Burden of gallstone disease in the United States population: Prepandemic rates and trends

BACKGROUND

Gallstone disease is one of the most common digestive disorders in the United States and leads to significant morbidity, mortality, and health care utilization.

AIM

To expand on earlier findings and investigate prepandemic rates and trends in the gallstone disease burden in the United States using national survey and claims databases.

METHODS

The National Ambulatory Medical Care Survey, National Inpatient Sample, Nationwide Emergency Department Sample, Nationwide Ambulatory Surgery Sample, Vital Statistics of the United States, Optum Clinformatics^® Data Mart, and Centers for Medicare and Medicaid Services Medicare 5% Sample and Medicaid files were used to estimate claims-based prevalence, medical care including cholecystectomy, and mortality with a primary or other gallstone diagnosis. Rates were age-adjusted (for national databases) and shown per 100000 population.

RESULTS

Gallstone disease prevalence (claims-based, 2019) was 0.70% among commercial insurance enrollees, 1.03% among Medicaid beneficiaries, and 2.09% among Medicare beneficiaries and rose over the previous decade. Recently, in the United States population, gallstone disease contributed to approximately 2.2 million ambulatory care visits, 1.2 million emergency department visits, 625000 hospital discharges, and 2000 deaths annually. Women had higher medical care rates with a gallstone disease diagnosis, but mortality rates were higher among men. Hispanics had higher ambulatory care visit and hospital discharge rates compared with Whites, but not mortality rates. Blacks had lower ambulatory care visit and mortality rates, but similar hospital discharge rates compared with whites. During the study period, ambulatory care and emergency department visit rates with a gallstone disease diagnosis rose, while hospital discharge and mortality rates declined. Among commercial insurance enrollees, rates were higher compared with national data for ambulatory care visits and hospitalizations, but lower for emergency department visits. Cholecystectomies performed in the United States included 605000 ambulatory laparoscopic, 280000 inpatient laparoscopic, and 49000 inpatient open procedures annually. Among commercial insurance enrollees, rates were higher compared with national data for laparoscopic procedures.

CONCLUSION

The gallstone disease burden in the United States is substantial and increasing, particularly among women, Hispanics, and older adults with laparoscopic cholecystectomy as the mainstay treatment. Current practice patterns should be monitored for better health care access.

The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey

OBJECTIVE

This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS.

BACKGROUND

Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist.

METHODS

An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023.

RESULTS

Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB.

CONCLUSION

Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.

Bouveret's syndrome: An old diagnosis. A modern multimodality approach (endoscopic and robotic surgical) of gastric outlet obstruction: Report of two cases

INTRODUCTION AND IMPORTANCE

Bouveret's syndrome is an uncommon condition characterized by the impaction of a gallstone in the pylorus or duodenum via a cholecysto-enteric fistula causing gastric outlet obstruction. We report two unusual cases of Bouveret's syndrome causing gastric outlet obstruction in two elderly patients.

CASE PRESENTATION

Two elderly female patients presented to the surgical assessment unit with features of gastric outlet obstruction. In both cases, an urgent computed tomography (CT) of the abdomen showed pneumobilia, gastric distension, and gallstones impaction at the duodenal bulb. In Patient 1, endoscopic removal of the impacted gallstones was done successfully. She was discharged three days following an uneventful recovery. In Patient 2, an endoscopic removal of a single large gallstone was attempted, which was unsuccessful. She underwent robotic gastrotomy with extraction of the large gallstone with primary repair. She was discharged on 8th postoperative day.

CLINICAL DISCUSSION

Treatment options for Bouveret's syndrome include endoscopic management and surgery. The selection of treatment options depends upon factors like the degree of obstruction, the impaction site, number, type or size of gallstones, patient co-morbidities and clinical parameters at presentation, as well as expertise available, both endoscopic and surgical.

CONCLUSIONS

Bouveret's syndrome is one of the rare complications of gallstone. Endoscopic management can be effective at removing the impacted gallstones, which is particularly helpful for those elderly patients who have multiple medical co-morbidities, as in our first patient. Surgical management like minimal invasive surgery (robotic) can be beneficial in failed endoscopic attempt of removal of stone like in the second patient.

Intra-operative ultrasound assessment of the biliary tree during robotic cholecystectomy

Image-guided assessment of bile ducts and associated anatomy during laparoscopic cholecystectomy can be achieved with intra-operative cholangiography (IOC) or laparoscopic ultrasound (LUS). Rates of robotically assisted cholecystectomy (RC) are increasing and herein we describe the technique of intra-corporeal biliary ultrasound during RC using the Da Vinci system. For intraoperative evaluation of the biliary tree during RC, in cases of suspected choledocholithiasis, the L51K Ultrasound Probe (Hitachi, Tokyo, Japan) is used. The extrahepatic biliary tree is scanned along its length, capitalising on the benefits of the full range of motion offered by the articulated robotic instruments and integrated ultrasonic image display using TileProTM software. Additionally, this technique avoids the additional time and efforts required to undock and re-dock the robot that would otherwise be required for selective IOC or LUS. The average time taken to perform a comprehensive evaluation of the biliary tree, from the hepatic ducts to the ampulla of Vater, is 164.1 s. This assessment is supplemented by Doppler ultrasound, which is used to fully delineate anatomy of the porta hepatis, and accurate measurements of the biliary tree and any ductal stones can be taken, allowing for contemporaneous decision making and management of ductal pathologies. Biliary tract ultrasound has been shown to be equal to IOC in its ability to diagnose choledocholithiasis, but with the additional benefits of being quicker and having higher completion rates. We have described our practice of using biliary ultrasound during robotically assisted cholecystectomy, which is ergonomically superior to LUS, accurate and reproducible.

Abdominal obesity mediates the causal relationship between depression and the risk of gallstone disease: retrospective cohort study and Mendelian randomization analyses

OBJECTIVE

Our study aimed to explore the causal effect of depression on the risk of gallstone disease, and the mediation effects of metabolic traits.

METHODS

A retrospective cohort study on Chinese elderly from the Dongfeng-Tongji cohort (including 18,141 individuals) was conducted to estimate the adverse effect of probable depression on the risk of gallstone disease. Two-sample Mendelian randomization was performed in European and East-Asian ancestries, to verify the causal relationship between major depression and gallstone disease. We further applied two-step Mendelian randomization to explore the mediation effects of metabolic traits.

RESULTS

In the cohort study, probable depression was associated with an increased risk of gallstone disease within 5 years, with RR (95% CI) of 1.33 (1.12, 1.58) in multivariable regression, and 1.34 (1.11, 1.61) following propensity score weighting. Bidirectional Mendelian randomization in European ancestry revealed a positive causal effect (OR: 1.21; 95% CI: 1.07 to 1.37) of genetically predicted major depression liability on gallstone disease, based on the inverse variance weighted method. Little evidence was presented from other complementary approaches, and the analysis in East-Asian ancestry (IVW estimated OR: 1.03; 95% CI: 0.92 to 1.15). The indirect effect via waist circumference and HDL-C were 1.06 (95% CI: 1.02 to 1.10) and 1.01 (95% CI: 1.00 to 1.01) respectively, which mediated 25.8% and 3.78% of the causal relationship.

CONCLUSIONS

Our study suggested a higher risk of gallstone disease in the population with probable depression, while the two-sample Mendelian randomization provided weak evidence for the causal relationship, which was moderately mediated by abdominal obesity.

Dietary inflammatory index and risk of gallstone disease in Iranian women: a case-control study

BACKGROUND

Considering inflammation as a primary occurrence in gallstone formation, this study aimed to determine the relation between serum biomarkers of inflammation and oxidative stress, and dietary Inflammatory Index (DII) score with the risk of gallstone disease (GD) among Iranian women.

MATERIALS AND METHODS

Present BMI-matched case-control study was performed among 75 women with GD and 75 healthy controls. Biochemical parameters were measured by standard laboratory methods. A validated food frequency questionnaire (FFQ) was used to assess the usual intake of participants. DII score was calculated for all participants. The linear and logistic regression were used to examine the association of DII with serum inflammatory biomarkers and the odds ratio of GD, respectively.

