Efficacy and Safety of Ursodeoxycholic Acid for the Prevention of Gallstone Formation After Gastrectomy in Patients With Gastric Cancer: The PEGASUS-D Randomized Clinical Trial

Gut microbiota promotes cholesterol gallstone formation through the gut-metabolism-gene axis

BACKGROUND

Gallstone disease, arising from the interplay between host metabolism and gut microbiota, represents a significant health concern. Dysbiosis of the gut microbiome and disruptions in circadian rhythm contribute to the pathogenesis of gallstones. This study conducted a comprehensive analysis of gut microbiota and metabolites derived from stool and serum samples of 28 patients with cholesterol gallstones (CGS) and 19 healthy controls, employing methodologies such as 16S rRNA sequencing, metaproteomics, metabolomics, and host genetic analysis. Additionally, a retrospective cohort study was utilized to assess the efficacy of probiotics or ursodeoxycholic acid (UDCA) in preventing CGS formation post-bariatric surgery.

RESULTS

In CGS patients, gut microbiota diversity shifted, with harmful bacteria rising and beneficial ones declining. The altered microbiota primarily affected amino acid, lipid, nucleotide, and carbohydrate metabolism. Metabolic abnormalities were noted in amino acids, glucose, lipids, and bile acids with decreased levels of ursodeoxycholic, glycosodeoxycholic, and glycolithocholic acids, and increased glycohyodeoxycholic and allocholic acids. Glutamine and alanine levels dropped, while phenylalanine and tyrosine rosed. Animal studies confirmed gene changes in gallbladder tissues related to bile acid, energy, glucose, and lipid metabolism. Importantly, UDCA and probiotics effectively reduced CGS risk post-bariatric surgery, especially when combined.

CONCLUSIONS

Multi-omics can clarify CGS pathology, by focusing on the gut-metabolism-gene axis, paving the way for future studies on CGS prevention and treatment through gut microbiota or metabolic interventions.

Host-Microbial Cometabolite Ursodeoxycholic Acid Protects Against Poststroke Cognitive Impairment

BACKGROUND

Poststroke cognitive impairment (PSCI) is a common residual disability after stroke, often underestimated and underdiagnosed. We previously found that ursodeoxycholic acid (UDCA), a host-microbiota cometabolite, ameliorates brain damage in stroke mice. Based on these findings, we aimed to evaluate the predictive value of UDCA for PSCI risk in a prospective cohort study.

METHODS AND RESULTS

We recruited 202 patients with mild acute ischemic stroke and 63 patients with symptomatic large-artery atherosclerotic stenosis as the modeling and external validation cohorts, respectively. Mice were subjected to transient middle cerebral artery occlusion, and cognitive function was assessed using the Morris water maze test. Patients with mild acute ischemic stroke who developed PSCI exhibited significant alterations in gut microbiota and plasma bile acid profiles during the acute stroke phase, including a notable reduction in UDCA level. Through feature selection and machine learning, we constructed a predictive model for PSCI incorporating plasma UDCA level, the relative abundance of Clostridia, Bacilli, and Bacteroides, as well as age, educational level, and the presence of moderate to severe white matter lesions. This model exhibited robust predictive performance in both internal (area under the curve, 0.904 [95% CI, 0.808-1.000]) and external (area under the curve, 0.838 [95% CI, 0.742-0.934]) validations. Animal studies in mice also showed reduced UDCA levels in plasma and brain tissue following stroke. UDCA administration improved cognitive function in stroke mice by reducing hippocampal microglial activation and neuronal apoptosis.

CONCLUSIONS

Our findings indicate that UDCA has potential as a biomarker for predicting PSCI risk and plays a neuroprotective role in the progression of PSCI. This suggests that early identification and intervention targeting UDCA could represent a promising strategy for the prevention and treatment of PSCI.

Korea, Japan, Europe, and the United States: Why are guidelines for gastric cancer different?

As a global health concern, gastric cancer management has been systematized by individual countries and regions into regimented guidelines. To explore international differences, we examined the guidelines of Korea, Japan, Europe, and the United States. Guidelines are created by experts in the field, focusing on evidence-based recommendations to standardize and improve patient care, but the methodology for guideline creation, incorporation of new innovations, and review differs significantly. National and regional differences within the guidelines are apparent, stemming from various factors including local incidence, stage, presentation, patient preferences, and governmental influences. Differences include the use of neoadjuvant chemotherapy, criteria for endoscopic resection, and extent of lymphadenectomy. Nonetheless, fundamental treatment principles remain universal, and the goals of national guidelines are uniform: standardizing patient care, providing the highest quality treatments, incorporating cutting-edge clinical trial results, and consensus in guidelines to help formulate governmental policies. This review highlights how the guidelines are constructed, the unique elements of each guideline, how they differ, and why they differ.

Laparoscopic Pylorus-preserving Gastrectomy Versus Distal Gastrectomy for Early Gastric Cancer: A Multicenter Randomized Controlled Trial (KLASS-04)

OBJECTIVE

To evaluate the long-term outcomes of laparoscopic pylorus-preserving gastrectomy (LPPG) with laparoscopic distal gastrectomy (LDG) for early gastric cancer.

BACKGROUND

Pylorus-preserving gastrectomy is considered a function-preserving surgery for early gastric cancer. However, there has been no multicenter randomized controlled trial comparing pylorus-preserving gastrectomy with distal gastrectomy until now.

METHODS

A multicenter randomized controlled trial (KLASS-04) with 256 patients with cT1N0M0 gastric cancer located in the mid portion of the stomach was conducted. The primary endpoint was the incidence of dumping syndrome at postoperative 1 year. Secondary endpoints included survival and recurrence, gallstone formation, nutritional parameters, gastroscopic findings, and quality of life for 3 years.

RESULTS

In the intention-to-treat analyses, there was no difference in the incidence of dumping syndrome at 1 year postoperatively (13.2% in LPPG vs 15.8% in LDG, P = 0.622). Gallstone formation after surgery was significantly lower in LPPG than in LDG (2.33% vs 8.66%, P = 0.026). Hemoglobin (+0.01 vs -0.76 gm/dL, P < 0.001) and serum protein (-0.15 vs -0.35 gm/dL, P = 0.002) were significantly preserved after LPPG. However, reflux esophagitis (17.8% vs 6.3%, P = 0.005) and grade IV delayed gastric emptying (16.3% vs 3.9%, P = 0.001) were more common in LPPG. Changes in body weight and postoperative quality of life were not significantly different between groups. Three-year overall survival and disease-free survival were not different (1 case of recurrence in each group, P = 0.98).

