Case Report of Overlapping Pyloric Obstruction Due to Dichlorvos Poisoning and Cholelithiasis with Choledocholithiasis

BACKGROUND Pyloric obstruction after dichlorvos poisoning causes repeated vomiting and inability to eat. Choledocholithiasis and cholelithiasis are the common digestive diseases, with high morbidity and relapse in elderly patients. However, the complex situation of these diseases' coexistence is a clinically intractable problem, and literature on selecting optimal surgical planning is scarce. CASE REPORT A thin 79-year-old woman took dichlorvos due to family conflicts. She improved after being urgently sent to local hospital for gastric lavage and detoxification. Over the next 3 months, she presented with intermittent nausea, vomiting, epigastric pain, and mental apathy, and was readmitted. Gastroscopy showed extensive scarring in the antrum, pyloric obstruction, and gastric retention. Magnetic resonance cholangiopancreatography revealed gallstones and choledocholithiasis. Also, she presented with gastric retention, hypertension, moderate anemia, hypoproteinemia, and electrolyte disturbances. After hospitalization, conservative treatment was performed, without improving vomiting, followed by surgical treatment. Gastrojejunostomy, Braun anastomosis, and nasojejunal feeding tube placement were performed for pyloric stenosis; cholecystectomy for cholelithiasis; and choledochotomy, intraoperative choledochoscopy examination, basket stone extraction, and primary suture of common bile duct without indwelling T tube for choledocholithiasis. Patient recovered and was discharged 9 days after surgery. She was recovered well, without vomiting, at 2-month follow-up. CONCLUSIONS Gastrojejunostomy plus Braun anastomosis is effective treatment of elderly patients with pyloric obstruction formed after pesticide-induced corrosion. Careful selection of choledocholithotomy with primary suture without indwelling T tube reduced postoperative pain and accelerated recovery. This complex case of pyloric obstruction with gallbladder and bile duct stones provides useful considerations for clinical treatment.

Ceftriaxone-induced severe hemolytic anemia, renal calculi, and cholecystolithiasis in a 3-year-old child: a case report and literature review

Ceftriaxone is widely used in pediatric outpatient care for its efficacy against respiratory and digestive system infections, yet its increasing association with severe immune hemolytic reactions requires heightened vigilance from pediatricians. This report details a rare and severe case of ceftriaxone-induced severe immune hemolytic anemia (IHA), hemolytic crisis, myocardial injury, liver injury, renal calculi, and cholecystolithiasis in a previously healthy 3-year-old child. The child, treated for bronchitis, experienced sudden pallor, limb stiffness, and altered consciousness following the fifth day of ceftriaxone infusion, with hemoglobin (Hb) levels precipitously dropping to 21 g/L. Immediate cessation of ceftriaxone and the administration of oxygen therapy, blood transfusion, intravenous immunoglobulin (IVIG), and corticosteroids led to a gradual recovery. Despite initial improvements, the patient's condition necessitated extensive hospital care due to complications including myocardial injury, liver injury, renal calculi, and cholecystolithiasis. After a 12-day hospital stay and a 3-month follow-up, the child showed complete normalization of Hb and liver function and resolution of calculi. In children, ceftriaxone infusion may trigger severe, potentially fatal, hemolytic reactions. Pediatricians must promptly recognize symptoms such as pallor, limb stiffness, and unresponsiveness, indicative of ceftriaxone-induced severe IHA, and immediately discontinue the drug. Effective management includes timely blood transfusion, respiratory support, IVIG administration, and corticosteroids when necessary, along with rigorous vital signs monitoring. Continued vigilance is imperative, even after cessation of ceftriaxone, to promptly address any residual adverse effects.

Prevalence and Risk Factors of Choledocholithiasis in Omani Patients With Sickle Cell Disease Undergoing Endoscopic Retrograde Cholangiopancreatography: A Retrospective Analysis