RESULTS

The mean serum levels of high-sensitivity C-reactive protein (hs-CRP) and Malondialdehyde (MDA) were significantly (P < 0.001) higher in GD patients compared to control subjects. Women in the highest tertile of DII compared to the lowest tertile had lower intake of macronutrients, minerals, vitamins garlic, onion, pepper and fiber. Moreover, the odd of GD was significantly higher in the third tertile of the DII versus the first tertile after adjustment of potential confounders (OR: 17.47; 95% CI: 4.64-65.72). Also, a positive and significant relationship was found between the serum level of inflammatory biomarkers with the risk of GD and the inflammatory score of the diet (P < 0.001).

CONCLUSION

Our data indicate that higher DII score, and serum inflammatory and oxidative stress biomarkers are related to higher risk of GD in Iranian women.

Impact of gallstone disease on the risk of stroke and coronary artery disease: evidence from prospective observational studies and genetic analyses

BACKGROUND

Despite epidemiological evidence associating gallstone disease (GSD) with cardiovascular disease (CVD), a dilemma remains on the role of cholecystectomy in modifying the risk of CVD. We aimed to characterize the phenotypic and genetic relationships between GSD and two CVD events - stroke and coronary artery disease (CAD).

METHODS

We first performed a meta-analysis of cohort studies to quantify an overall phenotypic association between GSD and CVD. We then investigated the genetic relationship leveraging the largest genome-wide genetic summary statistics. We finally examined the phenotypic association using the comprehensive data from UK Biobank (UKB).

RESULTS

An overall significant effect of GSD on CVD was found in meta-analysis (relative risk [RR] = 1.26, 95% confidence interval [CI] = 1.19-1.34). Genetically, a positive shared genetic basis was observed for GSD with stroke ([Formula: see text]=0.16, P = 6.00 × 10-4) and CAD ([Formula: see text]=0.27, P = 2.27 × 10-15), corroborated by local signals. The shared genetic architecture was largely explained by the multiple pleiotropic loci identified in cross-phenotype association study and the shared gene-tissue pairs detected by transcriptome-wide association study, but not a causal relationship (GSD to CVD) examined through Mendelian randomization (MR) (GSD-stroke: odds ratio [OR] = 1.00, 95%CI = 0.97-1.03; GSD-CAD: OR = 1.01, 95%CI = 0.98-1.04). After a careful adjustment of confounders or considering lag time using UKB data, no significant phenotypic effect of GSD on CVD was detected (GSD-stroke: hazard ratio [HR] = 0.95, 95%CI = 0.83-1.09; GSD-CAD: HR = 0.98, 95%CI = 0.91-1.06), further supporting MR findings.

CONCLUSIONS

Our work demonstrates a phenotypic and genetic relationship between GSD and CVD, highlighting a shared biological mechanism rather than a direct causal effect. These findings may provide insight into clinical and public health applications.

Preliminary exploration of the effects of environmental factors on the microsatellite status of BRAF-mutated colorectal cancer

BACKGROUND

To investigate the expression of EBV products and frequency of gallstone disease (GD) among different microsatellite status in colorectal cancer (CRC) with BRAFV600E mutation.

METHODS

We collected 30 CRC patients with BRAFV600E mutation and 10 BRAF ( -) CRC patients as well as 54 healthy subjects. Tumor tissue samples were collected to detect the mutation of BRAF, KRAS, and TP53. Microsatellite status was determined by immunohistochemistry and PCR. EBER in situ hybridization was performed to detect EBV. In addition, we also collected clinical information about the patients.

RESULTS

We found that although EBV products were detected in CRC, there were no significant differences in the EBV distribution between the different BRAF groups. Our study demonstrated that BRAFV600E mutation and BRAFV600E with MSI were significantly more frequent in the right CRC. Furthermore, the KRAS mutation rate in the BRAF-wild-type group was proved to be significantly higher than that in the BRAF mutation group. In addition, we revealed that BRAF mutation and MSI were independent risk factors of TNM stage. The frequency of GD was higher in CRC patients than in general population, and although there was no significant difference between CRC with or without BRAFV600E mutation, the highest frequency of GD was found in MSS CRC with BRAFV600E mutation.

CONCLUSIONS

EBV plays a role in CRC, but is not a determinant of different microsatellite status in CRC with BRAFV600E mutation. The frequency of GD in MSS CRC with BRAFV600E mutation is significantly higher than that in the general population.

Ten-Year Trends of Persistent Mortality With Gallstone Disease: A Retrospective Cohort Study in New Jersey

BACKGROUND AND AIMS

Recent trends in mortality with gallstone disease remain scarce in the United States. Yet multiple changes in clinical management, such as rates of endoscopy, cholecystectomy, and cholecystostomy, and insurance access at the state level, may have occurred. Thus, we evaluated recent secular trends of mortality with gallstone disease in New Jersey.

METHODS

We performed a retrospective, cohort study of mortality from 2009 to 2018 using the National Center for Health Statistics, Restricted Mortality Files. The primary outcome was any death with an International Classifications of Disease, 10th Revision, Clinical Modification diagnosis code of gallstone disease in New Jersey. Simple linear regression was used to model trends of incidence of death.

RESULTS

1580 deaths with diagnosed gallstone disease (dGD) occurred from 2009 to 2018. The annual trend of incidence of death was flat over 10 years. The incidence of death with dGD relative to all death changed only from 0.21% to 0.20% over 10 years. These findings were consistent also in 18 of 20 subgroup combinations, although the trend of death with dGD in Latinos 65 years or older increased [slope estimate 0.93, 95% confidence limit 0.42-1.43, P = .003].

CONCLUSION

The rate of death with dGD showed little change over the recent 10 years in New Jersey. This needs to be reproduced in other states and nationally. A closer examination of the changes in clinical care and insurance access is needed to help understand why they did not result in a positive change in this avoidable cause of death.

Associations of long-term exposure to particulate matter with gallstone risks in Chinese adults: A large cross-sectional study

BACKGROUND

Epidemiological evidence regarding the relation of exposure to ambient particulate matter (PM) with gallstone disease (GSD) risk remains lacking. We tested the hypothesis that long-term exposure to PM is related to the development of GSD and that dyslipidemia can mediate the effect of PM-associated GSD formation.

METHODS

We extracted related information on the basis of the baseline survey of the China Multi-Ethnic Cohort Study. The exposure levels of PM (PM₁, PM_2.5, and PM₁₀) were assessed by validated spatiotemporal models. The relation of exposure to ambient PM with GSD risks was analyzed by non-conditional logistic regression models. Additionally, mediation analysis was conducted to assess whether dyslipidemia was related to the relation of PM exposure with GSD risks.

RESULTS

A total of 72,893 participants were included. Increased ambient PM exposure was positively associated with a higher GSD risk, with ORs (and 95% CI) of 1.17 (1.06, 1.28), 1.10 (1.05, 1.15), and 1.07 (1.04, 1.10) for every 10 μg/m³ increment in PM₁, PM_2.5, and PM₁₀, separately. The association was more remarkable in males, drinkers, and central obesity participants. Dyslipidemia significantly mediated the association between PM and GSD, with mediating proportions of 5.37%, 9.13%, and 7.66% in PM₁, PM_2.5, and PM₁₀, respectively.

CONCLUSION

Exposure to PM may relate to the increased risk of GSD in Chinese adults, especially among males, drinkers, and central obesity participants. Dyslipidemia may partially mediate the effect of PM-associated GSD development. Our results might provide epidemiological evidence for the progression of GSD related to PM and give new insights into GSD prevention and screening priorities.

Proteomic analysis identifies dysregulated proteins and associated molecular pathways in a cohort of gallbladder cancer patients of African ancestry

BACKGROUND

Gallbladder cancer (GBC) is a lethal cancer with a poor prognosis. The lack of specific and sensitive biomarkers results in delayed diagnosis with most patients presenting at late stages of the disease. Furthermore, there is little known about the molecular mechanisms associated with GBC, especially in patients of African ancestry. This study aimed to determine dysregulated proteins in South African GBC patients to identify potential mechanisms of the disease progression and plausible biomarkers.

METHODS

Tissues (27 GBC, 13 Gallstone disease, and 5 normal tissues) and blood plasma (54 GBC and 73 Benign biliary pathology) were obtained from consenting patients. Protein extraction was performed on all tissues and liquid chromatography-mass spectrometry was used for proteomic profiling. A project-specific spectral library was built using the Pulsar search algorithm. Principal component and Spearman's rank correlation analyses were performed using PAST (V4.07b). Pathway and Network analyses were conducted using REACTOME (v3.7) and stringAPP (v1.7.0), respectively.

