European Association for the Study of the Liver (EASL). Electronic address: easloffice@easloffice.eu. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones

Evolving surgical techniques for hepatolithiasis: A retrospective analysis of 164 liver resections at a Western center

OBJECTIVE

To assess the outcomes of liver resection for primary intrahepatic lithiasis in a Western population, emphasizing the evolution of surgical techniques, including minimally invasive surgery, and their impact on patient outcomes.

METHODS

We performed a retrospective analysis of 164 patients who underwent liver resection for primary intrahepatic lithiasis at the Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy. Data included demographics, surgical techniques, complications, and long-term outcomes. Minimally invasive surgery was introduced and progressively adopted, and its outcomes were compared with open surgery using propensity score matching. This represents the largest Western dataset on liver resection for primary intrahepatic lithiasis published to date.

RESULTS

Liver resections were predominantly unilateral (96%) and commonly targeted the left liver (65%). Minimally invasive surgery use increased to 60% in the most recent period, showing reduced morbidity and shorter hospital stays compared with open surgery. Postoperative complications included bile fistula (16%) and septic events (30%). Independent risk factors for bile fistula were previous cholangitis (odds ratio, 4.7; P = .006) and major hepatectomy (odds ratio, 7.8; P = .002). Septic complications were associated with previous cholangitis (odds ratio, 2.3; P = .026), bilateral lithiasis (odds ratio, 4.0; P = .010), and major hepatectomy (odds ratio, 3.5; P = .003), with minimally invasive surgery providing a protective effect (odds ratio, 0.34; P = .028). Long-term follow-up revealed a 20% recurrence rate, linked to incomplete intraoperative stone clearance (hazard ratio, 2.645; P = .019) and biliary fistula (hazard ratio, 2.799; P = .016). Cholangiocarcinoma occurred in 6.6%, underscoring the need for surveillance.

CONCLUSION

Liver resection is an effective, curative treatment for primary intrahepatic lithiasis in Western populations. Minimally invasive surgery advancements significantly improve short-term outcomes, bridging the East-West gap in primary intrahepatic lithiasis management and highlighting the importance of individualized surgical approaches.

Research progress in the treatment of gallstones with laparoscopic and endoscopic surgery: a narrative review

Cholelithiasis, the formation of stones in the gallbladder, is a common surgical condition with an increasing incidence. Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallstones due to its favorable outcomes. However, with increasing recognition of the gallbladder's importance, this procedure no longer aligns with patients' desire to preserve the organ. Technological advancements and surgical innovations have led to emerging approaches such as natural orifice transluminal endoscopic surgery (NOTES), robot-assisted laparoscopic cholecystectomy, and cholangioscopy. This narrative review examines the current landscape of surgical interventions for gallstones, highlighting both gallbladder-preserving and removal approaches, and aims to provide insight into their respective outcomes and clinical implications.

Role of intraoperative indocyanine green roadmap as a safety measure in emergent laparoscopic cholecystectomy

Acute cholecystitis is a growing pathology, with high surgical risk due to the related patients' comorbidity. The gold standard treatment is laparoscopic cholecystectomy, which, despite its high volume, still presents elevated rates of biliary tract injury. Standardization of the procedure and accurate identification of the anatomical structures of the biliary tree are the key in avoiding severe complications associated with this injury. Innovation in minimally invasive technologies, such as infrared indocyanine green as a radiotracer to delimit the biliary anatomy, could reduce the rate of biliary tract lesions. A single-center case-control study was conducted, including patients undergoing emergency surgery between November 2023 and November 2024 for acute cholecystitis (Tokyo Guidelines 2018 criteria). Eighty-seven patients were allocated into two groups: emergency laparoscopic cholecystectomy with or without intraoperative indocyanine green cholangiography. The primary aim was to evaluate ICG's impact on reducing bile duct injury. Secondary outcomes included operative time, hospital stay, and conversion rates. The mean operative time (93 min vs. 104.6 min, p = 0.087), ASA scale (p = 0.302) and Charlson comorbidity index (2.55 vs. 2.84; p = 0.58) were not significantly different when comparing both groups. The control group showed duplicated preoperative CRP values as compared to the ICG group (138.24 mg/l vs. 71.02 mg/l; p = 0.06), and a higher median hospital stay (5 days ± 3 vs. 3 days ± 1.75; p = 0.001). The control group showed a greater need for conversion to open surgery (14.3% vs. 0%; p = 0.015). Trends towards fewer bile duct injuries (0% vs. 4.1%; p = 0.208) and fewer complications (15.87% vs. 18.4%; p = 0.752) in the ICG group were not statistically significant. The use of ICG may reduce the need for conversion to open surgery and median hospital stay. However, its use has not been proven to reduce bile duct injury, postoperative complications, or operative time.

Association of cardiometabolic index with gallstone disease and insulin resistance based on NHANES data

BACKGROUND

Cardiometabolic index (CMI) is an index integrating visceral obesity and dyslipidemia. This study intends to scrutinize the connection between CMI and gallstone disease (GSD) and to elucidate the association between CMI and insulin resistance (IR) in patients with GSD.

METHODS

To explore the potential nonlinear association and determine the inflection point, a restricted cubic spline (RCS) analysis was performed. Following categorization of CMI based on the identified inflection point, multivariate logistic regression models, subgroup analyses, and interaction tests were utilized to assess the connection between CMI and GSD, as well as between CMI and IR in GSD patients. The homeostasis model assessment for IR (HOMA-IR) and triglyceride-glucose (TyG) index was applied to evaluate IR. Spearman analysis was implemented to investigate the connection between CMI and HOMA-IR. The predictive performance of each indicator was evaluated by the receiver operating characteristic (ROC) curve and the area under the curve (AUC).

RESULTS

The study included 2311 individuals, with a GSD prevalence of 10.90%. RCS analysis revealed a nonlinear positive correlation between CMI and GSD (nonlinear P < 0.001), as well as between CMI and IR (nonlinear P < 0.001). In the fully adjusted multivariable logistic regression analysis of covariates, compared with the low-category CMI group, the high-category CMI was significantly associated with the risk of GSD (OR = 1.547, 95% CI: 1.143-2.092, P = 0.005), IR (OR = 4.990, 95% CI: 2.517-9.892, P < 0.001). Subgroup analysis demonstrated that the correlation between CMI and GSD was stronger in females. Spearman correlation analysis showed a positive association between CMI and HOMA-IR in GSD patients (r = 0.548, P < 0.001). The ROC curve demonstrated the predictive performance of the CMI model for GSD (AUC = 0.743), which was superior to conventional indicators such as Body Mass Index and Waist Circumference; the predictive performance of CMI (AUC = 0.772) for IR was consistent with that of TyG (AUC = 0.772).

CONCLUSION

Our research demonstrates that CMI exhibits a nonlinear positive correlation with the incidence of GSD and IR. This suggests that CMI may serve as a novel and valuable indicator for further investigating the intricate relationships among metabolic syndrome, obesity, and GSD.

Metabolic dysfunction-associated steatotic liver disease is a risk factor for gallstones: A multicenter cohort study

AIM

Gallstone formation is associated with metabolic dysfunction. Recently, new definitions of steatotic liver disease (SLD) have been proposed, including metabolic dysfunction-associated SLD (MASLD) and moderate alcohol intake (MetALD). We investigated the effects of MASLD/MetALD on gallstone formation.

METHODS

This multicenter observational cohort study enrolled 8766 consecutive health-check examinees who underwent abdominal ultrasonography between 2008 and 2021 (total observation period 39,105.9 person-years). All patients were classified into non-SLD, MASLD, or MetALD groups. The effect of MASLD on gallstone development was evaluated using multivariate Cox regression analysis.

RESULTS

Age, male sex, and MASLD were identified as independent risk factors for gallstone development. MASLD was associated with a significantly higher risk of developing gallstones than non-SLD (hazard ratio [HR] 1.7112; 95% confidence interval [CI] 1.4294-2.0486; p < 0.0001) and MetALD (HR 1.3516, 95% CI 1.0130-1.8033, p = 0.0406). However, the risk of MetALD did not significantly differ between the SLD and non-SLD groups. Hypertension was the only significant independent cardiometabolic risk factor for gallstone development in the MASLD group (HR 1.4350, 95% CI 1.0545-1.9528; p = 0.0216). Random forest analysis and directed acyclic graphs identified hypertension as the most important direct factor affecting gallstone development in patients with MASLD.

CONCLUSIONS

MASLD was an independent risk factor for gallstone development, whereas MetALD presented a similar risk as non-SLD. Moderate alcohol consumption may reduce the risk of gallstone formation in patients with MASLD. Hypertension may be the most significant cardiometabolic risk factor for gallstone development in patients with MASLD.

Re-do laparoscopic common bile duct exploration for recurrent common bile duct stones: a single-center retrospective cohort study

Purpose

Common bile duct (CBD) stone recurrence after laparoscopic CBD exploration (LCBDE) is relatively common. No studies have been conducted evaluating the safety and feasibility of re-do LCBDE in the treatment of recurrent CBD stones.

Methods

This single-center retrospective study reviewed 340 consecutive patients who underwent LCBDE for CBD stones between January 2004 and December 2020. Patients with pancreatobiliary malignancies and those who underwent other surgical procedures were excluded.

Results

Of the 340 included patients, 45 experienced a recurrence after a mean follow-up period of 24.2 months. Of them, 18 underwent re-do LCBDE, 20 underwent endoscopic intervention, 2 underwent radiologic intervention, and 5 underwent observation. Re-do LCBDE and initial LCBDE showed similar surgical outcomes in terms of operative time (113.1 minutes vs. 107.5 minutes, P = 0.515), estimated blood loss (42.5 mL vs. 49.1 mL, P = 0.661), open conversion rate (2.9% vs. 0%, P = 0.461), postoperative complication (15.3% vs. 22.2%, P = 0.430), and postoperative hospital stay (6.5 days vs. 6.4 days, P = 0.921). Comparing re-do LCBDE and nonsurgical treatment (endoscopic or radiologic), no statistically significant differences were noted in posttreatment complication (22.2% vs. 13.6%, P = 0.477), hospital stay (6.4 days vs.7.3 days, P = 0.607), and recurrence (50.0% vs. 36.4%, P = 0.385). The clearance rate was higher in the re-do LCBDE group than in the nonsurgical group (100% vs. 81.8%, P = 0.057).

