was to determine the frequency of gallstones in patients with decompensated cirrhosis and to know about mean Body mass index (BMI) in patients of decompensated cirrhosis i.e End stage liver disease (ESLD) with and without gallstones.

Methods

it is a cross sectional descriptive study, conducted at the department of Hepato-gastroenterology, Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1^st August 2014 to 28 February 2015. Two hundred patients were enrolled from outpatient clinics of Hepato-gastroenterology that fulfilled the defined selection criteria. Questionnaire was filled for data collection. SPSS version 20.0 was used to analyze data. Mean value of age and BMI was calculated by mean ± S.D. values. Mean ± SD was also calculated for BMI in patients with and without gallstones. Stratification of the age, gender, and liver disease severity were done and chi-Square test was applied. p-values less than 0.05 considered statistically significant.

Results

Two hundred consecutive patients were enrolled among them 112(56%) were male. Mean age was 46.89 ± 11.9, BMI 23.59 ± 4.7 and CTP score was 9.7 ± 1.9. Most of the patient had Child class 'B' cirrhosis 102(51%), most common etiology was found to be Hepatitis C 133 (66.5%), cholelithiasis was found in 59(29.5%), sludge in 36 (18%) and both stone and sludge in 24(12%) of the cases. Advanced liver disease that is, more CTP score and child class 'C' was associated with increased frequency of gall stone formation (p-value = 0.012), and advancing age on age stratification (p-value = 0.024) however no relation was observed with increase BMI, gender, ethnicity, cause or duration of disease in this population.

Conclusion

Gallstone formation is associated with advanced stage of cirrhosis and hepatitis C Virus related CLD, contrary to the established risk factors, no relation of gender or BMI was found in decompensated liver disease.

Association between Helicobacter pylori infection and gallbladder diseases: A retrospective study

BACKGROUND AND AIM

The association between Helicobacter pylori (H. pylori) and gallbladder diseases is still unclear and is controversial. We conducted a retrospective study to clarify the prevalence of gallbladder diseases and factors related to gallbladder diseases and relationships between H. pylori infection, gallstones, cholecystitis, and cholecystic polypus.

METHODS

The retrospective study was performed at the Aerospace Center Hospital in Beijing. The subjects in this study were a healthy population who underwent health examinations at the hospital between 2012 and 2015. The logistic regression models were used to explore the relationships between H. pylori infection and gallbladder diseases.

RESULTS

There were 7803 (43.4%) subjects with H. pylori infection, 995 (5.5%) with gallstones, 219 (1.2%) with cholecystitis, and 1003 (5.6%) with cholecystic polypus amongst 17 971 subjects, respectively. In subjects aged 45 years or less, the prevalence of gallstones in the H. pylori (+) group was lower than that in the H. pylori (-) group (odds ratio = 0.653; 95% confidence interval: 0.468-0.911; P = 0.012). The prevalence of cholecystic polypus in the H. pylori (+) group was significantly higher than that in the H. pylori (-) group (odds ratio = 1.160; 95% confidence interval: 1.012-1.328; P = 0.033).

CONCLUSIONS

Helicobacter pylori infection was related with cholecystic polypus and gallstones in a Chinese population.

Prevalence of Non-insulin-dependent Diabetes Mellitus Among Patients with Cholelithiasis: A Single-centered, Cross-sectional Study

Introduction Gallstone disease (GD) is one of the major causes of morbidity and mortality in the west and most of the countries worldwide. Cholelithiasis and diseases of the biliary tract are becoming more prevalent with the socioeconomic burden in developing countries like Pakistan. GD is a chronic, recurrent hepatobiliary disease, the basis of which is the impaired metabolism of cholesterol, bilirubin, and bile acids, which is characterized by the formation of gallstones in the hepatic bile duct, common bile duct, or gallbladder. Epidemiologic studies have shown that individuals with diabetes have a higher risk of cholelithiasis but only a few studies have been done in Pakistan to establish the association so far. Hence, the aim of the present study is to establish the association between diabetes and gallstone disease. Methods A cross-sectional study was conducted at Liaquat University Civil Hospital, Hyderabad, Pakistan, between February 2017 and August 2017. Patients between the ages of 10 and 70 from either sex, who were diagnosed with cholelithiasis were included in this study whereas those patients who underwent cholecystectomy previously were excluded. Diabetic cases were identified based on fasting glucose levels (FGL) and the serum levels of HbA1c. An interview-based questionnaire was employed to collect the patient's demographic profile and risk factors by the students. Informed consent was taken from all the study subjects and the confidentiality of the data was ensured. Results From the sample size of patients evaluated (a total of 204), based on investigative studies performed, 74 cholelithiatic patients (36.6%) were found to concurrently have diabetes as well. Among the 74 patients with both cholelithiasis and diabetes type-2 (NIDDM), 56 were female and 18 were males. The rest of the patients with cholelithiasis were found to be non-diabetic (78 were males and 52 female). The majority of the GD patients (51 (25 males and 26 females)) in the study sample was in the 50-60 age group. The mean age of the patients was 43 ± 12.1. In this study, we measured the fasting glucose levels (FGL). According to World Health Organization (WHO) and American Diabetes Association (ADA) criteria, we categorized 85 of the GD patients to be non-diabetic with serum fasting glucose levels between 70 and 100 gm/dL, and 45 patients were categorized to be in the pre-diabetic group with FGL levels between 100 and 126. Out of the 204 samples with GD, we found that 74 patients have diabetes, with serum FGL >126mg/dL. We measured HbA1c from each individual in the study sample. It was found that 79 patients had HbA1c levels <5.5, they are categorised as non-diabetic according to WHO and ADA criteria, 51 patients had values between 5.5 and 6.5 (pre-diabetic), and 35 GD patients had HbA1c values between 6.5 and 7.5 (categorized as diabetics with good control) and 39 patients with HbA1c above 7.5 (diabetes with poor control). Conclusion In this study, we concluded that there is a higher prevalence of NIDDM in GD patients and there is an association between GD and NIDDM. This study also reiterated the association between obesity and GD. Female sex and advancing age also contribute to the formation of cholelethiasis. Cigarette smoking and alcohol consumption further worsen cholelithiasis but are not established primary risk factors.

A systematic review of gallstone sigmoid ileus management

INTRODUCTION

Gallstone sigmoid ileus is a rare although serious complication of cholelithiasis resulting in large bowel obstruction. The condition accounts for 4% of all gallstone ileus patients. There are no recognized management guidelines currently. Management strategies range from minimally invasive endoscopy and lithotripsy to substantial surgery. We aim to identify trends when managing patients with gallstone sigmoid ileus to help improve outcomes.

METHODS

Literature searches of EMBASE, Medline and by hand were conducted. All English language papers published from 2000 to 2017(Oct) were included. The terms 'gallstone', 'sigmoid', 'colon', 'ileus', 'coleus' and 'large bowel obstruction' were used.

RESULTS

38 papers included, male:female ratio was 8:30. Average age was 81.11 (SD ± 7.59). Average length of preceding symptoms was 5.31days (+/-SD3.16). 20/38 (59%) had diverticulosis. 89% of patients had significant comorbidities documented. 34/38 patients underwent computerized tomography. 31 stones were located within sigmoid colon, 4 at rectosigmoid junction and 2 within descending colon. Average impacted gallstone size was 4.14 cm (2.3-7 cm range). 23/38 (61%) patients' initial management was conservative or with endoscopy ± lithotripsy. Conservative management successfully treated 26% of patients. 28/38 (74%) patients ultimately underwent surgical intervention. 5/38 patients died post-operatively. Patients treated non-operatively had shorter hospital stays (4:12.3days) although not significant (p-value = 0.0056).