CONCLUSIONS

LPPG can be used as an alternative surgical option for cT1N0M0 gastric cancer in the mid portion of the stomach.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

Efficacy of ursodeoxycholic acid for bile reflux after distal gastrectomy in patients with gastric cancer: a secondary analysis of the PEGASUS-D randomized clinical trial

BACKGROUND

Few studies have been conducted on the prevention of bile reflux in gastric cancer patients who have undergone gastrectomy. The aim of this study was to evaluate the efficacy and safety of ursodeoxycholic acid (UDCA) in preventing bile reflux after gastrectomy in patients with gastric cancer.

METHODS

This study was a secondary analysis of the PEGASUS-D trial, a randomized, double-blind, placebo-controlled clinical trial. Adults with a diagnosis of gastric cancer who underwent gastrectomy were enrolled. Eligible participants were randomly assigned to receive 300 mg of UDCA, 600 mg of UDCA, or placebo at a ratio of 1:1:1. UDCA and placebo were administered daily for 52 weeks. The primary outcomes included bile reflux symptoms at each time point, the percentage of participants with bile reflux, and the grade of gastritis.

RESULTS

Among 521 participants who underwent randomization, 151, 164, and 150 participants were analyzed from the 300 mg UDCA, 600 mg UDCA, and placebo groups, respectively. The difference in symptoms between the three groups was not significant. Bile reflux was less evident in the UDCA group than in the placebo group; however, this difference was significant only in the 300 mg group at 12 months postoperation (odds ratio, 0.44; P =0.0076). A significant reduction in gastritis was also observed in the 300 mg group at 12 months postoperation (odds ratio, 0.50; P =0.0368) compared to the placebo group.

CONCLUSIONS

This study showed that UDCA administration significantly reduced bile reflux and gastritis by ~50% at the 12 months-postoperative follow-up in patients who underwent gastrectomy for gastric cancer.

Investigating the potential mechanism and therapeutic effects of SLXG for cholesterol gallstone treatment

BACKGROUND

Shugan Lidan Xiaoshi Granules (SLXG) is a traditional Chinese medicine (TCM) formulation frequently employed to prevent and treat cholesterol gallstones. SLXG is formulated based on the Chaihu Shugan Formula found in an ancient Chinese medical book, a traditional remedy in China for centuries, and has demonstrated successful treatment of numerous patients with gallbladder stones.

PURPOSE

This research sought to clarify the therapeutic impact and molecular mechanisms of SLXG and its active components in the treatment of cholesterol gallbladder stones.

METHODS

The study employed network pharmacology, UPLC-HRMS transcriptome sequencing, animal model experiments, molecular docking, and Surface Plasmon Resonance (SPR) to explore the molecular mechanisms of SLXG and its relationship with Traditional Chinese Medicines (TCMs) and potential targets. Furthermore, PPI network analysis, along with GO and KEGG enrichment analyses, were performed to explore the potential mechanisms through which SLXG and its active ingredient, naringenin, prevent and treat cholesterol gallstones. The mechanism of action was further elucidated using an animal model for gallbladder stone formation.

RESULTS

The study employed a network pharmacology and UPLC-HRMS to investigate the active compounds of SLXG for the treatment of cholesterol gallbladder stones, and subsequently constructed a network of therapeutic targets of SLXG. The results from gene enrichment analyses indicated that SLXG targets the metabolic pathway of bile secretion and the cholesterol metabolism pathway in addressing cholesterol gallbladder stones. The molecular docking results confirmed the interaction between the genes enriched in the pathways and the active ingredients in SLXG. Transcriptome sequencing results demonstrated that SLXG exerts its therapeutic effect on gallstones by regulating cholesterol and bile acid synthesis and metabolism. Furthermore, animal model experiments and SPR provided evidence that SLXG and its active ingredient, naringenin, exert therapeutic effects on cholesterol gallbladder stones by targeting the genes HMGCR, SOAT2, and UGT1A1, and influencing substances associated with cholesterol synthesis and metabolism.

CONCLUSIONS

Using systematic network pharmacology methods combined with in vivo validation experiments, we uncovered the fundamental pharmacological effects and potential mechanisms of SLXG and its active ingredient, naringenin, in the treatment of cholesterol gallstones. This research underscores the valuable role that traditional remedies can play in addressing medical challenges and suggests a promising direction for further exploration of natural treatments for the disease.

Unveiling the gut-eye axis: how microbial metabolites influence ocular health and disease

The intricate interplay between the gut microbiota and ocular health has surpassed conventional medical beliefs, fundamentally reshaping our understanding of organ interconnectivity. This review investigates into the intricate relationship between gut microbiota-derived metabolites and their consequential impact on ocular health and disease pathogenesis. By examining the role of specific metabolites, such as short-chain fatty acids (SCFAs) like butyrate and bile acids (BAs), herein we elucidate their significant contributions to ocular pathologies, thought-provoking the traditional belief of organ sterility, particularly in the field of ophthalmology. Highlighting the dynamic nature of the gut microbiota and its profound influence on ocular health, this review underlines the necessity of comprehending the complex workings of the gut-eye axis, an emerging field of science ready for further exploration and scrutiny. While acknowledging the therapeutic promise in manipulating the gut microbiome and its metabolites, the available literature advocates for a targeted, precise approach. Instead of broad interventions, it emphasizes the potential of exploiting specific microbiome-related metabolites as a focused strategy. This targeted approach compared to a precision tool rather than a broad-spectrum solution, aims to explore the therapeutic applications of microbiome-related metabolites in the context of various retinal diseases. By proposing a nuanced strategy targeted at specific microbial metabolites, this review suggests that addressing specific deficiencies or imbalances through microbiome-related metabolites might yield expedited and pronounced outcomes in systemic health, extending to the eye. This focused strategy holds the potential in bypassing the irregularity associated with manipulating microbes themselves, paving a more efficient pathway toward desired outcomes in optimizing gut health and its implications for retinal diseases.

Understanding and Managing Metabolic Deficiencies Post Bariatric and Esophagectomy Surgeries: A Narrative Review of the Literature

Gastrectomy and esophagectomy are the most performed surgeries in the treatment of both esophageal and gastric cancers. The type of esophagectomy depends on the type of malignancy, site of the tumor, criteria of resection, and field of resection. The three standard approaches to esophagectomy are the transhiatal approach, the left thoracoabdominal approach, and a three-stage procedure. The transhiatal approach involves abdominal and cervical incisions, while the left thoracoabdominal approach is a one-stage procedure that utilizes a single incision exposing the dissection field. The Ivor Lewis and McKeown esophagectomies are two-stage and three-stage surgeries that include laparotomy with right thoracotomy. Malabsorption often emerges as a significant postoperative complication following esophagectomy and gastrectomy surgeries. Malnutrition linked with these cancers has detrimental effects, including heightened rates of postoperative complications, elevated infection risks, delayed wound healing, reduced tolerance to treatment, diminished quality of life, and heightened mortality rates. Our narrative review summarizes and sheds light on solutions to treat malabsorption disorders and malnutrition after gastric bypass surgery. These solutions include methods such as adjustments, supplements, and treatment. Although more research is needed to confirm their effectiveness, these methods indicate potential for lowering the impact on patients' diets. By considering the beneficial implications of these effects and considering solutions, we aim to improve the management of these adverse effects, ultimately improving the overall health and postoperative outcomes of patients.