Conclusion

Compared to initial LCBDE and endoscopic or radiological treatments, re-do LCBDE for recurrent CBD stones is a treatment option worth considering in selected patients.

Imaging of gallstones and complications

Gallbladder pathologies caused by gallstones are commonly encountered in clinical practice, making accurate diagnosis critical for effective patient management. Radiologists play a key role in differentiating these conditions through imaging interpretation, ensuring that appropriate treatment is initiated. The imaging features of gallstone associated diseases are classified into various categories, such as inflammatory conditions, benign lesions, malignant tumors, and associated complications. A comprehensive understanding of these categories and their radiologic manifestations is essential for accurate diagnosis and management of gallbladder pathology. By integrating clinical knowledge with radiologic findings, clinicians and radiologists will be equipped with practical tools to identify and distinguish between different gallstone causing conditions.

Association between dietary niacin intake and the odds of gallstones in US adults: A cross-sectional study in NHANES 2017-2020

Objective

To investigate the association between dietary niacin intake and the risk of gallstones in American adults using data from the National Health and Nutrition Examination Survey (NHANES) from 2017 to 2020.

Methods

This cross-sectional study analyzed data from 8191 participants aged 18 years and older. Dietary niacin intake was assessed using two 24-h dietary recalls. The presence of gallstones was identified through a questionnaire. Logistic regression models were used to estimate odds ratios (ORs) and 95 % confidence intervals (CIs) for gallstones across quartiles of niacin intake, adjusting for demographic and health-related covariates.

Results

Participants with higher niacin intake showed a significantly lower risk of gallstones. After adjusting for a wide range of covariates, individuals in the highest quartile of niacin intake had a 49 % reduced risk of gallstones compared to those in the lowest quartile (OR = 0.51, 95 % CI: 0.34, 0.76).

Conclusion

Higher dietary niacin intake is associated with a reduced risk of gallstones in US adults. These findings suggest that increasing niacin intake could be a viable strategy for the prevention of gallstones. Future longitudinal studies are needed to confirm these results and explore the underlying mechanisms.

Laparoscopic primary suture of the common bile duct in patients with common bile duct stones: a comparative analysis of two suturing methods in terms of safety, efficacy, and convenience with 16-month follow-up

BACKGROUND

Primary suturing of the common bile duct (CBD) is increasingly used in laparoscopic common bile duct exploration (LCBDE) for selected patients, though the optimal suturing method remains unclear. This study compares the efficacy of continuous versus interrupted sutures for primary CBD closure in patients with CBD stones.

METHODS

A retrospective analysis was conducted on 120 patients with CBD stones who underwent primary CBD closure at Yancheng First People's Hospital from October 2022 to December 2023. Data included demographics, hospital stay, complications, and follow-up outcomes. Of these, 69 received continuous sutures, and 51 received interrupted sutures.

RESULTS

No significant differences were found in age, gender, body mass index (BMI), CBD diameter, preoperative bilirubin levels, or stone residuals between groups. The incidence of postoperative fever, bile leakage, electrolyte disturbances, bleeding, wound infection, and CBD stricture was similar. Continuous suturing required less operative time than interrupted suturing (p < 0.01).

CONCLUSION

Both continuous and interrupted suturing techniques are safe and effective for CBD closure in selected patients, though continuous suturing is more time-efficient.

Non-programmed rehospitalizations after cholecystectomy

Cholecystectomy is one the most frequent procedures in digestive surgery. While the operation is generally associated with low rates of morbidity and mortality, frequency of occurrence can vary considerably according to surgical indication, time elapsed between symptom appearance and surgical intervention, anatomical area under treatment, and the experience of the different centers. Rehospitalization after cholecystectomy remains potentially problematic in numerous units, due in part to the ongoing development of day hospital treatment and short-term hospitalization. The objective of this update is to assess not only the rate, causes and risk factors of non-programmed hospitalizations subsequent to cholecystectomy, but also the available ways and means of prevention and management in the patient's best interests.

Ultrasound of Bile Ducts-An Update on Measurements, Reference Values, and Their Influencing Factors

Objective: To provide an overview of the technique and normal values of ultrasound studies of the bile system based on the published literature. Methods: A literature search for ultrasound studies with measurements of the bile ducts in healthy subjects was performed. Relevant data published between 1975 and end of 2024 were extracted, discussed, and complemented with the own experiences of the authors. The clinical implications are presented and discussed. Results: For the diameter of the common bile duct, reference values between 5 and 9 mm have been published. The main influencing factors are age and history of cholecystectomy, and other factors to be considered are discussed here. The cut-off for the common bile duct wall is set at 1.5 mm. The literature on measurements of intrahepatic bile ducts is scarce. A diameter of <2-3 mm can be considered normal. The method of ultrasound examination is presented here, as well as a comparison with other imaging methods and their clinical implications. Conclusions: Standardized measurement techniques and normal values in the context of influencing factors are crucial for the ultrasound examination of the bile system.

Risk factors for biliary tract events during elective cholecystectomy waiting time after endoscopic retrograde cholangiopancreatography for choledocholithiasis

Objectives

Endoscopic lithotripsy and elective cholecystectomy, followed by endoscopic retrograde cholangiopancreatography, are the first-line treatments for patients with common bile duct (CBD) stones (CBDS) and gallstones. However, this approach entails acute cholecystitis and recurrent cholangitis risk while patients await surgery. We aimed to identify acute cholecystitis and cholangitis risk factors during the waiting time for elective cholecystectomy.

Methods

This study comprised 151 patients with CBDS combined with gallstones who underwent cholecystectomy within 90 days of the first endoscopic retrograde cholangiopancreatography at two tertiary care centers between January 2019 and October 2021.

Results

The incidence of biliary tract events (acute cholecystitis, acute cholangitis, or any complications requiring unplanned cholangiopancreatography) was 28% (43 cases). In univariate and multivariate analyses, plastic stent placement as a bridge to surgery for the first treatment of CBDS was an independent risk factor for biliary tract events during the waiting time for surgery (odds ratio 4.25, p = 0.002). A subgroup analysis among those with plastic stent placement revealed a CBD diameter of ≤ 10 mm as an independent risk factor for acute cholecystitis (odds ratio 4.32; p = 0.027); a CBD diameter ≥ 11 mm was an independent risk factor for acute cholangitis and unplanned re-endoscopic retrograde cholangiopancreatography (odds ratio 5.66; p = 0.01).

Conclusions

Plastic stent placement for CBDS before elective cholecystectomy increases the risk of acute cholecystitis or acute cholangitis during the waiting time for elective cholecystectomy.

Feasibility and outcome of transcystic laparoscopic common bile duct exploration as first-line treatment for common bile duct stones: a retrospective cross-sectional study

BACKGROUND

For treatment of common bile duct stones (CBDS), guidelines recommend a one-stage approach, including laparoscopic common bile duct exploration (LCBDE) or intraoperative endoscopic retrograde cholangiopancreatography (intraERCP). Studies show favourable outcomes with transcystic LCBDE (tLCBDE), but this technique is not widely adopted. The use of tLCBDE may be limited by several factors, but to what degree is unknown. The aim of this study is to examine the feasibility and, secondarily, outcomes of tLCBDE for patients undergoing removal of CBDS and laparoscopic cholecystectomy (LC) when tLCBDE is the first-line treatment.

METHOD

A retrospective cross-sectional study including patients with removal of CBDS and LC at Horsens Regional Hospital during June 2017-March 2022. We classified patients into three groups: tLCBDE, preoperative ERCP (preERCP), and other procedures. The reasons for not performing tLCBDE were registered from medical charts. In the tLCBDE and the preERCP group, we registered clearance rate, postoperative complications, and subsequent ERCP.

RESULTS

In total, 229 patients received a procedure due to CBDS, of which 73% were emergency procedures. The groups were as follows: 179 (78%) tLCBDE, 25 (11%) preERCP, and 25 (11%) other procedures. preERCP was chosen due to the patient being unfit for emergency surgery, tLCBDE not being technically possible, and other reasons. Other procedures were chosen, because tLCBDE was not technically possible, lack of equipment or qualified surgeon, and other reasons. In the tLCBDE group, 94% of patients with CBDS were cleared, 5.6% had a complication of Clavien-Dindo grade ≥ 3, and 3.9% patients needed a subsequent ERCP.

CONCLUSION

tLCBDE is feasible, safe, and effective treatment which can be performed in the majority of patients with CBDS and should be considered an equivalent to ERCP or choledochotomy as first-line treatment of patients with CBDS. As some patients require ERCP or choledochotomy, tLCBDE should not be the sole treatment available.

Bromelain and liver health: A comprehensive systematic review of preclinical studies

BACKGROUND

Liver diseases pose a significant challenge to the well-being of the public, given their high prevalence and the potential to escalate to liver failure and hepatocellular carcinoma. The efficacy of current therapies is rather limited, resulting in the manifestation of severe side effects. Bromelain, derived from the pineapple plant, exhibits promising prospects for the treatment of inflammatory disorders, cancer, and wound healing, although its impact on liver functionality remains largely unexplored.

OBJECTIVE

To evaluate the efficiency of bromelain in liver injuries, we performed a systematic review of preclinical studies.

METHOD

Our search was conducted in August 2020 on PubMed and Scopus, employing the search terms "Liver disease," "Liver injury," and "Bromelain," with subsequent updates in December 2023.

RESULTS

Out of the 329 articles that were examined, only 7 fulfilled the criteria for inclusion.

CONCLUSION

Our research suggests that bromelain possesses both prophylactic and curative qualities in terms of liver damage, as supported by its ability to decrease enzyme levels, enhance liver structure, reduce oxidative stress markers, and regulate lipid metabolism. In summary, bromelain demonstrates a capacity to enhance liver function across a range of injury types.

[Stage I cholelithiasis. Approaches to diagnosis and treatment. Results of the Machaon study]

AIM

To review the results of the open observational study Makhaon on the use of a fixed combination of glycyrrhizic acid (GA) and ursodeoxycholic acid (UDCA) (Phosphogliv Urso) for the treatment of abdominal pain, assessment of contractile function of the gallbladder and bile rheology in patients with stage I cholelithiasis.