Background Sickle cell disease (SCD) is a prevalent genetic disorder in the Middle East, particularly in Oman, leading to significant morbidity. It is caused by a mutation in the gene encoding hemoglobin (Hb) molecules, resulting in the formation and polymerization of hemoglobin S (HbS), which subsequently leads to hemolysis. Chronic hemolysis in SCD patients often results in various complications, including increased bilirubin levels in the gallbladder and the formation of pigmented biliary stones, which may obstruct the biliary tract system. In such cases, endoscopic retrograde cholangiopancreatography (ERCP) is often employed as a diagnostic and therapeutic tool to manage biliary complications. Objectives and rationale Considering the lack of studies on the Omani population with SCD, our study aims to determine the incidence of biliary stone formation in SCD patients undergoing ERCP and identify associated risk factors. Subjects and methods This retrospective study included 79 SCD patients aged over 12 years who underwent ERCP at Sultan Qaboos University Hospital, Muscat, Oman, between January 2010 and January 2023. Patient data were extracted from medical records. Continuous variables were analyzed using mean and standard deviation calculations, with independent sample t-tests for mean comparisons. The chi-square test assessed associations between categorized variables, with a p-value of ≤0.05 denoting statistical significance. Results The prevalence of choledocholithiasis in SCD patients undergoing ERCP was 67.1%. The incidence was higher in females (68.9%) than males (65.9%), in patients aged 12-29 (71.2%) compared to those aged ≥29 (59.3%), in patients with SCD (70.6%) versus sickle cell thalassemia (66.1%), and in those who had undergone gallbladder removal (80.0%) compared to those who did not (61.3%). Prevalence was also higher in patients not using hydroxyurea and folic acid (70.6% and 84.6%, respectively); however, chi-square analysis showed no significant association (p-value > 0.05). Additionally, t-test comparisons of HbS and HbF levels showed no significant differences. Conclusion This study documents a high prevalence of choledocholithiasis (67.1%) in SCD patients undergoing ERCP. Although the prevalence is notable, the examined risk factors did not show a significant association with stone formation.

Patients with Clinically Suspected Gallstone Disease: A More Selective Ultrasound May Improve Treatment Related Outcomes

This study aimed to quantify the confirmation of gallstones on ultrasound (US) in patients with suspicion of gallstone disease. To aid general practitioners (GPs) in diagnostic workup, a model to predict gallstones was developed. A prospective cohort study was conducted in two Dutch general hospitals. Patients (≥18 years) were eligible for inclusion when referred by GPs for US with suspicion of gallstones. The primary outcome was the confirmation of gallstones on US. A multivariable regression model was developed to predict the presence of gallstones. In total, 177 patients were referred with a clinical suspicion of gallstones. Gallstones were found in 64 of 177 patients (36.2%). Patients with gallstones reported higher pain scores (VAS 8.0 vs. 6.0, p < 0.001), less frequent pain (21.9% vs. 54.9%, p < 0.001), and more often met criteria for biliary colic (62.5% vs. 44.2%, p = 0.023). Predictors for the presence of gallstones were a higher pain score, frequency of pain less than weekly, biliary colic, and an absence of heartburn. The model showed good discrimination between patients with and without gallstones (C-statistic 0.73, range: 0.68-0.76). Clinical diagnosis of symptomatic gallstone disease is challenging. The model developed in this study may aid in the selection of patients for referral and improve treatment related outcomes.

Acute recurrent pancreatitis during 3rd trimester of pregnancy

OBJECTIVE

We present an unusual case report of a pregnant patient with recurrent attacks of acute pancreatitis due to cholecystolithiasis.

CONCLUSION

Acute pancreatitis in pregnancy is a rare disease. Unlike the non-pregnant population, it is characterized by a high recurrence rate. Acute pancreatitis during pregnancy has a negative effect on both the mother and the fetus. The treatment is modified depending on the trimester of pregnancy.

The Symptomatic Outcomes of Cholecystectomy for Gallstones

Cholecystectomy is the definite treatment for symptomatic gallstones, and rates are rapidly rising. Symptomatic complicated gallstones are generally treated with cholecystectomy, but there is no consensus on the clinical selection of patients with symptomatic uncomplicated gallstones for cholecystectomy. The aim of this review is to describe symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones as reported in prospective clinical studies and to discuss patient selection for cholecystectomy. Following cholecystectomy, resolution of biliary pain is high and reported for 66-100%. Dyspepsia has an intermediate resolution of 41-91% and may co-exist with biliary pain but may also develop following cholecystectomy with an increase of 150%. Diarrhea has a high increase and debuts in 14-17%. Persisting symptoms are mainly determined by preoperative dyspepsia, functional disorders, atypical pain locations, longer duration of symptoms, and poor psychological or physical health. Patient satisfaction following cholecystectomy is high and may reflect symptom alleviation or a change in symptoms. Comparison of symptomatic outcomes in available prospective clinical studies is limited by variations in preoperative symptoms, clinical presentations, and clinical management of post-cholecystectomy symptoms. When selecting patients with biliary pain only in a randomized controlled trial, 30-40% still have persisting pain. Strategies for the selection of patients with symptomatic uncomplicated gallstones based on symptoms alone are exhausted. For the development of a selection strategy, future studies should explore the impact of objective determinants for symptomatic gallstones on pain relief following cholecystectomy.

