Gallbladder carcinosarcoma with a poor prognosis: A case report

BACKGROUND

Carcinosarcoma of the gallbladder is a rare malignant tumor with a very poor prognosis. To date, only approximately 100 patients have been reported in the English literature. The prognosis of this tumor type is poor, the preoperative diagnosis is difficult, and there is a possibility of a misdiagnosis. We present an unsuccessful case of carcinosarcoma of the gallbladder with a preoperative misdiagnosis and rapid early postoperative recurrence. Therefore, we have a deeper understanding of the poor prognosis of gallbladder carcinosarcoma (GBC) patients.

CASE SUMMARY

The patient is a 65-year-old male. He was admitted to the hospital because of right upper abdomen distending pain and discomfort for half a month. Abdominal magnetic resonance imaging revealed a polycystic mass in the right lobe of the liver and the fossa of the gallbladder. After admission, the patient was diagnosed with a liver abscess, which was treated by abscess puncture drainage. Obviously, this treatment was unsuccessful. Hepatectomy and cholecystectomy were performed one month after the puncture. Postoperative pathologic examination revealed carcinosarcoma of the gallbladder, and the resected specimen contained two tumor components. One month after surgery, the patient's tumor recurred in situ and started to compress the duodenum, resulting in duodenal obstruction and bleeding. The treatment was not effective. The patient died of gastrointestinal hemorrhage and hypovolemic shock.

CONCLUSION

Carcinosarcoma of the gallbladder is a rare malignant tumor that is easily misdiagnosed preoperatively and has a poor prognosis.

The Accuracy of Point-of-Care Ultrasound in the Detection of Gallbladder Disease: A Meta-analysis

RATIONALE AND OBJECTIVES

The aim of this meta-analysis was to systematically assess the diagnostic value of point of care ultrasound (POCUS) in the detection of gallbladder diseases.

MATERIALS AND METHODS

Pubmed, Web of Science, Embase, and the Cochrane Library were searched for studies up to May 22, 2023. Pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio, diagnostic odds ratio, area under the curve of summary receiver operating characteristic were calculated using the bivariate model. Subgroup analysis based on cholecystitis and cholelithiasis was conducted.

RESULTS

A total of seven studies with 1464 participants were identified in this meta-analysis. The pooled sensitivity of POCUS for the detection of gallbladder disease was 0.86 (95% CI: 0.75, 0.93) and the pooled specificity was 0.92 (95% CI: 0.87, 0.96). The pooled sensitivity and specificity of POCUS for the detection of acute cholecystitis were 0.73 (95% CI: 0.55, 0.86) and 0.93 (95% CI: 0.82, 0.98). The pooled sensitivity and specificity of POCUS for the detection of gallstones were 0.94 (95% CI: 0.91, 0.96) and 0.93 (95% CI: 0.91, 0.95).

CONCLUSION

POCUS was a favorable modality for the detection of patients suspected of gallbladder disease, especially for cholelithiasis. Physicians are advised to use POCUS in clinical practice as a non-invasive test to detect gallbladder disease.

Effectiveness of double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (DBE-ERCP): A multicenter real-world study

BACKGROUND AND AIMS

To investigate the effectiveness of double-balloon enteroscope-assisted retrograde cholangiopancreatography (DBE-ERCP) in patients with gastrointestinal surgically altered anatomy (SAA).

METHODS

From May 2013 to October 2021, all consecutive patients undergoing DBE-ERCP in three gastroenterological referral centers in Northern Italy were enrolled in the study. Patients were assessed regarding their medical history, previous surgery, time from previous surgery to the DBE-ERCP procedure, and the success or failure of DBE-ERCP.

RESULTS

Fifty-three patients (60% men, median age 65 (23-89) years) undergoing 67 DBE-ERCP procedures (1-3 DBE-ERCP per patient) were enrolled. Reasons for SAA included orthotopic liver transplantation (23%), ulcers (15%), malignancies (43%), difficult cholecystectomy (17%), and other causes (2%). Types of surgery included Roux-en-Y biliodigestive anastomosis (45%), Roux-en-Y gastrectomy (32%), pancreaticoduodenectomy (17%), and Billroth II gastrectomy (6%). The overall DBE-ERCP success rate was 86%. The type of surgery, indications, and the length of time between previous surgery and DBE-ERCP were not statistically associated with DBE-ERCP success. The DBE-ERCP success rate increased from 2018 to 2021.

CONCLUSIONS

DBE-ERCP is a successful procedure in challenging patients with SAA. The improvement in results over time indicates the necessity of adequate training and of centralizing patients in referral centers.

Gallbladder disease is associated with the risk of cardiovascular disease among Uyghurs in Xinjiang: a prospective cohort study

BACKGROUND

Gallbladder disease (GBD) can increase the risk of cardiovascular disease (CVD). However, GBD has rarely been reported in the less developed, rural areas of Xinjiang. This study aimed to determine the prevalence of GBD and incidence of CVD in a prospective cohort study in rural Xinjiang. Moreover, the study aimed to explore the association between GBD and CVD within this cohort.

METHODS

The study cohort included 11,444 Uyghur adults in Xinjiang, 3^rd division, from the 51st Mission. Study groups were classified according to whether GBD was present or absent at baseline. The occurrence of CVD was the end event. Demographic, anthropometric, and biochemical data were recorded, and the incidence of CVD in the GBD and non-GBD groups analysed. Cox proportional hazards regression models were used to assess the association between GBD and CVD and factors associated with their incidence. Several subgroup analyses were performed to assess CVD incidence in different subgroups. The interaction between GBD and cardiometabolic risk factors, and subsequent risk of developing CVD, was evaluated.

RESULTS

Prevalence of GBD in the study cohort was 10.29%. After a median follow-up of 4.92 years, the cumulative incidence of CVD in the study cohort was 10.49%, 8.43% in males and 12.65% in females. CVD incidence was higher in the GBD group (34.04% vs. 7.78%, HR = 4.96, 95% CI: 4.40-5.59). After multivariate adjustment, the risk of CVD remained higher in the GBD group (HR = 2.89, 95% CI: 2.54-3.29). Subgroup analyses showed male sex, smoking, alcohol consumption, lack of exercise, and abnormal renal function were all associated with increased risk of CVD. Moreover, the risk of CVD was markedly higher in GBD combined with cardiometabolic risk factors (hypertension, T2DM, dyslipidaemia, overweight, and abdominal obesity), than in cardiometabolic risk factors alone and this was higher in the GBD group than in the non-GBD group regardless of whether cardiometabolic risk factors were combined.

CONCLUSION

GBD is an important independent risk factor for CVD development. Awareness of these associations will raise concerns among clinicians about the risk of cardiovascular disease in patients with GBD.

Do current imaging modalities accurately depict the severity of final pathology?

BACKGROUND

Accuracy of imaging modalities for gallbladder disease(GBD) remains questionable. We hypothesize ultrasonography(US), computed tomography(CT), and magnetic resonance imaging(MRI) poorly correlate with final pathologic analysis.

METHODS

This was a retrospective review of all patients who underwent cholecystectomy at our institution. Primary outcome was agreement between US, CT, and MRI, and final pathology report of the gallbladder. Cohen's Kappa statistic was used to describe the level of agreement (0 = agreement equivalent to chance, 0.1-0.2 = slight agreement, 0.21-0.40 = minimal/fair agreement, 0.41-0.60 = moderate agreement, 0.61-0.80 = substantial agreement, 0.81-0.99 = near perfect agreement, 1 = perfect agreement). Significance was set at p < 0.05.

RESULTS

1107 patients were enrolled. Average age was 48.6(±17.6); 64.2% were female. There was minimal agreement between the three imaging modalities and final pathology (US = 0.363; CT = 0.223; MRI = 0.351;p < 0.001).