High incidence of gallstones after Roux-en-Y reconstruction gastrectomy in gastric cancer: a multicenter, long-term cohort study

BACKGROUND

Roux-en-Y reconstruction is a common anastomosis technique during gastrectomy in gastric cancer. There is a lack of studies on gallstones after Roux-en-Y reconstruction gastrectomy. This study investigated the incidence and potential risk factors associated with gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer.

METHODS

The study analyzed data from gastric cancer who underwent radical gastrectomy and Roux-en-Y reconstruction at two hospitals between January 2014 and December 2020. The patients fall into distal and total gastrectomy groups based on the extent of gastrectomy. The cumulative event probability curve was plotted using the Kaplan-Meier, and differences in gallstone between groups were evaluated using the Log-Rank. Propensity score matching was applied to construct a balanced total versus distal gastrectomies cohort. A Cox regression was employed to analyze the risk factors for gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer. Further subgroup analysis was performed.

RESULTS

Five hundred thirty-one patients were included in this study, 201 in the distal gastrectomy group and 330 in the total gastrectomy. During the follow-up, gallstones occurred in 170 cases after gastrectomy, of which 145 cases accounted for 85.29% of all stones in the first two years after surgery. Then, to reduce the impact of bias, a 1:1 propensity score matching analysis was performed on the two groups of patients. A total of 344 patients were evaluated, with each subgroup comprising 172 patients. In the matched population, the Cox regression analysis revealed that females, BMI ≥23 kg/m 2 , total gastrectomy, No.12 lymph node dissection, and adjuvant chemotherapy were risk factors for gallstones after Roux-en-Y reconstructive gastrectomy. Subgroup analysis showed that open surgery further increased the risk of gallstones after total gastrectomy.

CONCLUSION

The incidence of gallstones increased significantly within 2years after Roux-en-Y reconstructive gastrectomy for gastric cancer. Patients with these risk factors should be followed closely after gastrectomy to avoid symptomatic gallstones.

[New Progress in Longitudinal Research on the Risk Factors for Cholelithiasis]

Cholelithiasis is a common disease of the digestive system. The risk factors for cholelithiasis have been reported and summarized many times in the published literature, which primarily focused on cross-sectional studies. Due to the inherent limitations of the study design, the reported findings still need to be validated in additional longitudinal studies. Moreover, a number of new risk factors for cholelithiasis have been identified in recent years, such as bariatric surgery, hepatitis B virus infection, hepatitis C virus infection, kidney stones, colectomy, osteoporosis, etc. These new findings have not yet been included in published reviews. Herein, we reviewed the 101 cholelithiasis-associated risk factors identified through research based on longitudinal investigations, including cohort studies, randomized controlled trials, and nested case control studies. The risk factors associated with the pathogenesis of cholelithiasis were categorized as unmodifiable and modifiable factors. The unmodifiable factors consist of age, sex, race, and family history, while the modifiable factors include 37 biological environmental factors, 25 socioenvironmental factors, and 35 physiochemical environmental factors. This study provides thorough and comprehensive ideas for research concerning the pathogenesis of cholelithiasis, supplying the basis for identifying high-risk groups and formulating relevant prevention strategies.

Statins aggravate insulin resistance through reduced blood glucagon-like peptide-1 levels in a microbiota-dependent manner

Statins are currently the most common cholesterol-lowering drug, but the underlying mechanism of statin-induced hyperglycemia is unclear. To investigate whether the gut microbiome and its metabolites contribute to statin-associated glucose intolerance, we recruited 30 patients with atorvastatin and 10 controls, followed up for 16 weeks, and found a decreased abundance of the genus Clostridium in feces and altered serum and fecal bile acid profiles among patients with atorvastatin therapy. Animal experiments validated that statin could induce glucose intolerance, and transplantation of Clostridium sp. and supplementation of ursodeoxycholic acid (UDCA) could ameliorate statin-induced glucose intolerance. Furthermore, oral UDCA administration in humans alleviated the glucose intolerance without impairing the lipid-lowering effect. Our study demonstrated that the statin-induced hyperglycemic effect was attributed to the Clostridium sp.-bile acids axis and provided important insights into adjuvant therapy of UDCA to lower the adverse risk of statin therapy.

A Review of the Management of Cholelithiasis at Buraydah Central Hospital in the Qassim Region, Saudi Arabia: A Cross-Sectional Study

Cholelithiasis is the most common cause of gastroenterological hospitalization. Given this significant risk, perfectly managing cholelithiasis is crucial to reduce hospitalization. Unfortunately, we have not found a study on a review of the management of cholelithiasis in Saudi Arabia. Therefore, we aim to evaluate cholelithiasis concerning demographic features, presentation symptoms, predisposing risk factors, laboratory features, complications, and outcomes in the Qassim region. This cross-sectional study of all patients with a radiological diagnosis of gallstones, whether symptomatic or not, was diagnostic in 2022. The researchers fielded a preformed data collection sheet for each patient from the hospital system. Data obtained were entered into a spreadsheet and analyzed using SPSS Statistics version 23.0 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). A total of 526 patients were included in the study. Most patients (116, 22.1%), were aged 38-42. The finding also indicated that most patients were females (397, 75.5%), while males were only 129 (24.5%). The study also found that the difference between women and men presenting complaints of fat intolerance and right shoulder pain was statistically significant. Women were 100 (84%) and men were 19 (16%) for fat intolerance, while for right shoulder pain, women were 50 (89.3%) and men were six (10.7%). The p-values were 0.014 and 0.011, respectively. Further, there was a statistically significant difference in terms of the complaints presented by the patients between the complicated and non-complicated cases of abdominal pain (p=0.001), nausea (p=0.001), vomiting (p=0.001), change in urine and stool color (p=0.001), and right shoulder pain (p=0.001), among other complaints (p=0.001). The study concludes that most patients affected by cholelithiasis are individuals in the middle age group, with women being more affected by the disease than men. Further, among the individuals affected by the disease, the majority of them were overweight and obese. On the other hand, the study concludes that the majority of patients who suffer more from cholelithiasis are affected mainly by other associated diseases such as hypertension, hypothyroidism, and diabetes mellitus. In conclusion, many factors may contribute to gallstone formation and the outcome of the disease and surgery. Therefore, the study recommends that health workers offer tailored education, especially targeting the highlighted factors found in this study, to create awareness of disease control measures in the general population. Also, keep in mind these factors when dealing with patients who complain of abdominal pain.

