Contributions of obesity and weight loss to gallstone disease

Can caloric restriction improve outcomes of elective surgeries?

Energy restriction (ER) is a nutrition method to reduce the amount of energy intake while maintaining adequate nutrition. In clinical medicine, applications of ER have been implicated in longevity, mortality, metabolic, immune, and psychological health. However, there are limited studies showing the clinical benefit of ER within the immediate surgical setting. A specific, clinically oriented summary of the potential applications of ER is needed to optimize surgery outcomes for patients. The purpose of this article is to examine how ER can be used for perioperative optimization to improve outcomes for the patient and surgeon. It will also explore how these outcomes can feasibly fit in with enhanced recovery after surgery protocols and can be used as a method for nutrition optimization in surgery. Despite evidence of caloric restriction improving outcomes in critically ill surgical patients, there is not enough evidence to conclude that ER, perioperatively across noncritically ill cohorts, improves postoperative morbidity and mortality in elective surgeries. Nevertheless, a contemporary account of how ER techniques may have a significant role in reducing risk factors of adverse surgical outcomes in this cohort, for example, by encouraging preoperative weight loss contributing to decreased operating times, is reviewed.

Can Lipid-Lowering Drugs Reduce the Risk of Cholelithiasis? A Mendelian Randomization Study

Background and Aims

Cholelithiasis etiology intricately involves lipid metabolism. We sought to investigate the plausible causal link between genetically proxied lipid-lowering medications-specifically HMGCR inhibitors, PCSK9 inhibitors, and NPC1L1 inhibitors-and cholelithiasis risk.

Methods

Our study utilized two genetic instruments for exposure to lipid-lowering drugs. These instruments encompassed genetic variants linked to low-density lipoprotein (LDL) cholesterol within or in proximity to drug target genes, along with loci governing gene expression traits of these targets. Effect estimates were derived through Inverse-variance-weighted MR (IVW-MR) and summary-data-based MR (SMR) methods.

Results

Higher HMGCR-mediated LDL cholesterol levels (IVW-MR, OR = 2.15, 95% CI = 1.58-2.94; P = 0.000) and increased HMGCR expression (SMR, OR = 1.19, 95% CI = 1.04-1.37; P = 0.014) are linked to elevated cholelithiasis risk, suggesting potential benefits of HMGCR inhibition. In contrast, higher PCSK9-mediated LDL cholesterol levels (IVW-MR, OR = 0.72, 95% CI = 0.56-0.94; P = 0.015) and increased PCSK9 expression (SMR, OR = 0.90, 95% CI = 0.82-0.99; P = 0.035) both correlate with lower cholelithiasis risk, indicating that PCSK9 inhibition may elevate this risk. Nevertheless, no substantial link emerged between NPC1L1-mediated LDL cholesterol or NPC1L1 expression and cholelithiasis in both IVW-MR and SMR analyses.

Conclusion

This MR investigation affirms the causal link between the utilization of HMGCR inhibitors and a diminished risk of cholelithiasis. Additionally, it indicates a causal link between PCSK9 inhibitors use and increased cholelithiasis risk. However, no significant correlation was found between NPC1L1 inhibitors use and cholelithiasis risk.

Childhood Obesity: An Updated Review

BACKGROUND

Childhood obesity is an important and serious public health problem worldwide.

OBJECTIVE

This article aims to familiarize physicians with the evaluation, management, and prevention of childhood.

METHODS

A PubMed search was conducted in May, 2021, in Clinical Queries using the key terms "obesity" OR "obese". The search included clinical trials, randomized controlled trials, case-control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to English literature and children. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Most obese children have exogenous obesity characterized by a growth rate for height above the 50th percentile, normal intelligence, normal genitalia, and lack of historical or physical evidence of an endocrine abnormality or a congenital syndrome. Obese children are at risk for dyslipidemia, hypertension, diabetes mellitus, non-alcoholic fatty liver disease, obstructive sleep apnea, psychosocial disturbances, impaired quality of life, and shorter life expectancy. The multitude of serious comorbidities necessitates effective treatment modalities. Dietary modification, therapeutic exercise, and behavioral modification are the fundamentals of treatment. Pharmacotherapy and/or bariatric surgery should be considered for obese individuals who do not respond to the above measures and suffer from a serious comorbid condition.

CONCLUSION

Childhood obesity, once established, is often refractory to treatment. Most treatment programs lead to a brief period of weight loss, followed by rapid re-accumulation of the lost weight after the termination of therapy. As such, preventive activity is the key to solving the problem of childhood obesity. Childhood obesity can be prevented by promoting a healthy diet, regular physical activity, and lifestyle modification. Parents should be encouraged to get involved in school and community programs that improve their children's nutritional status and physical activity.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Gallstone Disease and Its Correlation With Thyroid Disorders: A Narrative Review

Over the years, several studies have revealed an important link between thyroid disorders and gallstone disease. According to these studies, hypothyroidism and hyperthyroidism are associated with cholesterol gallstone disease. This association between thyroid hormone disorders and cholesterol gallstone disease is due to the importance of thyroid hormones on cholesterol synthesis, bile functioning and content, and gallbladder motility. Several genes and receptors have been found on the thyroid gland, liver, and gallbladder to verify this association. These genes affect thyroid hormone secretion, lipid metabolism, and bile secretion. Defects in these various gene expression and protein functions lead to bile duct diseases. Other causes that lead to cholesterol gallstone disease are supersaturation of the bile with cholesterol and impaired gallbladder motility, which leads to bile stasis. This article has discussed these factors in detail while highlighting the association between thyroid hormones and cholesterol gallstone disease.

Association of milk consumption with the incidence of cholelithiasis disease in the US adult population

BACKGROUND

Cholelithiasis is a common digestive system disease that imposes major burden on patients and society. Investigating the relationship between dietary factors and cholelithiasis risk can provide a basis for disease prevention. Previous studies on milk intake and cholelithiasis incidence have been limited.Therefore, the aim of our study was to assess the association between milk consumption and the incidence of cholelithiasis in males and females.

METHODS

We selected 14,722 adults (≥ 18 years old) from National Center for Health Statistics (NHANSE) 2017-2020, and collected general characteristics of patients in the database, such as age, gender, race and body mass index (BMI), as well as dietary information (milk consumption). The occurrence of cholelithiasis was used as the outcome event, and the group was divided into cholelithiasis and non-cholelithiasis groups according to the outcome event. We used logistic regression models in generalized linear model (GLM) functions, controlling for demographic, lifestyle, and dietary factors, to estimate the association between milk intake and the incidence of cholelithiasis in males and females.