CONCLUSION

Poor agreement exists between imaging modalities and final pathology report for GBD. Urgent surgical intervention for patients presenting with symptoms of GBD should be considered, despite imaging results.

Obesity, Adiposity, and Risk of Symptomatic Gallstone Disease According to Genetic Susceptibility

BACKGROUND & AIMS

Adiposity has been consistently associated with gallstone disease risk. We aimed to characterize associations of anthropometric measures (body mass index [BMI], recent weight change, long-term weight change, waist circumference, and waist-to-hip ratio) with symptomatic gallstone disease according to strata of gallstone disease polygenic risk score (PRS).

METHODS

We conducted analysis among 34,626 participants with available genome-wide genetic data within 3 large, prospective, U.S. cohorts-the Nurses' Health Study (NHS), Health Professionals Follow-Up Study, and NHS II. We characterized joint associations of PRS and anthropometric measures and tested for interactions on the relative and absolute risk scales.

RESULTS

Women in the highest BMI and PRS categories (BMI ≥30 kg/m² and PRS ≥1 SD above mean) had odds ratio for gallstone disease of 5.55 (95% confidence interval, 5.29 to 5.81) compared with those in the lowest BMI and PRS categories (BMI <25 kg/m² and PRS <1 SD below the mean). The corresponding odds ratio among men was 1.65 (95% confidence interval, 1.02 to 2.29). Associations for BMI did not vary within strata of PRS on the relative risk scale. On the absolute risk scale, the incidence rate difference between obese and normal-weight individuals was 1086 per 100,000 person-years within the highest PRS category, compared with 666 per 100,000 person-years in the lowest PRS category, with strong evidence for interaction with the ABCG8 locus.

CONCLUSIONS

While maintenance of a healthy body weight reduces gallstone disease risk among all individuals, risk reduction is higher among the subset with greater genetic susceptibility to 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.

Diagnostic performance of endoscopic ultrasound-artificial intelligence using deep learning analysis of gallbladder polypoid lesions

BACKGROUND AND AIM

Endoscopic ultrasound (EUS) is the most accurate diagnostic modality for polypoid lesions of the gallbladder (GB), but is limited by subjective interpretation. Deep learning-based artificial intelligence (AI) algorithms are under development. We evaluated the diagnostic performance of AI in differentiating polypoid lesions using EUS images.

METHODS

The diagnostic performance of the EUS-AI system with ResNet50 architecture was evaluated via three processes: training, internal validation, and testing using an AI development cohort of 1039 EUS images (836 GB polyps and 203 gallstones). The diagnostic performance was verified using an external validation cohort of 83 patients and compared with the performance of EUS endoscopists.

RESULTS

In the AI development cohort, we developed an EUS-AI algorithm and evaluated the diagnostic performance of the EUS-AI including sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. For the differential diagnosis of neoplastic and non-neoplastic GB polyps, these values for EUS-AI were 57.9%, 96.5%, 77.8%, 91.6%, and 89.8%, respectively. In the external validation cohort, we compared diagnostic performances between EUS-AI and endoscopists. For the differential diagnosis of neoplastic and non-neoplastic GB polyps, the sensitivity and specificity were 33.3% and 96.1% for EUS-AI; they were 74.2% and 44.9%, respectively, for the endoscopists. Besides, the accuracy of the EUS-AI was between the accuracies of mid-level (66.7%) and expert EUS endoscopists (77.5%).

CONCLUSIONS

This newly developed EUS-AI system showed favorable performance for the diagnosis of neoplastic GB polyps, with a performance comparable to that of EUS endoscopists.

Triple cancer of gallbladder, common bile duct and papilla of Vater: Report of a case and review of literature

INTRODUCTION AND IMPORTANCE

Synchronous malignancies of gallbladder and biliary tree are together rare entity whose pathogenesis is yet unknown. We report the case of a triple synchronous cancer of 3 distinct location: gallbladder, common bile duct (CBD) and papilla of Vater.

CASE PRESENTATION

An 84-years-old woman, was admitted to our Hospital with clinics features of obstructive jaundice. Dilatation of the biliary tree and CBD without evidence of gallstones was seen at US. CT scan confirmed distal CBD obstruction. An endo-US showed a nodule of the head of pancreas infiltrating the lower CBD. Finally, hepatic-MRI displayed a gallbladder malignancy with invasion of CBD. Preoperative staging showed 3 diagnostic suspicions: carcinoma of CBD on CT, pancreatic carcinoma on endo-US and malignancy of gallbladder on MRI. A cephalic duodenopancreatectomy and radical gallbladder resection was performed. Final pathology revealed 3 distinct location of moderately differentiated adenocarcinomas: Gallbladder, CBD and Vater's papilla. Microscopic examination didn't detect any direct continuity between the 3 tumors. Metastases were identified in the pancreaticoduodenal, peri-hepatic and peri-gastric lymph nodes.

CLINICAL DISCUSSION

Literature displayed 22 cases of synchronous malignancies of gallbladder and CBD and 1 case of triple cancer with associated Vater's papilla carcinoma. In most of these cases, an association with an anomalous pancreatic-bile duct junction was reported. Although the real incidence remain unknown, it was reported to occur in 5-10% of CBD cancers.

CONCLUSION

Suspicion of such combination of cancer should be remembered, especially when preoperative investigations don't allow a precise localization of tumor in the biliary tree.

Gallbladder cancer: Historical treatment and new management options

Gallbladder cancer is a rare, aggressive malignancy that has a poor overall prognosis. Effective treatment consists of early detection and surgical treatment. With the wide spread treatment of gallbladder disease with minimally invasive techniques, the rate of incidental gallbladder cancer has seen an equitable rise along with stage migration towards earlier disease. Although the treatment remains mostly surgical, newer modalities such as regional therapy as well as directed therapy based on molecular medicine has led to improved outcomes in patients with advanced disease. We aim to summarize the management of gallbladder cancer along with the newer developments in this formidable disease process.

Laparoscopic cholecystectomy for left-sided gallbladder

PURPOSE

Left-sided gallbladder (LSGB) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament without situs inversus. We retrospectively analyzed 13 patients diagnosed with LSGB in a single center to confirm the safety of laparoscopic cholecystectomy (LC) and reviewed the anatomical implications in those patients.

METHODS

Of the 4910 patients who underwent LC for the treatment of gallbladder disease between August 2007 and December 2019, 13 (0.26%) were diagnosed as having LSGB. We retrospectively analyzed these 13 patients for general characteristics, perioperative outcomes, and other variations through the perioperative imaging workups.

RESULTS

All patients underwent LC for gallbladder disease. In all cases, the gallbladder was located on the left side of the falciform ligament. The operation was successfully performed with standard four-trocar technique, confirming "critical view of safety (CVS)" as usual without two cases (15.4%). In one case, which had an intraoperative complication and needed choledochojejunostomy because of common bile duct injury, there was an associated variation with early common bile duct bifurcation. The other patient underwent an open conversion technique because of severe fibrosis in the Calot's triangle. Furthermore, on postoperative computed tomography, abnormal intrahepatic portal venous branching was found in all cases.

CONCLUSIONS

Although LSGB is usually encountered by chance during surgery, it can be successfully managed through LC with CVS. However, surgeons who find LSGB have to make efforts to be aware of the high risk of bile duct injury and possibility of associated anomalies.