CONCLUSIONS

There is no management consensus from the literature. Current evidence highlights endoscopy and lithotripsy as practical firstline strategies. However, surgical intervention should not be delayed if non-operative measures fail or in emergency. Given the complexity of such patients, less invasive timesaving surgery appears practical, avoiding bowel resection and associated complications.

An update on the pathogenesis of cholesterol gallstone disease

PURPOSE OF REVIEW

Gallstone disease is a major epidemiologic and economic burden worldwide, and the most frequent form is cholesterol gallstone disease.

RECENT FINDINGS

Major pathogenetic factors for cholesterol gallstones include a genetic background, hepatic hypersecretion of cholesterol, and supersaturated bile which give life to precipitating cholesterol crystals that accumulate and grow in a sluggish gallbladder. Additional factors include mucin and inflammatory changes in the gallbladder, slow intestinal motility, increased intestinal absorption of cholesterol, and altered gut microbiota. Mechanisms of disease are linked with insulin resistance, obesity, the metabolic syndrome, and type 2 diabetes. The role of nuclear receptors, signaling pathways, gut microbiota, and epigenome are being actively investigated.

SUMMARY

Ongoing research on cholesterol gallstone disease is intensively investigating several pathogenic mechanisms, associated metabolic disorders, new therapeutic approaches, and novel strategies for primary prevention, including lifestyles.

Sex and ethnic/racial-specific risk factors for gallbladder disease

BACKGROUND

Gallbladder disease (GBD) is a highly prevalent condition; however, little is known about potential differences in risk factors by sex and ethnicity/race. Our aim was to evaluate dietary, reproductive and obesity-related factors and GBD in multiethnic populations.

METHODS

We performed a prospective analysis from the Multiethnic Cohort study who self-identified as non-Hispanic White (n = 32,103), African American (n = 30,209), Japanese (n = 35,987), Native Hawaiian (n = 6942) and Latino (n = 39,168). GBD cases were identified using Medicare and California hospital discharge files (1993-2012) and self-completed questionnaires. We used exposure information on the baseline questionnaire to identify exposures of interest. Associations were estimated by hazard ratios and 95% confidence intervals using Cox models adjusted for confounders.

RESULT

After a median 10.7 years of follow-up, there were 13,437 GBD cases. BMI over 25 kg/m2, diabetes, past and current smoking, red meat consumption, saturated fat and cholesterol were significant risk factors across ethnic/racial populations (p-trends < 0.01). Protective factors included vigorous physical activity, alcohol use, fruits, vegetables and foods rich in dietary fiber (p-trends < 0.01). Carbohydrates were inversely associated with GBD risk only among women and Latinos born in South America/Mexico (p-trend < 0.003). Parity was a significant risk factor among women; post-menopausal hormones use was only associated with an increased risk among White women (estrogen-only: HR = 1.24; 95% CI = 1.07-1.43 and estrogen + progesterone: HR = 1.23; 95% CI = 1.06-1.42).

CONCLUSION

Overall, dietary, reproductive and obesity-related factors are strong risk factors for GBD affecting men and women of different ethnicities/races; however some risk factors appear stronger in women and certain ethnic groups.

Application of ultrasonically modified cloud point extraction method for simultaneous enrichment of cadmium and lead in sera of different types of gallstone patients

A novel and greener ultrasonically assisted/modified cloud point extraction procedure for the simultaneous preconcentration of lead and cadmium in serum samples of different types of gallstone patients was developed. The chelates of the under study metals, formerly formed with 8-hydroxyquinoline, were extracted in the micelles of a nonionic surfactant prior to analysis by flame atomic absorption spectrometer (FAAS). After the arrival of the cloud point, the critical micellar mass produced was homogenously dispersed in the aqueous phase with the help of ultrasound energy. The reliability of the developed procedure was tested by relative standard deviation (% RSD), which was found to be <5%. The performance of the proposed procedure was checked by applying to certified reference material and spiking standard in real samples. All the experimental parameters were optimized. The developed procedure of Um-CPE was applied successfully for the analysis of the target heavy metals in serum samples of different types of gallstone patients and referents. The higher levels of the understudy metals were observed in the patients as compared to the referents but the levels of the both metal were found to be considerably higher in patients with pigmented gallstones.

A novel scoring system to analyze combined effect of lifestyle factors on pancreatic cancer risk: a retrospective case-control study

Although several risk factors for the onset of pancreatic ductal adenocarcinoma (PDAC) have been identified, currently, no scoring system to systemically evaluate the risk of PDAC has been established. In this study, we aimed to use a population of over 1200 patients to build a novel scoring system, and evaluated combined effects of risk factors for PDAC patients.A set of 4904 participants including 1274 PDAC patients and 3630 non-cancer individuals were recruited for the single-center study over 17-year period (1997~2013). Systematic logical analysis were presented for case and control groups, and a risk rating system was constructed to assess combined risk factors. Seven independent risk factors were identified with the increased risk of PDAC, were selected into the risk score. A merged risk assessment model was established, demonstrating significantly increased PDAC risk in following a number of rising scores. Individuals with scores from 1 to more than 4, the responding OR (95% CI) were 3.06 (2.57~3.65), 7.08 (5.63~8.91), 22.4 (14.2~35.4), and 31.4 (12.7~77.5), respectively. The integer-based risk score in the study can be used for risk stratification to accurately evaluate PDAC occurrence at an early stage. This scoring system provides an accurate risk assessment of PDAC risk.

Acute cholecystitis in elderly patients: A case for early cholecystectomy

BACKGROUND

Recent advances in laparoscopic techniques and perioperative care have changed the indications for surgery in elderly patients. Consequently, the willingness to offer early surgery for acute cholecystitis continues to increase. This study aims to assess the perioperative outcome of early cholecystectomy for acute calculous cholecystitis in elderly patients.

PATIENTS AND METHODS

All consecutive patients treated by early cholecystectomy for acute calculous cholecystitis in a major teaching hospital, between January 2002 and November 2016, were retrospectively analyzed. The outcome of elderly patients (≥75 years) was compared to that of all others. Conversion rate, 30 days morbidity, 30 days mortality and length of hospital stay were assessed.

RESULTS

Early cholecystectomy for acute calculous cholecystitis was performed in 703 patients: 121 (17%) aged ≥75 years and 582 (83%) aged <75 years. Significantly more elderly patients had an ASA score ≥3 (37% vs. 8%, P<0.001). Morbidity was higher in the elderly group (17% vs. 8%, P<0.004), mainly attributable to the high incidence of cystic stump leakage in this group; a complication that no longer occurred after changing the technique of ligation of the cystic stump. The cardiopulmonary complication rate (4% vs. 3%, P=0.35) as well as mortality did not significantly differ (3% vs. 1%, P=0.07). The conversion rate was higher in the elderly group (18% vs. 5%, P<0.001) and the median postoperative length of hospital stay was longer (5.0 vs. 3.0 days, P<0.001).

CONCLUSION

Early laparoscopic cholecystectomy is a treatment well suited to elderly patients with mild and moderate acute cholecystitis.