RESULTS

A total of 14,722 adults were included. In the present study, the overall weighted prevalence of cholelithiasis was 10.96%, with 15.18% and 6.48% prevalence in females and males, respectively. Compared to infrequent milk intake, frequent milk intake (once a week or more) in females was associated with reduced cholelithiasis risk (OR 0.74, 95% CI 0.61-0.90). Daily milk intake in males was also related to lower cholelithiasis risk (OR 0.69-0.82). As adjusted variables increased in the models, predictive performance was improved (AUC 0.711 in females, 0.730 in males).

CONCLUSIONS

Appropriate milk intake may correlate with decreased cholelithiasis risk. Our study provides a basis for dietary interventions against gallstones, but prospective studies are needed to verify the results.

Gallstone and Gallbladder Disease: Biliary Tract and Cholangiopathies

Cholestatic liver diseases are named primarily due to the blockage of bile flow and buildup of bile acids in the liver. Cholestasis can occur in cholangiopathies, fatty liver diseases, and during COVID-19 infection. Most literature evaluates damage occurring to the intrahepatic biliary tree during cholestasis; however, there may be associations between liver damage and gallbladder damage. Gallbladder damage can manifest as acute or chronic inflammation, perforation, polyps, cancer, and most commonly gallstones. Considering the gallbladder is an extension of the intrahepatic biliary network, and both tissues are lined by biliary epithelial cells that share common mechanisms and properties, it is worth further evaluation to understand the association between bile duct and gallbladder damage. In this comprehensive article, we discuss background information of the biliary tree and gallbladder, from function, damage, and therapeutic approaches. We then discuss published findings that identify gallbladder disorders in various liver diseases. Lastly, we provide the clinical aspect of gallbladder disorders in liver diseases and ways to enhance diagnostic and therapeutic approaches for congruent diagnosis. © 2023 American Physiological Society. Compr Physiol 13:4909-4943, 2023.

Very Low-Calorie Ketogenic Diet: A Potential Application in the Treatment of Hypercortisolism Comorbidities

A very low-calorie ketogenic diet (VLCKD) is characterized by low daily caloric intake (less than 800 kcal/day), low carbohydrate intake (<50 g/day) and normoproteic (1−1.5 g of protein/kg of ideal body weight) contents. It induces a significant weight loss and an improvement in lipid parameters, blood pressure, glycaemic indices and insulin sensitivity in patients with obesity and type 2 diabetes mellitus. Cushing’s syndrome (CS) is characterized by an endogenous or exogenous excess of glucocorticoids and shows many comorbidities including cardiovascular disease, obesity, type 2 diabetes mellitus and lipid disorders. The aim of this speculative review is to provide an overview on nutrition in hypercortisolism and analyse the potential use of a VLCKD for the treatment of CS comorbidities, analysing the molecular mechanisms of ketogenesis.

Pediatric biliary calculus disease: clinical spectrum, predisposing factors, and management outcome revisited

Background

Biliary calculus disease (BCD) is one of the most prevalent diseases and poses a significant burden to the health care system in adults. The prevalence of BCD in children and adolescents is about 0.1% and 0.6%, respectively. Although many factors have been attributed to BCD in children, exact etiopathogenesis is not clear. BCD has been extensively studied in adults, but not much literature is available in children. The current review was undertaken to study BCD in children focusing on the objectives like predisposing factors, various modes of presentation, and management outcome of BCD in children in the northern part of India.

Results

Out of 42 children, two children had a history of ceftriaxone therapy. Two underwent ileal resection. The mean reticulocyte count was 1.79%. None had G6PD deficiency or abnormal osmotic fragility test. Clinical presentation was right upper quadrant pain (n = 42, 100%), calculous cholecystitis (n = 8, 19.0%), and jaundice (n = 3, 7.14%). The majority (n = 26, 61.92%) were overweight. Only 16.6% (n = 7) children had normal body mass index (BMI), and 9.3% (n = 4) were obese. The mean BMI was 26.3 kg/m2. 85.5% of children frequently consume junk foods. The majority of calculi were GB calculi accounting for 92.8% (n = 39) whereas 7.1% (n = 3) children had CBD calculi. Thirty-five were managed by laparoscopic cholecystectomy, three were managed by non-operative management, and one was managed by open cholecystectomy; among the three cases of CBD calculi, two were managed by endoscopic retrograde cholangiopancreatography (ERCP), stenting, and CBD exploration and one was managed by ERCP sphincterotomy.

Conclusion

Diet and overweight both appear to be important risk factors for pediatric BCD. Drug-induced calculi can be safely observed.

Insights into modifiable risk factors of cholelithiasis: A Mendelian randomization study

BACKGROUND AND AIMS

The risk factors of cholelithiasis have not been clearly identified, especially for total cholesterol. Here, we try to identify these causal risk factors.

APPROACH AND RESULTS

We obtained genetic variants associated with the exposures at the genome-wide significance (p < 5 × 10^-8 ) level from corresponding genome-wide association studies. Summary-level statistical data for cholelithiasis were obtained from FinnGen and UK Biobank (UKB) consortia. Both univariable and multivariable Mendelian randomization (MR) analyses were conducted to identify causal risk factors of cholelithiasis. Results from FinnGen and UKB were combined using the fixed-effect model. In FinnGen, the odds of cholelithiasis increased per 1-SD increase of body mass index (BMI) (OR = 1.631, p = 2.16 × 10^-7 ), together with body fat percentage (OR = 2.108, p = 4.56 × 10^-3 ) and fasting insulin (OR = 2.340, p = 9.09 × 10^-3 ). The odds of cholelithiasis would also increase with lowering of total cholesterol (OR = 0.789, p = 8.34 × 10^-5 ) and low-density lipoprotein-cholesterol (LDL-C) (OR = 0.792, p = 2.45 × 10^-4 ). However, LDL-C was not significant in multivariable MR. In UKB, the results of BMI, body fat percentage, total cholesterol, and LDL-C were replicated. In meta-analysis, the liability to type 2 diabetes mellitus and smoking could also increase the risk of cholelithiasis. Moreover, there were no associations with other predominant risk factors.

CONCLUSIONS

Our MR study corroborated the risk factors of cholelithiasis from previous MR studies. Furthermore, lower total cholesterol level could be an independent risk factor.

Obesity, Type 2 Diabetes, Lifestyle Factors, and Risk of Gallstone Disease: A Mendelian Randomization Investigation

BACKGROUND & AIMS

Obesity, type 2 diabetes, and lifestyle factors (cigarette smoking, alcohol drinking, and coffee consumption) have been associated with the risk of developing gallstone disease in observational studies, but whether these associations are causal is undetermined. We conducted a Mendelian randomization study to assess these associations.

METHODS

Genetic instruments associated with the exposures at the genome-wide significance (p < 5×10^-8) level were selected from corresponding genome-wide association studies (n=224 459 to 1 232 091 individuals). Summary-level data for gallstone disease were obtained from the UK Biobank (10 520 cases and 350 674 non-cases) and FinnGen consortium (11 675 cases and 121 348 non-cases). Univariable and multivariable Mendelian randomization analyses were conducted. Results from UK Biobank and FinnGen were combined using fixed-effects meta-analysis.