The molecular insights of bile acid homeostasis in host diseases

Bile acids (BAs) function as detergents promoting nutrient absorption and as hormones regulating nutrient metabolism. Most BAs are key regulatory factors of physiological activities, which are involved in the regulation of glucose, lipid, and drug metabolisms. Hepatic and intestinal diseases have close connections with the systemic cycling disorders of BAs. The abnormal in BA absorption came up with overmuch BAs could be involved in the pathophysiology of liver and bowel and metabolic disorders such as fatty liver diseases and inflammatory bowel diseases. The primary BAs (PBAs), which are synthesized in the liver, can be transformed into the secondary BAs (SBAs) by gut microbiota. The transformation processes are tightly associated with the gut microbiome and the host endogenous metabolism. The BA biosynthesis gene cluster bile-acid-inducible operon is essential for modulating BA pool, gut microbiome composition, and the onset of intestinal inflammation. This forms a bidirectional interaction between the host and its gut symbiotic ecosystem. The subtle changes in the composition and abundance of BAs perturb the host physiological and metabolic activity. Therefore, maintaining the homeostasis of BAs pool contributes to the balance of the body's physiological and metabolic system. Our review aims to dissect the molecular mechanisms underlying the BAs homeostasis, assess the key factors sustaining the homeostasis and the role of BA acting on host diseases. By linking the BAs metabolic disorders and their associated diseases, we illustrate the effects of BAs homeostasis on health and potential clinical interventions can be taken under the latest research findings.

The necessity and safety of simultaneous cholecystectomy during gastric surgery for patients with asymptomatic cholelithiasis

OBJECTIVES

The incidence of cholelithiasis is higher among individuals who have undergone gastric surgery. The benefits of concomitant gallbladder removal in asymptomatic gallstone patients remain uncertain. The aim was to investigate the necessity and safety of simultaneous cholecystectomy in this particular patient population.

METHODS

We performed a systematic review and meta-analysis to assess the incidence of asymptomatic cholelithiasis converting to symptomatic after gastric surgery and the complication rate associated with simultaneous cholecystectomy. PubMed, Embase, and the Cochrane Library were searched for relevant articles published until 10 March 202210 March 2022.

RESULTS

Patients with asymptomatic cholelithiasis after gastric surgery were at a higher risk of developing symptomatic cholelithiasis compared to those without cholelithiasis (relative risk [RR] 2.28, 95% confidence interval [CI] 1.23-4.25) and those with unknown gallbladder conditions (RR 2.70, 95% CI 1.54-4.73). Additionally, patients who underwent simultaneous cholecystectomy did not face a higher risk of complications compared to those who only underwent gastric surgery (RR 0.86, 95% CI 0.48-1.53).

CONCLUSIONS

Simultaneous cholecystectomy is both necessary and safe for patients with asymptomatic cholelithiasis undergoing gastric surgery. It is crucial to assess the gallbladder's condition before gastric surgery, and if the gallbladder status is unknown, simultaneous cholecystectomy should be avoided.

Jasminoidin and ursodeoxycholic acid exert synergistic effect against cerebral ischemia-reperfusion injury via Dectin-1-induced NF-κB activation pathway

BACKGROUND

Jasminoidin (JA) and ursodeoxycholic acid (UA) were shown to act synergistically against ischemic stroke (IS) in our previous studies.

PURPOSE

To investigate the holistic synergistic mechanism of JA and UA on cerebral ischemia.

METHODS

Middle cerebral artery obstruction reperfusion (MCAO/R) mice were used to evaluate the efficacy of JA, UA, and JA combined with UA (JU) using neurological function testing and infarct volume examination. High-throughput RNA-seq combined with computational prediction and function-integrated analysis was conducted to gain insight into the comprehensive mechanism of synergy. The core mechanism was validated using western blotting.

RESULTS

JA and UA synergistically reduced cerebral infarct volume and alleviated neurological deficits and pathological changes in MCAO/R mice. A total of 1437, 396, 1080, and 987 differentially expressed genes were identified in the vehicle, JA, UA, and JU groups, respectively. A strong synergistic effect between JA and UA was predicted using chemical similarity analysis, target profile comparison, and semantic similarity analysis. As the 'long-tail' drugs, the top 20 gene ontology (GO) biological processes of JA, UA, and JU groups primarily reflected inflammatory response and regulation of cytokine production, with specific GO terms of JU revealing enhanced regulation on immune response and tumor necrosis factor superfamily cytokine production. Comparably, the Kyoto Encyclopedia of Genes and Genomes (KEGG) signaling of common targets of JA, UA, and JU focused on extracellular matrix organization and signaling by interleukins, immune system, phagosomes, and lysosomes, which interlock and interweave to produce the synergistic effects of JU. The characteristic signaling pathway identified for JU highlighted the crosstalk between autophagy activation and inflammatory pathways, especially the Dectin-1-induced NF-κB activation pathway, which was validated by in vivo experiments.

CONCLUSIONS

JA and UA can synergistically protect cerebral ischemia-reperfusion injury by attenuating Dectin-1-induced NF-κB activation. The strategy integrating high throughput data with computational models enables ever-finer mapping of 'long-tail' drugs to dynamic variations in condition-specific omics to clarify synergistic mechanisms.

Individualized Choice of Simultaneous Cholecystectomy in Patients with Gastric Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing gastrectomy for gastric cancer are more likely to develop gallstones than the general population. Prophylactic cholecystectomy remains controversial.

METHODS

Studies from 2000-2022 were systematically searched in the PubMed, EMBASE, and Cochrane Library databases. The search included simultaneous cholecystectomy or risk factors for gallstone formation with gastrectomy alone. Major prognostic factors included complications and mortality, and risk factor analyses included age, sex, TNM stage, gastrectomy type, lymph node dissection, diabetes, and duodenal exclusion. Random effects regression models were used to analyze risk estimates and data were presented as odds ratios (ORs) with corresponding 95% confidence intervals (CIs).