Iatrogenic Injury of Biliary Tree-Single-Centre Experience

Cholecystolithiasis is among the most prevalent gastrointestinal disorders requiring surgical intervention, and iatrogenic damage to the bile tree is a severe complication. We aimed to present the frequency of bile duct injuries and how our facility handles these complications. We retrospectively analyzed bile duct injuries in patients undergoing surgery. We concentrated on factors such as sex, age, indications for surgery, type of surgery, primary procedure, bile tree injury, repair, and timing as well as early and late complications. There were 22 cases of bile duct injury in the studied material, primarily affecting women-15 individuals (68.2%). Eleven cases (45.7%) of acute cholecystitis were the primary reason for surgery, and an injury to the common bile duct that extended up to 2 cm from the common hepatic duct was the most common complication (European Association for Endoscopic Surgery grade 2). Roux-en-Y hepaticojejunostomy was the most common repair procedure in 14 cases (63.6%). Eleven patients (50%) experienced early complications following reconstruction surgery, whereas five patients (22.7%) experienced late complications. An annual mortality rate of 22.7% (five patients) was observed. Iatrogenic bile duct injury is a severe complication of surgical treatment for cholecystolithiasis. Reconstruction procedures are characterized by high complication rates and high mortality.

Optimal Timing of Cholecystectomy for Patients with Concurrent Acute Cholecystitis and Acute Cholangitis after Successful Biliary Drainage by Interventional Endoscopic Retrograde Cholangiopancreatography

Background: Concurrent acute cholecystitis and acute cholangitis is a unique clinical situation. We tried to investigate the optimal timing of cholecystectomy after adequate biliary drainage under this condition. Methods: From January 2012 to November 2017, we retrospectively screened all in-hospitalized patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and then identified patients with concurrent acute cholecystitis and acute cholangitis from the cohort. The selected patients were stratified into two groups: one-stage intervention (OSI) group (intended laparoscopic cholecystectomy at the same hospitalization) vs. two-stage intervention (TSI) group (interval intended laparoscopic cholecystectomy). Interrogated outcomes included recurrent biliary events, length of hospitalization, and surgical outcomes. Results: There were 147 patients ultimately enrolled for analysis (OSI vs. TSI, 96 vs. 51). Regarding surgical outcomes, there was no significant difference between the OSI group and TSI group, including intraoperative blood transfusion (1.0% vs. 2.0%, p = 1.000), conversion to open procedure (3.1% vs. 7.8%, p = 0.236), postoperative complication (6.3% vs. 11.8%, p = 0.342), operation time (118.0 min vs. 125.8 min, p = 0.869), and postoperative days until discharge (3.37 days vs. 4.02 days, p = 0.643). In the RBE analysis, the OSI group presented a significantly lower incidence of overall RBE (5.2% vs. 41.2%, p < 0.001) than the TSI group. Conclusions: Patients with an initial diagnosis of concurrent acute cholecystitis and cholangitis undergoing cholecystectomy after ERCP drainage during the same hospitalization period may receive some benefit in terms of clinical outcomes.

National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society

BACKGROUND AND OBJECTIVE

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS).

METHODS

An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences.

RESULTS

For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation).

CONCLUSIONS

Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed.

ENDORSEMENT

The Danish Surgical Society.

The Mitochondrial tRNAPhe 625G>A Mutation in Three Han Chinese Families With Cholecystolithiasis

In this study, we assessed three Chinese families with inherited cholecystolithiasis and conducted the clinical, genetic, and molecular characterization of these subjects. Eight of eighteen matrilineal relatives had a clinical phenotype in these three families. Sequence analysis of complete mitochondrial genomes in these probands identified the homoplasmic tRNA^Phe 625 G > A mutation and distinct sets of mtDNA polymorphisms belonging to haplogroups H2, F4b, and M10a. The 625G > A mutation disturbed the classic G-C base-pairings at a highly conserved position 49 in the T-stem of mitochondrial tRNAs. Molecular dynamics simulation showed that the structure of tRNA^phe with 625 G > A mutation was noticeably remodeled while compared with the isoform of the wild type. The occurrence of tRNA^Phe 625 G > A mutation in these various genetically unrelated subjects strongly indicates that this mutation is involved in the pathogenesis of cholecystolithiasis. This is the first evidence that tRNA mutations are associated with cholecystolithiasis, and it provided more insights into the genetic mechanism of cholecystolithiasis.

Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis

Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.