RESULTS

The odds ratios were 1.63 (95% confidence interval (CI), 1.49, 1.79) for one standard deviation (SD) increase in body mass index, 1.81 (95% CI, 1.60, 2.05) for one SD increase in waist circumference, 1.13 (95% CI, 1.09, 1.17) for one unit increase in the log-odds ratio of type 2 diabetes and 1.25 (95% CI, 1.16, 1.34) for one SD increase in prevalence of smoking initiation. The associations for body mass index and type 2 diabetes persisted after mutual adjustment. Genetically predicted coffee consumption was inversely associated with gallstone disease after adjustment for body mass index and smoking (odds ratio per 50% increase 0.44, 95% CI, 0.21, 0.91). There was no association with alcohol consumption.

CONCLUSIONS

This study supports independent causal roles of obesity, type 2 diabetes, and smoking in gallstone disease.

Maternal smoking during pregnancy is risk factor for gallbladder disease in offspring during adulthood: a prospective study from UK Biobank

INTRODUCTION AND OBJECTIVES

Gallbladder disease is a common disease with high prevalence. Majority of gallbladder disease is due to gallstone. Though genetics are believed to play a role in its pathogenesis, the contribution of environmental pressures in early life to the development of this disease in adulthood has not been ever investigated. This study aimed to clarify the risk of maternal smoking exposure in association with gallbladder disease in adulthood. The interaction of maternal smoking and own smoking during adulthood on this association was studied as well.

PATIENTS AND METHODS

A total of 286,731 eligible participants from the UK Biobank population-based cohort were included. Multivariable Cox regression analysis were used to examine the HR and 95% CI with adjustment for covariates.

RESULT

During a median of 8.8 years follow-up, 7110 incident cases of gallbladder disease including 6800 (95.6%) gallstone were identified. Maternal smoking was associated with increased risk of incident total gallbladder disease (HR = 1.13; 95%CI: 1.06 - 1.21; P = 0.0002) as well as gallstones (HR = 1.13; 95%CI: 1.06 -1.21; P = 0.0003) in adulthood. Compared with those who were neither exposed to maternal smoking nor own smoking, subjects adherence to no smoking during adulthood but having maternal smoking exposure still had increased risk of total gallbladder disease (HR = 1.21; 95%CI: 1.1-1.34, P=0.0001) and gallstones (HR = 1.21; 95%CI: 1.1-1.35, P=0.0001).

CONCLUSION

The present study using large prospective cohort data from UK Biobank, for the first time, demonstrated maternal smoking exposure bringing elevated risk of incident total gallbladder disease/gallstone in adulthood.

Is there seasonal variation in gallstone related admissions in England?

BACKGROUND

Gallstone related pathology (GRP) accounts for a significant proportion of general surgery admissions. The aim of this study is to investigate if seasonal variation for GRP admissions exist in England allowing improved resource allocation and planning.

METHODS

This multicentre retrospective cohort study included only emergency adult (≥18 years old) admissions to acute secondary care with ICD-10 codes associated with gallstones between 01/01/2010 to 31/12/2019 in England using Hospital Episode Statistics data. Seasons were defined according to United Kingdom Met Office.

RESULTS

A total of 396 879 GRP related admissions were recorded during the specified period, accounting for 1.44% of all emergency admissions. Our study suggests a significant seasonal peak in Summer (n = 102 620) based cumulative admissions per season and a linear regression model (p < 0.001), followed by Autumn (n = 102 267), then Spring (n = 97 807) and finally Winter (n = 94 185). Spectral analysis confirmed there is seasonality in the emergency GRP admissions every 12 months. A forecasting model was shown to be reliable; all observed admissions for 2019 were within the 95% prediction intervals for each month for the proportion of emergency GRP admissions.

CONCLUSION

Resource allocation towards the Summer months to target seasonal peaks in GRP should be considered.

Obesity and Gallstones

BACKGROUND

The prevalence of obesity has been increasing globally and represents the main risk factor for the development of gallstone disease (GD).

SUMMARY

Excess body weight represents the main cause for the development of GD; nevertheless, there have been described multiple risk factors for its development, among them modifiable risk factors as diet, lifestyle, physical inactivity, and non-modifiable risk factors as ethnicity, female sex, advanced age, parity, and genetic mutations. Body mass index, abdominal perimeter, and waist-hip index have been used to determine the degree of adiposity of a person. Hence, central abdominal fat has been mostly associated with insulin resistance with the consequent increase in the hepatic cholesterol secretion; contributing as one of the multiple mechanisms associated with the development of gallstones. This disease has a low mortality; however, it has been associated with multiple diseases such as cardiovascular diseases, carotid atherosclerosis, metabolic associated fatty liver disease, and gallbladder cancer, probably because they share many of the risk factors.

KEY MESSAGES

GD continues to be considered a disease with a high medical burden, in which it is sought to intervene in modifiable risk factors to reduce its development.

Pearl-white gallstones: A report of a case and a chemical analysis by FTIR and XRD

Introduction

Gallstones' color is usually yellow, brown, black or more commonly a mixture of two or more of these colors in different proportions, depending on their composition, with yellow being the most commonly encountered color. Pearl-white gallstones are a very rare entity that has not been studied and reported sufficiently.

Case presentation

Our patient is a 44-year-old lady who was suffering from recurrent attacks of epigastric and right hypochondrial abdominal pain that was aggravated by consumption of fatty meals. Ultrasound Imaging revealed multiple gallbladder stones. After an elective cholecystectomy unusual pearl-white gallstones were found inside a distended gallbladder filled with transparent thick fluid.

Chemical analysis

To evaluate the chemical composition of these stones Fourier-transform infrared (FTIR) spectroscopy and X-Ray Diffraction (XRD) tests were performed and revealed that these stones are composed of cholesterol (99.6%) and calcium carbonate (0.4%).

Discussion

Gallstones are bile depositions of a solid consistency formed inside the gallbladder. Cholesterol, bilirubin, and other substances are involved in the composition of different kinds of gallstones. The presence of gallstones alone inside the gallbladder is usually presented as colicky abdominal pain. Cholecystectomy is a simple surgical removal of the gallbladder from it bed and is the definitive treatment of gallstone disease.

Conclusion

Pearl-white gallstones are rarely encountered and lack information about their pathogenesis, thus prompting further evaluation and studying.

•

Pearl-white coloration of gallstones in extremely rare.

•

FTIR and XRD are useful tools to analyze the chemical composition of gallstones.

•

Cholesterol is the major component of pearl-white gallstones.