A single centre case series of gallstone sigmoid ileus management

AIMS/INTRODUCTION

Gallstone sigmoid ileus is a rare condition that presents with symptoms of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon. This arises because of three primary factors: cholelithiasis causing a cholecystoenteric fistula; a gallstone large enough to obstruct the bowel lumen; and narrowing of the bowel. We describe 3 patients treated in a district general hospital over a 3-year period, and discuss their management.

METHODS

Cases were retrospectively analysed from a single center between 2015 and 2017 in line with the SCARE guidelines.

RESULTS

3 patients - 2 female, 1 male. Age: 89, 68, 69 years. 2 cholecystocolonic fistulae, 1 cholecystoenteric (small bowel) fistula. Patient 1: Unsuccessful endoscopic attempts to retrieve the (5×5cm) gallstone resulted in surgery. Retrograde milking of the stone to caecum enabled removal via modified appendicectomy. Patient 2: Endoscopy and lithotripsy failed to fragment stone. Prior to laparotomy the stone was palpated in the proximal rectum enabling manual extraction. Patient 3: Laparotomy for gallstone ileus failed to identify a stone within the small bowel. Gallstone sigmoid ileus then developed. Conservative measures successfully decompressed the large bowel 6days post-operation.

CONCLUSIONS

This is the first case series highlighting the differing strategies and challenges faced by clinicians managing gallstone sigmoid ileus. Conservative measures (including manual evacuation), endoscopy, lithotripsy and surgery all play important roles in relieving large bowel obstruction. It is essential to tailor care to individual patients' needs given the complexities of this potentially life threatening condition.

Practice Patterns for Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography for Patients With Choledocholithiasis

BACKGROUND & AIMS

Cholecystectomy (CCY) after an episode of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction reduces recurrent biliary events compared to expectant management. We studied practice patterns for performance of CCY after ERCP for choledocholithiasis using data from 3 large states and evaluated the effects of delaying CCY.

METHODS

We conducted a retrospective cohort study using the ambulatory surgery, inpatient, and emergency department databases from the states of California (years 2009-2011), New York (2011-2013), and Florida (2012-2014). We collected data from 4516 patients hospitalized with choledocholithiasis who underwent ERCP. We compared outcomes of patients who underwent CCY at index admission (early CCY), elective CCY within 60 days of discharge (delayed CCY), or did not undergo CCY (no CCY), calculating rate of recurrent biliary events (defined as an emergency department visit or unplanned hospitalization due to symptomatic cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis), mortality, and cost by CCY cohort. We also evaluated risk factors for not undergoing CCY. The primary outcome measure was the rate of recurrent biliary events in the 365 days after discharge from index admission.

RESULTS

Of the patients who underwent ERCP for choledocholithiasis, 41.2% underwent early CCY, 10.9% underwent delayed CCY, and 48.0% underwent no CCY. Early CCY reduced relative risk of recurrent biliary events within 60 days by 92%, compared with delayed or no CCY (P < .001). After 60 days following discharge from index admission, patients with early CCY had an 87% lower risk of recurrent biliary events than patients with no CCY (P < .001) and patients with delayed CCY had an 88% lower risk of recurrent biliary events than patients with no CCY (P < .001). A strategy of delayed CCY performed on an outpatient basis was least costly. Performance of early CCY was inversely associated with low facility volume. Hispanic race, Asian race, Medicaid insurance, and no insurance associated inversely with performance of delayed CCY.

CONCLUSIONS

In a retrospective analysis of >4500 patients hospitalized with choledocholithiasis, we found that CCY was not performed after ERCP for almost half of the cases. Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of recurrent biliary event while waiting for a delayed CCY compared with patients who underwent early CCY. Delayed CCY is a cost-effective strategy that must be balanced against the risk of loss to follow-up, particularly among patients who are ethnic minorities or have little or no health insurance.

Gallstone, cholecystectomy and risk of gastric cancer

Backgrounds/Aims

The aim of this retrospective study is to compare stomach cancer incidence, characteristics between gallstones, cholecystectomy and control groups. It also aims to investigate key variables' potential effects on overall survival.

Methods

A total of 99 patients, diagnosed with stomach cancers between April 1994 and December 2015, were identified. We excluded stomach cancer patients, accrued during the first year of follow-up in both the gallstones and cholecystectomy groups, assuming that they missed cancers. The main analyses addressing the objective were a chi-square analysis and a survival analysis.

Results

The incidence of stomach cancers was increased in both the gallstone and cholecystectomy groups, compared with the control group (p=0.003). Multivariate regression analysis showed that the overall survival in gallstones, cholecystectomy group patients as compared with those in the control group decreased (HR=6.66, 95 CI: 1.94–22.80, p=0.003). Also, T-stage was found to statistically affect the rate of overall survival (HR=9.85, 95% CI: 3.09–31.39, p=.000). The stomach cancer showed the worse survival at the posterior, greater curvature location than anterior, lesser curvature of the stomach. (HR=0.30, 95% CI: 0.11–0.80, p=0.017).

Conclusions

We provided an awareness of the possible increased risks of stomach cancer in gallstone and cholecystectomy group patients, which might be induced by duodenogastric bile reflux. Also, the survival rate was poor (p<0.000). Therefore, close follow-up strategies for early detection are recommended for such patients.

Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis

BACKGROUND

The purpose of this study was to evaluate improvements in cosmetic results and postoperative morbidity for single-incision laparoscopic cholecystectomy (SILC) in comparison with multiport laparoscopic cholecystectomy (MLC).

METHODS

A literature search was undertaken for RCTs comparing SILC with MLC in adult patients with benign gallbladder disease. Primary outcomes were body image and cosmesis scores at different time points. Secondary outcomes included intraoperative and postoperative complications, postoperative pain and frequency of port-site hernia.

RESULTS

Thirty-seven RCTs were included, with a total of 3051 patients. The body image score favoured SILC at all time points (short term: mean difference (MD) -2·09, P < 0·001; mid term: MD -1·33, P < 0·001), as did the cosmesis score (short term: MD 3·20, P < 0·001; mid term: MD 4·03, P < 0·001; long-term: MD 4·87, P = 0·05) and the wound satisfaction score (short term: MD 1·19, P = 0·03; mid term: MD 1·38, P < 0·001; long-term: MD 1·19, P = 0·02). Duration of operation was longer for SILC (MD 13·56 min; P < 0·001) and SILC required more additional ports (odds ratio (OR) 6·78; P < 0·001). Postoperative pain assessed by a visual analogue scale (VAS) was lower for SILC at 12 h after operation (MD in VAS score -0·80; P = 0·007). The incisional hernia rate was higher after SILC (OR 2·50, P = 0·03). All other outcomes were similar for both groups.

CONCLUSION

SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is four times higher after SILC than after MLC.