Duodenal bulbar necrosis with hemorrhage caused by cholecystolithiasis: a case report

Gastrointestinal bleeding and gallbladder stones are common diseases of the digestive system. However, duodenal necrosis and bleeding caused by gallbladder stone compression is relatively rare. The present report describes a patient with repeated hematemesis and melena that relapsed after several symptomatic treatments. The patient and his family elected surgical treatment. Intraoperative examination revealed necrosis of the duodenal bulb with hemorrhage, which was related to compression of the gallbladder neck. Because the imaging manifestations of this disease lack specificity, early diagnosis is difficult.

The optimal timing of interval laparoscopic cholecystectomy following percutaneous cholecystostomy based on pathological findings and the incidence of biliary events

BACKGROUND

The incidence of biliary events (BE) following percutaneous cholecystostomy (PC) in acute cholecystitis (AC) patients is high. Therefore, definitive laparoscopic cholecystectomy (LC) is recommended. We aimed to investigate the optimal timing of LC following PC with regard to the clinical course and pathological findings.

METHODS

All 744 AC patients with PC were included. The incidence and median number of BE were investigated with the concept of competing risks. The 344 patients with interval LC were divided into two groups based on the pathological findings of resected gallbladders: the acute/acute-and-chronic group (AANC group) (n = 221) and the chronic group (n = 123). A comparative analysis of the demographic data and perioperative outcomes was performed.

RESULTS

Among the 744 AC patients with PC, 142 patients experienced recurrent BE. The cumulative incidence of BE was 26.6%, and the median time to recurrence was 67.5 days. The PC-to-LC days of the chronic group were longer than those of the AANC group (73.51 vs 63.00, P < .001). The multivariate analysis indicated that the operation time was longer in the AANC group than in the chronic group (P = .040).

CONCLUSION

In terms of the clinical course and sequential pathological changes in the gallbladder, a 9- to 10-week interval after PC is the optimal timing for LC.

Diagnostic value of ultrasound combined with MRI in cholecystolithiasis: A protocol for systematic review and meta analysis

BACKGROUND

Early diagnosis of cholecystolithiasis is significant for prevention of further development of situation. Ultrasound is the best choice for the diagnosis of cholecystolithiasis with a sensitivity of >95% and specificity of practically 100%. However, ultrasound is not perfect for it is not so clear sometimes. So, MRI is needed to assist the diagnosing of cholecystolithiasis. Some studies have been conducted to investigate the diagnostic value of ultrasound combined with MRI in cholecystolithiasis, however, the evidence was not enough.

METHODS

We will search the following sources for the identification of trials: The Cochrane Library, PubMed, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure Database (CNKI), Chinese Science and Technique Journals Database (VIP), and the Wanfang Database. The searches were limited to articles published before 1st, April, 2021, and the language were limited to Chinese and English. Statistical analyses will be conducted with Sata 14.0 software and the evaluation of the quality of the included studies will be performed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).

RESULTS

This study will provide a rational synthesis of current evidences for MRI combined with ultrasound for cholecystolithiasis.

CONCLUSION

The conclusion of this study will provide evidence for the diagnostic value of MRI combined with ultrasound for cholecystolithiasis.

ETHICS AND DISSEMINATION

This protocol will not evaluate individual patient information or affect patient rights and therefore does not require ethical approval. Results from this review will be disseminated through peer-reviewed journals and conference reports.

PROSPERO REGISTRATION NUMBER

INPLASY202130003.

The evaluation of B-SAFE and ultrasonographic landmarks in safe orientation during laparoscopic cholecystectomy

INTRODUCTION

Even though the prevalence of bile duct injury (BDI) is nowadays lower than before and close to the era of open cholecystectomy, there is a strong need to make it even lower. B-SAFE is a group of five visual landmarks that may be used before dissection in the hepatocystic triangle for better orientation around the gallbladder. Another method is laparoscopic ultrasound (LUS), which enables confirmation of structures in the hepatoduodenal ligament and delineation of the safe plane of dissection.

AIM

To evaluate the use of B-SAFE and ultrasonographic landmarks during laparoscopic cholecystectomy in navigation around the gallbladder.

MATERIAL AND METHODS

The study group consisted of 158 patients with symptomatic cholecystolithiasis. The methods of intraoperative orientation around the gallbladder attempted in every patient during laparoscopic cholecystectomy included B-SAFE and ultrasonographic landmarks.

RESULTS

The identification rate of ultrasonographic landmarks - the upper border of "Mickey Mouse" sign (MMS) (the equivalent of the Rouviere's sulcus), the bile duct, and the hepatic artery - was significantly higher in patients with body mass index ≥ 30 kg/m2 and fibrosis and chronic inflammation in the gallbladder neck than B-SAFE. LUS was also significantly more successful in the identification of the bile duct in the whole study group than B-SAFE. There were no significant differences according to the identification of the duodenum. The conversion rate was 2.6%, and we did not observe any BDI.