European Guidelines for Obesity Management in Adults with a Very Low-Calorie Ketogenic Diet: A Systematic Review and Meta-Analysis

BACKGROUND

The very low-calorie ketogenic diet (VLCKD) has been recently proposed as an appealing nutritional strategy for obesity management. The VLCKD is characterized by a low carbohydrate content (<50 g/day), 1-1.5 g of protein/kg of ideal body weight, 15-30 g of fat/day, and a daily intake of about 500-800 calories.

OBJECTIVES

The aim of the current document is to suggest a common protocol for VLCKD and to summarize the existing literature on its efficacy in weight management and weight-related comorbidities, as well as the possible side effects.

METHODS

This document has been prepared in adherence with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Literature searches, study selection, methodology development, and quality appraisal were performed independently by 2 authors and the data were collated by means of a meta-analysis and narrative synthesis.

RESULTS

Of the 645 articles retrieved, 15 studies met the inclusion criteria and were reviewed, revealing 4 main findings. First, the VLCKD was shown to result in a significant weight loss in the short, intermediate, and long terms and improvement in body composition parameters as well as glycemic and lipid profiles. Second, when compared with other weight loss interventions of the same duration, the VLCKD showed a major effect on reduction of body weight, fat mass, waist circumference, total cholesterol and triglyceridemia as well as improved insulin resistance. Third, although the VLCKD also resulted in a significant reduction of glycemia, HbA1c, and LDL cholesterol, these changes were similar to those obtained with other weight loss interventions. Finally, the VLCKD can be considered a safe nutritional approach under a health professional's supervision since the most common side effects are usually clinically mild and easily to manage and recovery is often spontaneous.

CONCLUSIONS

The VLCKD can be recommended as an effective dietary treatment for individuals with obesity after considering potential contra-indications and keeping in mind that any dietary treatment has to be personalized. Prospero Registry: The assessment of the efficacy of VLCKD on body weight, body composition, glycemic and lipid parameters in overweight and obese subjects: a meta-analysis (CRD42020205189).

Laparoscopic assisted ERCP in patient with Roux-en-Y gastric bypass. A case report

INTRODUCTION

Choledocholithiasis in Roux-en-Y patients is a therapeutic challenge for both surgeons and endoscopists. In fact, typical procedures, such as ERCP, can't be performed due to the altered anatomy of the patient. Nowadays, procedures on this kind of patient are performed not only in specialized bariatric centers, but, due to the increasing number of patients undergoing bariatric surgery, are starting to become more common even in smaller and non-specialized centers that don't possess the same expertise and technology.

CASE PRESENTATION

We present the case of a 33-year-old patient, who had already undergone bariatric surgery, and presented to our department with a diagnosis of choledocholithiasis. Due to the altered anatomy the patient was treated through a laparoscopic assisted ERCP.

DISCUSSION

A review of the need and proper timing for a cholecystectomy in this kind of patient, in order to prevent choledocholithiasis, is discussed. Moreover, a review of the literature regarding the possible treatments of this pathology in bariatric patients underlines the presence of other treatments, beyond the one performed in our department, that can be performed even in small non-specialized centers.

CONCLUSIONS

Prophylactic cholecystectomy is not recommended in bariatric surgery. Laparoscopic assisted-ERCP is a safe and feasible intervention which is to be preferred, even if B-ERCP and EDGE are two valid alternatives.

A 3-Year MBSAQIP propensity-matched analysis of Roux-en-Y gastric bypass with concomitant cholecystectomy: Is the robotic or laparoscopic approach preferred?

BACKGROUND

The primary objective of this study was to compare outcomes of patients undergoing minimally invasive RYGB (MIS/RYGB) versus MIS/RYGB with concomitant Cholecystectomy (CCY). A secondary objective was to compare the outcomes for laparoscopic RYGB (LRYGB) and robotic RYGB (RRYGB) with concomitant CCY.

METHODS

Outcomes of 117,939 MIS/RYGB with and without CCY were propensity-matched (Age, Gender, BMI, Comorbidities), 10:1, using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2015-2017. The MIS/RYGB with CCY were then separated into LRYGB and RRYGB cases for comparison. Exclusion criteria included emergency cases, conversions to open, and age less than 18.

RESULTS

The operative time and length of stay (LOS) was significantly increased with addition of concomitant CCY. There was no significant difference in readmission, reoperation, intervention, morbidity, or mortality. The RRYGB with CCY approach was associated with a significantly longer operative times compared to the LRYGB with CCY (177 vs. 135 min, p < 0.0001). The laparoscopic and robotic groups demonstrated no significant difference LOS, readmission, reoperation, intervention, morbidity, or mortality rates.

CONCLUSIONS

Our study demonstrates that concomitant cholecystectomy increased the operative time and length of stay. However, concomitant CCY was not associated with any increased morbidity. The study demonstrated no significant difference in morbidity between robotic and laparoscopic approach. The robotic approach, however, was associated with a significantly longer operative time compared to the laparoscopic approach. While the indications for CCY remain controversial, concomitant CCY does not convey additional risk regardless of operative approach.

Common Bile Duct Stones After Roux-en-Y Gastric Bypass: Same Issue, Different Ways to Deal with

Background: Obesity is a complex chronic disease, which represents a severe and growing health issue all over the world. Bariatric surgery is an option when medical treatments failed. The average of complications is low. Common bile duct stones in a patient who underwent weight loss surgery, especially Roux-en-Y gastric bypass, one anastomosis gastric bypass, or duodenal switch, is challenging due to the difficult access to the biliary duct. Methods: We describe the different techniques we used to perform the treatment of common bile duct stones after a gastric bypass was performed. Results: The highlights of the different treatments to solve this big issue that is common bile duct after gastric bypass are described, such as the endoscopic, the surgical, the percutaneous, and combined ones. Conclusion: There are several therapeutic options; many of them have already demonstrated excellent results. Even though there is not a gold standard technique, the total endoscopic approach performed by trained hands should be the first line of treatment. Percutaneous approach represents also a safe and effective option that can avoid reoperations in an important number of patients. However, the choice will depend on the severity of the case to face with, the availability of resources, and the experience of the team.

Cholelithiasis after bariatric surgery, incidence, and prophylaxis: randomized controlled trial

BACKGROUND

Rapid weight loss is associated with a high incidence of cholelithiasis.

OBJECTIVES

To identify the incidence of gallstone formation after weight loss surgery and to detect the efficacy of 6 months regimen of prophylactic Ursodeoxycholic acid (UDCA).

METHODS

RCT included a total of 1530 morbid obese patients who were subjected to either laparoscopic one anastomosis gastric bypass (OAGB), sleeve gastrectomy (SG), or greater curve plication (GCP). Patients with previous or concomitant cholecystectomy and missed follow-up were excluded, leaving 1432 patients to analyze. They were randomly allocated into two groups receiving either UDCA or placebo with a minimum follow-up of one year for assessment of cholelithiasis and weight loss.