RESULTS

There were no significant differences in postoperative morbidity (OR 1.12, 95% CI 0.90-1.39; p = 0.33, I2 = 11%) and mortality (OR 1.23, 95% CI 0.62-2.43; p = 0.56, I2 = 0%) between gastrectomy alone and simultaneous cholecystectomy. Older age (OR 1.48, 95% CI 1.36-1.59; p < 0.001, I2 = 59%), male sex (OR 1.38, 95% CI 1.10-1.71; p = 0.004, I2 = 77%), total gastrectomy (OR 1.50, 95% CI 1.25-1.81; p < 0.001, I2 = 72%), diabetes mellitus (OR 1.38, 95% CI 1.17-1.63; p < 0.001, I2 = 8%), and duodenal exclusion (OR 1.77, 95% CI 1.47-2.15; p < 0.001, I2 = 30%) were risk factors for cholecystolithiasis.

CONCLUSIONS

Simultaneous cholecystectomy did not increase the incidence of postoperative complications or mortality. Older age, male sex, total gastrectomy, duodenal exclusion, and diabetes were risk factors for gallstone development after gastrectomy.

Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures

Obesity by itself is a factor in the development of gallstone disease, and periods of weight loss after bariatric surgery further increase the risk of gallstone formation. In patients with obesity, hypersecretion of cholesterol may increase the risk of gallstone formation, which is approximately five-fold higher than that in the general population. The incidence of gallstone formation after bariatric surgery is 10-38% and often associated with a proportional increase in the risk of developing biliary complications. Routine postoperative administration of ursodeoxycholic acid (UDCA) is recommended to prevent gallstone formation. Several randomized trials have indicated that UDCA can effectively prevent gallstones and reduce the risk of cholecystectomy after bariatric procedures. The effective daily dose of UDCA in each study ranged from 500 to 1,200 mg, and it may be considered at least during the period of rapid weight loss (first 3-6 months postoperatively) to decrease the incidence of symptomatic gallstones.

Clinical Characteristics of Symptomatic Cholecystitis in Post-Gastrectomy Patients: 11 Years of Experience in a Single Center

Background and Objectives: Gallbladder (GB) stones, a major cause of symptomatic cholecystitis, are more likely to develop in post gastrectomy people. Our purpose is to evaluate characteristics of symptomatic cholecystitis after gastrectomy. Materials and Method: In January 2011−December 2021, total 1587 patients underwent operations for symptomatic cholecystitis at our hospital. We reviewed the patients’ general characteristics, operation results, pathologic results, and postoperative complications. We classified the patients into non-gastrectomy and gastrectomy groups, further divided into subtotal gastrectomy and total gastrectomy groups. Result: The patients’ ages, male proportion, and the open surgery rate were significantly higher (127/1543 (8.2%) vs. 17/44 (38.6%); p < 0.001), and the operation time was longer (102.51 ± 52.43 vs. 167.39 ± 82.95; p < 0.001) in the gastrectomy group. Extended surgery rates were significantly higher in the gastrectomy group (56/1543 (3.6%) vs. 12/44 (27.3%); p < 0.001). The period from gastrectomy to symptomatic cholecystitis was significantly shorter in the total gastrectomy group (12.72 ± 10.50 vs. 7.25 ± 4.80; p = 0.040). Conclusion: GB stones were more likely to develop in post-gastrectomy patients and extended surgery rates were higher. The period to cholecystitis was shorter in total gastrectomy. Efforts to prevent GB stones are considered in post-gastrectomy patients.

Prophylactic cholecystectomy: A valuable treatment strategy for cholecystolithiasis after gastric cancer surgery

The main treatment for gastric cancer is surgical excision. Gallstones are one of the common postoperative complications of gastric cancer. To avoid the adverse effects of gallstone formation after gastric cancer surgery, we reviewed the causes and risk factors and mechanisms involved in gallstone formation after gastric cancer surgery. The evidence and value regarding prophylactic cholecystectomy (PC) during gastric cancer surgery was also reviewed. Based on previous evidence, we summarized the mechanism and believe that injury or resection of the vagus nerve or changes in intestinal hormone secretion can lead to physiological dysfunction of the gallbladder and Oddi sphincter, and the lithogenic components in the bile are also changed, ultimately leading to CL. Previous studies also have identified many independent risk factors for CL after gastric cancer, such as type of gastrectomy, reconstruction of the digestive tract, degree of lymph node dissection, weight, liver function, sex, age, diabetes and gallbladder volume are closely related to CL development. At present, there are no uniform guidelines for the selection of treatment strategies. As a new treatment strategy, PC has undeniable advantages and is expected to become the standard treatment for CL after gastric cancer in the future. The individualized PC strategy for CL after gastric cancer is the main direction of future research.

Roles of ursodeoxycholic acid in the bile biochemistry and metabolomics in patients with choledocholithiasis: a prospective study

INTRODUCTION

Recurrence after the endoscopic treatment of common bile duct stones (CBDS) is related to bile metabolism and bile compositions. Ursodeoxycholic acid (UDCA) has been proved effective in reducing the recurrence of CBDS. However, the detailed effects of UDCA on bile metabolism are still not extensively explored.

OBJECTIVES

This study aimed to analyze the role of UDCA in patients with choledocholithiasis (CDC) from the perspective of biochemistry and metabolomics.

METHODS

A total of 89 patients with CDC who underwent endoscopic retrograde cholangiopancreatography were prospectively examined and randomly assigned to control and UDCA groups. The biochemical detections (cholesterol, bilirubin, and so on) were performed on the collected bile. Moreover, the metabolomics analysis was conducted based on bile from 20 patients in the UDCA group.

RESULTS

The bile levels of cholesterol and endotoxins significantly decreased after UDCA treatment. Regarding bile metabolomics, the levels of 25 metabolites changed significantly after UDCA treatment. The pathway enrichment analysis showed that the UDCA addition evoked a common response related to phenylalanine, tyrosine, and tryptophan biosynthesis; phenylalanine metabolism; arachidonic acid metabolism; and terpenoid backbone biosynthesis.

CONCLUSIONS

UDCA treatment within a short time interval (7 days) did not improve the circulating laboratory values in patients with CDC who had undergone endoscopy surgery. However, relevant decreases in the bile levels of cholesterol and endotoxin were observed. UDCA evoked a common response related to lipid metabolism and amino acid metabolism, which probably reduced the bile level of cholesterol, protected hepatocytes, and corrected the abnormality of lipid metabolism caused by CDC.