RESULTS

In the tissue sample group, there were 62 and 194 dysregulated proteins in GBC compared to normal and gallstone groups, respectively. In the plasma group, there were 33 altered proteins in GBC compared to the benign biliary pathology group. We found 9 proteins (APOA1, APOA2, RET4, TTR, HEMO, HBB, HBA, PIGR, and APOE) to be commonly dysregulated in both tissue and plasma. Furthermore, a subset analysis demonstrated that 2 proteins, S100A8 and S100A9, were downregulated in GBC patients with GD history compared to those without. Pathway analysis showed that the dysregulated proteins in GBC patients were enriched in pathways involved in smooth muscle contraction, metabolism, ECM organization, and integrin cell surface interactions.

CONCLUSION

The identified dysregulated proteins help in understanding GBC molecular mechanisms in our patient group. Furthermore, the alteration of specific proteins in both tissue and plasma samples suggests their potential utility as biomarkers of GBC in this sample cohort.

Post-cholecystectomy syndrome in pediatric patients: Occurrence and spectrum of symptoms

BACKGROUND

Post-cholecystectomy syndrome (PCS) refers to persistent or new abdominal symptoms after cholecystectomy. As there are very few reports on PCS in pediatric patients, we aimed to examine whether it was a frequent finding and which symptoms the affected children experienced.

METHOD

This is a retrospective cross sectional study of pediatric patients, who underwent cholecystectomy during 2003-2019 at Oslo University Hospital. The PedsQL™ gastrointestinal symptoms scale questionnaire and a self-designed questionnaire exploring satisfaction after surgery and current medical conditions were mailed to all eligible patients. Patient/parental consent and approval from the local data protection officer (19/09054) were obtained.

RESULTS

Questionnaires were sent to 82 patients of whom 44 (54%) answered. There were no significant demographic differences between the responders and the non responders. We identified 16 (36.7%) patients to have PCS. The most common symptoms were diarrhea (25%), bloating (16%), and heartburn/reflux (16%). Overweight was more common in patients with PCS (31%) than in patients without PCS (4%) (p = 0.014). Altogether 34/44 (77.3%) patients were satisfied with the result of the cholecystectomy; 92,6% of patients without PCS and 56.6% of those with PCS (p = 0.012).

CONCLUSION

PCS is not uncommon in pediatric patients, and they report a wide range of gastrointestinal symptoms. We identified overweight as a potential risk factor for developing PCS. Nonetheless, most patients got total relief of abdominal pain and were satisfied with outcome after cholecystectomy.

LEVEL OF EVIDENCE

Level 3.

Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy

BACKGROUND

There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure.

METHODS

A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media.

RESULTS

638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m2, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy.

CONCLUSIONS

This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.

Novel advances in surgery for Gallstone Disease

PURPOSE OF REVIEW

Examine recent advances in the treatment of patients with complex gallstone disease.

RECENT FINDINGS

Laparoscopic common bile duct exploration (LCBDE) has been shown to be an effective and safe treatment for choledocholithiasis, resulting in decreased hospital length of stay and costs when compared with ERCP plus laparoscopic cholecystectomy (LC). Novel simulator-based curricula have recently been developed to address the educational gap that has resulted in an underutilization of LCBDE. Patients with cholecystitis who are too ill to safely undergo LC have traditionally been treated with percutaneous cholecystostomy (PC). Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel definitive treatment for such patients and has been shown to result in decreased complications and hospital readmissions compared to PC. The management of symptomatic gallstone disease during pregnancy has evolved over the last several decades. While it is now well established that laparoscopic procedures under general anesthesia are safe throughout a pregnancy, recent studies have suggested that laparoscopic cholecystectomy during the third trimester specifically may result in higher rates of preterm labor when compared with non-operative management. Finally, indocyanine green (ICG) fluorescence cholangiography is a novel imaging modality that has been used during laparoscopic cholecystectomy and may offer better visualization of biliary anatomy during dissection when compared with traditional intraoperative cholangiography. A number of recent technological, procedural, educational, and research innovations have enhanced and expanded treatment options for patients with complex gallstone disease.

Blood lipid metabolism and the risk of gallstone disease: a multi-center study and meta-analysis

Background

Gallstone disease (GSD) is a common and costly biliary disorder. Multiple studies have investigated the associations between blood lipid metabolism and GSD risk; however, the results are inconsistent. This research aimed to comprehensively evaluate the relationships among serum total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides and GSD risk.

Methods

Firstly, a multi-center cross-sectional study was carried out. Subjects who participated in the health examination in three hospitals between January 2015 and May 2020 were recruited. Multivariable logistic regression was used to investigate blood lipid metabolism associated with GSD risk. Then, a meta-analysis was performed to verify the associations further. Medline and Embase databases were systematically searched before June 10, 2021. The DerSimonian and Laird random-effect model was utilized when the heterogeneity was high; otherwise, fixed-effect model was adopted.

Results

There were 548,934 eligible participants included in the multi-center study, and 45,392 of them were diagnosed with GSD. The results demonstrated that total cholesterol and HDL cholesterol were negatively associated with GSD risk in both high vs. low model and per mmol/L increase model, while triglyceride was positively associated with GSD risk in the per unit increase model. In the meta-analysis, 104 studies with approximately 3 million participants were finally included. The results verified that HDL cholesterol [odds ratio (OR) = 0.636, P = 5.97 × 10^− 16 in high vs low model; OR = 0.974, P = 6.07 × 10^− 05 in per unit model] and triglyceride (OR = 1.192, P = 3.47 × 10^− 05 in high vs. low model; OR = 1.011, P = 5.12 × 10^− 05 in per unit model) were related to GSD risk in the two models.

Conclusions

The findings indicated that low HDL cholesterol levels and high triglyceride levels were risk factors for GSD. This study provides a basis for identifying the population at high risk for GSD and implementing tertiary prevention strategies for GSD, thus contributing to GSD prevention as well as disease burden relief.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12944-022-01635-9.

High dietary ω-6:ω-3 PUFA ratio and simple carbohydrates as a potential risk factors for gallstone disease: A cross-sectional study

BACKGROUND & AIMS

Gallstone disease (GD) is a major cause for consultation at general surgery services worldwide. In fact, GD has a strong relationship with environmental factors. However, specific characteristics in the Mexican population have not been established. The aim of this study was to compare the dietary components, physical activity, body composition and serum lipids in women with and without GD.

METHODS

54 women with GD and 75 without GD from West Mexico were enrolled in a cross-sectional study. Dietary intake was obtained through a habitual day food record and analyzed using the Nutritionist Pro™ software. Physical activity was evaluated in accordance with WHO recommendations. Body fat percentage (BF%) was estimated by bioimpedance (InBody 370) and serum lipids were measured using dry chemistry (Vitros-250 Analyzer). Student's t-test and binary logistic regression model were used.

RESULTS

Women with GD presented a higher BF% (40 ± 8.7 vs 35.21 ± 9.8%, p = 0.004), an elevated dietary ω-6:ω-3 polyunsaturated fatty acids (PUFA) ratio (18.0 ± 11.4 vs 10.9 ± 4.7, p<0.001) and a higher simple carbohydrates (sCH) intake (28.3 ± 17.8 vs 13.23 ± 8.2%, p<0.001) as well as lower HDL-cholesterol levels (37.43 ± 8.5 vs 46.6 ± 12.02 mg/dL, p<0.001) compared with women without GD. Furthermore, it was foun d a higher ω-6:ω-3 PUFA ratio (OR: 3.9, 95% CI 1.52-10.38, p = 0.005) and excessive sCH consumption (OR: 7.4, 95% CI 1.92-28.65, p = 0.004).

CONCLUSION

We suggest that a high dietary ω-6:ω-3 PUFA ratio and an excessive sCH intake are associated with an increased risk of GD in women.

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

Background

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

Methods

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

Results

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

Conclusion

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

Gallstone disease and nonalcoholic fatty liver disease in patients with type 2 diabetes: a cross-sectional study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) and gallstone disease (GSD) often coexist in the general population owing to shared risk factors. This study explored the relationship between NAFLD and GSD in patients with type 2 diabetes.