RESULTS

The overall incidence of cholelithiasis after surgery was 9.7%. There was a significant decrease in the incidence of gallstone formation from 22% in placebo to 6.5% in treated group with UDCA. The mean percentage of excess weight loss (%EWL) was significantly higher in those who develop gallstones than others. Of those developing gallstones, there was 64.7 % with SG versus 28.1% and 7.2% in OAGB and GCP, respectively, which is statistically significant. NNT to prevent cholelithiasis is six, AR% is 70.4%, and RR is 3.4%.

CONCLUSIONS

Cholelithiasis after SG and OAGB was higher than GCP. %EWL was rapid and higher in OAGB and SG contributing to the higher rate of symptomatic cholelithiasis and could be predictive for post-bariatric cholelithiasis. A 6-month use of UDCA is an effective prophylaxis decreasing gallstone formation after bariatric surgery at short-term follow-up.

Gallstone formation due to rapid weight loss through hyperthyroidism

Background Cholesterol metabolism has dramatically changed under hyperthyroid status. However, a combination of hyperthyroidism and cholecystolithiasis is very rare. Case presentation We report a case of cholelithiasis accompanied by hyperthyroidism in a 13-year-old girl who had recently lost 13 kg of weight (from 53 to 40 kg) in 1 month without loss of appetite. Ultrasonography showed multiple hyperechoic areas with acoustic shadowing in the gallbladder. Thyroid function tests showed that her serum free triiodothyronine (T3) and thyroxine (T4) levels were elevated and the thyroid-stimulating hormone level was decreased. In addition, serum thyrotropin receptor antibody and thyroid-stimulating antibody were detected. The final diagnosis was cholelithiasis with Graves' disease. Thiamazole ingestion was started immediately after the diagnosis, and laparoscopic cholecystectomy was performed 33 days after hospitalization. Conclusions Massive and sudden weight loss could be a risk factor for gallstone formation in children. In addition, hyperthyroidism has the potential to promote cholelithiasis via cholesterol metabolism.

The management of very low-calorie ketogenic diet in obesity outpatient clinic: a practical guide

The epidemic of obesity is growing steadily across the whole world. Obesity is not only a merely aesthetic disease but is the “mother” of most chronic diseases such as associated with a range of type 2 diabetes, cardiovascular disease, obstructive sleep apnea, and cancer. However, although there is a need to find a strategy to stop this epidemic disease, most of the times the current nutritional strategies are not effective in weight loss and in long term weight maintenance. Very low-calorie ketogenic diets (VLCKD) is increasingly establishing as a successful nutritional pattern to manage obesity; this is due to rapid weight loss that gives rise to a positive psychological cycle which in turn increases the compliance to diet. Another important key point of VLCKD is the ability to preserve fatty free mass which is known to play a role of paramount importance in glucose metabolism. Despite the clinical evidence of VLCKD there are paucity of data regarding to its management. Therefore, we will provide a useful guide to be used by nutrition experts taking care of subjects with obesity. In particular, we will report recommendations on the correct use of this therapeutic approach for weight loss and management of side effects.

The association between apolipoprotein E and gallstone disease: an updated meta-analysis

BACKGROUND

Gallstone disease (GSD) is a common biliary tract disease worldwide. Previous studies have investigated the association of apolipoprotein E (APOE) E4 with GSD and reported inconsistent results.

METHODS

In this paper, we conducted meta-analyses to examine whether APOE E4 is associated with the risk of GSD. A systematic literature search was performed in PubMed, Cochrane Library, EMBASE, and Google Scholar using the following inclusion criteria: 1) Studies on human subjects; 2) subjects in the control group must undergo ultrasound GSD screening, and presence of GSD in the experiment group can be clearly determined, e.g., diagnosis of GSD through ultrasound screening or a previous history of cholecystectomy or cholelithiasis; 3) the studies reported APOE genotype data (APOE E4+ vs. E4-) for subjects with and without GSD. In all the meta-analyses, we used random-effects models to calculate the odds ratios (ORs) as a measure of association as well as the corresponding confidence intervals (CIs).

RESULTS

Our literature search found 13 publications with 14 studies, including a total of 1632 GSD patients and 5001 controls, that met the eligibility criteria and were included in the meta-analyses. We did not find a significant association between APOE E4 and risk of GSD (OR = 1.23, 95% CI: 0.89-1.68; p = 0.205). No significant associations were observed in subgroup analyses by gender and mean age. We obtained similar insignificant findings if an additive model was used, if subjects who had E2E4 genotype were excluded, or if low-quality studies were excluded.

CONCLUSION

Our meta-analysis found insufficient evidence for the effect of APOE E4 on GSD risk. Future studies with large sample sizes that control for important confounding/risk factors are needed to validate our findings and to explore other genetic loci that might affect GSD risk.

Intragastric single-port surgery (IGS) accesses the gastric remnant and allows ERCP for common bile duct stones after RYGB: a simple solution for a difficult problem

BACKGROUND

Patients who have undergone a Roux-en-Ygastric bypass (RYGB) and suffer from choledocholithiasis postoperatively pose a medical dilemma. Treatment of the cholestasis can be complicated because of the altered anatomy in these patients. The gastric remnant and duodenum are isolated from the pancreaticobiliary limb, making endoscopic retrograde pancreatography (ERCP) challenging and often impossible.

OBJECTIVE

To describe a method for safe introduction of the endoscope into the gastric remnant through intragastric single-port surgery (IGS), thus allowing for simultaneous cholecystectomy.

SETTING

Pilot clinical study.

METHODS

The present study is a nonrandomized clinical series describing our preliminary results using a transgastric inserted single-port device for ERCP after RYGB. The series includes 8 patients who underwent IGS ERCP after RYGB.

RESULTS

The technique was successfully applied for intraoperative ERCP through a transgastric inserted single-port device (Gelpoint Mini, Applied Medical, Rancho Santa Margarita, CA). Papilotomy was easily achieved without complications. Average operative time was 144.75 minutes. The patients recovered without complications and could be discharged after a mean of 4.38 days.

CONCLUSIONS

The novel IGS technique is safe and effective and can be applied to perform ERCP in patients with RYGB anatomy. Transgastric single port ERCP was simple to perform, achieved excellent results, and allowed for endoscopic treatment and cholecystectomy to be performed in a single procedure. The technique can be indicated in patients with complicated gallstone obstruction under altered anatomy after RYGB.

Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention

Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.

Risk of cholecystectomy in morbidly obese patients after bariatric surgery in Taiwan

PURPOSE

The anatomic rearrangement of the gastrointestinal tract after bariatric surgery may result in alterations in the bile acid pool and consequently, gallstone disease. We aimed to investigate whether patients undergoing bariatric surgery are at risk of developing gallbladder disease postoperatively.

PATIENTS AND METHODS

We conducted a population-based cohort study by using claims data from the Taiwan National Health Insurance Research Database. The study cohort comprised 4197 patients diagnosed with morbid obesity.