Systematic review and meta-analysis: cholecystectomy and the risk of cholangiocarcinoma

Studies have reported that cholecystectomy may increase the risk of cholangiocarcinoma. However, this association is controversial. Thus, we conducted a systematic review and meta-analysis to explore the relationship between cholecystectomy and the risk of cholangiocarcinoma. Relevant studies were identified by searching PubMed, EMBASE, ISI Web of Science published before February 2017. We used the random effects model proposed by DerSimonian and Laird to quantify the relationship between cholecystectomy and risk of cholangiocarcinoma. Publication bias was evaluated using funnel plots, Begg's and Egger's tests. Subgroup and sensitivity analyses were performed to validate the stability of the results. 16 articles, comprising 220,376 patients with cholecystectomy and 562,392 healthy controls, were included in our research. Our meta-analysis suggested that the risk of cholangiocarcinoma was significantly higher in the cholecystectomized patients in comparison with healthy controls, with heterogeneity among studies (summary odds ratio [OR] = 0.72; confidence interval [CI] = 0.55-0.90; I² = 69.5%). Additionally, this association was also observed in cohort studies (OR = 0.83; 95% CI = 0.73-0.94) and case-control studies (OR = 0.60; 95% CI = 0.40-0.80). However, When the intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma were analyzed separately, the present study only indicated cholecystectomy was associated with increased the risk of extrahepatic cholangiocarcinoma (OR = 1.19; 95% CI = 0.32-2.05), rather than intrahepatic cholangiocarcinoma (OR = 1.19; 95% CI = 0.32-2.05). In conclusion, cholecystectomy was associated with a significant 54% increase in the risk of cholangiocarcinoma, especially in the extrahepatic cholangiocarcinoma.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Risk Factors for Cholelithiasis

Gallstone disease is one of the most common public health problems in the United States. Approximately 10%-20% of the national adult populations currently carry gallstones, and gallstone prevalence is rising. In addition, nearly 750,000 cholecystectomies are performed annually in the United States; direct and indirect costs of gallbladder surgery are estimated to be $6.5 billion. Cholelithiasis is also strongly associated with gallbladder, pancreatic, and colorectal cancer occurrence. Moreover, the National Institutes of Health estimates that almost 3,000 deaths (0.12% of all deaths) per year are attributed to complications of cholelithiasis and gallbladder disease. Although extensive research has tried to identify risk factors for cholelithiasis, several studies indicate that definitive findings still remain elusive. In this review, predisposing factors for cholelithiasis are identified, the pathophysiology of gallstone disease is described, and nonsurgical preventive options are discussed. Understanding the risk factors for cholelithiasis may not only be useful in assisting nurses to provide resources and education for patients who are diagnosed with gallstones, but also in developing novel preventive measures for the disease.

Alteration of gut microbiota in association with cholesterol gallstone formation in mice

Background

The gut microbiome exerts extensive roles in metabolism of nutrients, pharmaceuticals, organic chemicals. Little has been known for the role of gut microbiota in regulating cholesterol and bile acids in association with gallstone formation. This study investigated the changes in the composition of gut microbiota in mice fed with lithogenic diet (LD).

Methods

Adult male C57BL/6 J mice were fed with either lithogenic diet (1.25% cholesterol and 0.5% cholic acid) or chow diet as control for 56 days. The fecal microbiota were determined by 16S rRNA gene sequencing.

Results

LD led to formation of cholesterol gallstone in mice. The richness and alpha diversity of gut microbial reduced in mice fed with LD. Firmicutes was significantly decreased from 59.71% under chow diet to 31.45% under LD, P < 0.01, as well as the ratio of Firmicutes to Bacteroidetes. Differences in gut microbiota composition were also observed at phylum, family and genus levels between the two groups.

Conclusion

Our results suggested that gut microbiota dysbiosis might play an important role in the pathogenesis of cholesterol gallstone formation in mice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0629-2) contains supplementary material, which is available to authorized users.

Comparative performance of non-contrast MRI with HASTE vs. contrast-enhanced MRI/3D-MRCP for possible choledocholithiasis in hospitalized patients

PURPOSE

To compare the performance of non-contrast MRI with half-Fourier acquisition single-shot turbo spin echo (HASTE) vs. contrast-enhanced MRI/3D-MRCP for assessment of suspected choledocholithiasis in hospitalized patients.

METHODS AND MATERIALS

123 contrast-enhanced abdominal MRI/MRCP scans in the hospital setting for possible choledocholithiasis were retrospectively evaluated. Endoscopic retrograde cholangiopancreatography, intraoperative cholangiogram or documented clinical resolution served as the reference standard. Readers first evaluated the biliary tree using coronal and axial HASTE and other non-contrast sequences, and later reviewed the entire exam with post-contrast sequences and 3D-MRCP. Test performance for the image sets was compared for choledocholithiasis, acute hepatitis, cholangitis, and acute cholecystitis. Reader agreement, MRCP image quality, and confidence levels were also assessed. Clinical predictors of age and fever were tested for association with perceived need for contrast in biliary assessment.

RESULTS

There were 27 cases of choledocholithiasis, 31 cases of acute hepatitis, 37 cases of acute cholecystitis, and 3 clinically diagnosed cases of acute cholangitis. Both the abbreviated and full contrast-enhanced/MRCP image sets resulted in high accuracy for choledocholithiasis (91.1-94.3% vs. 91.9-92.7%). There was no difference in sensitivity or specificity for either reader for any diagnosis between image sets (p > 0.40). 1 reader showed improved confidence (p < 0.001) with inclusion of MRCP and contrast-enhanced images, but neither confidence nor MRCP quality scores were associated with diagnostic accuracy. Patient age and fever did not predict the need for contrast-enhanced images.

CONCLUSION

In hospitalized patients with suspected choledocholithiasis, performance of non-contrast abdominal MRI with HASTE is similar to contrast-enhanced MRI with 3D-MRCP, offering potential for decreased scanning time and improved patient tolerability.

A case of gallstones in an African green monkey (Chlorocebus aethiops)

Spontaneous cholelithiasis was found in a male African green monkey (Chlorocebus aethiops) at necropsy. Choleliths varied in size, shape and colour. Gallstones were analysed using accepted analytical methods. Results showed that the gallstones were composed of cholesterol and protein in varying proportions. Histologically, the gallbladder showed diffuse mild to moderate lymphocytic infiltration. The etiology of the cholelithiasis in the examined individual remains unknown.

Determinants for clinical events in gallstone carriers unaware of their gallstones

BACKGROUND AND AIM

Knowledge about determinants for clinical events in gallstone carriers is missing. The aim of this cohort study was to identify determinants of clinical gallstone events during long-term follow-up of a population unaware of their gallstones.

METHODS

Three randomly selected groups from the general population of Copenhagen (n = 6 037) underwent ultrasound examinations to detect gallstones in the period 1982-1994. Participants unaware of gallstone (n = 595) were followed up for clinical gallstone events through central registers until December 31, 2011. Follow-up length was median 17.5 years and 99.8% complete. Cox regression analyses were performed.

RESULTS

Gallstone events occurred in 16.6% participants of whom 7.2% were complicated and 9.4% were uncomplicated. Total events were associated with body mass index. Complicated events were associated with coffee consumption, vocational training, and inversely association to a higher physical activity level when compared with being sedentary. Multiple adjusted models confirmed association for total events and body mass index and for complicated events and physical activity. No significant associations were identified for alcohol, coffee, diet, smoking, or visits to general practitioner and clinical events.

CONCLUSIONS

Body mass index, vocational training, and physical activity level were associated with clinical events in long-term follow-up of unaware gallstone carriers. Future trials should investigate clinical effects of lifestyle and medical interventions in gallstone carriers.