MATERIALS AND METHODS

The study included 330 subjects, 44.5% males and 55.5% females. The study participants were 18-70 years old, with a mean age of 43.8±0.6 years. In 2021-2022, patients were treated in 14 clinical centers in 10 cities of the Russian Federation: Moscow, St. Petersburg, Stavropol, Volgograd, Perm, Samara, Ufa, Omsk, Novosibirsk, Tomsk. All patients received Phosphogliv Urso (UDCA 250 mg + sodium glycyrrhizinate 35 mg), 1 capsule 3 times daily with food for 6 months.

RESULTS

Based on the clear improvement, therapy with a combination of GA and UDCA has demonstrated high efficacy and safety and appears to be optimal for the treatment of abdominal pain, improvement of the contractile function of the gallbladder, and physicochemical properties of bile in patients with stage I cholelithiasis.

CONCLUSION

Treating all variants of baseline changes in the bile rheology is an urgent task of modern biliology. Universal drugs for stage I cholelithiasis are UDCA and its fixed combination with GA.

Differentiation of "Polyp" and "Pseudo Polyp" in Gallbladder Polyps, Single-center Experience

OBJECTIVE

The prevalence of gallbladder polyps is 0.3% to 9.5%. Gallbladder polyps are divided into polyps and pseudo polyps. We aim to determine the rate of polyps after histopathologic examination in patients who were operated on for gallbladder polyps and to choose the factors affecting the diagnosis of polyps.

PATIENTS AND METHODS

Patients who underwent cholecystectomy between January 2012 and January 2022 were analyzed retrospectively. Demographic data of the patients, anthropometric measurements, preoperative radiologic imaging methods, characteristics (size and number of polyps), and histopathologic results of the gallbladder after cholecystectomy were recorded. After histopathologic examination, the patients were grouped as gallbladder polyp and pseudo polyp and compared.

RESULT

A total of 162 (4.7%) patients were included in the study. 109 (67.3%) of the patients were in the polyp group, and 53 (32.7%) were in the pseudo polyp group. Polyp size and number were larger in the polyp group than in the pseudo polyp group and were odd in number (P = 0.03, P < 0.001). The radiologic polyp size cut-off value to identify the polyp was >8 mm (sensitivity: 84.2%, specificity: 66.0%).

CONCLUSION

Gallbladder polyps are a common pathology. The distinction between true and pseudo polyp is critical. Therefore, it is essential to distinguish between polyps and pseudo polyps for cholecystectomy.

Clinical and microbiological profile in obstructive biliary disease in a tertiary center: Observational study

AIMS

There is limited information on bacterial isolation, antibiotic susceptibility, and microbiological profile in obstructive biliary disease (OBD). Providing information on this could help offer more effective empirical antibiotic therapy in clinical cholangitis. This study aims to evaluate the clinical and microbiological profile in obstructive biliary disease.

PATIENTS AND METHODS

The study was conducted at a tertiary academic center between August 2021 and January 2023. Hospitalized patients with OBD, with indication for biliary drainage by endoscopic retrograde cholangiopancreatography, were recruited. Biliary samples were obtained following a standardized protocol, and were processed in laboratory for Gram staining, culture, subculture. Microorganisms were identified and subjected to antibiotic susceptibility testing.

RESULTS

A total of 61 patients were included, 73.8% were women, average age was 44.8 years. Overweight/obesity was the most common comorbidity (62.3%); clinical cholangitis was present in 75.4%. Biliary lithiasis was the most common etiology of OBD (86.9%). Positive cultures were obtained in 44.3% of participants, predominating the group of Gram-positive bacteria; individually, Escherichia coli was the most isolated microorganism. A 68.2% of bacteria showed resistance to at least one antibiotic. We found significant associations between bile appearance and cholangitis, bile appearance and OBD etiology, OBD etiology and cholangitis severity. Male sex, increased age, tobacco use were associated with positive cultures. We found a spectrum of microorganisms and antibiotic susceptibilities partially different from those of Tokyo Guidelines 2018 and other publications.

CONCLUSIONS

Our findings highlight the need to characterize microbiological profile in OBD according to each region.

Meta-analysis of randomized controlled trials comparing single-stage laparoscopic versus two-stage endoscopic management followed by laparoscopic cholecystectomy of preoperatively diagnosed common bile duct stones

BACKGROUND

Common bile duct stones are a significant public health issue that often requires surgical intervention. Two primary surgical techniques for addressing these conditions are laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) in 1 or 2 stages, respectively. This systematic review and meta-analysis compared the efficacy and results of these 2 techniques.

METHODS

A systematic review and meta-analysis of randomized clinical trials followed the PRISMA and AMSTAR 2 guidelines. Literature research were performed in the Cochrane Library, PubMed/MEDLINE, Embase, and Google Scholar up to March 1, 2023.

RESULTS

Fourteen studies with a total of 1849 patients were included. The success rate was similar between LCBDE (872/919 patients) and ERCP followed by LC (866/930 patients) (odds ratio [OR] = 1.31; 95% confidence interval [CI] [0.76, 2.25], P = .33). There was no significant difference in residual stones (OR = 0.71; 95% CI [0.28, 1.83], P = .48), mortality (OR = 0.55; 95% CI [0.14, 2.14], P = .39), morbidity (OR = 0.87; 95% CI [0.66, 1.16], P = .36) or hospital stay (mean difference = -1.31; 95% CI [-2.89, 0.26], P = .10) between the 2 groups. Meta-analysis found no significant differences between LCBDE and ERCP followed by LC in terms of success rate, residual stones, mortality, morbidity or hospital stay.

CONCLUSION

Both techniques are viable options for the treatment of choledocholithiasis and gallbladder stones. More multicentric randomized controlled trials are recommended to confirm these findings and explore long-term outcomes.

Gallstones after bariatric surgery: mechanisms and prophylaxis

Gallstones represent a common yet often underappreciated complication following bariatric surgery, with reported incidence rates ranging widely from 10.4% to 52.8% within the first postoperative year. Multiple factors contribute to gallstone formation in this setting, including intraoperative injury to the hepatic branch of the vagus nerve, alterations in bile composition, reduced food intake, shifts in gastrointestinal hormone levels, and dysbiosis of the gut microbiota. Notably, the risk of cholelithiasis varies by surgical procedure, with sleeve gastrectomy (SG) generally associated with a lower incidence compared to Roux-en-Y gastric bypass (RYGB). Prophylactic cholecystectomy during bariatric surgery may benefit patients with preexisting gallstones, whereas preserving the hepatic branch of the vagus is an important technical consideration, particularly in RYGB, to mitigate postoperative gallstone risk. Pharmacological interventions, such as ursodeoxycholic acid (UDCA), have demonstrated efficacy in preventing gallstones and reducing subsequent cholecystectomy rates. However, consensus is lacking on the optimal dosing, duration, and administration frequency of UDCA across different bariatric procedures. Additionally, dietary measures, such as moderate fat intake or fish oil supplementation, have shown promise in alleviating lithogenic processes. Emerging evidence supports the use of probiotics as a safe and patient-friendly adjunct or alternative to UDCA, given their ability to improve gut dysbiosis and reduce gallstone formation. Further high-quality studies are needed to define standardized prophylactic strategies that balance efficacy with patient adherence, offering personalized gallstone prevention protocols in the era of widespread bariatric surgery.

Clinical Guidelines of the Russian Society for the Study of the Liver, Russian Gastroenterological Association, Russian Society for the Prevention of Non-Communicable Diseases, Russian Association of Endocrinologists, Russian Scientific Medical Society of Therapists, National Society of Preventive Cardiology, Russian Association of Gerontologists and Geriatricians on Non-Alcoholic Fatty Liver Disease

Aim. The clinical guidelines are intended to provide information support for making decisions by gastroenterologists, general practitioners and internists that will improve the quality of medical care for patients with non-alcoholic fatty liver disease, taking into account the latest clinical data and principles of evidence-based medicine. Key points. Clinical guidelines contain information about current views on etiology, risk factors and pathogenesis of nonalcoholic fatty liver disease, peculiarities of its clinical course. Also given recommendations provide information on current methods of laboratory and instrumental diagnostics, invasive and non-invasive tools for nonalcoholic fatty liver disease and its clinical phenotypes assessment, approaches to its treatment, considering the presence of comorbidities, features of dispensary monitoring and prophylaxis. The information is illustrated with algorithms of differential diagnosis and physician's actions. In addition, there is information for the patient and criteria for assessing the quality of medical care. Conclusion. Awareness of specialists in the issues of diagnosis, treatment and follow-up of patients with nonalcoholic fatty liver disease contributes to the timely diagnosis and initiation of treatment, which in the long term will significantly affect their prognosis and quality of life.

Fungal mycobiome dysbiosis in choledocholithiasis concurrent with cholangitis

BACKGROUND

The gut mycobiome might have an important influence on the pathogenesis of choledocholithiasis concurrent with cholangitis (CC). The aim of this study was to characterize the fungal mycobiome profiles, explore the correlation and equilibrium of gut interkingdom network among bacteria-fungi-metabolites triangle in CCs.

METHODS

In a retrospective case-control study, we recruited patients with CC (n = 25) and healthy controls (HCs) (n = 25) respectively to analyze the gut fungal dysbiosis. Metagenomic sequencing was employed to characterize the gut mycobiome profiles, and liquid chromatography/mass spectrometry (LC/MS) analysis was used to quantify the metabolites composition.

RESULTS

The Shannon index displayed a reduction in fungal α-diversity in CCs compared to HCs (p = 0.041), and the overall fungal composition differed significantly between two groups. The dominant 7 fungi species with the remarkable altered abundance were identified (LDA score > 3.0, p < 0.05), including CC-enriched Aspergillus_niger and CC-depleted fungi Saccharomyces_boulardii. In addition, the correlations between CC-related fungi and clinical variables in CCs were analyzed. Moreover, the increased abundance ratio of Basidiomycota-to-Ascomycota and a dense linkage of bacteria-fungi interkingdom network in CCs were demonstrated. Finally, we identified 30 markedly altered metabolites in CCs (VIP > 1.0 and p < 0.05), including low level of acetate and butyrate, and the deeper understanding on the complexity of bacteria-fungi-metabolites triangle involving bile inflammation was verified.