CONCLUSIONS

Visual landmarks defined in B-SAFE are not as reliable as ultrasonographic landmarks; thus, LUS should be taken into consideration in the first place as a method of navigation around the gallbladder.

Gender as a predictive factor in cholecystectomy - is it true or false?

INTRODUCTION

Cholecystolithiasis is one of the most frequent disorders of the human digestive system in a present population. It is common to point out that male gender is one of strong risk factors for complications during cholecystectomy, however the debate about that seems to be still open.

AIM OF THE STUDY

The aim of this study was to compare the values related to the course and treatment effects between gender in patients undergoing cholecystectomy, based on own material.

MATERIALS AND METHODS

The study encompassed 504 patients who were admitted to General Surgery And Polytraumatic Injury Department of University Hospital in Kraków, Poland between 2013 and 2018, with the initial diagnosis of cholecystolithiasis (scheduled cases) and acute cholecystitis (emergency cases). The patients underwent surgical gallbladder removal. In this group there were 326 (64.7%) female and 178 (35.3%) male patients.

RESULTS

Statistically significant differences between both genders were found containing age, type of admission, numeric rating scale of pain during admission, results in American Society of Anesthesiologists physical status classification system, outcomes in Acute Physiology And Chronic Health Evaluation II severity-of-disease classification system, percentage of conversions, mortality, period of time from admission to surgical procedure, mean duration of the procedure, blood tests and histopathological results.

CONCLUSIONS

Subgroups of the cases where determining factor is gender are strongly heterogeneous. Although treatment results were different for both subgroups and these differences were partly statistically significant, it cannot be clearly determined on the basis of a study with such selection of patients, that gender is an independent risk factor for surgical gallbladder removal.

Laparoscopic Cholecystectomy During Pregnancy: A Case Report and Review of Literature in Japan

Herein we report a case of laparoscopic cholecystectomy in a 26-year-old pregnant woman with no remarkable medical history. Laparoscopic cholecystectomy was performed at 21 weeks of gestation. To prevent uterus injury, the first trocar was inserted into the right hypochondrium using the open method after marking the site of the uterus via ultrasonography. After confirming the site of the uterus, the second trocar with a balloon was inserted 3 finger widths above the umbilicus. Additional 5-mm trocars were inserted into the epigastric and hypochondrial regions. A good surgical view was obtained with a pneumoperitoneal pressure of 8 mmHg. Laparoscopic cholecystectomy was successfully performed without any complications during or after the operation. She had a normal delivery at 39 weeks of gestation. Laparoscopic cholecystectomy is a viable treatment option during pregnancy, provided there is close consultation and cooperation between obstetricians and anesthesiologists.

Reconsideration of indications for choledochoscopic gallbladder-preserving surgery and preventive measures for postoperative recurrence of gallstones

Introduction

The recurrence of cholecystolithiasis after choledochoscopic gallbladder-preserving surgery is a major problem. It is unclear whether the recurrence of cholecystolithiasis is due to the limitations of the operation itself or to the selection of inappropriate candidates.

Aim

To analyze the recurrence of cholecystolithiasis after choledochoscopic gallbladder-preserving surgery and to provide guidance for the treatment of cholecystolithiasis by choledochoscopic gallbladder-preserving surgery.

Material and methods

A total of 145 patients who had undergone choledochoscopic gallbladder-preserving surgery were studied from January 2012 to January 2018. The recurrence rate, recurrence time, and risk factors were evaluated.

Results

Of these 145 patients, 14 (9.66%) experienced recurrence with a mean follow-up time of 39.72 ±24.44 months. The mean time to recurrence was 30.07 ±21.21 months. Univariate analysis showed that pregnancy history (p = 0.008), the uniformity of gallstones (p = 0.002), preoperative inflammation (p = 0.022), postoperative oral drugs (p = 0.022) and the regularity of diet (p = 0.001) were significantly related to recurrence. The uniformity of gallstones (odds ratio (OR) = 0.079; 95% confidence interval (CI): 0.010–0.590; p = 0.013) and the regularity of diet (OR = 0.074; 95% CI: 0.010–0.528; p = 0.009) were independent prognostic factors for recurrence according to multivariate analysis.

Conclusions

Nonuniform gallstones combined with an irregular diet are significant risk factors that predict cholecystolithiasis recurrence.

[Optimal dates of surgery for acute calculous cholecystitis]

OBJECTIVE

To analyze the results of surgical treatment of acute calculous cholecystitis depending on dates of surgery.