Prevalence of Cholelithiasis Among Igbo Adult Subjects in Nnewi, Southeast Nigeria

Aim: To determine the prevalence of cholelithiasis in a Nigerian population. Subjects and Methods: A cross-sectional study of Igbo adult subjects in Nnewi, Nigeria, was conducted from June 2011 to April 2014. A sample of 3501 adult subjects’ gallbladders and associated biliary systems was evaluated by sonography, and the presence or absence of cholelithiasis was documented. The age and anthropometric variables of the subjects were recorded. Results: The subjects (18-92 years) comprised 1731 men (49.4%) and 1770 women (50.6%). Only 4.4% (n = 154) had cholelithiasis. It is more common in women than men, at a ratio of 2.8:1. It is also more common in subjects with a high body mass index. Conclusion: The prevalence of cholelithiasis among the Igbo people in Nnewi is 4.40%, and it is about three times more common in women than men.

A Study of Alcohol Consumption and Obesity as Main Risk Factor for Symptomatic Gallbladder Stone: a Case-Control Study

Background: Gallbladder stone (GBS) is a common gastrointestinal disease that can progress to severe cholecystitis and is a strong risk factor for gallbladder cancer (GBC). The present study was conducted to evaluate region-specific causes of GBS which was proved as major risk factor for GBC in Jeju Island, Korea. Methods: Age and sex match case-control study was performed among 171 pairs of case and controls. The cases were patients who were diagnosed with GBS, had definite clinical symptoms, and underwent a cholecystectomy in Cheju Halla General Hospital, Jeju, Korea during 2010-2014. The control group included 1:1 age and sex-matched participants without GBS at the Health Promotion Center in the same institute during the same period. We compared the histories of previous chronic diseases (hypertension, diabetes, hyperlipidaemia, vascular occlusive diseases, or parity), alcohol consumption (standard drinks/week [SDW]), smoking habits, body mass index (BMI), and presence of concomitant polypoid lesions of the gallbladder. Results: A dose-dependent positive relationship existed between BMI and the risk of GBS: BMI 23–27.4 kg/m2, OR=2.5, , p=0.24; 27.5–29.9 kg/m2, OR=8.9, p=0.002; ≥30 kg/m2, OR=7.2, p=0.004. A negative correlation existed between alcohol consumption and the risk of GBS: Standard drinks per week (SDW), OR=0.24, p=0.002; 15–29.9 SDW, OR=0.26, p=0.022; ≥30 SDW, OR=0.2, 95% p=0.005. Conclusion: The present results suggest that a higher BMI and less alcohol consumption are associated with a risk of symptomatic GBS.

Management of suspected common bile duct stone: diagnostic yield of current guidelines

BACKGROUND

The American Society for Gastrointestinal Endoscopy (ASGE) has recently published a guideline for suspected CBDS with the intention of reducing unnecessary ERCP and thereby complications. The aim of this study was to assess the diagnostic efficacy of the ASGE guideline.

METHODS

Data of patients who underwent ERCP with suspected CBDS were analyzed retrospectively. Patients were classified into high, intermediate and low risk groups based on predictors that have been suggested by the ASGE. Very strong predictors of the presence of ductal stones included: CBDS on transabdominal ultrasonography (US), clinical ascending cholangitis or total bilirubin (TBIL) >4 mg/dL). Strong predictors included dilated CBD >6 mm on US with gallbladder in situ and TBIL level of 1.8-4.0 mg/dL whereas moderate predictor included abnormal liver biochemical test other than bilirubin, age more than 55 years and clinical findings of biliary pancreatitis.

RESULTS

Of 888 enrolled patients, 704 had CBDS demonstrated by ERCP and the remainder did not. All very strong and strong predictors were found to be significantly higher among patients who had CBDS. Detection of CBDS by ultrasonography and a dilated common biliary duct were observed to be independent risk factors associated with the existence of CBDS. The high risk group had a high (86.7%) positive predictive value (PPV), however, sensitivity and specificity were observed to be moderate (67.8% and 60.3% respectively). PPV was 67.9% in the intermediate risk group and the sensitivity and specificity were very low (31.9% and 42.3%).

DISCUSSION

The probability of CBDS was observed to be high in the intermediate and high risk groups. However due to low sensitivity and specificity values, the ASGE guideline needs additional or different predictors.

Emergency Versus Delayed Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage in Grade II Acute Cholecystitis Patients

INTRODUCTION

In grade II acute cholecystitis patients presenting more than 72 h after onset of symptoms, we prospectively compared treatment with emergency (ELC) to delayed laparoscopic cholecystectomy performed 6 weeks after percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

Four hundred ninety-five patients with acute cholecystitis were assessed for eligibility; 345 were excluded or declined to participate. One hundred fifty patients were treated after consent with either ELC or PTGBD.

RESULTS

Both PTGBD and ELC were able to resolve quickly cholecystitis sepsis. ELC patients had a significantly higher conversion rate (24 vs. 2.7 %, P < 0.001), longer mean operative time (87.8 ± 33.06 vs. 38.09 ± 8.23 min, P < 0.001), higher intraoperative blood loss (41.73 ± 51.09 vs. 26.33 ± 23.86, P = 0.008), and longer duration of postoperative hospital stay (51.71 ± 49.39 vs. 10.76 ± 5.75 h, P < 0.001) than those in the PTGBD group. Postoperative complications were significantly more frequent in the ELC group (26.7 vs. 2.7 %, P < 0.001) with a significant increase in incidence (10.7 %) of bile leak (P = 0.006) compared to those in the PTGBD group.

CONCLUSION(S)

PTGBD and ELC are highly efficient in resolving cholecystitis sepsis. Delayed cholecystectomy after PTGBD produces better outcomes with a lower conversion rate, fewer procedure-related complications, and a shorter hospital stay than emergency cholecystectomy.

Torsion of Hydrosalpinx with Concurrent Acute Cholecystitis: Case Report and Review of Literature

Introduction. Isolated torsion of the Fallopian tube is an uncommon cause of acute lower abdominal pain and can occur in women of all age groups. Cholecystitis is a frequent cause of upper abdominal pain. We present an unusual case with the presence of these two distinct pathological entities occurring concurrently in the same patient, causing simultaneously occurring symptoms. To our knowledge, this is the first reported presentation of such a case. Methods. We describe a 34-year-old premenopausal woman who presented with right sided upper and lower abdominal pain and nausea. Abdominal ultrasound (US) revealed acute cholecystitis. Vaginal US was suggestive of right hydrosalpinx. Intravenous antibiotics were administered and consent was obtained for operative intervention. During laparoscopy, the right Fallopian tube with hydrosalpinx was noted to be twisted three times. The right ovary appeared normal. The gall bladder wall was thickened and inflamed. Laparoscopic right salpingectomy and cholecystectomy were performed. Results. Surgical pathology revealed hydrosalpinx with torsion and acute calculous cholecystitis. The patient had an uneventful postoperative course and was discharged home on the first postoperative day. Her symptoms resolved after the procedure. Conclusions. In women with abdominal pain, both gynecologic and nongynecologic etiologies should be considered in the differential diagnoses. Concurrent presence of symptomatic gynecologic and nongynecologic intra-abdominal pathology is rare. Isolated Fallopian tube torsion is rare and is associated most often with hydrosalpinx. Some torqued Fallopian tubes can be salvaged. Laparoscopy is useful in management of both Fallopian tube torsion and cholecystitis.