Tauroursodeoxycholic acid: a potential therapeutic tool in neurodegenerative diseases

Most neurodegenerative disorders are diseases of protein homeostasis, with misfolded aggregates accumulating. The neurodegenerative process is mediated by numerous metabolic pathways, most of which lead to apoptosis. In recent years, hydrophilic bile acids, particularly tauroursodeoxycholic acid (TUDCA), have shown important anti-apoptotic and neuroprotective activities, with numerous experimental and clinical evidence suggesting their possible therapeutic use as disease-modifiers in neurodegenerative diseases. Experimental evidence on the mechanisms underlying TUDCA's neuroprotective action derives from animal models of Alzheimer's disease, Parkinson's disease, Huntington's diseases, amyotrophic lateral sclerosis (ALS) and cerebral ischemia. Preclinical studies indicate that TUDCA exerts its effects not only by regulating and inhibiting the apoptotic cascade, but also by reducing oxidative stress, protecting the mitochondria, producing an anti-neuroinflammatory action, and acting as a chemical chaperone to maintain the stability and correct folding of proteins. Furthermore, data from phase II clinical trials have shown TUDCA to be safe and a potential disease-modifier in ALS. ALS is the first neurodegenerative disease being treated with hydrophilic bile acids. While further clinical evidence is being accumulated for the other diseases, TUDCA stands as a promising treatment for neurodegenerative diseases.

Effect of ursodeoxycholic acid on gallstone formation after bariatric surgery: An updated meta-analysis

OBJECTIVE

Bariatric surgery increases the risk of postoperative gallstone formation. Many studies have proposed ursodeoxycholic acid (UDCA) as a preventive agent for postoperative gallstone formation. This study aimed to investigate the effect of UDCA on gallstone formation after bariatric surgery in patients without preoperative gallstones.

METHODS

PubMed, the Web of Science, the Cochrane Library, and EBSCO were searched for articles assessing the effect of UDCA on gallstone formation after bariatric surgery. The outcome was the incidence of postoperative gallstones. Odds ratios were used to assess dichotomous variables, and random-effects models were used for statistical analyses.

RESULTS

A total of 18 studies including 4,827 participants met the inclusion criteria. The statistical results showed that the incidence of gallstones in the UDCA group was significantly lower than in the control group. Furthermore, the occurrence of symptomatic gallstones and cholecystectomy was significantly reduced.

CONCLUSIONS

In patients without preoperative gallstones, UDCA can effectively prevent the formation of gallstones after bariatric surgery. In addition, UDCA can significantly reduce the occurrence of symptomatic gallstones and the risk of postoperative cholecystectomy. Doses of 500 to 600 mg/d can be used as a measure to prevent postoperative gallstone formation.

Gypenosides Prevent and Dissolve Cholesterol Gallstones by Modulating the Homeostasis of Cholesterol and Bile Acids

Gypenosides (GPs), obtained from Gynostemma pentaphyllum (Thunb.) Makino, have been traditionally prescribed to treat metabolic disorders in Asians. This study assessed whether GPs could prevent lithogenic diet (LD)-induced cholesterol gallstone (CG) formation and enhance CG dissolution in mice. Gallstone-susceptible C57BL/6J mice were fed an LD or normal chow, with or without GPs. Bile acids (BAs) in gallbladder bile were analyzed by liquid chromatography-tandem mass spectrometry. Differentially expressed hepatic genes were identified by RNA sequencing, followed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. GPs were found to prevent LD-induced CG formation and to dissolve pre-existing LD-induced CGs. GPs reduced total cholesterol levels and increased BA levels in bile, as well as reducing the BA Hydrophobicity Index, ratio of 12α-hydroxylated (12α-OH) to non-12α-OH BAs, and Cholesterol Saturation Index in gallbladder bile. GO and KEGG pathway enrichment analyses indicated that GPs-induced genes were involved in BA biosynthesis and cholesterol metabolism. GPs increased the hepatic expression of genes encoding the cytochrome P450 (Cyp) enzymes Cyp7a1, Cyp7b1, and Cyp8b1, while decreasing the hepatic expression of genes encoding the adenosine triphosphate-binding cassette (Abc) transporters Abcg5 and Abcg8. GPs may be a promising strategy for preventing and dissolving CGs.

Gallbladder-preserving cholecystolithotomy

INTRODUCTION

Cholecystectomy is the preferred option for symptomatic gallstones. Gallbladder-preserving cholecystolithotomy (GPC) is proposed to satisfy the specific surgical patients with high-risks, biliary deformity and suffered from concomitant gallstone and choledocholithiasis.

AREAS COVERED

This review summarizes and compares the various GPC operations for cholelithiasis in some specific cases.

EXPERT OPINION

Transmural GPC mainly focuses on the gallstones, including endoscopic minimally invasive cholecystolithotomy (EMIC)-, natural orifice transluminal endoscopic surgery-, and endoscopic ultrasonography (EUS)-GPC. These GPC procedures potentially preserve gallbladder integrity and function after clearance of gallstones. Additionally, transmural GPC may overcome the disadvantages of cholecystectomy, including cosmetic considerations and postoperative complications. However, the stone recurrence rate of EMIC varies greatly from 4.92% to 40.0%, and based on limited studies, long-term adverse events due to gallbladder mucosa and natural lumen injury are largely unknown in transmural GPC. Thus, transmural GPC may be an alternative to cholecystectomy for surgical patients with high-risks and abnormal biliary anatomy. Endoscopic retrograde cholangiopancreatography-based transcystic GPC may be promising for some specific patients with concomitant gallstones and choledocholithiasis, since gallbladder integrity and function may be completely preserved as the gallbladder wall was hardly injured and the function of sphincter of Oddi was retained.

Early gastric cancer: A challenge in Western countries

Early gastric cancer (EGC) is an invasive carcinoma involving only the stomach mucosa or submucosa, independently of lymph node status. EGC represents over 50% of cases in Japan and in South Korea, whereas it accounts only for approximately 20% of all newly diagnosed gastric cancers in Western countries. The main classification systems of EGC are the Vienna histopathologic classification and the Paris endoscopic classification of polypoid and non-polypoid lesions. A careful endoscopic assessment is fundamental to establish the best treatment of EGC. Generally, EGCs are curable if the lesion is completely removed by endoscopic resection or surgery. Some types of EGC can be resected endoscopically; for others the most appropriate treatment is surgical resection and D2 lymphadenectomy, especially in Western countries. The favorable oncological prognosis, the extended lymphadenectomy and the reconstruction of the intestinal continuity that excludes the duodenum make the prophylactic cholecystectomy mandatory to avoid the onset of biliary complications.

Exploration of Prognostic Immune-Related Genes and lncRNAs Biomarkers in Kidney Renal Clear Cell Carcinoma and Its Crosstalk with Acute Kidney Injury

Kidney renal clear cell carcinoma (KIRC) has a poor prognosis and a high death rate globally. Cancer prognosis is strongly linked to immune-related genes (IRGs), according to numerous research. We utilized KIRC RNA-seq data from the TCGA database to build a prognostic model incorporating seven immune-related (IR) lncRNAs, and we constructed the model using LASSO regression. Additionally, we calculated a risk score for each patient using a prognostic model that divided patients into high-risk and low-risk groups. The ESTIMATE and CIBERSORT methodologies were then used to analyze the differences in the tumor microenvironment of the two groups of patients. Finally, we predicted three small molecule drugs that may have potential therapeutic effects for high-risk patients. We combined the acute kidney injury dataset to obtain differential genes that may serve standard biological functions with two risk groups. Our study shows that the model we constructed for IR-lncRNAs has reliable predictive efficacy for patients with KIRC.