METHODS

We conducted a retrospective cross-sectional analysis of 4325 patients with type 2 diabetes. GSD and NAFLD were confirmed using ultrasonography. GSD was defined as either asymptomatic gallstones or previous cholecystectomy, and each was analyzed separately.

RESULT

There was no significant difference in the prevalence of GSD between patients with and without NAFLD (23.8% vs. 21.2%, P = 0.15). After case-control matching (1:1) of baseline data such as age, sex, duration of diabetes, and HbA1c between patients with and without NAFLD, there was still no significant difference in the prevalence of GSD (25.5% vs. 23.6%, P = 0.15). The prevalence of NAFLD in patients with asymptomatic gallstones was lower than that of patients without GSD (38.6% vs. 47.3%, P < 0.001), whereas the prevalence in those who had undergone cholecystectomy was much higher (61.2% vs. 47.3%, P < 0.001). The ratio of cholecystectomy to asymptomatic gallstone in patients with or without NAFLD was 1.97 and 0.79, respectively. The rate of cholecystectomy was higher in the patients with NAFLD than in those without NAFLD (15.8% vs. 9.3%, P < 0.001), consistent with the result after case-control matching (17.3% vs. 11.2%, P < 0.001). Multivariate logistic regression analysis, after adjusting for numerous potential confounding factors, revealed that GSD (OR = 1.241, 95%CI: 1.036-1.488, P = 0.002) and cholecystectomy (OR = 1.946, 95%CI: 1.546-2.445, P < 0.001) were both strongly associated with NAFLD. However, asymptomatic gallstone (OR = 0.663, 95%CI: 0.513-0.856, P = 0.002) seemed to be negatively correlated with NAFLD.

CONCLUSIONS

The prevalence of GSD was similar in patients with type 2 diabetes with and without NAFLD. The higher proportion of cholecystectomy and lower proportion of asymptomatic gallstones in patients with NAFLD suggests that NAFLD may increase the risk of complications of GSD.

Risk Factors for Gallstones and Cholecystectomy: A Large-Scale Population-Based Prospective Cohort Study in Japan

INTRODUCTION

Studies investigating the risk of gallstones in the Japanese population are sparse. To our knowledge, this is the first prospective cohort study assessing risk factors of gallstones in Japan.

METHODS

A nationwide population-based prospective cohort of 112,109 men and women, aged 40-69 years, self-completed questionnaires at baseline regarding exposures to potential risk factors, between 1990 and 1994. The occurrence of gallstones and cholecystectomy for gallstones were ascertained from another questionnaire after 10 years. Odds ratios and the 95% confidence intervals were calculated using the multivariate logistic regression.

RESULTS

During the 10-year follow-up, 3,092 (5.0%) participants developed gallstones and 729 (1.2%) participants required cholecystectomy. Increasing age, high body mass index, and diabetes mellitus were associated with the risk of gallstones in both sexes. In men, weight gain or loss of >5 kg over the follow-up period and stress were associated with risk of gallstones, whereas alcohol intake was inversely associated with the risk. In women, weight gain of >5 kg during the follow-up period, smoking, menopause, and lipid-lowering drugs were associated with risk of gallstones, whereas late onset of menarche was inversely associated with risk of gallstones. The risk of cholecystectomy broadly reflected the risk of gallstones for both sexes respectively.

CONCLUSION

Risk factors for both gallstones and cholecystectomy for gallstones are multifactorial and differ between men and women. Novel findings in this study include an inverse association between late onset of menarche and gallstones, and an association between self-reported stress in men and gallstones.

Association of apolipoprotein B XbaI (rs693) polymorphism and gallstone disease risk based on a comprehensive analysis

BACKGROUND

Our aim was to investigate the association between XbaI gene polymorphisms in the apolipoprotein B (APOB) gene and gallstone disease (GD) risk through a comparison of the allele and genotype distribution frequencies at this site using meta-analysis.

METHODS

A literature search was performed using PubMed and Wanfang through Jun 1, 2020. Odds ratios (ORs) and 95 % confidence intervals (CIs) were used to assess the strength of associations.

RESULTS

After a comprehensive search, 14 different articles that met the inclusion criteria were selected, with 1583 cases and 1794 controls. Individuals carrying the A-allele or AA genotype of the rs693 polymorphism were determined to possibly have an increased risk of GD. For example, there was a significant relationship between the rs693 polymorphism and increased GD risk in the whole group (OR: 1.40, 95 % CI: 1.05-1.87 in the allelic contrast model), the Asian population (OR: 1.58, 95 % CI: 1.48-2.84 in the heterozygote model), and the hospital-based source of the control (OR: 1.79, 95 % CI: 1.13-2.84 in the dominant model).

CONCLUSIONS

This study suggests that the APOB rs693 polymorphism is potentially associated with GD susceptibility, which might offer a detection marker for use in future large scale clinic research.

Cholecystectomy After Previous Bariatric Surgery with Special Focus on Pregnant Patients-Results from Two Large Nationwide Registries

Background

Biliary complications during pregnancy is an important issue. The aim of this study was to examine if there is an increased risk to perform cholecystectomy during pregnancy in patients with previous bariatric surgery in comparison to other females subjected to cholecystectomy.

Methods

The Nationwide Swedish Registry for Gallstone Surgery (GallRiks) and the Scandinavian Obesity Surgery Registry (SOReg) were combined. Female patients 18–45 years old were included. The study group was patients with a history of bariatric surgery whom were pregnant at the time of cholecystectomy. This group was compared with pregnant patients without previous bariatric surgery and non-pregnant with and without previous bariatric surgery.

Results

In total, 21,314 patients were included and 292 underwent surgery during pregnancy. From 1282 patients identified in both registers, 16 patients were pregnant at the time of cholecystectomy. Acute cholecystectomy was performed in 5922 (28%) non-pregnant and 199 (68%) pregnant (p < 0.001), including 11/16 (69%) pregnant with previous bariatric surgery. When comparing all pregnant patients, those with previous bariatric surgery had longer operative time (p = 0.031) and length of stay (p = 0.043), but no differences were seen when only comparing patients with an acute indication for surgery. There was no difference in complications comparing pregnant patients with previous bariatric surgery with non-pregnant, both with and without previous bariatric surgery.

Conclusions

Cholecystectomy during pregnancy in patients with previous bariatric surgery seems to be safe. The increased risk seen in the non-pregnant group after previous bariatric surgery is not seen in pregnancy, possibly due to an optimization of the circumstances at surgery.

Routine postoperative blood tests fail to reliably predict procedure-related complications after laparoscopic cholecystectomy

Purpose

Laparoscopic cholecystectomy is a highly standardized surgical procedure with a low risk of complications. However, once complications develop, they can be life-threatening. The aim of this study was to evaluate the value of blood tests on postoperative day one regarding their potential to predict postoperative complications

Methods

A cohort study of 1706 consecutive cholecystectomies performed at a tertiary hospital and teaching facility over a 5-year period between 2014 and 2019.

Results

Patients that had open CCE or conversion CCE were excluded. One thousand five hundred eighty-six patients were included in the final analysis that received a laparoscopic cholecystectomy (CCE). One thousand five hundred twenty-three patients had blood tests on POD 1. Forty-one complications were detected including 14 bile leaks, 2 common bile duct injuries, 13 choledocholithiasis, 9 hematomas, and 2 active bleedings. Bilirubin was elevated in 351 patients on POD 1. A drop of more than 3 mg/dl of hemoglobin was reported in 39 patients. GPT was elevated 3 × above the upper limit in 102 patients. All three tests showed a low sensitivity and specificity in detecting postoperative complications.

Conclusions

Early postoperative blood tests alone show a low specificity in detecting postoperative complications after laparoscopic CCE. Their main benefit appears to be the negative predictive value, when they are normal. Routine blood testing appears to be unnecessary and should be based on the intraoperative diagnosis and postoperative clinical findings.