Endoscopic gallbladder drainage for symptomatic gallbladder disease: a cumulative systematic review meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided transmural or endoscopic retrograde cholangiography (ERC)-based transpapillary drainage may provide alternative treatment strategies for high-risk surgical candidates with symptomatic gallbladder (GB) disease. The primary aim of this study was to perform a systematic review and meta-analysis to investigate the efficacy and safety of endoscopic GB drainage for patients with symptomatic GB disease.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed in accordance with PRISMA and MOOSE guidelines. Pooled proportions were calculated for measured outcomes including technical success, clinical success, adverse event rate, recurrence rate, and rate of reintervention. Subgroup analyses were performed for transmural versus transpapillary, transmural lumen apposing stent (LAMS), and comparison to percutaneous transhepatic drainage. Heterogeneity was assessed with I² statistics. Publication bias was ascertained by funnel plot and Egger regression testing.

RESULTS

Thirty-six studies (n = 1538) were included. Overall, endoscopic GB drainage achieved a technical and clinical success of 87.33% [(95% CI 84.42-89.77); I² = 39.55] and 84.16% [(95% CI 80.30-87.38); I² = 52.61], with an adverse event rate of 11.00% [(95% CI 9.25-13.03); I² = 7.08]. On subgroup analyses, EUS-guided transmural compared to ERC-assisted transpapillary drainage resulted in higher technical and clinical success rates [OR 3.91 (95% CI 1.52-10.09); P = 0.005 and OR 4.59 (95% CI 1.84-11.46); P = 0.001] and lower recurrence rate [OR 0.17 (95% CI 0.06-0.52); P = 0.002]. Among EUS-guided LAMS studies, technical success was 94.65% [(95% CI 91.54-96.67); I² = 0.00], clinical success was 92.06% [(95% CI 88.65-94.51); I² = 0.00], and adverse event rate was 11.71% [(95% CI 8.92-15.23); I² = 0.00]. Compared to percutaneous drainage, EUS-guided drainage possessed a similar efficacy and safety with significantly lower rate of reintervention [OR 0.05 (95% CI 0.02-0.13); P < 0.001].

DISCUSSION

Endoscopic GB drainage is a safe and effective treatment for high-risk surgical candidates with symptomatic GB disease. EUS-guided transmural drainage is superior to transpapillary drainage and associated with a lower rate of reintervention compared to percutaneous transhepatic drainage.

Association between the use of hormonal contraceptives and risk of cholecystectomy in women of reproductive age

PURPOSE

Previous studies have indicated an increased risk of gallbladder disease with hormonal contraceptives although with discordant results. The potential increased risk of gallbladder disease with hormonal contraceptives is concerning given that women are at increased risk of this disease. Thus, the aim of this study was to examine risk of surgery-confirmed gallbladder disease (cholecystectomy) with oral contraceptives, intrauterine devices, and injectable hormonal contraceptives.

METHODS

We conducted a retrospective cohort study. Females aged 15-45 who initiated hormonal contraceptive use were identified in the United States IQVIA Ambulatory electronic medical record database between 2008 and 2018. Cox proportional hazards models were used to estimate adjusted hazards ratios and 95% confidence intervals for cholecystectomy with eight formulations of contraceptives compared with levonorgestrel and ethinyl estradiol combined oral contraceptive. Sensitivity analysis was conducted by lagging exposure by 90 days and by excluding patients with history of gallbladder disease. Secondary analyses were conducted by cumulative duration of use.

RESULTS

We identified 1,425,821 females who initiated the use of hormonal contraceptives and generated 4417 cholecystectomy events. Overall, the use of medroxyprogesterone acetate (HR: 1.22, 95% CI: 1.07-1.40) and at least 1 year of levonorgestrel intrauterine device use (HR: 1.74: 95% CI: 1.19-2.54) were associated with increased risk of cholecystectomy when compared with levonorgestrel and ethinyl estradiol combined oral contraceptive. However, we did not observe an increased risk with other hormonal contraceptives. Consistent results were observed across sensitivity analyses.

CONCLUSION

In this large population-based study, there was an increased risk of cholecystectomy with medroxyprogesterone acetate and intrauterine device but not other hormonal contraceptives. Additional large observational studies are required to corroborate these findings.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis

BACKGROUND

Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP.

METHODS

FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost.

RESULTS

During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs.

CONCLUSIONS

In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Emergency General Surgery and the Gallbladder: The Affordable Care Act's Impact on Practice Patterns

BACKGROUND

Gallbladder disease frequently requires emergency general surgery (EGS). The Affordable Care Act (ACA) mandated health insurance coverage for all with the intent to improve access to care and decrease morbidity, mortality, and costs. We hypothesize that after the ACA open-enrollment in 2014 the number of EGS cholecystectomies decreased as access to care improved with a shift in EGS cholecystectomies to teaching institutions.

METHODS

A retrospective review of the National Inpatient Sample Database from 2012 to quarter 3 of 2015 was performed. Patients age 18-64, with a nonelective admission for gallbladder disease based on ICD-9 codes, were collected. Outcomes measured included cholecystectomy, complications, mortality, and wage index-adjusted costs. The effect of the ACA was determined by comparing preACA to postACA years.

RESULTS

189,023 patients were identified. In the postACA period the payer distribution for admissions decreased for Self-pay (19.3% to 13.6%, P < 0.001), Medicaid increased (26.3% to 34.0%, P < 0.001) and Private insurance was unchanged (48.6% to 48.7%, P = 0.946). PostACA, admissions to teaching hospitals increased across all payer types, EGS cholecystectomies decreased, while complications increased, and mortality was unchanged. Median costs increased significantly for Medicaid and Private insurance while Self-pay was unchanged. Based on adjusted DID analyses for Insured compared to Self-pay patients, EGS cholecystectomies decreased (-2.7% versus -1.21%, P = 0.033) and median cost increased more rapidly (+$625 versus +$166, P = 0.017).

CONCLUSIONS

The ACA has changed EGS, shifting the majority of patients to teaching institutions despite insurance type and decreasing the need for EGS cholecystectomy. The trend toward higher complication rate with increased overall cost requires attention.

Incidence of and risk factors for late cholecystectomy in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

Gallbladder disease and need for cholecystectomy are common and significant contributors to patient morbidity and healthcare costs. Childhood cancer survivors are at elevated risk for developing cholelithiasis. However, their incidence of and risk factors for late (>5 years from diagnosis) cholecystectomy have not been studied.

METHODS

A total of 25,549 survivors (median age at diagnosis 6.9 years, range 0-21.0; current age 30.7 years, range 5.6-65.9) diagnosed between 1970 and 1999 and 5037 siblings were queried for self-reported cholecystectomy occurring five or more years from primary cancer diagnosis. Piecewise exponential models evaluated associations between cancer treatment exposures and late cholecystectomy.

RESULTS

Over a median follow-up period of 21.9 and 26.0 years, respectively, 789 survivors and 168 siblings underwent late cholecystectomy (cumulative incidence 7.2%, 95% confidence interval [CI] = 6.5-7.8% and 6.6%, 95% CI = 5.4-7.6%, respectively; rate ratio [RR] = 1.3, 95% CI = 1.1-1.5). Compared with siblings, survivors of acute lymphoblastic leukaemia (RR = 1.4, 95% CI = 1.2-1.8), soft tissue sarcoma (RR = 1.4, 95% CI = 1.0-1.8) and bone cancer (RR = 1.3, 95% CI = 1.0-1.8) were at the greatest risk. In addition to attained age, female sex and increasing body mass index, exposure to high-dose (≥750 mg/m²) platinum chemotherapy (RR = 2.6, 95% CI = 1.5-4.5), vinca alkaloid chemotherapy (RR = 1.4, 95% CI = 1.1-1.8) or total body irradiation (TBI; RR = 2.2, 95% CI = 1.2-4.2) were each associated with late cholecystectomy.