MATERIAL AND METHODS

There were 123 patients with acute calculous cholecystitis in 2017. The sample enrolled 111 females (90.2%) and 12 (9.8%) males. Mean age of patients was 63.4±5.7 years. Patients were divided into 4 groups depending on dates of surgery. Group A - 18 (16.2%) patients with destructive forms of cholecystitis. These patients underwent surgery after a short preoperative preparation. Group B comprised of 32 patients (28.8%) who were operated within 72 hours. Group C enrolled 34 patients (30.7%). These patients underwent operation within 7-12 days after clinical manifestation of disease. Group D enrolled 27 patients (24.3%). Delayed surgical strategy was applied in this group. Surgical treatment was scheduled 2-3 months later. Duration of surgery, intraoperative technical features, length of hospital-stay and postoperative morbidity were studied.

RESULTS

Similar outcomes were observed in groups A and B. Group B was characterized by less duration of surgery and hospital-stay. The most significant technical difficulties arose in group C. The best results were achieved in group D.

CONCLUSION

Surgical treatment of acute calculous cholecystitis within 72 hours after clinical manifestation is the most preferable. However, surgical treatment should be performed in few months if medication is effective.

Transgastric endoscopic gallbladder polypectomy and cholecystolithiasis: A case report

As the most common digestive-system disease, cholelithiasis and gallbladder polyps have a high incidence. The most common treatment is laparoscopic cholecystectomy, but there are numerous drawbacks, including stump syndrome. In the present study, a novel treatment, namely transgastric endoscopic gallbladder polypectomy and cholecystolithiasis, was applied. To the best of our knowledge, the present study is the first to report on this application, which can potentially avoid open surgery and associated scars and allows for rapid recovery after surgery, and may therefore be worthy of further development and implementation in clinical practice. It is esteemed that in the future, transgastric endoscopy gallbladder polypectomy and cholecystolithiasis will be considered as a treatment option for certain patients and is subjected to constant improvements.

Laparoscopic cholecystectomy for cholecystolithiasis with Dubin-Johnson syndrome

Dubin–Johnson syndrome is a rare, autosomal recessive hereditary disease, commonly known as “black liver disease.” It is of great interest for surgeons to accidentally find the “black liver” during laparoscopic cholecystectomy (LC). We performed an emergency LC for cholecystolithiasis with Dubin–Johnson syndrome in 2013. We only performed cholecystectomy and liver tissue biopsy. Following a 5‐year follow‐up period, the patient does not appear to have abdominal pain and any other discomfort. Dubin–Johnson syndrome has no significant relationship with the occurrence of cholecystolithiasis and generally requires no special treatment. It is necessary to avoid misdiagnosis and overtreatment in the clinic.

Clinical Efficacy Analysis of the Combination of the Laparoscope and Preoperative or Intraoperative Duodenoscope in the Treatment of Cholecystolithiasis with Choledocholithiasis: A Retrospective Study

Aim: This study aims to analyze the efficacy and safety of the combination of laparoscope and preoperative (PODL) or intraoperative (IODL) duodenoscope in the treatment of cholecystolithiasis with choledocholithiasis.

Materials and Methods: From January 2015 to February 2017, 51 patients with cholecystolithiasis and choledocholithiasis, who were treated with the PODL (n = 29) or IODL (n = 22), were reviewed retrospectively. The efficacy and safety were evaluated and compared between these two groups.

Results: The success rates were 100% in IODL group and 96.6% in PODL group. There was no statistical significance in the difference of stone clearance rate and residual stone rate between two groups (P > .05). There were no significant differences in complications, like aspiration, gastrointestinal perforation, and acute cholangitis between two groups (P > .05). IODL significantly decreased numeric rating scale (NRS) scoring, reduced surgery cost and shortened hospitalization time compared to that of PODL group (P < .05). No cholangitis, reoccurrence of stones or biliary obstruction occurred in all 51 patients.

Conclusion: In this retrospective study, IODL was found superior to PODL. And the IODL can significantly decrease NRS scoring, reduce surgery cost and shorten hospitalization time.