RESULTS

Among the morbidly obese patients, 2698 underwent bariatric surgery. Females and younger subjects were more prevalent in the surgical group than non-surgical group. Bariatric surgery reduced all obesity-related comorbidities. Cox proportional hazards regression was performed, which revealed increased risk of cholecystectomy after bariatric surgery among obese patients (adjusted hazard ratio, 3.43; p=0.0165). After adjusting for sex and age, the incidence of cholecystectomy was increased in the females population (adjusted hazard ratio, 3.74; p<0.05) and in 30-64 years-old-group (adjusted hazard ratio: 3.69, p<0.05). The cumulative incidence rate of cholecystectomy showed an increased tendency in those undergoing bariatric surgery by log-rank test.

CONCLUSION

Based on the Taiwan database population-based cohort study, bariatric surgery increases the risk of cholecystectomy among morbidly obese patients, especially in the female population and patients aged 30-64 years.

Weight Loss in Adolescents After Bariatric Surgery: A Systematic Review

INTRODUCTION

Bariatric surgery is a treatment option for the obese adolescent. There are three primary surgical procedures: the bypass, sleeve gastrectomy, and lap band. The most recent literature was reviewed to examine changes in weight, comorbidities, and complications after bariatric surgery in the adolescent.

METHOD

A systematic search was performed to identify original research articles published in the United States between the years of 2000 and 2017 with patients between the ages of 11 and 21 years that provided greater than 30 days of results.

RESULTS

A total of 23 articles were identified. Weight loss, improvement in comorbidities, and complications after all procedures were reported.

DISCUSSION

Outcomes were not reported in a standardized fashion, creating much difficulty in interpreting and comparing results. The sleeve gastrectomy is increasing in incidence, whereas the lap band is decreasing. Further research is needed to draw more definitive conclusions regarding long-term results in the adolescent undergoing bariatric surgery.

Mirizzi's syndrome in Roux-en-Y bypass patient successfully treated with cholangioscopically-guided laser lithotripsy via percutaneous gastrostomy

Obesity and bariatric surgery are major risk factors in gallstone disease. In patients with a past history of Roux-en-Y gastric bypass, Mirizzi's syndrome is a challenging endoscopic situation because of the modified anatomy. Here we report the first case of a patient with a Roux-en-Y gastric bypass treated by intracorporeal lithotripsy with a digital single-operator cholangioscope following an endoscopic retrograde cholangiopancreatography (ERCP) using a percutaneous gastrostomy access.

Complications of Bariatric Surgery: What You Can Expect to See in Your GI Practice

Obesity is one of the most significant health problems worldwide. Bariatric surgery has become one of the fastest growing operative procedures and has gained acceptance as the leading option for weight-loss. Despite improvement in the performance of bariatric surgical procedures, complications are not uncommon. There are a number of unique complications that arise in this patient population and require specific knowledge for proper management. Furthermore, conditions unrelated to the altered anatomy typically require a different management strategy. As such, a basic understanding of surgical anatomy, potential complications, and endoscopic tools and techniques for optimal management is essential for the practicing gastroenterologist. Gastroenterologists should be familiar with these procedures and complication management strategies. This review will cover these topics and focus on major complications that gastroenterologists will be most likely to see in their practice.

Gallstones and Bariatric Surgery: To Treat or Not to Treat?

BACKGROUND

Obesity and rapid weight loss after bariatric surgery are risk factors for gallstone disease.

OBJECTIVES

The present study sought to evaluate the feasibility of selective concomitant cholecystectomy only in patients with symptomatic disease and study risk factors for the development of symptomatic gallstones after bariatric surgery.

METHODS

Between January 2010 and December 2012, 734 consecutive patients presenting to our institution underwent bariatric surgery. From these, 81 patients were excluded due to prior or concurrent cholecystectomy. The remaining 653 patients with in situ gallbladder were followed for 12 months and were clinically screened for symptomatic or complicated cholelithiasis. Clinical and demographic characteristics were compared at baseline and 12 months after surgery.

RESULTS

Of the 653 patients with in situ gallbladder, only 24 (3.3 %) developed symptomatic gallstones and only nine presented complicated disease. None of the patients with asymptomatic disease at the time of surgery progressed to symptomatic or complicated disease. Patients who developed symptomatic disease were not significantly different, although there was a trend toward longer obesity evolution, lower insulin levels, and lower hepatic enzymes level. A multivariate regression analysis revealed that patients with gastric sleeve were more likely to develop symptomatic gallstones.

CONCLUSIONS

Although further studies are required, the management of gallstones in morbidly obese patients should not be different from normal-weight patients. Therefore, performing a laparoscopic cholecystectomy only in symptomatic patients is an effective approach and asymptomatic gallstones should not be treated at the time of bariatric surgery.

Physical Activity and the Risk of Gallstone Disease: A Systematic Review and Meta-analysis

BACKGROUND

The role of physical activity in preventing gallstone disease independent of its effect on the body weight has not been well established. We performed a systematic review and meta-analysis of cohort and case-control studies to analyze this potential association.

METHODS

We searched PubMed and EMBASE to identify all published studies in English through April 2016. We pooled the relative risks (RRs) or odds ratios (ORs) and corresponding 95% confidence intervals (CIs) from individual studies using a random-effects model to investigate associations between physical activity and the risk of gallstone disease.

RESULTS

A total of 16 studies comprising 19 independent reports of approximately 260,000 participants met the inclusion criteria, including 6 case-control studies and 13 cohort studies. In a pooled analysis of cohort studies, physical activity (in a comparison of the highest-level and the lowest-level groups) was associated with a reduced risk of gallstone disease (RR=0.85; 95% CI, 0.78-0.92; I=79.5%). For men, the RR was 0.76 (95% CI, 0.60-0.97), and for women, the RR was similar (RR=0.77; 95% CI, 0.66-0.91). In a dose-response analysis, the RR of gallstone disease was 0.87 (95% CI, 0.83-0.92; I=1.0%) per 20 metabolic equivalent-hours of recreational physical per week. In comparison, case-control studies yielded a stronger significant risk reduction for gallstone disease (OR=0.64; 95% CI, 0.46-0.90; I=76.6%).

CONCLUSIONS

This study suggests an inverse association between physical activity and gallstone disease in both men and women; however, these findings should be interpreted cautiously because of study heterogeneity.

Prevalence of Cholelithiasis and Choledocholithiasis in Morbidly Obese South Indian Patients and the Further Development of Biliary Calculus Disease After Sleeve Gastrectomy, Gastric Bypass and Mini Gastric Bypass

BACKGROUND

Evaluation of the prevalance of cholelithiasis, choledocholithiasis and there management after sleeve gastrectomy, gastric bypass and mini gastric bypass in Indian bariatric patients.