CONCLUSION

Our investigation demonstrated a distinct gut fungal dysbiosis in CCs and proposed that, beyond bacteria, the more attention should be paid to significantly potential influence of fungi and bacteria-fungi-metabolites triangle interkingdom interactions on pathogenesis of CC.

Thulium laser-assisted laparoscopic management of intrahepatic stones in recurrent pyogenic cholangitis: A case report and review of minimally invasive approaches

INTRODUCTION

Recurrent pyogenic cholangitis (RPC) presents significant management challenges, particularly when complicated by large intrahepatic stones. While thulium laser technology has demonstrated excellent results in urological stone treatment, its application in biliary stones remains relatively unexplored. We present a novel approach utilizing laparoscopic choledochoscopy with thulium laser lithotripsy for managing intrahepatic stones in RPC.

CASE PRESENTATION

A 65-year-old female presented with a two-year history of recurrent right upper quadrant pain, fever, and jaundice. Diagnostic imaging revealed multiple large intrahepatic stones without any liver atrophy or mass lesions. After initial ERCP for acute cholangitis management, the patient underwent laparoscopic choledochoscopy with thulium laser lithotripsy. The procedure included stone fragmentation, extraction, and choledochoduodenostomy for long-term biliary drainage. The procedure was successfully completed with minimal blood loss and no intraoperative complications. At 6-month follow-up, the patient remained asymptomatic with normal liver function, despite small retained stones.

DISCUSSION

This approach combines the benefits of minimally invasive surgery with advanced laser technology. Thulium laser offers potential advantages over conventional lithotripsy methods, including enhanced precision and reduced risk of bile duct injury. The successful outcome in this case suggests that this technique may be a viable option for complex hepatolithiasis in RPC.

CONCLUSION

Laparoscopic choledochoscopy with thulium laser lithotripsy represents a promising minimally invasive option for managing intrahepatic stones in RPC. While our case demonstrates technical feasibility, long-term follow-up and larger studies are needed to fully evaluate its efficacy.

Incretin-based drugs and the risk of gallbladder or biliary tract diseases among patients with type 2 diabetes across categories of body mass index: a nationwide cohort study

Background

Despite emerging evidence of gallbladder or biliary tract diseases (GBD) risk regarding incretin-based drugs, population-specific safety profile considering obesity is lacking. We aimed to assess whether stratification by body mass index (BMI) modifies the measures of association between incretin-based drugs and the risk of GBD.

Methods

We conducted an active-comparator, new-user cohort study using a nationwide claims data (2013-2022) of Korea. We included type 2 diabetes (T2D) patients stratified by Asian BMI categories: Normal, 18.5 to <23 kg/m2; Overweight, 23 to <25 kg/m2; Obese, ≥25 kg/m2. The primary outcome was a composite of GBD, including cholelithiasis, cholecystitis, obstruction of the gallbladder or bile duct, cholangitis, and cholecystectomy. We used 1:1 propensity score (PS) matching and estimated hazard ratios (HR) with 95% confidence intervals (CI) using Cox models.

Findings

New users of DPP4i and SGLT2i were 1:1 PS matched (n = 251,420 pairs; 186,697 obese, 39,974 overweight, and 24,749 normal weight pairs). The overall HR for the risk of GBD with DPP4i vs. SGLT2i was 1.21 (95% CI 1.14-1.28), with no effect modification by BMI (p-value: 0.83). For the second cohort, new users of GLP1RA and SGLT2i were 1:1 PS matched (n = 45,443 pairs; 28,011 obese, 8948 overweight, and 8484 normal weight pairs). The overall HR for the risk of GBD with GLP1RA vs. SGLT2i was 1.27 (1.07-1.50), with no effect modification by BMI (p-value: 0.73).

Interpretation

The increased risks of GBD were presented in both cohorts with no evidence of effect heterogeneity by BMI.

Funding

Ministry of Food and Drug Safety, Health Fellowship Foundation.

The association between trajectory of serum cholesterol, statin dosage, and the risk of recurrent biliary stone diseases

BACKGROUND

Statins may reduce the risk of recurrent gallstone disease by decreasing bile cholesterol saturation and pathogenicity. However, limited studies have investigated this issue. This study aimed to assess whether statin doses and serum cholesterol levels were associated with a decreased risk of recurrent biliary stone diseases after the first event index, with a follow-up time of 15 years.

METHODS

Based on the Chang Gung Research Database (CGRD) between January 1, 2001, and December 31, 2020, we enrolled 68,384 patients with the International Classification of Diseases, Ninth and Tenth Revision codes of choledocholithiasis. After exclusions, 32,696 patients were divided into non-statin (<28 cDDD, cumulative defined daily doses) (n = 27,929) and statin (≥28 cDDD) (n = 4767) user groups for analysis. Serum cholesterol trajectories were estimated using group-based trajectory modeling (n = 8410).

RESULTS

The statin users had higher Charlson Comorbidity Index (CCI) scores than the non-statin users. Time-dependent Cox regression analysis showed that statin use >365 cDDD was associated with a significantly lower risk of recurrent biliary stones (adjusted hazard ratio [aHR] = 0.28, 95% CI, 0.24-0.34; p < 00.0001), acute pancreatitis (aHR = 0.24, 95% CI, 0.17-0.32, p < 00.0001), and cholangitis (aHR = 0.28, 95% CI, 0.25-0.32, p < 00.0001). Cholecystectomy was also a protective factor for recurrent biliary stones (aHR = 0.41, 95% CI, 0.37-0.46; p < 00.0001). The higher trajectory serum cholesterol group (Group 3) had a lower risk trend for recurrent biliary stones (aHR = 0.79, p = 0.0700) and a lower risk of cholangitis (aHR = 0.79, p = 0.0071).

CONCLUSION

This study supports the potential benefits of statin use and the role of cholecystectomy in reducing the risk of recurrent biliary stone diseases.

Effect of comprehensive perioperative nursing on pain intensity, complication rates, and comfort levels in patients undergoing gallstone surgery

BACKGROUND

Surgery is the gold standard for gallstone treatment. Nevertheless, the complications associated with the surgical procedure can exert diverse and adverse impacts on patients’ health and quality of life to varying extents. Hence, it is essential to offer perioperative care to patients undergoing gallstone surgery.

AIM

To examine the impact of perioperative comprehensive nursing on pain intensity, complication rates, and patient comfort in individuals undergoing gallstone surgery.

METHODS

From February 2022 to February 2024, 195 patients who underwent gallstone surgery at Sanmen People’s Hospital were selected and divided into two groups: A control group receiving routine nursing care (95 patients) and a research group receiving perioperative comprehensive nursing (100 patients). Key postoperative recovery indicators, including time to first postoperative anal exhaust, oral food intake, and ambulation, were observed, along with pain intensity (measured by the numeric rating scale), complication rate (bleeding, incision infection, recurrence), patient comfort (assessed using the visual analogue scale), and quality of life (measured by the World Health Organization Quality of Life-BREF).

RESULTS

The research group showed significantly shorter times to first postoperative anal exhaust, oral intake, and ambulation. Moreover, numeric rating scale pain scores in the research group were markedly lower post-nursing, and the total complication rate was significantly reduced compared to the control group. Furthermore, comfort levels improved considerably in the research group, and World Health Organization Quality of Life-BREF scores across the physical, psychological, social, and environmental domains were significantly higher compared to the control group following nursing care.

CONCLUSION

Perioperative comprehensive nursing effectively enhances postoperative recovery in patients undergoing gallstone surgery, reducing pain, lowering complications, and improving patient comfort and quality of life, which deserves clinical application.

Clip-stone and T clip-sinus post laparoscopic biliary surgery: Two case reports and review of the literature

BACKGROUND

Laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) are widely used in gallbladder and biliary tract diseases. During these procedures, vessels or tissues are commonly ligated using clips. However, postoperative migration of clips to the common bile duct (CBD) or T-tube sinus tract is an overlooked complication of laparoscopic biliary surgery. Previously, most reported cases of postoperative clip migration involved metal clips, with only a few cases involving Hem-o-lok clips and review of the literature.

CASE SUMMARY

This report describes two cases in which Hem-o-lok clips migrated into the CBD and the T-tube sinus tract following laparoscopic surgery. Case 1 is a 68-year-old female admitted due to abdominal discomfort, and two Hem-o-lok clips were found to have migrated into the CBD 17 months after LC and LCBDE with T-tube drainage, and were removed using a stone extraction balloon. The patient was discharged smoothly after recovery. Case 2 is a 74-year-old male who underwent LC and LCBDE with T-tube drainage and laparoscopic biliary tract basket stone extraction. Nine weeks postoperatively, following T-tube removal, a Hem-o-lok clip was found in the sinus tract, and was extracted from the T-tube sinus tract. The patient recovered smoothly postoperatively. This study also reviews the literature from 2013 to July 2024 on using Hem-o-lok clips in LC and/or LCBDE treatment of gallbladder and biliary diseases and the postoperative migration of these clips into the CBD, T-tube sinus tract, or duodenum.

CONCLUSION

In patients with a history of LC and/or LCBDE, clip migration should be considered as a differential diagnosis.

Genetics of Gallstones

Gallstone disease (GSD) is a common gastrointestinal disorder affecting approximately 10-20% of the global adult population, characterized by the presence of gallstones, predominantly cholesterol-based, in the gallbladder and/or biliary ducts. While many patients remain asymptomatic, more than 20% develop clinical symptoms such as abdominal pain, nausea, vomiting, jaundice, and anorexia, potentially leading to severe complications like acute cholecystitis and biliary pancreatitis. GSD has a significant genetic predisposition, with the variable prevalence of the disease according to ethnicity being highest in American and European countries and lowest in Asian and African populations. Numerous genes encoding membrane transporters involved in bile metabolism are associated with GSD, including in particular members of ATP-binding cassette transporters and others, which affect bile lithogenicity and contribute to the development of gallstones. Specific mutations in these genes are linked to an increased risk of gallstone formation, especially in individuals with certain hereditary conditions such as hemolytic diseases, thyroid disorders, and hyperparathyroidism. Advances in genetic studies have identified new variants that influence the risk of cholelithiasis, although the exact mechanisms remain partially understood in many cases. This review briefly summarizes the genetic causes of cholelithiasis, highlighting various pathogenetic mechanisms. It presents the currently used treatments and the potential implications of widely applied genetic diagnostics.