CONCLUSIONS

Independent of traditional risk factors for gallbladder disease, exposure to high-dose platinum chemotherapy, vinca alkaloid chemotherapy or TBI increased risk for late cholecystectomy. These findings should inform current long-term follow-up guidelines and education regarding risk for late cholecystectomy.

Cholecystoenteric fistula with and without gallstone ileus: A case series

BACKGROUND

A cholecystoenteric fistula (CEF) is an uncommon complication of gallstone disease. The aim of this study was to present our experience of a series of patients with CEF, presenting with or without gallstone ileus, along with their surgical outcomes.

METHODS

From 2015 to 2018, 3245 consecutive patients underwent cholecystectomy for gallbladder disease at our institution, of which 15 were diagnosed with a CEF. All electronic medical records were retrospectively reviewed.

RESULTS

Fifteen patients presented with CEF. Ten patients presented cholecystoduodenal fistula, four patients cholecystocolonic, and one patient cholecystogastric counterparts. Twelve patients were female. The median patient age was 61 years (range 33-86 years). Five patients presented with gallstone ileus treated by laparotomy and enterolithotomy. In ten patients, a laparoscopic approach was attempted, but conversion to open surgery was necessary for eight of them. The median operative time was 140 min (range 60-240 min), and the median operative blood loss was 50 mL (range 10-600 mL). The procedure-related morbidity and mortality rates were 13.3% and 6.7%, respectively.

CONCLUSIONS

There is no consensus on the best treatment modality for a CEF, as the treatment outcome is mostly dependent on the surgeon's expertise and the patient's condition. Not all CEFs are accompanied by gallstone ileus. For such case, the main purpose is to resolve the intestinal obstruction and, unless necessary, avoidance of the gallbladder area.

High-Frequency of Computer Tomography and Surgery for Abdominal Pain After Roux-en-Y Gastric Bypass

INTRODUCTION

Acute, intermittent, and chronic abdominal pain is a common complaint after Roux-en-Y gastric bypass (RYGB).

OBJECTIVES

The aim of the study was to evaluate the use of medical imaging and the need for surgery treating abdominal pain after RYGB in a cohort with long-term follow-up.

METHODS

Data from 569 patients who underwent RYGB as the primary bariatric procedure at a public hospital in Norway between April 2004 and June 2011 were prospectively registered in a local quality registry for bariatric surgery. All abdominal imaging and abdominal surgical procedures were registered until August 2017.

RESULTS

Mean follow-up was 100 months (61-159). During the observation period, 22% had one CT, 9% had two CTs, 4% had three CTs, and 5% had four or more CTs for abdominal pain. Twenty-two percent underwent abdominal surgery, as 16% had one and 6% had two or more operations and gynecological procedures excluded. The purpose of operation was postoperative complications (1.4%), suspected internal herniation (9.3%), cholecystectomy (9.3%), appendectomy (2.3%), hernias (3.2%), and perforated ulcer in the gastrojejunal anastomosis (0.7%). Mean time interval was 42 ± 27 months from RYGB to cholecystectomy and 51 ± 26 months for suspected IH.

CONCLUSION

With a mean follow-up period of more than 8 years after RYGB, 40% of the patients suffered from abdominal pain, needing one or more CT scans. The need for surgery treating suspected internal hernia and cholecystectomy was equal, at 9.3% for both procedures, but the mean time from RYGB to operation was shorter for cholecystectomies.

Does pregnancy increase the risk of cholecystectomy following bariatric surgery? A cross-sectional cohort study

BACKGROUND

Reproductive-aged women constitute a substantial proportion of patients who undergo weight loss procedures. While the risk of gallstone disease after such procedures has been addressed extensively, the impact of pregnancy on gallstone disease after bariatric procedures has not been reported.

OBJECTIVES

To explore the effects of pregnancy on cholecystectomy rates after laparoscopic sleeve gastrectomy (LSG).

SETTING

A university hospital.

METHODS

A cross-sectional cohort study of reproductive aged women (18-45 yr) who underwent LSG. The association between pregnancy and cholecystectomy was evaluated with Cox regression analysis.

RESULTS

Of 1056 women of childbearing age who underwent LSG during 2006-2017, 128 (12.1%) subsequently experienced a pregnancy. Median follow-up durations were 3.9 and 4.9 years for women who did and did not conceive, respectively (P < .001). The median time from procedure to conception was 509 (374-1031) days. Overall, 117 (11.1%) women underwent cholecystectomy after LSG. The rate of cholecystectomy among those who conceived was higher than among those who did not (18.8% versus 10.0%, P = .005). In an unadjusted analysis, pregnancy was associated with an increased risk of cholecystectomy (hazard ratio [95% confidence interval]: 3.97 [2.58, 6.09], P < .0001). The association between pregnancy and cholecystectomy persisted after controlling for confounding factors (hazard ratio [95% confidence interval]: 3.82 [2.47, 5.92], P < .0001). Among those who experienced pregnancy, lower gestational weight gain was the only factor found to be associated with cholecystectomy after surgery (P = .05).

CONCLUSIONS

Pregnancy is associated with a 4-fold increased risk of cholecystectomy after LSG. Thus, the desire for future pregnancy should be considered before LSG.

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.

A Duplicated Gallbladder in a Patient Presenting with Acute Cholangitis. A Case Study and a Literature Review

Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a simple hepatobiliary surgical procedure. The case report of a 63-year-old woman who presented with cholangitis and underwent a successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Using ERCP, MRCP and 3D reconstructions the two cystic ducts with one common bile duct were identified. A review of the literature in referral of this variant, its anatomical classifications and significance to clinical and surgical practice is included. In conclusion, gallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder when evaluating radiologic studies. In case of surgery, preoperative diagnosis is essential to prevent possible biliary injuries or reoperation if accessory gallbladder has been overlooked during initial surgery. Laparoscopic cholecystectomy remains feasible for intervention can be safely done and awareness is necessary to avoid complications or multiple procedures.

Dedifferentiated liposarcoma of the gallbladder: first reported case

Background

Liposarcoma of the gallbladder is an extremely rare sarcoma, with only five cases reported in the literature according to our knowledge.

Case presentation

A 71-year-old woman was referred to the Surgical Oncology Division of Napoleão Laureano Hospital (João Pessoa, PB, Brazil) due to a solid mass at the right side of the abdomen and fever, with no signs of jaundice. Abdominal ultrasonography and computed tomography (CT) evidenced an extensive gallbladder lobular formation adhered to the inferior border of the right hepatic lobe and cholelithiasis. The CT report suggested gallbladder liposarcoma. A cholecystectomy associated with resection of segments IV-B and V of the liver were performed. Intraoperative frozen sections were compatible with gallbladder sarcoma. Anatomopathological examination and immunohistochemistry confirmed dedifferentiated liposarcoma with foci of heterologous leiomyosarcomatous differentiation and undifferentiated fusocellular areas of high histological grade.

Conclusion

This is the first case of dedifferentiated liposarcoma of the gallbladder to be reported.

Is Concomitant Cholecystectomy Necessary for Asymptomatic Cholelithiasis During Laparoscopic Sleeve Gastrectomy?

BACKGROUND

There is not any consensus on concomitant cholecystectomy for asymptomatic gallbladder stones during laparoscopic sleeve gastrectomy (LSG). The aim of this study was to evaluate the surveillance results of the LSG patients who have asymptomatic gallbladder stones and did not undergo cholecystectomy.

METHODS

Patients who underwent laparoscopic sleeve gastrectomy with preoperatively detected gallbladder stones and completed at least 6 months follow-up were included in the study. Concomitant cholecystectomy was performed for symptomatic patients while it was not performed for asymptomatic subjects. At the end of the follow-up time, symptoms and signs related to gallbladder disease were recorded. Clinical and demographic characteristics were compared between symptomatic and asymptomatic patients.