CT attenuation values and mineral distribution can be used to differentiate dogs with and without gallbladder mucoceles

Gallbladder mucoceles are potentially fatal in dogs. Multiphase CT angiography was performed to evaluate the canine gallbladder in three conditions: no sludge, sludge occupying ≥25% of the lumen, and mucoceles. Twenty dogs with normal hepatobiliary bloodwork and no-to-minimal gallbladder sludge, 13 dogs with normal bloodwork and ≥25% sludge in the gallbladder lumen, and 18 dogs with histologically confirmed gallbladder mucoceles were enrolled in a prospective, observational diagnostic accuracy study. Three regions of interest (ROI) were stratified in the dorsal-ventral orientation and a single ROI was measured within the hepatic parenchyma. Mean attenuation and presence of mineral were recorded. Average Hounsfield units (HU) were recorded for precontrast, arterial, portovenous, and late venous phases. The overall median HU value for mucoceles was significantly higher than gallbladders without sludge and with sludge; precontrast median overall attenuation was 49.3, 35.8, and 39.7 HU, respectively (P < .000004). Mineral was seen in four (20%) dogs with no sludge, seven (56%) dogs with sludge, and nine (50%) dogs with mucoceles. Mineral in the dogs with mucoceles was located within the central aspect of the gallbladder lumen in 67% of mucoceles; this mineral distribution was not seen in any dog without a mucocele. Computed tomography can differentiate a subset of gallbladder mucoceles from dogs with and without gallbladder sludge, especially in the precontrast series. An HU value of 48.6 is 52% sensitive and 96% specific for a gallbladder mucocele. A hyperattenuating gallbladder on precontrast CT images and centrally distributed mineral can be a gallbladder mucocele.

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.

Systematic review and meta-analysis: cholecystectomy and the risk of cholangiocarcinoma

Studies have reported that cholecystectomy may increase the risk of cholangiocarcinoma. However, this association is controversial. Thus, we conducted a systematic review and meta-analysis to explore the relationship between cholecystectomy and the risk of cholangiocarcinoma. Relevant studies were identified by searching PubMed, EMBASE, ISI Web of Science published before February 2017. We used the random effects model proposed by DerSimonian and Laird to quantify the relationship between cholecystectomy and risk of cholangiocarcinoma. Publication bias was evaluated using funnel plots, Begg's and Egger's tests. Subgroup and sensitivity analyses were performed to validate the stability of the results. 16 articles, comprising 220,376 patients with cholecystectomy and 562,392 healthy controls, were included in our research. Our meta-analysis suggested that the risk of cholangiocarcinoma was significantly higher in the cholecystectomized patients in comparison with healthy controls, with heterogeneity among studies (summary odds ratio [OR] = 0.72; confidence interval [CI] = 0.55-0.90; I² = 69.5%). Additionally, this association was also observed in cohort studies (OR = 0.83; 95% CI = 0.73-0.94) and case-control studies (OR = 0.60; 95% CI = 0.40-0.80). However, When the intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma were analyzed separately, the present study only indicated cholecystectomy was associated with increased the risk of extrahepatic cholangiocarcinoma (OR = 1.19; 95% CI = 0.32-2.05), rather than intrahepatic cholangiocarcinoma (OR = 1.19; 95% CI = 0.32-2.05). In conclusion, cholecystectomy was associated with a significant 54% increase in the risk of cholangiocarcinoma, especially in the extrahepatic cholangiocarcinoma.

Incidental gallbladder cancer after cholecystectomy: 1990 to 2014

INTRODUCTION

Cancer of the gallbladder is a serious diagnostic and therapeutic problem. According to the literature, 30% of cases are not confirmed before surgery. Other cases are detected incidentally by histopathology. Clinical trials and meta-analyses show that incidental gallbladder cancer (iGBC) occurs in 0.19%-2.8% of patients after cholecystectomy. The aim of this study was to analyze the incidence and severity of iGBC in cholecystectomy procedures performed in the surgical department at the 4th Military Teaching Hospital in Wroclaw during the years 1990-2014.

PATIENTS AND METHODS

In the years 1990-2014, a total of 7,314 cholecystectomies were performed in the surgical department because of cholecystolithiasis: 6,145 were performed using the laparoscopic approach (84.02%), 867 were performed as open surgery (11.8%), and 302 cases required conversion (5.1%). In this group, 5,214 of the patients were females (71.3%) and 2,100 were males (28.7%), with an average age of 54.7 years.

RESULTS

We found 64 iGBC cases which were confirmed by histopathology. This represented 0.87% of all cases. In this group, 50 patients were females (78.1%) and 14 were males (21.8%), with an average age of 67.1 years. Of this group, 40 patients underwent a classic cholecystectomy, while 24 underwent laparoscopic procedures, out of which 13 cases ultimately required traditional surgery. The histopathology showed 15 carcinomas that were classified as G1 (23.4%), 28 were G2 (43.75%), and 21 were G3 (32.8%).

CONCLUSION

iGBC detected after a cholecystectomy due to cholecystolithiasis is a rare disease. We found iGBC in 0.87% of cases, which is on a comparable scale to the world literature. In the case of cancer, we frequently found it necessary to convert to an open surgical procedure. This cancer is more common in females and in people over 60 years of age.