Laparoendoscopic Rendezvous: An Effective and Safe Approach in the Management of Cholecysto-Choledocholithiasis in Selected Patients

Background: Different techniques have been proposed to manage Cholecysto-choledocholithiasis (CCL) advantageously in one stage. Among these, Laparoendoscopic Rendezvous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy, with insertion of a guide wire into the common bile duct through an incision of the cystic duct, followed by the clearance of the bile duct carried out by the endoscopists. The aim of this study was to evaluate the safety and the efficacy of the one-stage vs. a two-stage approach (pre-operative ERCP followed by cholecystectomy), and to compare our results with data from the current literature. Methods: All patients that underwent LERV in our facilities between January 2018 and December 2023 were evaluated. As a control group, we included patients that underwent a two-stage technique called the "sequential approach". The primary outcome was to evaluate the efficacy in obtaining complete clearance of the common bile duct (CBD). The secondary outcomes included morbidity, mortality, operative time, conversion rate, hospital stay and CDB stone recurrence. Results: 120 patients in the LERV group were included; meanwhile, 70 patients underwent pre-operative ERCP plus cholecystectomy. A 97% bile duct clearance success rate in the LERV group and 93% in the ERCP group was observed, respectively. The median intraoperative time for the one-stage technique was 122 min (p < 0.001) and the median hospital stay was 4 days (p < 0.001). In the LERV group, an overall morbidity of 15% was reported (18/120): 15 Clavien-Dindo type 1, one type 3a and two type 3b (p < 0.001). At a median follow-up of 14 months, five patients experienced stone recurrence. In the ERCP group, we had a 93% success rate; meanwhile, we had longer hospitalization (p < 0.001), 27% post-ERCP pancreatitis (p < 0.001) and a cumulative morbidity of 30%. Conclusions: LERV offers the advantages of a being single-stage procedure and shorter hospitalization, with a lower risk of clinically relevant post-ERCP pancreatitis and failed CBD cannulation.

Short-Term Efficacy of LCBDE+LC Versus ERCP/EST+LC in the Treatment of Cholelithiasis Combined with Common Bile Duct Stones: A Retrospective Cohort Study

Background: Minimally invasive treatments for cholelithiasis have gained popularity. The complexity of diagnosing and treating choledocholithiasis offers multiple surgical options, including laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy plus laparoscopic cholecystectomy (ERCP/EST+LC). Objective: To compare outcomes in patients with typical signs, symptoms, laboratory, and imaging features of cholelithiasis combined with common bile duct stones, we retrospectively analyzed the short-term outcomes of LCBDE+LC and ERCP/EST+LC. Methods: We analyzed 318 patients with gallbladder stones treated between January 2022 and May 2024. Of these, 152 underwent LCBDE+LC, and 166 underwent ERCP/EST+LC. We compared patients' baseline characteristics, perioperative outcomes, and short-term complications between the two groups. The primary outcome was the effectiveness of choledochal stone removal, while secondary outcomes included length of stay, hospitalization costs, and patient satisfaction. Results: Patients' baseline characteristics were similar between the LCBDE+LC and ERCP/EST+LC groups. Stone clearance rates were comparable (97.37% versus 95.18%, P = .306), with a slight advantage in the LCBDE+LC group. The length of hospitalization was significantly shorter in the LCBDE+LC group (6.49 ± 1.18 days versus 6.77 ± 1.11 days, P < .05). The LCBDE+LC group also had lower total hospitalization costs ($5188.78 ± 861.26 versus $6498.76 ± 1190.58 P < .01). Additionally, the incidence of pancreatitis was lower in the LCBDE+LC group (0.66% versus 6.02%, P < .01). There were no significant differences between the groups in other short-term complications such as abdominal infection, cholangitis, biliary bleeding, or bile leakage. Postoperative follow-up indicated higher patient satisfaction and acceptance in the LCBDE+LC group (SSQ-8, 85.84 ± 4.31 points versus 81.20 ± 4.54 points, P < .01). Conclusion: Our findings suggest that the LCBDE+LC holds promise as a safe and efficacious approach for the management of cholelithiasis combined with common bile duct stones. However, further prospective clinical trials are essential to corroborate these results and confirm their broader applicability.

Bibliometric Analysis on Cholecystectomy Surgery in the Nursing Field

PURPOSE

This study aimed to bibliometrically examine nursing publications regarding cholecystectomy surgery.

DESIGN

The study is a bibliometric analysis.

METHODS

The study was conducted in the Web of Science database. The keywords "cholecystectomy AND nursing" were used during the scanning. The data were evaluated in quantitative aspects.

FINDINGS

In the study, 481 publications were identified, publications were made between 1987 and 2023, the average number of years since the release of the publication was 10.2, and the annual increase rate was 8.19%. The most active country was the United States, and the journal most often published in was the "Journal of Perianesthesia Nursing." In the last 3 years, the themes of "meta-analysis, complication, pain, anxiety, quality of life" have been trending, the most working and continuing to develop our "laparoscopic cholecystectomy" and "pain" themes, and the leading theme in the field was "anxiety".

CONCLUSIONS

This study is the first bibliometric study examining nursing studies on cholecystectomy and provides a comprehensive overview of cholecystectomy and nursing issues over 36 years. In quantitative data, it was concluded that although studies in this field have a long history, the number of publications is low, and the annual growth rate is low. According to the quantitative evaluation results, it was found that the most studied topic in this field was laparoscopic cholecystectomy and pain, minimally invasive intervention and perioperative period topics remained isolated, and computerized tomography and gallbladder themes were among the newly emerging themes.

Gallstones, cholecystectomy, and cancer risk: an observational and Mendelian randomization study

This study aimed to comprehensively examine the association of gallstones, cholecystectomy, and cancer risk. Multivariable logistic regressions were performed to estimate the observational associations of gallstones and cholecystectomy with cancer risk, using data from a nationwide cohort involving 239 799 participants. General and gender-specific two-sample Mendelian randomization (MR) analysis was further conducted to assess the causalities of the observed associations. Observationally, a history of gallstones without cholecystectomy was associated with a high risk of stomach cancer (adjusted odds ratio (aOR)=2.54, 95% confidence interval (CI) 1.50-4.28), liver and bile duct cancer (aOR=2.46, 95% CI 1.17-5.16), kidney cancer (aOR=2.04, 95% CI 1.05-3.94), and bladder cancer (aOR=2.23, 95% CI 1.01-5.13) in the general population, as well as cervical cancer (aOR=1.69, 95% CI 1.12-2.56) in women. Moreover, cholecystectomy was associated with high odds of stomach cancer (aOR=2.41, 95% CI 1.29-4.49), colorectal cancer (aOR=1.83, 95% CI 1.18-2.85), and cancer of liver and bile duct (aOR=2.58, 95% CI 1.11-6.02). MR analysis only supported the causal effect of gallstones on stomach, liver and bile duct, kidney, and bladder cancer. This study added evidence to the causal effect of gallstones on stomach, liver and bile duct, kidney, and bladder cancer, highlighting the importance of cancer screening in individuals with gallstones.

Cardiometabolic index as a predictor of gallstone incidence in U.S. adults: insights from NHANES 2017-2020

BACKGROUND

Gallstone disease (GSD) is associated with obesity. The Cardiometabolic Index (CMI), a metric that accurately assesses central adiposity and visceral fat, has not been extensively studied in relation to GSD risk. This study investigates the link between CMI and GSD incidence in U.S. adults.

METHODS

This study utilized data from the National Health and Nutrition Examination Survey(NHANES)(2017-2020) to assess the association between CMI and GSD, adjusting for confounders such as age, sex, race, chronic diseases, and lifestyle factors. Multivariable logistic regression models and subgroup analyses were employed. Generalized Additive Models (GAM) and advanced curve fitting techniques were used to explore potential non-linear relationships, with threshold effects determined via piecewise linear regression if such relationships were identified. Receiver Operating Characteristic (ROC) curves evaluated and compared the predictive performance of CMI, Body Mass Index (BMI), and Waist Circumference (WC), establishing optimal cutoff values along with their sensitivity and specificity.

RESULTS

This study included 3,706 participants, of whom 10.6% (392) had GSD. Participants with GSD showed significantly higher CMI values (0.57 vs. 0.44, P = 0.0002). The GSD group included more females and older adults, with increased risks for hypertension, diabetes, higher serum cholesterol and creatinine levels, and a higher risk of cancer. Logistic regression analysis revealed that higher CMI was significantly associated with greater GSD incidence (OR = 1.19, 95% CI = 1.02-1.38, P < 0.0001). The ROC curve demonstrated superior predictive performance (AUC = 0.778), outperforming conventional metrics like BMI and WC. GAM analysis indicated a non-linear positive correlation between CMI and GSD, with an optimal threshold of 0.996. Subgroup analysis found the strongest association among females, individuals aged 20-39, non-Hispanic Whites, those without a history of coronary heart disease, and alcohol consumers.

CONCLUSION

Our study reveals a nonlinear positive correlation between the CMI and the incidence of GSD among U.S. adults, with a threshold value of 0.996. Despite limitations in sample size that constrained the analysis of a fully adjusted model, after adjusting for confounding factors, the AUC for predicting GSD using CMI reached 0.778, surpassing traditional metrics. These findings underscore the importance of CMI as a critical risk factor and emphasize the necessity of targeted interventions for high-risk populations.