RESULTS

Between February 2012 and October 2016, 312 laparoscopic sleeve gastrectomies were performed. Among the patients, 24 were regarded as asymptomatic cholelithiasis, and cholecystectomy was not performed. The mean follow-up period was 27 (6-58) months. The mean preoperative BMI was 50.0 ± 7.6 kg/m², and at the end of the follow-up time, it decreased to 35.6 ± 8.8 kg/m². Five (20.8%) patients experienced biliary colic. Acute cholecystitis or obstructive jaundice was not observed in any of the patients. Characteristics of patients who developed symptomatic gallbladder disease (n = 5) were not significantly different from those of patients who remained asymptomatic (n = 19).

CONCLUSIONS

The risk of becoming symptomatic for asymptomatic cholelithiasis is very close to the healthy population after sleeve gastrectomy. Although further studies with a high number of cases are needed, we suggest only observation for asymptomatic gallbladder stones in patients who will undergo sleeve gastrectomy.

Screen-detected gallstone disease and autoimmune diseases - A cohort study

BACKGROUND

Gallstone disease is highly prevalent and is associated with systemic inflammation.

AIMS

To determine whether screen-detected gallstones or cholecystectomy are associated with the occurrence of autoimmune and autoinflammatory diseases and the most common subgroups thereof.

METHODS

A cohort study of three randomly selected general population samples from Copenhagen was performed. Participants (n = 5928) were examined in the period 1982-1992, underwent abdominal ultrasound examination to detect gallstone disease, and followed through national registers until December 2014 (median 24.7 years) for occurrence of immunological diseases. Multivariable Cox regression analyses were performed.

RESULTS

Gallstone disease was identified in 10% (591/5928) of participants, of whom 6.8% had gallstones and 3.2% had cholecystectomy at baseline. Gallstone disease was associated with incidence of autoimmune diseases (12.9% versus 7.92%; hazard ratio 1.46; 95% confidence interval [CI], [1.11;1.91]), diabetes mellitus type 1 (5.95% versus 3.67%; 1.53; [1.02;2.30]), and autoimmune thyroid disease (3.70% versus 1.59%; 2.06; [1.26;3.38]). Rheumatoid arthritis, autoinflammatory diseases, or any subgroups thereof were not associated.

CONCLUSIONS

In a large general population sample, screen-detected gallstone disease was associated with the development of autoimmune diseases during long-term follow-up. Future research efforts are needed to further explore common disease mechanisms.

Contrast-enhanced ultrasonography improves the diagnostic specificity for gallbladder-confined focal tumors

PURPOSE

To investigate the value of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of malignant and benign focal gallbladder diseases confined to the gallbladder wall.

METHODS

From July 2006 to May 2016, 88 patients (mean age 48.8 years; age range 18-77 years) were enrolled. All patients had focal gallbladder lesions confined to the gallbladder wall according to CEUS examination. The conventional ultrasound and CEUS characteristics of the lesions were evaluated, and diagnostic performance was evaluated via receiver-operating characteristic (ROC) analysis.

RESULTS

Multiple logistic regression analysis showed that three characteristics, an irregular shape, branched intralesional vessels and hypo-enhancement in the late phase, were features indicating a malignant gallbladder disease (all P < 0.05). When combining any two of these three features, diagnostic specificity improved from 51.5%-77.3% to 92.4% (P < 0.05 for all), and the area under the ROC (AUROC) curve improved from 0.735-0.874 to 0.917, without a significant loss of sensitivity.

CONCLUSIONS

CEUS features have greater specificity than those from conventional US for the differentiation of benign and malignant gallbladder diseases confined to the gallbladder wall, without a loss of sensitivity.

Gallbladder Nonvisualization in Cholecystectomy: A Factor for Conversion

Background and Objectives:

Many risk factors have been identified in minimally invasive cholecystectomies that lead to higher complications and conversion rates. No study that we encountered looked at nonvisualization of the gallbladder (GB) during surgery as a risk factor. We hypothesized that nonvisualization was associated with an increased risk of complications and could be an early intraoperative identifier of a higher risk procedure. Recognizing this could allow surgeons to be aware of potential risks and to be more likely to convert to open for the safety of the patient.

Methods:

We looked at minimally invasive cholecystectomies performed at our institution from January 2015 through April 2016 and had the performing resident fill out a survey after the surgery. Outcomes were conversion rates, intraoperative complications, and blood loss and were analyzed via Pearson χ² test or Mann-Whitney U test.

Results:

The primary outcome showed a conversion rate of 37% in nonvisualized GBs versus 0% in visualized (P = .001). Secondary outcomes showed significant differences in GB perforations (74% vs 13%, P = .001), omental vessel bleeding (16% vs. 0%, P = .005), and EBL (46 mL vs 29 mL, P = .001).

Conclusions:

Intraoperative nonvisualization of the GB after adequate positioning caused significantly increased risk of intraoperative complications and conversion. This knowledge could be useful during intraoperative assessment, to decide whether a case should be continued as a minimally invasive procedure or converted early to help reduce risk to the patient. Further randomized controlled studies should be performed to further demonstrate the value of this assessment.

Effect of socioeconomic inequalities on cholecystectomy outcomes: a 10-year population-based analysis

BACKGROUND

Although numerous epidemiological studies on cholecystectomy have been conducted worldwide, only a few have considered the effect of socioeconomic inequalities on cholecystectomy outcomes. Specifically, few studies have focused on the low-income population (LIP).

METHODS

A nationwide prospective study based on the Taiwan National Health Insurance dataset was conducted during 2003-2012. The International Classification of ICD-9-CM procedure codes 51.2 and 51.21-51.24 were identified as the inclusion criteria for cholecystectomy. Temporal trends were analyzed using a joinpoint regression, and the hierarchical linear modeling (HLM) method was used as an analytical strategy to evaluate the group-level and individual-level factors. Interactions between age, gender and SES were also tested in HLM model.

RESULTS

Analyses were conducted on 225,558 patients. The incidence rates were 167.81 (95% CI: 159.78-175.83) per 100,000 individuals per year for the LIP and 123.24 (95% CI: 116.37-130.12) per 100,000 individuals per year for the general population (GP). After cholecystectomy, LIP patients showed higher rates of 30-day mortality, in-hospital complications, and readmission for complications, but a lower rate of routine discharge than GP patients. The hospital costs and length of stay for LIP patients were higher than those for GP patients. The multilevel analysis using HLM revealed that adverse socioeconomic status significantly negatively affects the outcomes of patients undergoing cholecystectomy. Additionally, male sex, advanced age, and high Charlson Comorbidity Index (CCI) scores were associated with higher rates of in-hospital complications and 30-day mortality. We also observed that the 30-day mortality rates for patients who underwent cholecystectomy in regional hospitals and district hospitals were significantly higher than those of patients receiving care in a medical center.

CONCLUSION

Patients with a disadvantaged finance status appeared to be more vulnerable to cholecystectomy surgery. This result suggested that further interventions in the health care system are necessary to reduce this disparity.

Laparoscopic Cholecystectomy in Patients With History of Gastrectomy

Background and Objectives:

Patients with previous gastrectomy have an increased incidence of gallstones and gallbladder morbidity requiring surgery. We investigated the possible risk factors that contribute to severe gallbladder disease in patients with previous gastrectomy and the role of laparoscopic cholecystectomy (LC) in the treatment of these patients.

Methods:

In this retrospective study, we reviewed a database of patients who underwent LC in our hospital during the period January 1, 2010, through May 1, 2015.