Vitamin D and gallstone disease-A population-based study

Gallstone disease is highly prevalent in the general population and is a major gastrointestinal cause of hospital admissions. The objectives were to determine whether circulating levels of 25-hydroxyvitamin D were associated to ultrasound proven gallstones or cholecystectomy in a general population sample. Determinants of vitamin D status were also explored. A random sample of 4130 people from the population of Copenhagen with ages 41-71 years were invited (N = 4130) and 2650 participants were included. Ultrasound examinations were performed to assess gallstone status and blood samples were drawn to assess 25-hydroxyvitamin D and biomarkers of renal and hepatic function. Gallstone disease was found in 422 participants. Associations were estimated by logistic regression models. Levels of 25-hydroxyvitamin D was not significantly associated with gallstone disease. Time of birth during low vitamin D exposure was associated with gallstone disease (gallstone prevalence 18.0 versus 14.4 %, odds ratio 1.33, 95 % confidence interval [1.07; 1.65]). Highest quartile of cystatin C was significantly associated with gallstone disease (gallstone prevalence 22.1 versus 12.0 %, odds ratio 1.53, 95 % confidence interval [1.08; 2.18]). Serum levels of creatinine and alanine amino transferase were not associated with gallstone disease. Sensitivity analyses excluding participants with cholecystectomy did not alter results significantly. No association between 25-hydroxyvitamin D and gallstone disease was identified. Findings suggest gallstones to be associated to low vitamin D exposure in utero and to renal failure suggesting that vitamin D might have an impact on gallstone disease. Future studies should explore associations for vitamin D and gallstone disease prospectively.

Determinants for gallstone formation - a new data cohort study and a systematic review with meta-analysis

OBJECTIVE

Only few determinants of gallstone formation have been identified in cohort studies. The aim was to identify further determinants for gallstones in a Danish cohort and to perform a meta-analysis of results from existing cohorts.

MATERIAL AND METHODS

Data from a cohort study was used. Gallstone incidence was assessed through repeated ultrasound examinations. Body mass index (BMI), blood pressure, self-rated health, lifestyle variables, blood lipids, and use of female sex hormones were measured at the baseline examination. Statistical analyses included logistic regression. Based on a prospective protocol, a systematic review of the literature was performed identifying all articles dealing with determinants of incident gallstones. Meta-analyses of comparable determinants were performed through fixed effect models.

RESULTS

Participants with no gallstones at baseline and with at least one re-examination were followed-up completely (mean 11.6 years, N = 2848). The overall cumulative incidence of gallstones was 0.60% per year. Independent positive determinants for incident gallstones were age, female sex, non-high density lipoprotein (non-HDL) cholesterol, and gallbladder polyps. In addition, BMI was positively associated in men. The systematic review additionally identified associations for comorbidities, parity, and dietary factors. Meta-analysis confirmed the significant associations for incident gallstones and age, female sex, BMI, and non-HDL cholesterol. No significant associations were found for blood pressure, smoking, alcohol consumption, HDL cholesterol, or triglycerides in meta-analyses.

CONCLUSIONS

Age, female sex, BMI, non-HDL cholesterol, and polyps are independent determinants for gallstone formation. Incident gallstones and the metabolic syndrome share common risk factors. More studies are needed for further exploration.

Burden of gallbladder cancer in Central and South America

RATIONALE AND OBJECTIVE

Gallbladder carcinoma (GBC) is a rare neoplasm yet it is the most common malignancy of the biliary tract and its prognosis is poor. Incidence of GBC is high in some areas of Central and South America and the Caribbean. We described the current burden of GBC in Central and South America (CSA).

METHODS

We obtained GBC incidence data from 48 population-based cancer registries in 13 countries in CSA, and national level cancer death data from the WHO mortality data base for 18 countries. We estimated World population age-standardized incidence and mortality rates per 100,000 persons-years, including distribution and incidence rates by anatomic subsite.

RESULTS

GBC rates were the highest in countries located in the Andean region. In 2003-2007, Chile had the highest incidence and mortality rates in CSA (17.1 and 12.9 in females and 7.3 and 6.0 in males, respectively). Females had higher GBC rates than males. The most frequently diagnosed anatomic subsite was gallbladder (60%). Unspecified subsite represented 21% of all cases. Trends in incidence and mortality of GBC remained unchanged in Argentina, Brazil, Chile and Costa Rica in 1998-2008.

CONCLUSION

GBC rates varied extensively across the CSA region reflecting, in part, differences in data quality, coverage and healthcare access. Chile had the highest GBC rates in CSA and the world. The large proportion of unspecified cases indicates low precision in diagnosis/registration and highlights the need to promote and improve cancer registration in the region to better understand the burden of GBC in CSA.

Vegetable protein intake is associated with lower gallbladder disease risk: Findings from the Women's Health Initiative prospective cohort

OBJECTIVE

This study aimed to measure associations between gallbladder disease and protein intake patterns, separated by quantity and type (vegetable vs. animal), among postmenopausal women.

METHODS

Analyses were based on 130,859 postmenopausal women enrolled from 1993 to 1998 at 40 U.S. clinical centers in the Women's Health Initiative clinical trials and observational study. Women were excluded if they reported a history of gallbladder disease prior to baseline. Cox proportional hazards regression models, adjusted for gallbladder disease risk factors, were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between energy-adjusted protein intake and gallbladder disease.

RESULTS

In this study sample, 8.1% of postmenopausal women self-reported incident gallbladder disease. In multivariate analysis, women in the highest quintile of energy-adjusted vegetable protein intake (>24.0g/d) had a lower risk of gallbladder disease (HR, 0.87; 95% CI, 0.81-0.93) as compared to women in the lowest quintile (<16.3g/d) (Ptrend<0.001). Total protein intake was modestly protective against gallbladder disease (Ptrend<0.021). Animal protein intake was not associated with gallbladder disease risk. The protective effect of vegetable protein held stable only for women without history of diabetes (HR, 0.86; 95% CI, 0.80-0.92) and without recent weight loss (HR, 0.88; 95% CI, 0.80-0.97).

CONCLUSIONS

Vegetable protein intake is inversely associated with gallbladder disease risk in our sample of postmenopausal women. In addition to weight management, healthcare providers could emphasize vegetable protein as an additional dietary modality to promote lower risk for gallbladder disease.

Preventing a Mass Disease: The Case of Gallstones Disease: Role and Competence for Family Physicians

Gallstone formation is the result of a complex interaction between genetic and nongenetic factors. We searched and reviewed the available literature to define how the primary prevention of gallstones (cholesterol gallstones in particular) could be applied in general practice. Electronic bibliographical databases were searched. Prospective and retrospective cohort studies and case-controlled studies were analyzed and graded for evidence quality. The epidemiological data confirmed that genetic factors are estimated to account for only approximately 25% of the overall risk of gallstones, while metabolic/environmental factors are at least partially modifiable in stone-free risk groups, and are thus modifiable by primary prevention measures related to diet, lifestyle, and environmental factors (i.e., rapid weight loss, bariatric surgery, somatostatin or analogues therapy, transient gallbladder stasis, and hormone therapy). There is no specific recommendation for the secondary prevention of recurrent gallstones. Family physicians can contribute to preventing gallstones due to their capability to identify and effectively manage several risk factors discussed in this study. Although further studies are needed to better elucidate the involvement of epigenetic factors that may regulate the effect of environment and lifestyle on gene expression in the primary prevention of gallstone formation, preventive interventions are feasible and advisable in the general practice setting.