Indocyanine green fluorescence improves safety in laparoscopic cholecystectomy using the Fundus First technique: a retrospective study

Introduction

As one of the most commonly performed surgeries in the world, safety during laparoscopic cholecystectomy (LC) is of utmost importance. Indocyanine green (ICG) has been used for different medical purposes including assessment of liver function since the 1950s. Its use during LC was first described in 2009 by Ishizawa. Since ICG is excreted in the bile, its fluorescent properties can be used to illuminate the bile ducts, and may reduce the risk for bile duct injury and other complications. Previous studies have compared ICG with conventional visualization showing shorter operation time and lower conversion rates during LC performed with traditional operation techniques. Results from LC performed with the Fundus First method (FF-LC) and ICG fluorescence has not been previously reported. The aim of this retrospective study was to compare LC with and without the aid of ICG fluorescence at a Swedish hospital routinely performing FF-LC.

Methods

Data from all patients operated with LC at Sundsvall General Hospital before and after the implementation of routine ICG between 2016 and 2023 were analyzed.

Results

The study included 2,009 patients; 1,455 operated with ICG (ICG-group) and 549 without (comparison group). FF-LC was used in 94.9% of all operations. The groups were comparable regarding gender, BMI, age, presence of acute cholecystitis and proportion urgent/elective surgery. ICG was found to be safe, with similar 30-day complication rates between study groups. A lower conversion rate was seen in the ICG-group (1.2% vs. 3.3%, p = 0.001) and there was a non-significant reduction in readmissions (p = 0.054). In univariate analysis, ICG was associated with prolonged operation time, but this was not supported in multivariate analysis. Time to cholangiography was prolonged in the ICG-group in both univariate and multivariate analyses.

Discussion

ICG fluorescence is an adjunct that could improve the operative safety. Implementation of routine ICG fluorescence at this Swedish hospital was found to be safe and efficient, suggesting improvement in safety during FF-LC. Further studies are needed to see if ICG increases safety in LC.

High serum uric acid levels are associated with increased prevalence of gallstones in adult women: a cross-sectional study based on NHANES

Objective

We investigated the association between serum uric acid (SUA) levels and gallstone (GS) prevalence in adult women.

Methods

Participants' information were taken from the United States National Health and Nutrition Examination Survey (2017-2020). Logistic regression analysis and dose-response curve were used to assess the association between SUA levels and the prevalence of GS in adult women. Subgroup analyses were performed to investigate associations between SUA levels and age, ethnicity, body mass index, hypertension, and diabetes.

Results

A total of 600 participants self-reported a history of GS. After adjusting for confounding, the prevalence of GS in adult women increased by 14% for every 1 mg/dL increase in SUA (odds ratio [OR]: 1.14, 95% confidence interval [CI]: 1.06, 1.22). Testing SUA as a categorical variable for sensitivity analyses indicated a 1.6-fold increase in the prevalence of GS in tertile 3 (OR=1.60, 95% CI: 1.25, 2.04) compared to tertile 1. Dose-response curves showed a nonlinear correlation between SUA levels and the prevalence of GS. Subgroup analyses indicated that SUA level was associated with an increased prevalence of GS in most subgroups, although subtle differences existed.

Conclusion

SUA was positively and non-linearly associated with the prevalence of GS in adult females. Despite the inability to clarify the causal relationship between them, our results remain interesting.

Age-period-cohort analysis of gallbladder and biliary diseases epidemiological trends from 1990 to 2021 and forecasts for 2035: a systematic analysis from the global burden of disease study 2021

BACKGROUND

Gallbladder and biliary diseases (GABD) represent prevalent disorders of the digestive system.

METHODS

Data on age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), and age-standardized disability-adjusted life years (DALYs) rate (ASDR) were extracted from the Global Burden of Disease (GBD) 2021 study. The estimated annual percentage change (EAPC) was utilized to quantify temporal trends in GABD. Age-period-cohort analysis was conducted to determine the effects attributable to age, period, and birth cohort. Additionally, we projected global trends to 2035.

RESULTS

Globally, GABD incident cases, mortality cases, and DALYs increased by 60.11%, 71.71%, and 56.90%, respectively. However, all corresponding age-standardized rates (ASRs) demonstrated overall downward trends with estimated annual percentage changes (EAPC) of -0.32 (-0.38 to -0.26), -0.95 (-1.08 to -0.83), and - 0.69 (-0.74 to -0.65), respectively. The number of incident cases was higher in females than in males across all age groups. The age effect indicated that older individuals had higher age-specific incidence and death rates. Both period and cohort effects showed declining risk across incidence and mortality. The ASIR and ASMR of GABD are projected to continue decreasing over the next 15 years.

CONCLUSION

GABD continue to pose a significant global public health challenge, particularly affecting women and the elderly population. Consequently, the implementation of effective interventions to mitigate the GABD burden is of paramount importance.

Application of EUS or MRCP prior to ERCP in patients with suspected choledocholithiasis in clinical practice

Background and study aims Patients with symptomatic cholelithiasis can be stratified according to the 2019 European Society for Gastrointestinal Endoscopy (ESGE) guideline into low-, intermediate- and high-likelihood groups for presence of choledocholithiasis. For the intermediate group, endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is recommended to assess whether an endoscopic retrograde cholangiopancreatography (ERCP) is necessary prior to cholecystectomy. The aim of the study was to investigate adherence to the guideline for diagnostic and treatment strategy for cholelithiasis in daily clinical practice. Patients and methods A multicenter, retrospective cross-sectional observational study of the diagnostic pathway of patients with suspicion of choledocholithiasis was conducted between 2019 and 2021. Patients were stratified according to the ESGE guideline "Endoscopic management of common bile duct stones". Results A total of 305 patients were included in the analysis and stratified into low- (17%), intermediate- (40%) and high- (43%) likelihood of choledocholithiasis. In these three categories, 182 patients (60%) underwent ERCP. Adherence to the ESGE guideline recommendation was 59.7% overall and was the highest in the intermediate-likelihood group (83.6%), compared with 45.1% in the low- and 43.2% in the high-likelihood group, respectively ( P < 0.001). In the high-likelihood group, 49% underwent additional imaging. In 195 patients who underwent additional imaging, 55 ERCPs (28.2%) could be avoided. Conclusions This study shows that stratification according to the ESGE guideline is useful to reduce the number of unnecessary additional imaging procedures and ERCPs in patients with a suspicion of choledocholithiasis. It seems worthwhile to perform EUS prior to ERCP in the same session.

Association between metabolic dysfunction associated steatotic liver disease and gallstones in the US population using propensity score matching

The novel diagnostic term Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) requires at least one cardiovascular risk factor for diagnosis. While the relationship between gallstones and Non-Alcoholic Fatty Liver Disease (NAFLD) has been debated, the association between MASLD and gallstones remains unclear. This cross-sectional study aimed to explore this relationship using National Health and Nutrition Examination Survey (NHANES) data from 2017 to 2020. Participants were stratified into two groups based on MASLD diagnosis, and propensity score matching (PSM) was employed to reduce biases. Of 15,560 participants, 7922 met the inclusion criteria, with 2697 (34.0%) diagnosed with MASLD. Gallstone prevalence was higher in the MASLD group (14.2%) compared to the non-MASLD group (8.5%). After PSM, 4536 participants were analyzed, revealing a significant association between MASLD and gallstones (OR = 1.30, 95% CI 1.09-1.56, P = 0.003). This association remained robust across crude and adjusted analyses, with subgroup and sensitivity analyses further supporting the findings. In conclusion, MASLD is significantly associated with an increased risk of gallstones in the US population. These findings highlight the need to consider this relationship in clinical strategies for prevention and management of gallstone disease.

Predictive factors of spontaneous common bile duct clearance and unnecessary ERCP in patients with choledocholithiasis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line procedure for choledocholithiasis treatment. However, it is associated with a 10 % rate of adverse events. Spontaneous migration of common bile duct (CBD) stones occurs in 6-33 % of choledocholithiasis cases, making ERCP avoidable. This study aimed to identify predictors of spontaneous CBD stones' migration.

METHODS

Retrospective study including patients diagnosed with choledocholithiasis and submitted to ERCP. Patients were divided into 2 groups considering spontaneous stone migration (i.e.: the absence of CBD stones on ERCP). Data on patients' characteristics, imaging findings, biochemical analysis, and ERCP procedure were analyzed to identify predictors of spontaneous migration of CBD stones.

RESULTS

334 patients with a mean age of 71.7 years were included in the study: 76.6 % without and 23.4 % with spontaneous migration of CBD stones. Although some patients' features (gender and clinical presentation), imaging findings (diameters of the largest stone and CBD), biochemical analysis (bilirubin levels at diagnosis and pre-ERCP), and ERCP procedure characteristics (time from diagnosis to ERCP) were different between groups, only three variables were defined as predictors: the absence of acute cholangitis, the largest stone diameter ≤5 mm, and the bilirubin levels pre-ERCP ≤ 2mg/dL. When using those variables together there was a chance of 81-86 % to correctly distinguishing patients with and without spontaneous CBD stone migration.

CONCLUSION

The size of the largest stone at diagnosis was validated as a predictor of CBD stones' spontaneous migration. Furthermore, two new predictors were identified: bilirubin levels pre-ERCP ≤ 2 mg/dL, and no acute cholangitis at the clinical presentation of choledocholithiasis. EUS and ERCP in the same session should be considered in patients with factors predictive of stone migration, especially when combined, to minimize unnecessary ERCP and possible complications.

Emergency cholecystectomy: risk factors and impact of delay on electively booked patients, a 5-year experience of a tertiary care center

BACKGROUND

Gallstone disease is one of the most resource-intensive surgical conditions. Despite the significant burden of emergency cholecystectomy on healthcare system, there is lack of research assessing the risk factors predisposing scheduled elective cholecystectomy patients to emergency surgery. Characterization of patients with gallstones helps to prioritize delivery of health care to avoid urgent surgery. The objective of the present study is to analyze risk factors associated with emergency cholecystectomy and assess the impact of delay on electively scheduled patients.

METHODS

This retrospective cohort study at a tertiary care center in Jeddah, Saudi Arabia, between January 2018 and June 2022. Net total of 823 patients.The study has collected data retrospectively from an electronic health record system. The data were entered and coded in excel sheet. All statistical tests were 2-sided and were conducted using SAS statistical software version 9.4 (SAS Institute Inc. Cary, NC).