METHODS

We did a retrospective analysis of our bariatric patient from January 2007 to December 2013 (n = 1397), for prevalence of cholelithiasis and choledocholithiasis. We did synchronous cholecystectomy in all patients planned for bariatric surgery found to have cholelithiasis on USG. Post-operatively, we followed all the patients with gallbladder in situ for minimum of 18-88 months (mean -32.4) and reviewed data for subsequent development of cholelithiasis/choledocholithiasis. Only those patients who were symptomatic underwent intervention.

RESULTS

Prevalence of cholelithiasis and choledocholithiasis in our study was 21.76 and 9.63 %, respectively. The incidence of post-bariatric surgery development of cholelithiasis was 10.53 %; individually, it was 8.42 % in LSG group, 13.4 % in LRYGB group and 12.7 % in MGB patients. The incidence of symptomatic cholelithiasis requiring surgery was 1.94 % after LSG, 4.54 % after LRYGB and 4.25 % after MGB. Post-surgery, six patients developed choledocholithiasis. In our post-bariatric group, the 33 patients who developed symptomatic stones had percentage total weight loss of 30.99 + 4.1 (P < 0.001). The average time period for readmission of symptomatic patient was 11.26 + 2.67 months.

CONCLUSIONS

We recommend routine synchronous cholecystectomy with bariatric procedure. In spite of synchronous cholecystectomy, incidence of cholelithiasis in our post-bariatric patient is 10.53 % of which up to one third were symptomatic and required surgery, and incidence of choledocholithiasis is comparable to that of general population.

Gastrointestinal Complications of Obesity

Obesity usually is associated with morbidity related to diabetes mellitus and cardiovascular diseases. However, there are many gastrointestinal and hepatic diseases for which obesity is the direct cause (eg, nonalcoholic fatty liver disease) or is a significant risk factor, such as reflux esophagitis and gallstones. When obesity is a risk factor, it may interact with other mechanisms and result in earlier presentation or complicated diseases. There are increased odds ratios or relative risks of several gastrointestinal complications of obesity: gastroesophageal reflux disease, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Gastroenterologists are uniquely poised to participate in the multidisciplinary management of obesity as physicians caring for people with obesity-related diseases, in addition to their expertise in nutrition and endoscopic interventions.

Persistent organic pollutants in adipose tissue should be considered in obesity research

Although low doses of persistent organic pollutants (POPs), strong lipophilic chemicals with long half-lives, have been linked to various endocrine, immune, nervous and reproductive system diseases, few obesity studies have considered adipose tissue as an important POPs exposure source. Because the toxicodynamics of POPs relate directly to the dynamics of adiposity, POPs might explain puzzling findings in obesity research. In two people exposed to the same amounts of environmental POPs, the one having more adipose tissue may be advantaged because POPs storage in adipose tissue can reduce burden on other critical organs. Therefore, adipose tissue can play a protective role against the POPs effects. However, two situations increase the POPs release from adipose tissue into the circulation, thereby increasing the risk that they will reach critical organs: (i) weight loss and (ii) insulin resistance. In contrast, weight gain reduces this possibility. Therefore, avoiding harmful health effects of POPs may mostly contradict conventional judgments about obesity and weight change. These contradictory situations can explain the obesity paradox, the adverse effects of intensive intentional weight loss and the protective effects of obesity against dementia. Future studies should consider that adipose tissue is widely contaminated with POPs in modern society.

Nutrition Interventions for Obesity

Obesity is a common disorder with complex causes. The epidemic has spurred significant advances in the understanding of nutritional approaches to treating obesity. Although the primary challenge is to introduce a dietary intake that creates an energy deficit, clinicians should also consider targeted risk factor modification with manipulation of the nutrient profile of the weight-reducing diet. These strategies produce significant weight loss and improvements in cardiometabolic risk factors. Future research is needed to better understand how to personalize nutrient prescriptions further to promote optimal risk modification and maintenance of long-term energy balance in the weight-reduced state.

Fruit and vegetable consumption and risk of cholecystectomy: a prospective cohort study of women and men

Purpose

Epidemiologic data on whether consumption of fruit and vegetables (FVs) decreases the risk of gallstone disease are sparse. Therefore, we examined the association between FV consumption and the 14-year risk of symptomatic gallstone disease (defined as occurrence of cholecystectomy) in a large group of middle-aged and elderly persons.

Methods

Data from two population-based cohorts were used, which included 74,554 men and women (born 1914–1952). Participants filled in a food frequency questionnaire in the late fall of 1997 and were followed up for cholecystectomy between 1998 and 2011 via linkage to the Swedish Patient Register. Cox regression models were used to obtain hazard ratios (HRs).

Results

During 939,715 person-years of follow-up, 2120 participants underwent a cholecystectomy (1120 women and 1000 men). An inverse association between FV consumption and risk of cholecystectomy was observed in age- and sex-adjusted analyses (P_trend = .036) but not in confounder-adjusted analyses (P_trend = .43). The multivariable-adjusted HR was 0.95 (95 % CI 0.83–1.08) for the highest compared with the lowest sex-specific quartile of FV consumption. There was no evidence of interactions with age (P = .25) or sex (P = .72) in analyses pooled by sex. However, an age-by-FV consumption interaction was observed in separate analyses of women (P = .010), with decreased HRs of cholecystectomy for ages up to 60 years.

Conclusions

This study supports an inverse association between FV consumption and risk cholecystectomy in women, although the association was restricted to women aged 48–60 years. In contrast, the study does not support an association in men.

Electronic supplementary material

The online version of this article (doi:10.1007/s00394-016-1298-6) contains supplementary material, which is available to authorized users.

The Effectiveness of Screening for Obesity in Primary Care: Weighing the Evidence

In response to growing alarm about the increase in the prevalence of obesity in the United States, several organizations have recommended that physicians screen their adult patients for this condition and initiate treatment. Screening can be an effective intervention when the condition is grave and prevalent, when an accurate test exists, when effective treatment exists, when the screening program itself does not pose undue risks, and when early detection and treatment improve outcomes. This article critically reviews the evidence supporting these criteria in the case of obesity in adults. It extends previous reviews by assessing the potential impact that uncertainties in the evidence base may have on the effectiveness a screening program. It also examines the feasibility of such a program. We conclude that following the recommendation to screen all adults for obesity is unlikely to improve outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Obesity in Women: The Clinical Impact on Gastrointestinal and Reproductive Health and Disease Management

Approximately 36% of adult women in the United States are obese. Although obesity affects women similarly to men in terms of prevalence, there seem to be gender-specific differences in the pathophysiology, clinical manifestations, and treatment of obesity. Obesity is linked to comorbid diseases involving multiple organ systems, including the gastrointestinal tract, like gastroesophageal reflux disease, fatty liver disease, and gallstones. This article focuses on obesity in women, specifically the impact of obesity on gastrointestinal diseases and reproductive health, as well as the treatment of obesity in women.