The association between gallstone disease (GSD) and hip fracture: a nationwide population-based study

Objectives: Despite the high prevalence of gallstone disease (GSD), the shared risk factors of GSD and osteoporosis, and the known association between hip fracture and hepatobiliary diseases, the association between hip fracture and GSD is not currently clear. Therefore, we performed a nationwide population-based study to investigate the association between GSD and hip fracture to determine the impact of cholecystectomy on the risk of fracture.Methods: In this study, we assessed all subjects in the longitudinal health insurance database (LHID) between 2000 and 2011, excluding those subjects aged >20 years old and those with a previous history of hip fracture (ICD-9-CM 820). Among those that were included, subjects with at least two or more outpatient visits or with one record of hospitalization under the coding of GSD (ICD-9-CM code: 574) were allocated to the GSD cohort. The remaining subjects were designated to the control cohort. All participants were followed till the onset of hip fracture, withdrawal from the NHI, or the end of 2013.Results: We found that the cumulative incidence of hip fracture was higher in the GSD cohort than in the control cohort (log-rank test: p-value < 0.01). After adjustment, the GSD patients had a 1.21-fold risk of hip fracture compared to control subjects (aHR = 1.21, 95% CI = 1.21-1.30). Comparison between those subjects without GSD and those without cholecystectomy revealed that the risk of hip fracture was higher among GSD patients that had not undergone cholecystectomy (aHR = 1.17, 95% CI = 1.06-1.29) or those that had undergone cholecystectomy (aHR = 1.22, 95% CI = 1.06-1.41).Conclusion: Based upon these results, we concluded that GSD was associated with an increased risk of hip fracture regardless of whether the patient had undergone cholecystectomy.

Iatrogenic Biliary Injury during Cholecystectomy: Critical Review of a Historical Case and Its Political Consequences

Biliary injuries during cholecystectomy represent serious adverse events that can have a profound impact on the patient's quality of life and on the surgeon's well-being and career. Sometimes, they can have an unexpectedly disastrous effect on the whole community, as demonstrated by the case of Anthony Eden, former foreign secretary and prime minister of Britain in the 1950s. Mr. Eden, later Lord Avon, had been suffering from biliary symptoms for a while when he had his cholecystectomy performed on April 12, 1953. On post-op day 1, a bile leak was evident, possibly due to a complete transection of the common bile duct. After a first reoperation to drain a bile collection, the definitive repair was performed in Boston by Dr. Cattell on June 10, 1953, with a loop hepatico-jejunostomy. Unfortunately, the bilioenteric anastomosis became gradually narrow, causing recurrent cholangitis, and Mr. Eden started a symptomatic treatment with pethidine, barbiturate, and amphetamine. These could have affected his perception of reality and his political judgement during the Suez Canal Crisis and, other than being the ultimate reason for 3,000+ war casualties, might have caused a Third World War. The historical and clinical implications of this case are thoroughly discussed.

Managing Gallstone Disease in the Elderly

Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.

The Induction of Antioxidant Catalase Enzyme With Decrease of Plasma Malonidialdehyde: An Important Reactive Oxidative Species Inhibiting Mechanism

BACKGROUND/AIM

The simultaneous increase of antioxidant CAT (catalase) enzyme and plasma MDA (malonidialdehyde) concentrations versus the numeric rating scale (NRS) pain score following surgery is unknown. Patients and Methods: The study included 114 patients with gallstone disease and 29 patients in the cancer group.

RESULTS

Following surgery, the plasma CAT concentrations increased and plasma MDA concentrations decreased in all patients and especially in cancer patients. The linear mixed model time-effect was statistically significant in CAT and MDA (p<0.001 and p=0.02, respectively). In addition, a significant correlation between NRS pain score values and plasma MDA median concentrations in cancer patients was identified (r=0.430, p<0.001).

CONCLUSION

The plasma MDA concentrations decreased and CAT concentrations increased significantly in all patients and especially in cancer patients following surgery. The simultaneous increase of antioxidant CAT enzyme with the decrease of plasma MDA may be an important ROS inhibiting mechanism to help patients return to normal antioxidant-oxidant status.

Global management of a common, underrated surgical task during the COVID-19 pandemic: Gallstone disease - An international survery

Background

Since the Coronavirus disease-19(COVID-19) pandemic, the healthcare systems are reallocating their medical resources, with consequent narrowed access to elective surgery for benign conditions such as gallstone disease(GD). This survey represents an overview of the current policies regarding the surgical management of patients with GD during the COVID-19 pandemic.

Methods

A Web-based survey was conducted among 36 Hepato-Prancreato-Biliary surgeons from 14 Countries. Through a 17-item questionnaire, participants were asked about the local management of patients with GD since the start of the COVID-19 pandemic.

Results

The majority (n = 26,72.2%) of surgeons reported an alarming decrease in the cholecystectomy rate for GD since the start of the pandemic, regardless of the Country: 19(52.7%) didn't operate any GD, 7(19.4%) reduced their surgical activity by 50–75%, 10(27.8%) by 25–50%, 1(2.8%) maintained regular activity. Currently, only patients with GD complications are operated. Thirty-two (88.9%) participants expect these changes to last for at least 3 months.

In 15(41.6%) Centers, patients are currently being screened for SARS-CoV-2 infection before cholecystectomy [in 10(27.8%) Centers only in the presence of suspected infection, in 5(13.9%) routinely]. The majority of surgeons (n = 29,80.6%) have adopted a laparoscopic approach as standard surgery, 5(13.9%) perform open cholecystectomy in patients with known/suspected SARS-CoV-2 infection, and 2(5.6%) in all patients.

Conclusion

In the ongoing COVID-19 emergency, the surgical treatment of GD is postponed, resulting in a huge number of untreated patients who could develop severe morbidity. Updated guidelines and dedicated pathways for patients with benign disease awaiting elective surgery are mandatory to prevent further aggravation of the overloaded healthcare systems.

•

Since the start of the COVID-19 pandemic, elective surgeries for benign diseases have been postponed, in order to preserve healthcare resources.

•

During the COVID-19 pandemic, patients with cholelithiasis, awaiting surgery, are not operated unless if complicated.

•

The blockage of elective surgery will result in a large number of patients with cholelithiasis at risk of severe morbidity.

•

COVID-19 free pathways for patients awaiting elective surgery are needed to prevent aggravation of healthcare systems.

Association of Common Single Nucleotide Polymorphisms of Candidate Genes with Gallstone Disease: A Meta-Analysis

Numerous studies have investigated the relationship between various candidate gene polymorphisms and gallbladder stone disease (GSD) across ethnic populations; however, the results are often inconsistent. This meta-analysis aims to comprehensively evaluate the influence of common ABCG8 T400K, ABCG8 D19H, ABCG8 C54Y, ApoB100 EcoRI, ApoB100 XbaI, ApoE HhaI, CETP TaqI, CYP7A1 Bsa, LRPAP1 I/D and TNF-α A308G polymorphisms on the risk of gallbladder stone disease. 33 Full-text articles with 9250 cases and 12,029 healthy controls (total 21,279 subjects) were analyzed using the RevMan software (V5.1) and the Comprehensive Meta-analysis software (Version 2.0, BIOSTAT, Englewood, NJ) a Random-effects model was applied. Begg's funnel plots, Fail-safe number, Egger's regression intercept and Begg and Mazumdar rank correlation tests were performed for the potential publication bias and sensitivity analysis. The studies were also sub-grouped into European and non-European groups to find out role of ethnicity, if any, on GSD risk. Studies included in quantitative synthesis were ABCG8 T400K rs4148217 (cases/controls, n = 671/1416) (4 studies), ABCG8 D19H rs11887534 (n = 1633/2306) (8 studies), ABCG8 C54Y rs4148211 (n = 445/1194) (3 studies), ApoB100 EcoRI rs1042031 (n = 503/390) (4 studies), ApoB100 XbaI rs693 (n = 1214/1389) (9 studies), ApoE HhaI rs429358 (n = 1335/1482) (12 studies), CETP TaqI rs708272 (n = 1038/1025) (5 studies), CYP7A1 Bsa rs3808607 (n = 565/514) (3 studies), LRPAP1 I/D rs11267919 (n = 849/900) (3 studies), TNF-α A308G rs1800629 (n = 997/1413) (3 studies). The combined results displayed significant association of ABCG8 D19H (GC + CC) [OR with 95%CI = 2.2(1.7-2.8); p < 0.00001], ABCG8 Y54C (GA + GG) [OR with 95%CI = 0.65(0.5-0.9); p = 0.01]. APOB100 EcoRI (GG vs. AA) [OR with 95%CI = 0.51(0.3-0.9); p = 0.05], (GG vs. GA) [OR with 95%CI = 0.6(0.4-0.9); p = 0.04], (GA + AA) [OR with 95%CI = 0.6(0.4-0.9); p = 0.006]. APOB Xba I (X^- vs. X⁺) [OR with 95%CI = 0.53(0.3-0.8); p = 0.006. APOE Hha I (E4/E4 vs. E3/E3) [OR with 95%CI = 3.5(1.1-14.9); p = 0.04] and LRPAP1 I/D (ID + II) [OR with 95%CI = 1.27(1.0-1.6); p = 0.03] with the GSD risk. It was found that ABCG D19H was significantly associated with GSD in both European and Non-European populations. While APOB XbaI and LRPAP1 I/D markers were associated with gallstone disease only in Non- European population. Additionally, APOE HhaI and APOB 100 ECoRI were found to be associated with GSD only in European population. The results of quantitative synthesis suggest that the ABCG8 D19H polymorphism was associated with the increased risk of GSD in both European and Non-European populations, APOE Hha I and LRPAP1 I/D polymorphisms were associated with the increased risk of GSD in European and Non-European population respectively. However, no association was found in ABCG8 T400K, CETP Taq1, CYP7A1 Bsa and TNF-A308G polymorphisms with Gallstone Disease.