Important risk factors for gallstones after laparoscopic gastrectomy: a retrospective study

Background

The frequency of gallstones is higher in patients who have undergone gastrectomy than in the general population. While there have been some studies of gallstone formation after open gastrectomy, there are few reports of gallstones after laparoscopic gastrectomy (LG). Therefore, this study aimed to evaluate the incidence of gallstones after LG.

Methods

We retrospectively reviewed the records of 184 patients who underwent LG between January 2011 and May 2016 at Saiseikai Utsunomiya Hospital. After gastrectomy, abdominal ultrasonography was generally performed every 6 months for 5 years. Patients who underwent cholecystectomy before LG, underwent simultaneous cholecystectomy, and did not undergo abdominal ultrasonography, with an observation period of < 24 months, were excluded from the study. Finally, 90 patients were analyzed. Laparoscopic cholecystectomy was performed whenever biliary complications occurred. Patient characteristics were compared using the two-tailed Fisher’s exact test or Chi-square test. In addition, the risk factors for postoperative gallstones were analyzed using logistic regression analysis.

Results

Among the 90 patients included in this study, 60 were men (78%), and the mean age was 65.5 years. Laparoscopic total gastrectomy was performed for 15 patients and laparoscopic distal gastrectomy for 75 patients. D2 lymph node dissection was performed for 8 patients (9%), whereas 68 patients underwent LG with Roux-en-Y reconstruction (76%). Gallstones were detected after LG in 27 of the 90 (30%) patients. Multivariate analysis identified Roux-en-Y reconstruction and male sex as significant risk factors of gallstones after gastrectomy. The incidence of gallstones was significantly higher (53%) in male patients who underwent Roux-en-Y reconstruction. Symptomatic gallstones after laparoscopic cholecystectomy were found in 6 cases (6/27, 22%), and all patients underwent laparoscopic cholecystectomy.

Conclusion

Roux-en-Y reconstruction and male sex were identified as significant risk factors for gallstones after LG.

Dietary plant sterols prevented cholesterol gallstone formation in mice

Cholesterol gallstone disease is a common global condition. This study investigated the role of plant sterols (PS) in the prevention of gallstone formation and the underlying mechanisms. Adult male mice were fed a lithogenic diet (LD) alone or supplemented with PS (LD-ps), phospholipids (LD-pl) or both PS and phospholipids (LD-ps/pl) for 8 weeks. Incidences of gallstone formation were compared among the groups. Lipids in the bile, liver and serum were analyzed. The expression of genes involved in cholesterol absorption, transport and metabolism in the liver and small intestine was determined. The incidences of gallstone formation were 100% (10/10), 20% (2/10), 100% (10/10) and 40% (4/10) in the LD, LD-ps, LD-pl and LD-ps/pl groups, respectively. Serum cholesterol and intestinal cholesterol absorption were decreased in PS-supplemented mice. The expression of genes related to cholesterol transport and metabolism in the liver was down-regulated by dietary PS. PS supplementation decreased Niemann-Pick C1-like 1 expression in the small intestine and reduced intestinal cholesterol absorption. Our results demonstrated that PS could inhibit intestinal cholesterol absorption and thus prevent cholesterol gallstone formation.

Analysis of the Occurrence of Diseases Following Gastrectomy for Early Gastric Cancer: a Nationwide Claims Study

Purpose

Various changes in nutrition, metabolism, immunity, and psychological status occur through multiple mechanisms after gastrectomy. The purpose of this study was to predict disease status after gastrectomy by analyzing diseases pattern that occur or change after gastrectomy.

Materials and Methods

A retrospective cohort study was conducted using nationwide claims data. Patients with gastric cancer who underwent gastrectomy or endoscopic resection were included in the study. Eighteen target diseases were selected and categorized based on their underlying mechanism. The incidence of each target disease was compared by dividing the study sample into those who underwent gastrectomy (cases) and those who underwent endoscopic resection for early gastric cancer (controls). The cases were matched with controls using propensity score matching. Thereafter, Cox proportional hazard models were used to evaluate intergroup differences in disease incidence after gastrectomy.

Results

A total of 97,634 patients who underwent gastrectomy (84,830) or endoscopic resection (12,804) were included. The incidence of cholecystitis (P<0.0001), pancreatitis (P=0.034), acute kidney injury (P=0.0083), anemia (P<0.0001), and inguinal hernia (P=0.0007) were higher after gastrectomy, while incidence of dyslipidemia (P<0.0001), vascular diseases (ischemic heart disease, stroke, and atherosclerosis; P<0.0001, P<0.0001, and P=0.0005), and Parkinson's disease (P=0.0093) were lower after gastrectomy.

Conclusions

This study identifies diseases that may occur after gastrectomy in patients with gastric cancer.

Adrenal Nodules Detected at Staging CT in Patients with Resectable Gastric Cancers Have a Low Incidence of Malignancy

Background Guidelines recommending additional imaging for adrenal nodules lack relevant epidemiologic evidence. Purpose To measure the prevalence of adrenal nodules detected at staging CT in patients with potentially resectable gastric cancer and the proportion of patients with malignant nodules among them. Materials and Methods This retrospective study included 10 250 consecutive patients (median age, 63 years; interquartile range, 53-71 years; 6884 men) who underwent staging CT and had potentially resectable gastric cancer in a tertiary center (May 2003 to December 2018). All 10 250 CT studies were retrospectively reviewed, and patients with adrenal nodules (or thickening ≥10 mm) were identified to measure the prevalence of adrenal nodules. Among patients with adrenal nodules, the per-patient proportions of malignant nodules, adrenal metastasis from gastric cancer, and additional adrenal examinations were measured. A secondary analysis was performed by using data from the original CT reports. The same metrics that were used in the retrospective review were assessed. Results The prevalence of adrenal nodules was 4.5% (95% CI: 4.1, 4.9; 462 of 10 250). The proportions of malignant nodules and adrenal metastasis from gastric cancer were 0.4% ( 95% CI: 0.1, 1.6; two of 462) and 0% (95% CI: 0.0, 0.8; 0 of 462), respectively. A total of 27% of the patients (95% CI: 23, 31; 123 of 462) underwent additional adrenal examination. According to original CT reports, the prevalence of adrenal nodules and the proportions of malignant nodules, adrenal metastases from gastric cancer, and additional adrenal examination were 2.7% (95% CI: 2.4, 3.0; 272 of 10 250), 0.7% (95% CI: 0.1, 2.6; two of 272), 0% (95% CI: 0.0, 1.4; 0 of 272), and 42.6% (95% CI: 36.7, 48.8; 116 of 272), respectively. Conclusion Although adrenal nodules were detected frequently on staging CT images of patients with otherwise resectable gastric cancer, these nodules were rarely malignant. ©RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Baumgarten in this issue.