RESULTS

A total of 823 patients met the inclusion criteria and enrolled in the analysis. Among them, 129 patients (15.67%) underwent emergency cholecystectomy, while 694 patients (84.33%) underwent elective cholecystectomy. The waiting time in days was significantly longer for patients undergoing emergency cholecystectomy (mean of 362 days) compared to those undergoing elective cholecystectomy (mean of 305 days). Patients with more than two previous ED visits were over five times more likely to undergo emergency cholecystectomy compared to those who had never visited the ED previously (p-value < 0.0001) Moreover, patients diagnosed with acute cholecystitis and pancreatitis were more likely to undergo emergency cholecystectomy compared to those not diagnosed with these conditions (p-value < 0.0001; p-value 0.02).

CONCLUSION

Analysis of risk factors and delay in patients with gallstones scheduled for elective cholecystectomy demonstrates that long waiting times, severity of the initial visit setting, Hemolytic anemia, and male gender were significantly related to emergency cholecystectomy. Independent risk factors for emergency cholecystectomy were frequency of ED visits, acute cholecystitis, pancreatitis, and CBD stone. Patients with these risk factors should be given priority on the waiting list to avoid emergency surgery. Future research is required to design a scoring system or specific criteria for elective patients at risk of developing acute cholecystitis.

Non-linear relationship between the first meal time of the day and gallstone incidence in American adults: a population-based cross-sectional study

Background

Irregular meal time is associated with gallstones. The time-dose effect between meal time and gallstone formation remains unknown.

Objective

This study aimed to investigate the association between the first meal time (FMT) of the day and the prevalence of gallstones.

Methods

Based on data from the National Health and Nutrition Examination Survey from 2017 to March 2020, the associations between the FMT of the day and the prevalence of gallstones were analyzed via multivariable logistic regression, restricted cubic spline curves, subgroup analysis, and interaction tests.

Results

A total of 6,547 participants were included. The fully adjusted model indicated a positive correlation between the FMT of the day and the prevalence of gallstones (odds ratio [OR] = 1.05, 95% confidence interval [CI] = 1.02 ~ 1.08); this association was consistent across subgroups. The risk of developing gallstones was the greatest when the FMT was between 09:00 and 14:00 (OR [95% CI] = 1.49 [1.24 ~ 1.77]). There was a non-linear relationship between the FMT and gallstone incidence (P for non-linearity = 0.042), with an inflection point at 13.4 h. After the 13.4-h mark, the risk of developing gallstones did not increase further.

Conclusion

The FMT of the day is positively correlated with the prevalence of gallstones, and there is a non-linear relationship and threshold effect between the two. Skipping breakfast is associated with a greater risk of developing gallstones. This study provides new evidence for the dietary prevention of gallstones.

Bidirectional associations among gallstone disease, non-alcoholic fatty liver disease, kidney stone disease

BACKGROUND

A body of evidence has suggested bidirectional relationships among gallstone disease (GSD), non-alcoholic fatty liver disease (NAFLD), and kidney stone disease (KSD). However, the results are inconsistent, and studies on this topic in China are relatively few. Our goal is to explore the bidirectional associations among these three diseases through a multicenter study, systematic review, and meta-analysis.

AIM

To explore the bidirectional associations among these three diseases through a multicenter study, systematic review, and meta-analysis. The results may help to investigate the etiology of these diseases and shed light on the individualized prevention of these three diseases.

METHODS

Subjects who participated in physical examinations in Beijing, Tianjin, Chongqing in China were recruited. Multivariable logistic regression was employed to explore the bidirectional relationships among GSD, KSD, and NAFLD. Systematic review and meta-analysis were initiated to confirm the epidemiologic evidence from previous observational studies. Furthermore, trial sequential analysis (TSA) was conducted to evaluate whether the evidence was sufficient and conclusive.

RESULTS

Significant bidirectional associations were detected among the three diseases, independent of potential confounding factors. The pooled results of the systematic review and meta-analysis also corroborated the aforementioned results. The combined evidence from the multicenter study and meta-analysis was significant [pooled odds ratio (OR) = 1.42, 95%CI: 1.16-1.75, KSD → GSD; pooled OR = 1.48, 95%CI: 1.31-1.67, GSD → KSD; pooled OR = 1.31, 95%CI: 1.17-1.47, GSD → NAFLD; pooled OR = 1.37, 95%CI: 1.26-1.50, NAFLD → GSD; pooled OR = 1.28, 95%CI: 1.08-1.51, NAFLD → KSD; pooled OR = 1.21, 95%CI: 1.16-1.25, KSD → NAFLD]. TSA indicated that the evidence was sufficient and conclusive.

CONCLUSION

The present study presents relatively sufficient evidence for the positive bidirectional associations among GSD, KSD, and NAFLD. The results may provide clues for investigating the etiology of these three diseases and offer a guideline for identifying high-risk patients.

Combinatorial Effects of Terpene, Chenodeoxycholic Acid, and Ursodeoxycholic Acid on Common Bile Duct Stone Recurrence and Gallbladder Stone Dissolution

Background: Ursodeoxycholic acid (UDCA), chenodeoxycholic acid (CDCA) plus UDCA (C&U), and terpene are widely administered to prevent common bile duct (CBD) stone recurrence and dissolve gallbladder (GB) stones. We evaluated and compared the combined effects of these agents on CBD stone recurrence and GB stone resolution. Methods: This study included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at six referral centers, retrospectively. A total of 940 patients who underwent cholecystectomy before or after CBD stone removal by ERCP were evaluated to assess CBD stone recurrence (the CBD recurrence cohort), and 98 patients with GB stones were assessed by abdominal or endoscopic ultrasonography before and 6 months after ERCP to evaluate GB stone resolution (GB cohort). Patients were divided into no-medication, single-agent treatment (UDCA, C&U, or terpene), or dual-agent treatment (terpene plus UDCA or C&U) groups for the analysis. Results: In the CBD recurrence cohort, baseline characteristics were similar in the three groups. CBD stone recurrence rates were 41.5%, 12.7%, and 9.8% in the no-medication, single-agent, and dual-agent groups, respectively (p < 0.001), and the recurrence rate was significantly lower for those administered C&U plus terpene (5.2% vs. 13.2%, p = 0.002). In the GB cohort, baseline characteristics were also similar in the groups. GB stone resolution rates of >30% were observed in 5.3%, 14.3%, and 34.8% of patients in the no-medication, single-agent, and dual-agent groups, respectively (p = 0.028). Conclusions: C&U plus terpene was significantly more effective for preventing CBD stone recurrence and achieving GB stone resolution than no medication or single agents.

Non-Surgical Management of Gallstones During Pregnancy: A Clinical Case Report

Gallstone disease during pregnancy, or cholelithiasis, presents significant clinical challenges due to hormonal, anatomical, and metabolic changes. Progesterone therapy, commonly used in pregnancy for uterine bleeding, can exacerbate gallstone risk by reducing gallbladder motility and promoting cholesterol gallstone formation. This case report describes a 29-year-old pregnant woman with no prior gallbladder disease who developed multiple cholesterol gallstones during the third trimester while undergoing progesterone therapy for bleeding associated with a bicornuate uterus. Conservative management during pregnancy, including dietary modifications and close monitoring, was successful, and the patient delivered a healthy infant via cesarean section. Postpartum, the patient developed obstructive jaundice, severe right hypochondriac pain, and scleral icterus due to common bile duct obstruction from gallstones. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement resolved the obstruction, and pharmacological treatment with ursodeoxycholic acid (UDCA) and omega-3 fatty acids led to complete gallstone resolution within three months. Surgical intervention was avoided to prioritize postpartum recovery and breastfeeding, which resumed successfully after a brief interruption. This case highlights the value of individualized, multidisciplinary care in managing pregnancy-associated gallstone disease. Conservative approaches, including pharmacological and minimally invasive interventions, can achieve effective outcomes while minimizing maternal-fetal risks. Routine ultrasound screening in high-risk pregnancies and further investigation into UDCA and omega-3 therapies, progesterone-related gallbladder stasis, and postpartum biliary stenting protocols are recommended to optimize management strategies.

The effect of lung-recruitment maneuver on postoperative shoulder pain in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial

PURPOSE

Lung-recruitment maneuvers (LRM) have been shown to reduce postoperative pain after laparoscopic surgery. This study aimed to investigate the association of LRM with the incidence of shoulder pain after laparoscopic cholecystectomy.

METHODS

A randomized controlled study was conducted with 110 patients undergoing elective laparoscopic cholecystectomy from July 2022 to March 2023. Participants were randomized to receive either routine exsufflation or LRM at pneumoperitoneum release. The postoperative shoulder pain and abdominal pain were assessed at 1, 4, 6, 12, and 24 h after surgery using a numeric rating scale. Analgesic consumption and postoperative nausea or vomiting (PONV) were evaluated during the first 24 h after surgery.

RESULTS

The incidence of shoulder pain during the first 24 h after surgery was significantly lower in the LRM group compared to the control group (26.9 vs. 59.3%; P = 0.001). The median [interquartile range] score of worst shoulder pain was significantly lower compared to the control group (3 [2-3] vs 4 [3-5.5]; P = 0.003). Participants in the LRM group showed reduced abdominal pain at rest at 4 and 24 h after surgery, and experienced significantly lower intensities of abdominal pain during mobilization at all time points over 24 h after surgery. There were no significant differences in opioid consumption or the incidence of PONV between the groups.

CONCLUSIONS

LRM reduces both the incidence and intensity of shoulder pain during 24 h after laparoscopic cholecystectomy. Additionally, LRM was associated with reduced intensity of abdominal pain during mobilization over the study period.

Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients

BACKGROUND

In adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance.

METHODS

A multicenter, retrospective review of pediatric (<18 years) and adult patients with choledocholithiasis managed from 2018 to 2024 was performed. Demographic and clinical data were obtained. Rate of successful duct clearance with LCBDE was compared. Surgical and endoscopic complications (infections, bleeding, pancreatitis, bile leak) were also compared.