Epigastric port retrieval of the gallbladder following laparoscopic cholecystectomy is associated with the reduced risk of port site infection and port site incisional hernia: An updated meta-analysis of randomized controlled trials

Aims

The objective of this article is to compare the surgical outcomes for epigastric port or umbilical port retrieval of the gallbladder (GB) following laparoscopic cholecystectomy (LC).

Methods

The data retrieved from the published randomized, controlled trials (RCT) comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC was analysed using the principles of meta-analysis. The summated outcome of continuous variables was expressed as standardized mean difference (SMD) and dichotomous data was presented in odds ratio (OR).

Results

Eight RCTs on 2676 patients comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC were analysed. In the random effects model analysis using the statistical software Review Manager 5.3, the GB retrieval through epigastric port was associated with the reduced duration of operation (SMD, 0.41; 95% CI, 0.18, 0.64; z = 3.52; P = 0.0004). Epigastric retrieval was also associated with reduced risk of surgical site infection (OR, 1.95; 95% CI, 0.75, 5.11; z = 1.36; P = 0.17), and port site incisional hernia (OR, 4.22; 95% CI, 0.43, 41.40; z = 1.24; P = 0.22) compared to umbilical port retrieval though it did not reach statistical significance. The need for port enlargement to retrieve the GB was similar in both groups. In contrast, the umbilical port retrieval of the GB was associated with significantly less post-operative pain (SMD, −0.51; 95% CI, −0.95, −0.06; z = 2.24; P = 0.03), reduced GB perforation rate, reduced port site bleeding rate and reduced difficulty in GB retrieval.

Conclusion

GB retrieval through epigastric port following LC has clinically proven advantage of reduced retrieval site infection rate, lower operation time and incisional hernia rate but at the cost of increased pain at 24 h, higher risk of GB perforation, port site bleeding and technical difficulties.

•

An updated meta-analysis providing better evidence on gall bladder extraction port following laparoscopic cholecystectomy(LC).

•

Epigastric port retrieval of gallbladder following LC has advantage of reduced rate of both infection and incisional hernia.

•

Umbilical port retrieval of gallbladder following LC has advantage of reduced pain, port site bleeding and perforation risk.

•

In conclusion from this meta-analysis epigastric port retrieval seems to be more advantageous compared to the umbilical port.

Prevalence and risk factors of gallstone disease in patients undergoing ultrasonography at Mulago hospital, Uganda

Background

Gallstone disease (GSD) is the most prevalent medical condition in the pancreatobiliary system. The burden of GSD and its complications are major public health issues globally. It is a common cause of surgical intervention, contributing substantially to health care costs. Most patients are asymptomatic, however 20% become symptomatic after 10 years. Its prevalence differs among populations and remains unknown in Uganda.

Objective

To determine the prevalence and risk factors of GSD in patients undergoing abdominal ultrasonography at Mulago hospital, Uganda.

Methods

This was a cross-sectional study at the Department of Radiology in Mulago hospital. Convenient sampling was used to recruit individuals having an abdominal ultrasound scan. Questionnaires were used to assess risk factors, and an abdominal exam was performed for individuals with gallstones to assess symptomatology.

Results

The prevalence of GSD was 22%. Statistically significant factors associated with GSD were a history of hormonal contraceptive use OR 3.2 (1.88–5.41) and a history of previous biliary symptoms OR 2.9 (1.68–4.91). Ninety-four percent of individuals with gallstones had epigastric/right upper quadrant pain.

Conclusion

The prevalence of GSD is high in Mulago hospital; use of hormonal contraceptives and a previous history of biliary symptoms were significant risk factors for GSD in this study. Majority of patients with GSD were symptomatic with epigastric pain as the cardinal symptom. We recommend a countrywide screening program using abdominal ultrasonography to determine the prevalence of GSD in the general population. There is need to study further the risk of hormonal contraceptive use and GSD. Women on these contraceptives should be informed of the potential risk, and offered alternative options where feasible.

Association of complicated gallstone disease in pregnancy and adverse birth outcomes

BACKGROUND

Complicated gallstone disease (CGD) is a common condition requiring intervention during pregnancy to avert adverse birth outcomes (ABO).

METHODS

Cohort study using the California OSHPD 2007-2014 database. Records of pregnant patients were analyzed for gallbladder calculus within four months of delivery. Biliary system interventions were evaluated as the primary exposure.

RESULTS

Of 7,597 patients, those with CGD had a greater likelihood of biliary system procedures than those with uncomplicated gallstone disease (36.6% vs. 2.5%, p < 0.001). Patients with CGD also had increased odds of ABO (OR 2.02, 95% CI, 1.48-2.76). Compared to patients without biliary system procedures, those with interventions for gallstones had an OR of 3.46 (95% CI, 2.48-4.82) for ABO. After adjustment, biliary system intervention for CGD had an even greater risk of ABO (OR 4.26, 95% CI, 2.86-6.35).

CONCLUSIONS

The risk of ABO is significantly increased in women with CGD and intervention for gallstones.

A case report and review of the literature of Bouveret syndrome

Bouveret syndrome is a rare variant of gallstone ileus causing gastric outlet obstruction. It results from the formation of either a cholecystoduodenal or a cholecystogastric fistula and subsequent migration of gallstone into the duodenum or pylorus of stomach, causing obstruction. The first case was reported by Leon Bouveret in 1896. We report a case illustrating the rarity and severity of this condition, together with a review of the literature of the different methods of endoscopic and surgical treatment.

Endoscopic minimally invasive cholecystolithotomy in a patient with duplicate gallbladder: a case report

Gallstone disease is common in China and is generally treated with laparoscopic cholecystectomy. For some patients with normal contraction function and a small number of stones, endoscopic minimally invasive cholecystolithotomy is an additional possible treatment method that avoids complications related to laparoscopic cholecystectomy. Here, we describe a 45-year-old woman who underwent endoscopic minimally invasive cholecystolithotomy and was found to have duplicate gallbladder, which was not diagnosed preoperatively. We discuss the usefulness of the endoscopic minimally invasive cholecystolithotomy procedure and the management of duplicate gallbladder in patients undergoing endoscopic minimally invasive cholecystolithotomy.

Gallstone Disease is an Independent Predictor for Poststroke Cognitive Impairment in Young Patients with Acute Ischemic Stroke

BACKGROUND

Poststroke cognitive impairment (PCI) is an important public health issue. Previous studies proved that gallstone disease (GD) was a predictor for cardiovascular and cerebrovascular disease. However, association between PCI and GD remains unclear. We aimed to investigate the predictive value of GD on cognitive impairment after acute ischemic stroke (AIS).

METHODS

We recruited 373 AIS patients, and the information on patient demographics and risk factors was collected. Cognitive function would be assessed 3-month after AIS. They would undergo gallbladder ultrasonographic examination and structured assessment during hospitalization. Patients were divided into young group (age <65 years) and elder group (age ≥65 years). Multivariate logistic regression models were used to identify the predictors of PCI.

RESULTS

PCI was identified in 176 (47.18%) AIS patients. Independent predictors of PCI were GD (p = 0.014), the National Institutes of Health Stroke Scale score and age. While carotid plaque (p = 0.058) seemed like a potential risk factor for PCI. In young group, GD (p = 0.027) was associated to PCI, in elder group, carotid plaque (p = 0.006), and age (p = 0.033) were significantly correlated to PCI.