Laparoscopic treatment of a recurrent biliary stone forming around a Hem-o-lok clip in a patient with previous gastrectomies: Case report

RATIONALE

A history of gastrectomy is associated with an increased incidence of gallstones requiring surgery. Endoscopic retrograde cholangiopancreatography is challenging for patients who undergo total or Billroth II gastrectomy. Laparoscopic common bile duct exploration (LCBDE) has been attempted in such cases. Herein, we report a case of choledocholithiasis in which a stone formed around a migrated Hem-o-lok clip.

PATIENT CONCERNS

A 67-year-old man was admitted to the hospital for acute right upper abdominal pain. He had a history of 2 open gastric cancer surgeries in the previous seven years and had undergone LCBDE 12 months prior to this admission. Postoperative examination revealed recurrence of bile duct stones.

INTERVENTIONS

The patient underwent repeat LCBDE plus primary closure with an evaluation of abdominal adhesion. A stone had formed around a Hem-o-lok clip in the common bile duct was removed.

OUTCOMES

The patient had an uneventful recovery with no stone recurrence or movement of the remaining Hem-o-lok clips after a 1-year follow-up.

LESSONS

LCBDE with primary closure should be carefully considered in patients with certain gallstone diseases after complicated upper abdominal surgery.Postoperative clip migration is a rare complication; hence care must be taken in placing the clip appropriately to ensure that it is not too close to the common bile duct.

Ursodeoxycholic acid for the prevention of gallstone and subsequent cholecystectomy following gastric surgery: A systematic review and meta-analysis

BACKGROUND/PURPOSE

Patients who undergo gastric surgery are prone to form postsurgical gallstones. Debates still exist about the need for prevention and the selection of preventive methods. No studies had been reported comparing the efficacy of prophylactic ursodeoxycholic acid (UDCA) and prophylactic cholecystectomy (PC) for lowering postsurgical gallstone formation and subsequent cholecystectomy (SC) in patients who have undergone gastric surgery.

METHODS

We did a systematic review to identify studies from PUBMED, EMBASE, and the Cochrane database through 30 June 2020. We conducted direct and indirect comparisons of each prophylaxis using conventional and network meta-analysis. Studies with patients who have no history of cholecystectomy and who have not had preoperative gallstone were included.

RESULTS

The excellent preventive effects of PC and UDCA were demonstrated for gallstone formation (odds ratio [OR] 0.05, [95% CI 0.01, 0.22] and 0.20, [95% CI 0.16, 0.24], respectively) and the need for SC (OR 0.10, [95% CI 0.02, 0.57] and OR 0.22, [95% CI 0.14, 0.35], respectively) than control group. The UDCA group showed a tendency to generate more gallstones (OR 3.74, [95% CI 0.88, 15.82]) and a greater need for SC (OR 2.19, [95% CI 0.47-10.14]) than did the PC group without statistical significance.

CONCLUSIONS

Prophylaxis for gallstone formation may be needed for patients who undergo gastric surgery to reduce troublesome morbidities. Prophylactic UDCA seems to be a reasonable preventive method for postsurgical gallstone formation to ensure clinical benefit while reducing the burden of subsequent cholecystectomy for the patient as compared to a PC.

Essential updates 2019/2020: Perioperative and surgical management of gastric cancer

Perioperative and surgical management of gastric cancer have been changing as pivotal phase II trials and landmark phase III trials offer new insights to the existing knowledge. The results of many landmark trials have been published or presented in the past year, many of which have changed or will change current clinical practice. For example, FLOT4 has completely changed the regimen of perioperative chemotherapy in Europe. Furthermore, evidence for minimally invasive surgery for clinical Stage I was firmly established by KLASS-01 and JCOG0912 for distal gastrectomy and CLASS-02, KLASS-03, and JCOG1401 for total gastrectomy. Moreover, promising results were provided by CLASS-01 and KLASS-02 for locally advanced gastric cancer. For adjuvant chemotherapy, JACCRO GC-07 (START-2) has provided a new doublet regimen for pathological Stage III, which is often refractory to chemotherapy. Conversely, JCOG0501 poses a significant challenge for advanced tumors, such as large type 3 and scirrhous (type 4) tumors. In this review, we briefly review recent updates and discuss future perspectives of gastric cancer treatment.

Safety and Efficacy of Percutaneous Gallstone Extraction in High-Risk Patients: An Alternative to Cholecystectomy or Long-Term Drainage?

BACKGROUND

Acute cholecystitis in nonsurgical candidates is often managed with cholecystostomy tube drainage. After symptom resolution, management options include cholecystectomy, long-term tube drainage, or tube removal. Percutaneous cholecystolithotomy (PCCL) can offer another therapeutic option for patients who are poor operative candidates.

STUDY DESIGN

A retrospective study of PCCL performed between December 2000 and September 2017 was conducted. Demographic characteristics, procedure details, gallstone-related complications, procedure-related complications, readmission, and mortality data were collected.

RESULTS

Seventy-five patients were identified (52.0% male, 48.0% female, mean ± SD age 75.6 ± 13.9 years). Mean ± SD follow-up time was 2.8 ± 3.7 years. Most of the patients (90.7%) had an American Society of Anesthesiologists physical status classification of 3 or 4. Eleven patients (14.7%) had failed earlier cholecystectomy. A total of 96 PCCL procedures were performed, and complete gallstone removal was achieved in 68 of 75 patients (90.7%), including all patients with previously aborted cholecystectomy. The 30-day and 90-day readmission rates were 4% and 8%, respectively. Three patients (3.9%) subsequently underwent cholecystectomy after PCCL. Ten (10.4%) procedure-related complications (Clavien-Dindo grade I and II) and 17 (22.7%) gallstone-related complications occurred during the follow-up period. Postprocedural choledocholithiasis occurred in 6 patients (8.0%). Recurrent gallstones developed in 5 patients (6.3%) (3 patients undergoing cholecystectomy and 2 patients treated with cholecystostomy tube).

CONCLUSIONS

PCCL is a viable option for management of symptomatic gallbladder stones in high-risk surgical patients. There is a high technical success rate, even in patients with earlier failed cholecystectomy. Most patients (77.3%) avoided gallstone-related complications after the procedure.