Results:

The average operation time in patients with previous gastrectomy was longer (P < .05), but the operation times of patients with a long interval (>5 years) between gastrectomy and LC showed no statistical difference from those of patients without a history of gastrectomy (P > .05). The conversion rate did not differ between the 2 groups (P > .05), but in patients with previous gastrectomy, the conversion rate was significantly reduced after we adopted a comprehensive preoperative evaluation procedure (P < .05). The frequency of cholecystitis attacks, rate of combination with gallbladder polyps, and rate of combination with pancreatitis were higher and gallstone formation time shorter, in the patients with malignant tumor, those undergoing Billroth II gastroenterostomy or esophagojejunostomy, and those with accompanying diabetes mellitus or hypercholesterolemia (P < .05).

Conclusion:

LC plays an important role in the treatment of benign gallbladder diseases in patients with a history of gastrectomy, and a comprehensive preoperative evaluation and accomplished surgical technique are necessary for successful outcomes. Previously identified clinical features may represent a risk factor for severe cholecystic morbidity in these patients.

Is the male gender an independent risk factor for complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis?

This paper was designed to investigate the gender dependent risk of complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy is the standard procedure for benign gallbladder disorders. The role of gender as an independent risk factor for complicated laparoscopic cholecystectomy remains unclear. A retrospective single-center analysis of laparoscopic cholecystectomies performed for acute cholecystitis over a 5-year period in a community hospital was performed. Within the period of examination, 1884 laparoscopic cholecystectomies were performed. The diagnosis was acute cholecystitis in 779 cases (462 female, 317 male). The male group was significantly older (P = 0.001). Surgery lasted significantly longer in the male group (P = 0.008). Conversion was done in 35 cases (4.5%). There was no significant difference in the rate of conversion between both groups. However the rate of conversion was significantly higher in male patients > 65 years (P = 0.006). The length of postoperative hospital stay was significantly longer in the male group (P = 0.007), in the group > 65 years (P = 0.001) and following conversion to open surgery (P = 0.001). The male gender was identified as an independent risk factor for prolonged laparoscopic cholecystectomy on multivariate analysis. The male gender could be an independent risk factor for complicated or challenging surgery in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.

Single incision laparoscopic cholecystectomy in geriatric patients

BACKGROUND

Laparoscopy is a surgical approach recommended for the treatment of gall bladder disease. It is recommended also in geriatric patients. Recently Single Incision Laparoscopic Cholecystectomy (SILC) has been proposed to minimize surgical trauma, recovery and hospitalization time. However, the results and advantages of SILC in the geriatric population have received minimal attention. This case series review is focused on the results of SILC in the geriatric population.

METHODS

The records of 355 patients who had undergone SILC were reviewed. This report identifies, in the entire cohort, 40 patients aged 65 years or older at the time of surgery who will be the object of this study (geriatric series). Clinical outcomes and results were evaluated. Moreover, post-operative pain of the geriatric cohort was compared to that of the entire series.

RESULTS

SILC was successfully completed for 347 out of 355 patients of the entire series, with no mortality reported. In total SILC was converted to standard laparoscopy in 10 patients (2.2%) but never to open procedure. No significant difference was found between the total cohort and the geriatric series in terms of median time of operation (61.20 min vs 68.38 min). Post-operative pain was significantly lower in geriatric patients.

CONCLUSION

SILC is an effective and safe procedure for the treatment of gallbladder disease of elderly, also in terms of post-operative pain and it represents an alternative to the standard laparoscopic approach on a routine basis.

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.

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.

Safety of outpatient laparoscopic cholecystectomy in children: analysis of 2050 elective ACS NSQIP-pediatric cases

PURPOSE

Limited data exists evaluating the extent of utilization and safety of outpatient laparoscopic cholecystectomy (LC) in children. The aim of this study was to investigate the safety of outpatient LC in the pediatric population utilizing a national surgical quality improvement database.

METHODS

The National Surgical Quality Improvement Program-Pediatric (NSQIP-P) databases from 2012 and 2013 were queried to identify pediatric patients who underwent elective LC. Patients who underwent outpatient LC were compared with those who underwent inpatient LC. Outcomes of interest included 30-day overall morbidity, readmission, and reoperation.

RESULTS

A total of 2,050 LC were identified, 995 (48.5 %) were performed as an outpatient procedure and 1055 (51.5 %) as inpatient. Patients who underwent outpatient LC were more often white (79.6 vs. 69.2 %; p = <0.0001). Choledocholithiasis was more often treated in inpatient setting (12.5 vs. 1.7 %; p < 0.0001), while biliary dyskinesia was performed in outpatient setting (26.1 v. 12.6 %; p = 0.0001). Overall 30-day morbidity was greater in the inpatient group (2.5 vs. 0.8 %; p = 0.03). There were no differences in term of 30-day readmission rate and related reoperations (0.9 vs 0.3 % respectively; p = 0.09).

CONCLUSION

This analysis of a large multicenter dataset demonstrates that pediatric patients without significant associated comorbidities can safely undergo laparoscopic cholecystectomy as an outpatient procedure.

A case report of symptomatic gallbladder disease in the setting of peritoneal carcinomatosis originating from invasive lobular carcinoma of the breast

INTRODUCTION

Invasive lobular carcinoma is the second most common type of breast cancer, responsible for 5-15 percent of all cases. Peritoneal carcinomatosis secondary to breast cancer is a rare event, frequently resulting in morbidity and mortality. Symptomatic gallbladder disease in the setting of peritoneal carcinomatosis originating from invasive lobular carcinoma of the breast is a very rare event and is not well covered in literature.

PRESENTATION OF CASE

A 44year old female patient previously diagnosed with stage IV invasive lobular carcinoma of the left breast with widespread systemic metastases and peritoneal carcinomatosis presented with a three week history of right upper quadrant pain trigged by food intake only, greatly diminishing her quality of life. She had spent almost a year in a progression free disease status but was now suffering from debilitating symptomatic gallbladder disease. Despite the extent of her peritoneal carcinomatosis, she elected to undergo a laparoscopic cholecystectomy.

DISCUSSION

We are presenting a rare case of symptomatic gallbladder disease in the setting of peritoneal carcinomatosis secondary to invasive lobular carcinoma. A major concern is tumor load within nearby portal structures. Even though laparoscopic cholecystectomy could be a viable option to treat the condition, it needs to be applied selectively and very cautiously in the respective patient population.

CONCLUSION

Symptomatic gallbladder disease in the setting of peritoneal carcinomatosis secondary to invasive lobular carcinoma is an uncommon presentation to surgeons. A diagnostic laparoscopy is the preferred initial evaluation. If deemed feasible, and if the surgeon has the required experience, a laparoscopic cholecystectomy can be undertaken selectively.

Ultrasonography of gallbladder abnormalities due to schistosomiasis

After malaria, schistosomiasis remains the most important tropical parasitic disease in large parts of the world. Schistosomiasis has recently re-emerged in Southern Europe. Intestinal schistosomiasis is caused by most Schistosoma (S.) spp. pathogenic to humans and leads to chronic inflammation and fibrosis of the colon as well as to liver fibrosis. Gallbladder abnormalities usually occur in patients with advanced hepatic portal fibrosis due to Schistosoma mansoni infection. Occasionally, gallbladder abnormalities have been seen also in children and occurring without associated overt liver abnormalities.The specific S. mansoni-induced gallbladder abnormalities detectable by ultrasound include typical hyperechogenic wall thickening with external gallbladder wall protuberances. The luminal wall surface is smooth. The condition is usually clinically silent although some cases of symptomatic cholecystitis have been described. The ultrasonographic Murphy response is negative. Gallbladder contractility is impaired but sludge and calculi occur rarely. Contrary to other trematodes such as liver flukes, S. mansoni does not obstruct the biliary tract. Advanced gallbladder fibrosis is unlikely to reverse after therapy.