RESULTS

724 patients, 333 (45.9%) pediatric and 391 (54.0%) adults, were included. The median age of pediatric vs adult patients was 15.2 years [13.1, 16.6] vs 55.5 years [34.1, 70.5], respectively. Of these, 201 (60.4%) pediatric vs 169 (43.2%) adult patients underwent SF, p < 0.001. LCBDE was attempted in 84 (41.7%) pediatric vs 140 (82.8%) adults, p = 0.002. LCBDE success was higher in pediatric vs adult patients (82.1% vs 71.4%, p = 0.004). Complications rates were similar however, pediatric patients who underwent EF had higher endoscopic complications (9.1% vs 3.6%, p = 0.03).

CONCLUSION

LCBDE is highly successful in children vs adults with no increased surgical complications. This data, coupled with the limited ERCP access for children, supports that LCBDE is an equally effective tool for managing choledocholithiasis in children as is accepted in adults.

LEVEL OF EVIDENCE

Level III.

Asymptomatic cholecystitis and its controversial issues in biliary surgery

Gallbladder stones are present in 10-20 % of the population of Western countries, and the incidence rate has almost tripled over the past 30 years. Asymptomatic cholecystitis is more common than it is mentioned in the literature. Approximately 80 % of the GI have no clinical manifestations. In most cases, the disease will remain asymptomatic throughout life. The problem of asymptomatic cholecystitis is often hushed up and ignored. Surgeons try to avoid examining this pathology. Works on asymptomatic cholecystitis are not only few, but also scattered. At the same time, there is no uniformity in the literature. Since the tactics of treating such patients still does not have an unambiguous approach. Many surgeons doubt the decision on surgical treatment, a smaller part chooses cholecystectomy at the same time, without substantiating the indications for it. That is why most cases of postcholecystectomy syndrome occur in patients operated on for asymptomatic cholecystitis. The unwillingness to discover the secret of stone formation and asymptomatic cholecystitis in humans when concretions in the gallbladder are detected without reference to surgery, to indicate the trajectory of the examination, leads to a number of tactical errors, preserving the risk of PES, and erasing practical recommendations for the management of such patients. The solution to this issue lies in a thorough study of each stage of the tactical search in patients with asymptomatic cholecystitis, which will determine a new strategy in biliary surgery.

Restrictive Strategy vs Usual Care for Cholecystectomy in Patients With Abdominal Pain and Gallstones: 5-Year Follow-Up of the SECURE Randomized Clinical Trial

Importance

The 1-year results of the SECURE trial, a randomized trial comparing a restrictive strategy vs usual care for select patients with symptomatic cholelithiasis for cholecystectomy, resulted in a significantly lower operation rate after restrictive strategy. However, a restrictive strategy did not result in more pain-free patients at 1 year.

Objective

To gauge pain level and determine the proportion of pain-free patients, operation rate, and biliary and surgical complications at the 5-year follow-up.

Design, Setting, and Participants

This randomized clinical trial was a multicenter, parallel-arm, noninferiority, prospective study. Between February 2014 and April 2017, patients from 24 hospitals with symptomatic, uncomplicated cholelithiasis were included. Uncomplicated cholelithiasis was defined as gallstone disease without signs of complicated cholelithiasis, ie, biliary pancreatitis, cholangitis, common bile duct stones, or cholecystitis. Follow-up data for this analysis were collected by telephone from July 11, 2019, to September 23, 2023.

Interventions

Patients were randomized (1:1) to receive usual care or a restrictive strategy with stepwise selection for cholecystectomy.

Main Outcomes and Measures

The primary, noninferiority end point was proportion of patients who were pain free as evaluated by Izbicki pain score at the 5-year follow-up. A 5% noninferiority margin was chosen. The secondary end points included cholecystectomy rates, biliary and surgical complications, and patient satisfaction.

Results

Among 1067 patients, the median (IQR) age was 49.0 years (38.0-59.0 years); 786 (73.7%) were female, and 281 (26.3%) were male. At the 5-year follow-up, 228 of 363 patients (62.8%) were pain free in the usual care group, compared with 216 of 353 patients (61.2%) in restrictive strategy group (difference, 1.6%; 1-sided 95% lower confidence limit, -7.6%; noninferiority P = .18). After cholecystectomy, 187 of 294 patients (63.6%) in the usual care group and 160 of 254 patients (63.0%) in the restrictive strategy group were pain free, respectively (P = .88). The restrictive care strategy was associated with 387 of 529 cholecystectomies (73.2%) compared with 437 of 536 in the usual care group (81.5%; 8.3% difference; P = .001). No differences between groups were observed in biliary and surgical complications or in patient satisfaction.

Conclusions and Relevance

In the long-term, a restrictive strategy results in a significant but small reduction in operation rate compared with usual care and is not associated with increased biliary and surgical complications. However, regardless of the strategy, only two-third of patients were pain free. Further criteria for selecting patients with uncomplicated cholelithiasis for cholecystectomy and rethinking laparoscopic cholecystectomy as treatment is needed to improve patient-reported outcomes.

Trial Registration

CCMO Identifier: NTR4022.

The Efficacy of a Combination of Milk Thistle, Artichoke, and Green Tea in the Treatment of Biliary Sludge: An Interventional Prospective Open Study

Background: In Western countries, 10–20% of adults have gallstones, of which about 1–3% of patients are symptomatic for biliary colic. The treatment with ursodeoxycholic acid is debated. Silymarin is emerging nowadays as a natural substance with choleretic and beneficial properties, useful in the case of gallbladder sludge. Aim: The aim of our study was to evaluate the efficacy of supplementation with a mix of natural compounds (milk thistle 150 mg, artichoke 150 mg, and green tea 150 mg) in patients affected by biliary sludge in reducing biliary colic and biliary sludge and improving lipid profiles after 3 months of treatment compared to a control group. Patients and Methods: This was an interventional open study on 65 consecutive adult patients (23 M/42 F; mean age 61.0 ± 18.7 years) affected by biliary sludge without indication for surgery, admitted to the Internal Medicine Department of San Carlo di Nancy Hospital Rome. Forty patients were treated with milk thistle 150 mg, artichoke 150 mg, and green tea 150 mg, 2 capsules/day for three months, and followed up for abdominal ultrasound, the frequency of occurrence of biliary colic, and blood tests. Twenty-five control group patients were followed up for abdominal ultrasound, the frequency of occurrence of biliary colic, and blood tests after 3 months. Results: In Group A, we observed a disappearance of biliary sludge in 32.4% (12/37) of patients compared to 8.7% in the control group (p < 0.05). In 32.4% of treated patients, we report a reduction in biliary sludge. There were no side effects during treatment. In both groups, we registered a significant reduction in transaminases and gamma-glutamyl transferase (γ-GT) (p < 0.05). No significant modification of the lipid profile was observed. Conclusions: The treatment with a mix of natural compounds (milk thistle, artichoke, and green tea) in patients affected by symptomatic biliary colic resulted in efficacy and safety in reducing biliary sludge, biliary colic, and transaminases levels after three months of treatment. The limitations of this study include a small number of patients and the absence of long-term follow up after the end of treatment.

Endoscopic management of postcholecystectomy complications at a Nigerian tertiary health facility

BACKGROUND

Cholecystectomy and common bile duct exploration for biliary stone disease are common hepatobiliary surgeries performed by general surgeons in Nigeria. These procedures can be complicated by injury to the biliary tree or retained stones, requiring repeat surgical intervention. This study presents the experience of using endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary surgery complications at the academic referral center of Obafemi Awolowo University Teaching Hospital (OAUTHC) Ile-Ife, Nigeria.

METHODS

All patients with postcholecystectomy complications referred to the endoscopy unit at OAUTHC from March 2018 to April 2023 were enrolled. Preoperative imaging included a combination of abdominal ultrasound, CT, MRI, magnetic resonance cholangiopancreatography (MRCP), and T-tube cholangiogram. All ERCP procedures were performed under general anesthesia.

RESULTS

Seventy-two ERCP procedures were performed on 45 patients referred for postcholecystectomy complications. The most common mode of presentation was ascending cholangitis [16 (35.6%)], followed by persistent biliary fistula [12 (26.7%)]. The overall median duration of symptoms after cholecystectomy was 20 weeks, with a range of 1-162 weeks. The most common postcholecystectomy complication observed was retained stone [16 (35.6%)]. Other postcholecystectomy complications included bile leakage, bile stricture, bile leakage with stricture, and persistent bile leakage from the T-tube in 12 (26.7%), 11 (24.4%), 4 (8.9%), and 2 (4.4%) patients, respectively. Ampullary cannulation during ERCP was successful in all patients (45, 100%). Patients with complete biliary stricture (10/12) required hepaticojejunostomy.

CONCLUSION

Endoscopic management of postcholecystectomy complications was found to be safe and reduce the number of needless surgeries to which such patients are exposed. We recommended prompt referral of such patients for ERCP.

Different types and numbers metabolic abnormalities and risk of gallbladder stone disease in adults

Background

Metabolic abnormalities in the body increase the risk of gallbladder stones and their complications, which brings a great economic and social burden. The relationship between different types and amounts of metabolic abnormalities and gallstone risk in different sexes is poorly documented and controversial.

Methods

Based on the baseline survey data of the Chinese Multi-Ethnic Cohort (CMEC) study, 4,075 Chinese adults aged 30-79 years with complete abdominal ultrasound results and metabolic index data. Logistic regression model was used to evaluate the correlation between five metabolic abnormalities and gallstones, and to explore the gender difference.

Results

The detection rate of gallbladder stones was found to be 7.0%, with a higher rate in women (8.6%) than in men (4.1%). Logistic results showed adjustment odds ratio (ORs) and 95% confidence interval (95% CI) of dysglycemia + hypertension + central obesity in 3 metabolic combinations was 4.459 (1.653, 12.029). The four metabolic combinations, dysglycemia + dyslipidemia + hypertension + central obesity, dysglycemia + dyslipidemia + hypertension + abnormal blood uric acid and dysglycemia + dyslipidemia + central obesity + abnormal blood uric acid adjusted OR and 95%CI were 3.342 (1.459, 7.659), 5.439 (1.555, 19.018) and 2.971 (1.187, 7.435), respectively. Gender-stratified analysis found that "any three or more metabolic abnormalities and their components were associated with gallstone risk, more significantly in women.

Conclusion

Different types and amounts of five metabolic abnormalities were associated with the risk of gallstone development, and the differences were more significant in women than men.