Novel FXR (farnesoid X receptor) modulators: Potential therapies for cholesterol gallstone disease

Metabolic disorders such as diabetes are known risk factors for developing cholesterol gallstone disease (CGD). Cholesterol gallstone disease is one of the most prevalent digestive diseases, leading to considerable financial and social burden worldwide. Ursodeoxycholic acid (UDCA) is the only bile acid drug approved by FDA for the non-surgical treatment of gallstones. However, the molecular link between UDCA and CGD is unclear. Previous data suggest that the farnesoid X receptor (FXR), a bile acid nuclear receptor, may protect against the development of CGD. In studies aimed at identifying the role of FXR, we recently identify a novel chemical tool, 6EUDCA (6-αethyl-ursodeoxycholic acid), a synthetic derivative of UDCA, for studying FXR. We found that 6EUDCA binds FXR stronger than UDCA in a TR-FRET binding assay. This result was supported by computational docking models that suggest 6EUDCA forms a more extensive hydrogen bound network with FXR. Interestingly, neither compound could activate FXR target genes in human nor mouse liver cells, suggesting UDCA and 6EUDCA activate non-genomic signals in an FXR-dependent manner. Overall these studies may lead to the identification of a novel mechanism by which bile acids regulate cell function, and 6EUDCA may be an effective targeted CGD therapeutic.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Nationwide trends of hospital admissions for acute cholecystitis in the United States

Background and aims: Acute cholecystitis is a fairly common inpatient diagnosis among the gastrointestinal disorders. The aim of this study was to use a national database of US hospitals to evaluate the incidence and costs of hospital admissions associated with acute cholecystitis.

Method: We analyzed the National Inpatient Sample Database (NIS) for all patients in which acute cholecystitis (ICD-9 codes: 574.00, 574.01, 574.30, 574.31, 574.60, 574.61 or 575.0) was the principal discharge diagnosis from 1997 to 2012. The NIS is the largest all-payer inpatient database in the United States and contains data from approximately 8 million hospital stays each year. The statistical significance of the difference in the number of hospital discharges, lengths of stay and associated hospital costs over the study period was determined by using the Chi-square test for trends.

Results: In 1997, there were 149 661 hospital admissions with a principal discharge diagnosis of acute cholecystitis, which increased to 215 995 in 2012 ( P < 0.001). The mean length of stay for acute cholecystitis decreased by 17% between 1997 and 2012 (i.e. from 4.7 days to 3.9 days; (P < 0.05). During the same time period, however, mean hospital charges have increased by 195.4 % from US$14 608 per patient in 1997 to US$43 152 per patient in 2012 ( P < 0.001).

Conclusion: The number of inpatient discharges related to acute cholecystitis has increased significantly in the United States over the last 16 years, along with a great increase in the associated hospital charges. However, there has been a gradual decline in the mean length of stay. Inpatient costs associated with acute cholecystitis contribute significantly to the total healthcare bill. Further research on cost-effective evaluation and management of acute cholecystitis is required.

A randomised, single blinded trial, assessing the effect of a two week preoperative very low calorie diet on laparoscopic cholecystectomy in obese patients

BACKGROUND

Laparoscopic cholecystectomy (LC) can be technically challenging in the obese. The primary aim of the trial was to establish whether following a Very Low Calorie Diet (VLCD) for two weeks pre-operatively reduces operation time. Secondary outcomes included perceived operative difficulty and length of hospital stay.

METHODS

A single-blinded, randomized controlled trial of consecutive patients with symptomatic gallstones and BMI >30 kg/m(2) 46 patients were randomized to a VLCD or normal diet for two weeks prior to LC. Food diaries were used to document dietary intake. The primary outcome measure was operation time. Secondary outcomes were length of stay, weight change operative complications, day case rates and perceived difficulty of operation.

RESULTS

The VLCD was well tolerated and had significantly greater preoperative weight loss (3.48 kg vs. 0.98 kg; p < 0.0001). Median operative time was significantly reduced by 6 min in the VLCD group (25 vs. 31 min; p = 0.0096). There were no differences in post-operative complications, length of stay, or day case rates between the groups. Dissection of Calot's triangle was deemed significantly easier in the VLCD group.

CONCLUSION

A two week VLCD prior to elective laparoscopic cholecystectomy in obese patients is safe, well tolerated and was shown to significantly reduce pre-operative weight and operative time.

ISRCTN

61630192. http://www.isrctn.com/ISRCTN61630192 Trial registration.

Frequency of cholecystectomy and associated sociodemographic and clinical risk factors in the ELSA-Brasil study

CONTEXT AND OBJECTIVE

There are few data in the literature on the frequency of cholecystectomy in Brazil. The frequency of cholecystectomy and associated risk factors were evaluated in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

DESIGN AND SETTING

Cross-sectional study using baseline data on 5061 participants in São Paulo.

METHODS

The frequency of cholecystectomy and associated risk factors were evaluated over the first two years of follow-up of the study and over the course of life. A multivariate regression analysis was presented: odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

A total of 4716 individuals (93.2%) with information about cholecystectomy were included. After two years of follow-up, 56 had undergone surgery (1.2%: 1.7% of the women; 0.6% of the men). A total of 188 participants underwent cholecystectomy during their lifetime. The risk factors associated with surgery after the two-year follow-up period were female sex (OR, 2.85; 95% CI, 1.53-5.32), indigenous ethnicity (OR, 2.1; 95% CI, 2.28-15.85) and body mass index (BMI) (OR, 1.10; 95% CI, 1.01-1.19 per 1 kg/m2 increase). The risk factors associated over the lifetime were age (OR, 1.03; 95% CI, 1.02-1.05 per one year increase), diabetes (OR, 1.92; 95% CI, 1.34-2.76) and previous bariatric surgery (OR, 5.37; 95% CI, 1.53-18.82). No association was found with parity or fertile age.

CONCLUSION

Female sex and high BMI remained as associated risk factors while parity and fertile age lost significance. New factors such as bariatric surgery and indigenous ethnicity have gained importance in this country.

[Simultaneous abdominal and retroperitoneal surgery]

AIM

To study the results of simultaneous abdominal and retroperitoneal interventions.

MATERIAL AND METHODS

The article presents analysis of 856 simultaneous operations whose proportion was 3.49% of total number of operations. Most of them was performed via videolaparoscopic approach (697, 81.4%), open access and mini-laparotomy were used rarer (111, 12.9%) and 48 (6,7%) respectively). Severity of great number of interventions corresponded to degree I and II of D. Lochlein and R. Pichlmayer classification. Modern diagnostic methods including sonography, computed tomography, magnetic resonance imaging, angiography, endoscopy and laboratory data were used to define diagnosis.

RESULTS

Simultaneous approach increases duration of surgery 30.3% on the average that is significant risk factor in case of surgery of severity degree III and videolaparoscopic interventions. Simultaneous surgery does not significantly increase ICU-stay and incidence of postoperative complications.