Diabetes mellitus and the risk of gallbladder disease: A systematic review and meta-analysis of prospective studies

BACKGROUND

Diabetes has been hypothesized to increase the risk of gallbladder disease based on the observation that obesity and insulin resistance are associated with gallbladder disease. Although several studies have investigated the association between a diabetes diagnosis and risk of gallbladder disease, the results have not been entirely consistent. For this reason we conducted a systematic review and meta-analysis of the available cohort studies.

MATERIALS AND METHODS

We searched the PubMed and Embase databases for studies of diabetes and gallbladder disease (defined as gallstones, cholecystectomy, or cholecystitis) up to January 9th 2015. Prospective studies were included if they reported relative risk estimates and 95% confidence intervals of gallbladder disease associated with a diabetes diagnosis. Summary relative risks were estimated by use of a random effects model.

RESULTS

We identified 10 prospective studies that could be included in the meta-analysis which included 223,651 cases among 7,365,198 participants. The summary RR for diabetes patients was 1.56 (95% CI: 1.26-1.93, I(2)=99.4%, pheterogeneity<0.0001). The results persisted when stratified by gender, and in most subgroup analyses and there was no heterogeneity among studies with more than 10 years duration of follow-up. There was no evidence of publication bias.

CONCLUSIONS

Our analysis provides further support for an increased risk of gallbladder disease among diabetes patients.

Tobacco smoking and the risk of gallbladder disease

Tobacco smoking has been inconsistently associated with gallbladder disease risk. To clarify the association we conducted a systematic review and meta-analysis of cohort studies published on the subject. We searched the PubMed and Embase databases for studies of smoking and gallbladder disease up to January 9th 2015. Prospective studies were included if they reported relative risk estimates and 95 % confidence intervals of gallbladder disease associated with current, former or ever smoking and by number of cigarettes per day. Summary relative risks were estimated by use of a random effects model. We identified ten prospective studies including 59,530 gallbladder disease cases among 4,213,482 participants that could be included in the meta-analysis. The summary RR was 1.19 (95 % CI 1.12-1.28, I(2) = 46.9 %, n = 6) for current smokers, 1.10 (95 % CI 1.07-1.13, I(2) = 0 %, n = 6) for former smokers and 1.15 (95 % CI 1.13-1.18, I(2) = 0 %, n = 7) for ever smokers. In the dose-response analysis the summary relative risk was 1.11 (95 % CI 1.08-1.14, I(2) = 33 %, n = 3) per 10 cigarettes per day and although there was indication of nonlinearity there was a dose-dependent positive association with increasing number of cigarettes smoked per day. The current meta-analysis provides evidence of an increased risk of gallbladder disease associated with tobacco smoking.

Body mass index, abdominal fatness and the risk of gallbladder disease

Epidemiological studies have indicated a positive association between adiposity and gallbladder disease risk, however, the shape of the dose-response relationship and differences between overall and abdominal adiposity remains to be clarified. We conducted a systematic review and dose-response meta-analysis of cohort studies of body mass index (BMI), waist circumference and waist-to-hip ratio and risk of gallbladder disease. PubMed and Embase databases were searched up to January 9th 2015. Summary relative risks were calculated using a random effects model. Seventeen prospective studies of BMI and gallbladder disease risk with 55,670 cases among 1,921,103 participants were included. The summary relative risk (RR) for a 5 unit increment in BMI was 1.63 (95 % CI 1.49-1.78, I(2) = 98 %). There was evidence of a nonlinear association overall and among women, p(nonlinearity) < 0.0001, but not among men, p(nonlinearity) = 0.99, with a slight flattening of the curve at very high BMI levels (BMI 40-45), however, the risk of gallbladder disease increased almost twofold even within the "normal" BMI range. The summary RR for a 10 cm increase in waist circumference was 1.46 (95 % CI 1.24-1.72, I(2) = 98 %, n = 5) and for a 0.1 unit increment in waist-to-hip ratio was 1.44 (95 % CI 1.26-1.64, I(2) = 92 %, n = 4). Associations were attenuated, but still significant, when BMI and abdominal adiposity measures were mutually adjusted. Our results confirm a positive association between both general and abdominal fatness and the risk of gallbladder disease. There is an almost twofold increase in the risk even within the "normal" BMI range, suggesting that even moderate increases in BMI may increase risk.

Is routine single-incision laparoscopic cholecystectomy feasible? A retrospective observational study

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) has been shown to be safe for uncomplicated gallbladder diseases. Routinely applying SILC is debatable.

METHODS

Two hundred SILCs were performed with single-incision multiple-port longitudinal-array and self-camera techniques.

RESULTS

Eighty-eight (44%) procedures were scheduled for complicated diseases. The routine group had a higher comorbidity rate, a lower preoperative endoscopic retrograde cholangiopancreatography rate, a higher intraoperative cholangiography rate, a higher proportion of complicated gallbladder diseases, shorter operative time, more intraoperative blood loss, and lower postoperative pethidine dose than the selective group (the first 73 patients). The conversion and complication rates showed no statistical difference. It took fewer cases but longer time to pass the learning phase of SILC for complicated gallbladder diseases. The multivariate analysis showed that male sex and complicated gallbladder diseases were associated with a higher procedure conversion rate, and increased patient age was related to a higher complication rate.

CONCLUSIONS

Routine SILC for benign gallbladder diseases is feasible in the experienced phase. Practicing SILC for uncomplicated gallbladder diseases helps to achieve competence in this technique for complicated diseases.

Dietary patterns and risk of gallbladder disease: a hospital-based case-control study in adult women

Gallbladder disease is one of the most prevalent gastrointestinal disorders that may result from a complex interaction of genetic and environmental factors. This study examined the association of dietary patterns with gallstone disease among Iranian women. This case-control study was conducted in general teaching hospitals in Tehran, Iran. Participants were 101 female cases and 204 female controls aged 40-65 years who were admitted for problems other than GBD. Dietary patterns were identified using principal components analysis based on food frequency questionnaire. Compared to the control group, cases were less educated, less physically active, and consumed more total energy (p<0.02). Having ≥ 3 livebirths increased the risk of gallstone by more than 5 times, followed by having rapid weight loss, being single, having familial history of gallstone, and consuming high total energy. Two distinct dietary patterns were identified in women (healthy and unhealthy). After adjustment for several confounding variables, healthy dietary pattern was associated with a decreased risk of gallstone disease (OR=0.14, 95% CI 0.048-0.4) while unhealthy dietary pattern was associated with an increased risk (OR=3.77, 95% CI 1.52-9.36). These findings confirm that dietary pattern approach provides potentially useful and relevant information on the relationship between diet and disease. Identifying risk factors will provide an opportunity for prevention of gallbladder disease in developing countries facing an increased risk of obesity.

Giant gallbladder: A case report and review of literature

•

Reports of giant gallbladders are rare and do not exceed eight cases worldwide.

•

We presented here a case of a giant gallbladder and review of literature.

•

We define a gallbladder as ‘giant’ if the volume of the organ exceeds 1.5 L.

•

A giant gallbladder may develop patients of any age, mimicking an abdominal tumour.

•

Diagnostics and treatment of a giant gallbladder demand non-routine approaches.

INTRODUCTION

Reports of a giant gallbladder are rare.

PRESENTATION OF CASE

A 77-year-old woman was admitted with complaints of dull pain in the right half of the abdomen and a palpable mass at the same place. A computerized tomography scan revealed an extremely enlarged gallbladder. Open cholecystectomy was performed. The volume of the removed organ was as much as 3.35 L.