Gallstones

Gallstones grow inside the gallbladder or biliary tract. These stones can be asymptomatic or symptomatic; only gallstones with symptoms or complications are defined as gallstone disease. Based on their composition, gallstones are classified into cholesterol gallstones, which represent the predominant entity, and bilirubin ('pigment') stones. Black pigment stones can be caused by chronic haemolysis; brown pigment stones typically develop in obstructed and infected bile ducts. For treatment, localization of the gallstones in the biliary tract is more relevant than composition. Overall, up to 20% of adults develop gallstones and >20% of those develop symptoms or complications. Risk factors for gallstones are female sex, age, pregnancy, physical inactivity, obesity and overnutrition. Factors involved in metabolic syndrome increase the risk of developing gallstones and form the basis of primary prevention by lifestyle changes. Common mutations in the hepatic cholesterol transporter ABCG8 confer most of the genetic risk of developing gallstones, which accounts for ∼25% of the total risk. Diagnosis is mainly based on clinical symptoms, abdominal ultrasonography and liver biochemistry tests. Symptoms often precede the onset of the three common and potentially life-threatening complications of gallstones (acute cholecystitis, acute cholangitis and biliary pancreatitis). Although our knowledge on the genetics and pathophysiology of gallstones has expanded recently, current treatment algorithms remain predominantly invasive and are based on surgery. Hence, our future efforts should focus on novel preventive strategies to overcome the onset of gallstones in at-risk patients in particular, but also in the population in general.

Predictive factors of biliary complications after bariatric surgery

BACKGROUND

Obesity and rapid weight loss are risk factors for gallstone development. Bariatric surgery and significant postoperative weight loss are associated with postoperative biliary complications.

OBJECTIVE

We aim to identify predictive factors of biliary complications after bariatric surgery.

SETTING

University hospital.

METHODS

After Institutional Review Board approval, charts at a single institution were reviewed to identify patients with biliary complications after bariatric surgery from 2005 to 2012. Data collected included baseline patients demographic characteristics, perioperative parameters, and postoperative biliary complications. Parameters were analyzed using paired and unpaired Student t test for continuous variables and χ² test for categorical variables. Univariate and multivariate analyses were used to assess risk factors for complications after bariatric surgery. All tests were 2 tailed; results with P<.05 were considered statistically significant.

RESULTS

One hundred thirty-eight (3.6%) of 3765 patients who underwent bariatric surgery developed postoperative biliary complications. Mean time from surgery to biliary complication was 1.8±1.4 years. Complications included acute cholecystitis (18.1%), chronic cholecystitis (70.2%), acute pancreatitis (9.4%), choledocholithiasis (5.7%), and jaundice (2.8%). Interventions were laparoscopic (n = 134, 97.0%) and open (n = 1, .7%) cholecystectomy. Forty patients (28.9%) had known cholelithiasis before surgery. There were no mortalities. Univariate analysis identified female gender, age>50, cholelithiasis at time of bariatric procedure, and Roux-en-Y gastric bypass independent of excess weight loss as predictive factors of biliary complications. Multivariate analysis confirmed advanced age as an independent predictive factor.

CONCLUSION

The results of our study suggest that patients of advanced age are at higher risk of biliary complications. However, the indications for prophylactic cholecystectomy at time of bariatric surgery remain unclear.

Effectiveness of a Medifast meal replacement program on weight, body composition and cardiometabolic risk factors in overweight and obese adults: a multicenter systematic retrospective chart review study

BACKGROUND

Recent medical guidelines emphasize the importance of actively treating overweight and obesity with diet and lifestyle intervention to achieve ≥ 5% weight loss in a 6-month period. Commercial programs offer one approach provided there is evidence of their efficacy and safety. This study was conducted to evaluate the effectiveness of the Medifast® 4 & 2 & 1 Plan™ on weight loss, body composition and cardiometabolic risk factors in overweight and obese adults.

METHODS

A systematic retrospective chart review of 310 overweight and obese clients following the Medifast 4 & 2 & 1 Plan at one of 21 Medifast Weight Control Centers® was conducted. Data were recorded electronically and key data points were independently verified. The primary endpoint was change from baseline body weight at 12 weeks. Within group paired t-tests were used to examine changes from baseline in a completers population. Differences between gender and age subgroups were examined using bivariate t-tests and mixed model regression analyses.

RESULTS

For the primary endpoint at 12 weeks, body weight among completers (n = 185) was reduced by a mean of 10.9 ± 5.6 kg (-10.1%, p < 0.0001), and at 24 weeks (n = 81) mean weight was reduced by 16.0 ± 7.9 kg (-14.3%). At 12 and 24 weeks, 85% and 96% of those remaining on the plan, respectively, had lost ≥ 5% of their baseline body weight. Lean mass was preserved to within 5% of baseline throughout the 24 weeks, and fat mass represented ≥ 80% of the body weight lost from 12 weeks onward. Men, women, seniors (≥ 65 years), and non-seniors (<65 years) all had significant weight reductions with preservation of lean mass. Significant improvements in blood pressure, pulse and waist-to-hip ratio were observed. Mean weight regain among the subset who entered a formal maintenance phase was <2% during an average follow-up of 34 weeks. The meal plan was well tolerated, and program adherence was >85%.

CONCLUSIONS

The 4 & 2 & 1 Plan used at Medifast Weight Control Centers was effective for weight loss, preservation of lean mass and improvement in cardiometabolic risk factors. The plan was generally well tolerated in a broad population of overweight and obese adults. #NCT02150837.

Non-alcoholic fatty liver disease associated with gallstones in females rather than males: a longitudinal cohort study in Chinese urban population

Background

Whether non-alcoholic fatty liver disease (NAFLD) is a risk factor for gallstones remains uncertain. Few longitudinal or cohort studies have been used to identify this relationship. The aim of this study was to confirm the association between NAFLD and gallstones in a longitudinal cohort of urban dwellers in China.

Methods

To elucidate the association between NAFLD and gallstones, we fitted a generalized estimating equation (GEE) model in a large-scale longitudinal cohort over 6 years, which included 11,200 participants with at least three regular health check-ups.

Results

A total of 498 cases of gallstones occurred during the 6-year follow-up, which resulted in a total incidence density of 12.73 per 1000 person-years (498/39, 135.5 person-years). The GEE analyses confirmed and clarified the association between NAFLD and gallstones (relative risk (RR) = 1.2381, 95% confidence interval (CI) = 1.003–1.528, P = 0.047) after adjusting for other potential confounding factors, especially in females (RR = 1.707, 95% CI = 1.245–2.341, P = 0.001).

Conclusions

NAFLD is associated with gallstones in an urban Chinese population from the middle to upper socioeconomic strata. Moreover, this association is more strongly apparent in females than in males. Further cohort studies must be conducted to confirm this association in the general population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-014-0213-y) contains supplementary material, which is available to authorized users.