CONCLUSION

GD was an age-dependent predictor for PCI, particularly in the young AIS patients. Therefore, AIS patients with GD, especially the young, should be systematically evaluated for cognitive function.

Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project

BACKGROUND

Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy.

METHODS

Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams' ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project.

RESULTS

Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others' experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway.

CONCLUSION

Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort.

FMO3 and its metabolite TMAO contribute to the formation of gallstones

Trimethylamine-N-oxide (TMAO) is a metabolite derived from trimethylamine (TMA), which is first produced by gut microbiota and then oxidized by flavin-containing monooxygenase 3 (FMO3) in the liver. TMAO may contribute to the development of diseases such as atherosclerosis because of its role in regulating lipid metabolism. In this study, we found that high plasma TMAO levels were positively associated with the presence of gallstone disease in humans. We further found increased hepatic FMO3 expression and elevated plasma TMAO level in a gallstone-susceptible strain of mice C57BL/6J fed a lithogenic diet (LD), but not in a gallstone-resistant strain of mice AKR/J. Dietary supplementation of TMAO or its precursor choline increased hepatic FMO3 expression and plasma TMAO levels and induced hepatic canalicular cholesterol transporters ATP binding cassette (Abc) g5 and g8 expression in mice. Up-regulation of ABCG5 and ABCG8 expression was observed in hepatocytes incubated with TMAO in vitro. Additionally, in AKR/J mice fed a LD supplemented with 0.3% TMAO, the incidence of gallstones rose up to 70% compared with 0% in AKR/J mice fed only a LD. This was associated with increased hepatic Abcg5 and g8 expression induced by TMAO. Our study demonstrated TMAO could be associated with increased hepatic Abcg5/g8 expression, biliary cholesterol hypersecretion and gallstone formation.

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.

Comparative analysis of serum lipid profiles in patients with and without gallstones: A prospective cross-sectional study

Objectives

Gallbladder disease is one of the most common diseases of the gastrointestinal tract. Various studies have shown an association between gallstones and an alteration in the serum lipids. The objective of this study was to compare serum lipid profile of gallstone patients with the controls.

Methods

This prospective cross-sectional study was conducted in the Surgical Department of the Services Institute of Medical Sciences from August 2017 to August 2018. A total of 50 patients were included in the study after screening through the inclusion criteria. A control group of 50 inpatients with no personal or family history of gallstones were also recruited for comparison. Results were expressed as mean with standard deviation. Students t-test was used to compare the data between the patients and the control groups (p < 0.05 was considered statistically significant). SPSS software, version 20 was used for statistical analysis.

Results

The mean age of the patients was 40.90 years and that of controls was 34.74 years. 46 patients were females and 44 controls were females. The serum cholesterol levels were high in the patients as compared to the controls but the comparison was not statistically significant. Serum triglycerides levels were high in the patients as compared to the controls and the analysis was statistically significant. Furthermore, the serum HDL levels were low in the patients as compared to the controls with a statistically significant p-value. However, the serum LDL levels were low in the patients as compared to the control group.

Conclusion

It was concluded that serum triglyceride levels and serum HDL levels were statistically significant in gallstone patients and there was a positive correlation between these parameters and gallstone disease.

•

Gallbladder disease is one of the most common diseases of the gastrointestinal tract in Pakistan.

•

Various studies have shown an association between gallstones and an alteration in the serum lipids.

•

This study was conducted to find out the association of dyslipidemias with formation of gallstones.

•

Serum lipid profile of gallstones patient was compared with inpatient control group.

•

It was concluded in study that serum triglyceride levels and serum HDL levels were statistically significant in gallstone patients and there was a positive correlation between these parameters and gallstone disease.

Conservative Management of Gallstone Disease in the Elderly Population: Outcomes and Recurrence

BACKGROUND & AIMS

The prevalence of gallstone disease increases with age, being early cholecystectomy the most accepted treatment in the vast majority of patients in order to prevent complications and recurrence. The aim of this study is to determine the recurrence rate and its possible predictors after initial non-operative management.

MATERIALS AND METHODS

We reviewed a consecutive series of patients, older than 65 years, admitted for a gallstone-related disease and treated with a non-operative management between January 2010 and December 2013. We analyzed comorbidities, clinical data, diagnosis, management, recurrence, and its treatment. Median follow-up after the discharge was 2 years. Recurrence was analyzed by a Kaplan-Meier survival curve. Possible recurrence's predictors were analyzed.

RESULTS

The study included 226 patients. Mean age was 80.4 ± 7.2 years, 127 (56%) were female. The main causes of index hospitalization were acute cholecystitis (58%) and biliary pancreatitis (18.1%). After 2 years of follow-up, the recurrence rate was 39.8%; mean time to recurrence was 255.2 ± 42.1 days, 81% of patients recurred within 1 year. Bile duct disease implied a higher recurrence rate than the gallbladder disease group (52% vs 33%, p < 0.001). Subjects with two or more diagnoses during index admission presented higher recurrence rate (32% vs 49%, p < 0.001).

CONCLUSION

More than a third of elderly patients could present a recurrence within 2 years after initial non-operative management. Early cholecystectomy should be considered at index admission in order to prevent recurrence.

Alcohol Consumption Can Reduce the Risk of Gallstone Disease: A Systematic Review with a Dose-Response Meta-Analysis of Case-Control and Cohort Studies

Background/Aims

Gallstone disease (GSD) is a common gastrointestinal disorder. Clinical epidemiological studies revealed that alcohol consumption has a preventive effect on the development of GSD. This study aimed to evaluate the relative risks of drinking for GSD development and investigate the dose-response relationships.

Methods

A systematic search of the MEDLINE, EMBASE, and Cochrane Library databases for studies published up to 2018 was performed. All studies that satisfied the following eligibility criteria were included: patients with GSD with or without cholecystitis; and cohort or case-control studies investigating the association between alcohol consumption and GSD development.

Results

Sixteen case-control studies including 24,401 gallstone cases and 76,185 controls, and eight cohort studies with 14,693 GSD cases among 2,432,471 person-years were enrolled. Alcohol consumption presented a decreased overall risk of GSD (pooled relative ratio [RR], 0.84; 95% confidence interval [CI], 0.79 to 0.89; p=0.02). Subgroup analyses according to drinking levels indicated a gradual risk reduction for GSD compared to nondrinkers (light: RR, 0.96; 95% CI, 0.94 to 0.99; p=0.75; moderate: RR, 0.80; 95% CI, 0.75 to 0.85; p=0.27; high: RR, 0.66; 95% CI, 0.56 to 0.79; p<0.01). A nonlinear risk reduction was observed in a dose-response meta-analysis of all the studies (n=14, p<0.01 for nonlinearity).

Conclusions

In this systematic review with meta-analysis, alcohol consumption could decrease the risk of GSD, and the dose-response analysis revealed a dose-dependent linear risk reduction and a weakened linear trend between alcohol consumption levels less than and greater than 28 g/day.

Hem-o-lok clip found in the common bile duct 3 years after laparoscopic cholecystectomy and surgical exploration

Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is a common and preferred choice for gallstone disease. Laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) are being increasingly used for managing choledocholithiasis and cholecystolithiasis. We report a case of a Hem-o-lok clip that was dropped into the common bile duct (CBD) after LC and surgical common bile duct exploration (CBDE). An 84-year-old man presented with right upper quadrant pain and jaundice for 2 months, and chills and hyperpyrexia for 1 day. The patient had received ERCP and surgical CBDE at a local hospital 3 years previously. The patient first received ERCP and endoscopic nasobiliary drainage (ENBD). When laboratory tests were normal, the patient then received LCBDE. During exploration, stones and a Hem-o-lok clip in the CBD were removed. The patient made good progress after LCBDE + T-tube placement and was discharged from hospital. The findings from this case suggest the following: 1) an appropriate therapy method should be considered for certain gallstone diseases, especially for choledocholithiasis and cholecystolithiasis; and 2) a Hem-o-lok clip should be carefully used during laparoscopic or robot-assisted surgery and the Hem-o-lok clip should not be in close proximity to the incision on the CBD.