Follow-up after 18 months showed that the patient was well. Examination revealed no significant acquired or congenital anomalies that might explain the excessive enlargement of the gallbladder.

DISCUSSION

We define a ‘giant’ gallbladder as an extreme enlargement of the organ with a volume exceeding 1.5 L, so that its weight is comparable to or even exceeds the mean (estimated) weight of the adult liver (1.5 kg). The first clinical presentation of such an enlargement is likely to differ from any other gallbladder disease, but rather to resemble a tumour or cyst of the abdominal cavity.

CONCLUSION

A giant gallbladder is a special clinical and pathological entity in surgical practice, of unknown origin. It may develop in patients of any age, and mimics a large abdominal tumour or peritoneal cyst. Both the diagnostic process and surgical treatment demand non-routine approaches. Early and late follow-up results seem to be favourable.

Robotic cholecystectomy with new port sites

AIM: To introduce robotic cholecystectomy (RC) using new port sites on the low abdominal area.

METHODS: From June 2010 to June 2011, a total of 178 RCs were performed at Ajou University Medical Center. We prospectively collected the set-up time (working time and docking time) and console time in all robotic procedures.

RESULTS: Eighty-three patients were male and 95 female; the age ranged from 18 to 72 years of age (mean 54.6 ± 15.0 years). All robotic procedures were successfully completed. The mean operation time was 52.4 ± 17.1 min. The set-up time and console time were 11.9 ± 5.4 min (5-43 min) and 15.1 ± 8.0 min (4-50 min), respectively. The conversion rate to laparoscopic or open procedures was zero. The complication rate was 0.6% (n = 1, bleeding). There was no bile duct injury or mortality. The mean hospital stay was 1.4 ± 1.1 d. There was a significant correlation between the console time and white blood cell count (r = 0.033, P = 0.015). In addition, the higher the white blood cell count (more than 10000), the longer the console time.

CONCLUSION: Robotic cholecystectomy using new port sites on the low abdominal area can be safely and efficiently performed, with sufficient patient satisfaction.

Health-related quality of life outcomes after cholecystectomy

Gallbladder diseases are very common in developed countries. Complicated gallstone disease represents the most frequent of biliary disorders for which surgery is regularly advocated. As regards, cholecystectomy represents a common abdominal surgical intervention; it can be performed as either an elective intervention or emergency surgery, in the case of gangrene, perforation, peritonitis or sepsis. Nowadays, the laparoscopic approach is preferred over open laparotomy. Globally, numerous cholecystectomies are performed daily; however, little evidence exists regarding assessment of post-surgical quality of life (QOL) following these interventions. To assess post-cholecystectomy QOL, in fact, documentation of high quality care has been subject to extended discussions, and the use of patient-reported outcome satisfaction for quality improvement has been advocated for several years. However, there has been little research published regarding QOL outcomes following cholecystectomy; in addition, much of the current literature lacks systematic data on patient-centered outcomes. Then, although several tools have been used to measure QOL after cholecystectomy, difficulty remains in selecting meaningful parameters in order to obtain reproducible data to reflect postoperative QOL. The aim of this study was to review the impact of surgery for gallbladder diseases on QOL. This review includes Medline searches of current literature on QOL following cholecystectomy. Most studies demonstrated that symptomatic patients profited more from surgery than patients receiving an elective intervention. Thus, the gain in QOL depends on the general conditions before surgery, and patients without symptoms profit less or may even have a reduction in QOL.

An epidemiological survey of benign gallbladder disease in Songjiang District of Shanghai, China

AIM: To investigate the epidemiological characteristics of benign gallbladder disease in Songjiang District of Shanghai, China.

METHODS: The clinical data for 30 901 patients with benign gallbladder disease who underwent physical examination at our hospital in 2009 were retrospectively analyzed. The relationship of cholelithiasis with obesity, blood sugar, blood lipid was analyzed.

RESULTS: The incidence of benign gallbladder disease was 15.87%, increasing with the age. The male/female ratio was 1.252. Gallbladder stones, polypoid lesions of gallbladder (PLG) and cholecystitis were common benign gallbladder disease, with an incidence of 5.94%, 5.23% and 3.91%, respectively. The sex ratio of patients with these three diseases were 0.998：1, 1.678：1 and 1.518：1, respectively. The incidence of gallbladder stone increased with age, while that of PLG decreased with age. Both diseases had little relationship with sex. The percentages of patients with cholelithiasis who had obesity, high blood sugar, high triglycerides and low high-density lipoprotein were 10.73%, 21.73%, 19,66% and 2.07%, respectively, while the percentages for non-gallstone patients were 7.04%, 13.37%, 16.56% and 1.45%, with significant differences between the two groups (all P < 0.05).

CONCLUSION: The prevalence of benign gallbladder disease in Songjiang District increases with age. Gallstones and PLG are common benign gallbladder disease. Obesity, high blood sugar, high triglycerides, low high-density lipoprotein are risk factors for gallstones. Cholesterol has no significant correlation with the incidence of cholelithiasis.

Relationship between gallbladder distension and lipid profiles in kawasaki disease

BACKGROUND AND OBJECTIVES

Kawasaki disease (KD) is an acute systemic vasculitis in children which causes coronary arterial dilatation (CAD) and gallbladder distension (GBD). There is a dearth of investigating the relationship between the severity of KD and GBD with lipid profiles.

SUBJECTS AND METHODS

A total of 80 patients with 'complete KD' who were diagnosed from January 2005 to May 2009 was enrolled in this study. Serum cholesterol {total, high density lipoprotein-cholesterol (HDL-C) and low density lipoprotein-cholesterol (LDL-C)}, triglyceride (TG), complete blood count, inflammation markers {erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)} were measured at the time of admission during febrile period. Echocardiography and abdominal sonogram were performed in all patients to determine CAD and gallbladder size. According to GBD, patients with KD were classified as patients with GBD and patients without GBD. Between two groups, demographic and clinical data were analyzed.

RESULTS

The serum level of LDL-C was significantly lower in patients with GBD (p=0.03) compared with patients without GBD or febrile control. There was no significant difference in inflammatory indices between patients with GBD and patients without GBD. GBD was not significant risk factor of CAD in this study (odds ratio=2.0, 95% confidence interval=0.82-5.3, p=0.16).

CONCLUSION

This is the first study that highlights the relationship between the GBD and lipid metabolism in patients with KD. This study provides clinical insights about potential mechanism underpinning the relationship between the GBD and lipid metabolism.

Expression of pituitary adenylate cyclase-activating polypeptide 1 and 2 receptor mRNA in gallbladder tissue of patients with gallstone or gallbladder polyps

AIM: To detect the expression of pituitary adenylate cyclase-activating polypeptide receptor 1 (VPCAP₁-R) and VPCAP₂-R mRNA in gallbladder tissues of patients with gallstone or gallbladder polyps.

METHODS: The expression of VPCAP₁-R and VPCAP₂-R mRNA in gallbladder tissues was detected in 25 patients with gallstone, 8 patients with gallbladder polyps and 7 donors of liver transplantation by reverse transcription polymerase chain reaction (RT-PCR).

RESULTS: The VPCAP₂-R mRNA expression level in the control group (1.09±0.58) was lower than that in the gallbladder polyp group (1.64 ± 0.56) and the gallstone group (1.55±0.45) (P < 0.05) while the VPCAP₁-R mRNA expression level in the control group (1.15 ± 0.23) was not apparently different from that in the gallbladder polyp group (1.28±0.56) and the gallstone group (1.27 ± 0.38).

CONCLUSION: The abnormal expression of VPCAP₂-R mRNA in gallbladder tissue may play a role in the formation of gallbladder stone and gallbladder polyps.