Age at Menarche and Gallstone Disease in Middle-Aged Women

The goal of this study was to explore the association between age at menarche and gallstone disease (GSD) in Korean women and to determine whether any of the observed associations were mediated by adult adiposity. A cross-sectional study was performed on 83 275 Korean women, aged 30 years or older, who underwent a health checkup examination between March 2011 and April 2013. Information regarding age at menarche was collected using standardized, self-administered questionnaires. Gallstone disease was defined as either having gallstones or having had a cholecystectomy based on ultrasound. Logistic regression models were used to evaluate the association between age at menarche and GSD. Of the 83 275 women evaluated in this study, 3341 had GSD. Age at menarche was negatively associated with the prevalence of GSD. In a multivariable-adjusted model adjusting for potential confounders including reproductive factors and body weight at age 20, the odds ratios (95% confidence intervals) for GSD comparing menarche at <12, 12, 14, 15, and 16 to 18 years to menarche at 13 years were 1.46 (1.23-1.75), 1.19 (1.04-1.35), 0.97 (0.87-1.09), 0.92 (0.82-1.03), and 0.89 (0.78-1.02), respectively (P for trend <.001). Adjusting for adult body mass index or percentage fat mass (%) partially reduced these associations; however, they remained statistically significant. Early menarche was associated with increasing prevalence of GSD in a large sample of middle-aged women. The findings of this study extend the range of adverse health outcomes associated with early menarche and suggest that obesity prevention strategies could be useful for reducing the risk of GSD in women who experience early menarche.

Metagenomic sequencing of bile from gallstone patients to identify different microbial community patterns and novel biliary bacteria

Despite the high worldwide prevalence of gallstone disease, the role of the biliary microbiota in gallstone pathogenesis remains obscure. Next-generation sequencing offers advantages for systematically understanding the human microbiota; however, there have been few such investigations of the biliary microbiome. Here, we performed whole-metagenome shotgun (WMS) sequencing and 16S rRNA sequencing on bile samples from 15 Chinese patients with gallstone disease. Microbial communities of most individuals were clustered into two types, according to the relative enrichment of different intestinal bacterial species. In the bile samples, oral cavity/respiratory tract inhabitants were more prevalent than intestinal inhabitants and existed in both community types. Unexpectedly, the two types were not associated with fever status or surgical history, and many bacteria were patient-specific. We identified 13 novel biliary bacteria based on WMS sequencing, as well as genes encoding putative proteins related to gallstone formation and bile resistance (e.g., β-glucuronidase and multidrug efflux pumps). Bile samples from gallstone patients had reduced microbial diversity compared to healthy faecal samples. Patient samples were enriched in pathways related to oxidative stress and flagellar assembly, whereas carbohydrate metabolic pathways showed varying behaviours. As the first biliary WMS survey, our study reveals the complexity and specificity of biliary microecology.

Interactions between the intestinal microbiota and bile acids in gallstones patients

Cholecystectomy, surgical removal of the gallbladder, changes bile flow to the intestine and can therefore alter the bidirectional interactions between bile acids (BAs) and the intestinal microbiota. We quantified and correlated BAs and bacterial community composition in gallstone patients scheduled for cholecystectomy before and after the procedure, using gas-liquid chromatography and 16S rRNA amplicon sequencing, followed by quantitative real-time polymerase chain reaction of the phylum Bacteroidetes. Gallstone patients had higher overall concentrations of faecal BAs and a decreased microbial diversity, accompanied by a reduction in the beneficial genus Roseburia and an enrichment of the uncultivated genus Oscillospira, compared with controls. These two genera may thus serve as biomarkers for symptomatic gallstone formation. Oscillospira was correlated positively with secondary BAs and negatively with primary BAs, while the phylum Bacteroidetes showed an opposite trend. Cholecystectomy resulted in no substantial change in patients' faecal BAs. However, bacterial composition was significantly altered, with a significant increase in the phylum Bacteroidetes. Given that cholecystectomy has been associated with a higher risk of colorectal cancer and that members of the Bacteroidetes are increased in that disease, microbial consequences of cholecystectomy should be further explored.

Cost variation in a laparoscopic cholecystectomy and the association with outcomes across a single health system: implications for standardization and improved resource utilization

BACKGROUND

Payers and regulatory bodies are increasingly placing emphasis on cost containment, quality/outcome measurement and transparent reporting. Significant cost variation occurs in many operative procedures without a clear relationship with outcomes. Clear cost-benefit associations will be necessary to justify expenditures in the era of bundled payment structures.

METHODS

All laparoscopic cholecystectomies (LCCKs) performed within a single health system over a 1-year period were analysed for operating room (OR) supply cost. The cost was correlated with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) outcomes.

RESULTS

From July 2013 to June 2014, 2178 LCCKs were performed by 55 surgeons at seven hospitals. The median case OR supply cost was $513 ± 156. There was variation in cost between individual surgeons and within an individual surgeon's practice. There was no correlation between cost and ACS NSQIP outcomes. The majority of cost variation was explained by selection of trocar and clip applier constructs.

CONCLUSIONS

Significant case OR cost variation is present in LCCK across a single health system, and there is no clear association between increased cost and NSQIP outcomes. Placed within the larger context of overall cost, the opportunity exists for improved resource utilization with no obvious risk for a reduction in the quality of care.

Phase composition and morphological analysis of human gallstones using IR spectroscopy, scanning electron microscopy and X-ray Rietveld analysis

Quantitative phase composition and morphological characterization of 12 human gallbladder stones (GS1–GS12) retrieved from patients of eastern India have been carried out using IR-spectroscopy, powder X-ray diffraction (PXRD) and scanning electron microscopy (SEM). The FTIR spectra indicated that the primary composition of gallstones studied was cholesterol. X-ray powder diffraction study revealed cholesterol monohydrate (CHM) as the major crystalline phase in GS1–GS12. The Rietveld analysis showed that nine of the gallstones were composed exclusively of CHM, while the remaining three stones contained in addition to CHM, small amounts (4.2–10.6 wt%) of calcium carbonate as aragonite and vaterite. The crystallite size of CHM in GS1–GS12 varied between 82(6) and 249(3) nm. The SEM images of gallstones showed different crystal habits of CHM such as plates, thin rods, rectangular and hexagonal blocks, which resulted into different levels of agglomeration at the mesoscopic scale. Presence of numerous parasitic eggs with a typical muskmelon surface in three gallstones (GS2, GS7 and GS9) suggests possible association between the liver fluke infection and biliary stone formation in these patients. To the best of our knowledge, the study constitutes the first report of X-ray quantitative phase analysis of gallstones using the Rietveld methodology.

Management of gallstones and its related complications

The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications.

Excess Secretion of Gel-Forming Mucins and Associated Innate Defense Proteins with Defective Mucin Un-Packaging Underpin Gallbladder Mucocele Formation in Dogs

Mucosal protection of the gallbladder is vital yet we know very little about the mechanisms involved. In domestic dogs, an emergent syndrome referred to as gallbladder mucocele formation is characterized by excessive secretion of abnormal mucus that results in obstruction and rupture of the gallbladder. The cause of gallbladder mucocele formation is unknown. In these first mechanistic studies of this disease, we investigated normal and mucocele-forming dog gallbladders to determine the source, identity, biophysical properties, and protein associates of the culprit mucins with aim to identify causes for abnormal mucus behavior. We established that mucocele formation involves an adoptive excess secretion of gel forming mucins with abnormal properties by the gallbladder epithelium. The mucus is characterized by a disproportionally significant increase in Muc5ac relative to Muc5b, defective mucin un-packaging, and mucin-interacting innate defense proteins that are capable of dramatically altering the physical and functional properties of mucus. These findings provide an explanation for abnormal mucus behavior and based on similarity to mucus observed in the airways of people with cystic fibrosis, suggest that abnormal mechanisms for maintenance of gallbladder epithelial hydration may be an instigating factor for mucocele formation in dogs.