Management of complicated gallstones in the elderly: comparing surgical and non-surgical treatment options

Objective

The aim of this study was to evaluate the differences in clinical outcomes of endoscopic retrograde cholangiopancreatography (ERCP), ERCP followed by cholecystectomy (EC) and percutaneous aspiration (PA) in the elderly population with choledocholithiasis.

Methods

We included a total of 43 338 elderly patients aged 60 years or older and 45 295 patients younger than 60 years for comparison in our study. Data were obtained from the Nationwide Inpatient Sample (Healthcare Utilization Project) for years 2001–14 by identifying patients who were admitted for gallstone complications based on the ICD 9 diagnostic code. Multiple logistic regression was used to calculate the odds of in-hospital mortality and to detect statistical differences among the treatment groups, age groups and between male and female patients. Univariate ordinary linear regression was used to compare the length of hospital stay and readmission frequency among the different age groups.

Results

The age of the patient affected mortality and the length of hospital stay after any type of procedure of gallstones removal. In a manner independent of the patient’s age, PA was associated with the highest risk of death and length of stay, while the EC was characterized by lowest mortality and ERCP by the shortest length of stay. Neither age of the patient nor the type of procedure affected the likelihood of readmission. The odds of death and the probability of readmission were not affected by patient sex. However, in patients aged between 60 and 79 years, the female gender predicted a shorter duration of stay in the hospital.

Conclusions

A patient’s age negatively affects the treatment outcomes of cholelithiasis with associated complications. The EC procedure appears to be the method of choice for the management of complicated gallstones in patients of all ages.

Incidence of nonalcoholic fatty liver disease in patients undergoing laparoscopic cholecystectomy

Introduction

Nonalcoholic fatty liver disease (NAFLD) includes a host of disease spectrum ranging from simple steatosis to steatohepatitis, cirrhosis liver, and even hepatocellular carcinoma. NAFLD can occur at all ages, and the highest prevalence is found in the age group of 35-55 years. NAFLD is becoming the commonest cause leading to hepatic cirrhosis, but there is no prescribed therapy for this common condition. Reduction in body weight may reverse the condition.

Aim

To find the prevalence of NAFLD in a cohort of patients undergoing laparoscopic cholecystectomy in this part of the country and also to evaluate the usefulness of routine liver biopsy for the diagnosis of NAFLD.

Materials and Methods

Interventional type of cross-sectional study. In all, 200 consecutive patients underwent a liver biopsy at the end of a standard laparoscopic cholecystectomy, and detailed histopathological examination was done. Clinical, biochemical, demographic, and anthropometric variables were obtained prospectively. NAFLD Activity Score (NAS) was obtained for each patient. Statistical analysis was done using SPSS version 22.

Results

A total of 200 patients (140 females and 60 males) were included in the study. In all, 138 patients were categorized as non-nonalcoholic steatohepatitis (NASH), 39 patients as borderline/suspicious NASH, and 23 patients had definitive NASH. A higher body mass index, weight, total cholesterol, low-density lipoprotein, alkaline phosphatise, and weight circumference were found in patients with NASH.

Conclusion

The high prevalence of NAFLD in patients with gallstone disease may justify routine liver biopsy during cholecystectomy to establish the diagnosis, stage, and possibly direct therapy.

Cholecystectomy Risk in Crohn's Disease Patients After Ileal Resection: a Long-term Nationwide Cohort Study

BACKGROUND

The risk of gallstone disease necessitating cholecystectomy after ileal resection (IR) in Crohn's disease (CD) patients is not well established. We studied the incidence, cumulative and relative risk of cholecystectomy after IR in CD patients, and associated risk factors.

METHODS

CD patients with a first IR between 1991 and 2015 were identified in PALGA, a nationwide pathology database in the Netherlands. Details on subsequent cholecystectomy and IR were recorded. Yearly cholecystectomy rates from the general Dutch population were used as a reference.

RESULTS

A cohort of 8302 (3466 (41.7%) males) CD patients after IR was identified. During the 11.9 (IQR 6.3-18.0) years median follow-up, the post-IR incidence rate of cholecystectomy was 5.2 (95% CI 3.5-6.4)/1000 persons/year. The cumulative incidence was 0.5% at 1 year, 2.4% at 5 years, 4.6% at 10 years, and 10.3% after 20 years. In multivariable analyses, female sex (HR 1.9, CI 1.5-2.3), a later calendar year of first IR (HR_{/5-year increase}, HR 1.27, CI 1.18-1.35), and ileal re-resection (time-dependent HR 1.37, CI 1.06-1.77) were associated with cholecystectomy. In the last decade, cholecystectomy rates increased and were higher in our postoperative CD population than in the general population (relative incidence ratio 3.13 (CI 2.29-4.28; p < 0.0001) in 2015).

CONCLUSIONS

Although higher in females, increasing in recent years, and higher than in the general population, the overall risk of cholecystectomy in CD patients following IR is low and routine prophylactic measures seem unwarranted.

Cholecystectomy Patients with High Plasma Level of Catalase Have Significantly Lower Analgesia Requirement: A Prospective Study of Two Different Cholecystectomy Techniques with Special Reference to Patients with Cancer

BACKGROUND/AIM

The plasma level of the oxidative stress biomarker catalase in patients with gallstone disease has not been previously compared with that of patients with cancer. Moreover, the number of analgesic doses required during the first 24 h postoperatively (NAD₂₄) after laparoscopic cholecystectomy (LC) or mini-cholecystectomy (MC) in patients with gallstones is unreported. The aim of the present study was to determine the correlation between the plasma catalase level in patients with gallstones according to cholecystectomy technique versus patients with cancer.

PATIENTS AND METHODS

Initially, 114 patients with symptomatic gallstone disease were randomized into LC (n=54) or MC (n=60) groups. The plasma level of catalase was measured immediately before, immediately after and 6 hours after operation.

RESULTS

The median plasma catalase levels preoperatively and following surgery in the LC and MC patients versus those with cancer did not differ statistically significantly. The median plasma level of catalase increased immediately after operation, but the alteration was statistically insignificant (p=0.132). Interestingly, there was a statistically significant weak inverse correlation between the individual NAD₂₄ and median plasma catalase values postoperatively in patients with gallstone disease (r=-0.283, p=0.042).

CONCLUSION

The plasma catalase levels preoperatively and following surgery in the LC and MC patients versus those with cancer were quite similar. Cholecystectomy patients with high plasma levels of catalase appeared to require significantly fewer analgesic doses during the first 24 hours postoperatively (NAD₂₄), suggesting that better oxidative balance following surgery could have a protective role against postoperative pain.

Cholecystectomy and risk of metabolic syndrome

The gallbladder physiologically concentrates and stores bile during fasting and provides rhythmic bile secretion both during fasting and in the postprandial phase to solubilize dietary lipids and fat-soluble vitamins. Bile acids (BAs), major lipid components of bile, play a key role as signaling molecules in modulating gene expression related to cholesterol, BA, glucose and energy metabolism. Cholecystectomy is the most commonly performed surgical procedure worldwide in patients who develop symptoms and/or complications of cholelithiasis of any type. Cholecystectomy per se, however, might cause abnormal metabolic consequences, i.e., alterations in glucose, insulin (and insulin-resistance), lipid and lipoprotein levels, liver steatosis and the metabolic syndrome. Mechanisms are likely mediated by the abnormal transintestinal flow of BAs, producing metabolic signaling that acts without gallbladder rhythmic function and involves the BAs/farnesoid X receptor (FXR) and the BA/G protein-coupled BA receptor 1 (GPBAR-1) axes in the liver, intestine, brown adipose tissue and muscle. Alterations of intestinal microbiota leading to distorted homeostatic processes are also possible. According to this view, cholecystectomy, via BA-induced changes in the enterohepatic circulation, is a risk factor for the metabolic abnormalities and becomes another “fellow traveler” with, or another risk factor for the metabolic syndrome.

[Research advances of relationship between non-alcoholic fatty liver disease and biliary tract diseases]

Recent studies have found that non-alcoholic fatty liver disease(NAFLD) has great impact on the development of biliary tract diseases. Here in this review, we summarized the relationship between NAFLD and the occurrence and development, risk factors and severity of cholestasis, gallstones, intrahepatic cholangiocarcinoma, primary biliary cirrhosis and bile microbiota, so as to further illuminate the pathogenesis of NAFLD and biliary tract diseases, obtain better diagnostic and therapeutic outcomes on NAFLD and biliary tract diseases.