Aquaporin-1 and 8 expression in the gallbladder mucosa might not be associated with the development of gallbladder stones in humans

BACKGROUND

Cholecystolithiasis is a highly prevalent condition in the Western world. Gallbladder stone-related conditions represent the second most common gastrointestinal pathology. Cholesterol stones represent over 80% of gallstones. Cholesterol stones develop secondary to crystallization of bile cholesterol. Water resorption from gallbladder bile via aquaporin in the gallbladder mucosa might play a role in the development of cholesterol stones. This study investigated the expression of Aquaporin-1 (AQP1) and Aquaporin-8 (AQP8) in the human gallbladder mucosa and their possible association with the formation of gallbladder stones.

METHODS

The expression of AQP1 and AQP8 in the gallbladder mucosa was examined via immunohistochemical staining. The expression of both AQP1 and AQP8 in the gallbladder mucosa of stone carriers (study group) was compared to that of nonstone carriers (control group).

RESULTS

Eighty-four gallbladder specimens from 44 male (52·2%) and 40 female (47·6%) patients were analysed. The study group included 47 specimens from stone carriers, while 37 specimens from stone-free gallbladders were included in the control group. Immunostaining for both AQP1 and AQP8 was positive in 80 cases. AQP1 was expressed both over the apical and intercellular membrane, while AQP8 was expressed only over the apical membrane. A similar distribution was recorded in specimens from the cystic duct. Immunostaining with AQP1 was generally stronger in comparison with AQP8. No significant (P > 0·05) relationship was found between aquaporin expression and the presence or absence of gallbladder stones.

CONCLUSION

AQP1 and AQP8 are both expressed in the gallbladder and cystic duct mucosa. However, their role in the development of gallbladder stones is still to be proven.

Biliary dyskinesia and symptomatic gallstone disease in children: two sides of the same coin?

BACKGROUND

Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis.

AIMS

We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH).

METHODS

Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh.

RESULTS

Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy.

CONCLUSIONS

A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.

Has the prevalence of cholesterol gallstones increased in Korea? A preliminary single-center experience

OBJECTIVES

We aimed to determine the prevalence of cholesterol gallstones, the compositional changes of gallstones and its predisposing factors in Korea with this single-center study.

METHODS

Data of 365 patients who underwent cholecystectomy for cholecystolithiasis from July 2008 to September 2011 were reviewed. Based on the compositional analysis of the gallstones, patients were assigned to either cholesterol gallstone group or pigment gallstone group. The characteristics of the patients and the gallstones were summarized and compared.

RESULTS

After eight patients with mixed gallstones were excluded, 357 patients were enrolled in the study, including cholesterol gallstones in 175 (49.0%) and pigment gallstones in 182 (51.0%). The number of patients with cholecystolithiasis increased but the prevalence of cholesterol gallstone decreased with age. Compared with the pigment gallstone group, the cholesterol gallstone group was associated with young age (<50 years), female gender, obesity (body mass index ≥ 25 kg/m²) and the absence of chronic liver diseases.

CONCLUSION

The relative prevalence of cholesterol gallstones in Korea has been stationary so far, but may change in the future since cholesterol gallstones are increasingly prevalent in the young generation.

Optic properties of bile liquid crystals in human body

AIM: To further study the properties of bile liquid crystals, and probe into the relationship between bile liquid crystals and gallbladder stone formation, and provide evidence for the prevention and treatment of cholecystolithiasis.

METHODS: The optic properties of bile liquid crystals in human body were determined by the method of crystal optics under polarizing microscope with plane polarized light and perpendicular polarized light.

RESULTS: Under a polarizing microscope with plane polarized light, bile liquid crystals scattered in bile appeared round, oval or irregularly round. The color of bile liquid crystals was a little lighter than that of the bile around. When the stage was turned round, the color of bile liquid crystals or the darkness and lightness of the color did not change obviously. On the border between bile liquid crystals and the bile around, brighter Becke-Line could be observed. When the microscope tube is lifted, Becke-Line moved inward, and when lowered, Becke-Line moved outward. Under a perpendicular polarized light, bile liquid crystals showd some special interference patterns, called Malta cross. When the stage was turning round at an angle of 360°, the Malta cross showed four times of extinction. In the vibrating direction of 45° angle of relative to upper and lower polarizing plate, gypsum test-board with optical path difference of 530 nm was inserted, the first and the third quadrants of Malt a cross appeared to be blue, and the second and the fourth quadrants appeared orange. When mica test-board with optical path difference of 147 nm was inserted, the first and the third quadrants of Malta cross appeared yellow, and the second and the fourth quadrants appeared dark grey.

CONCLUSION: The bile liquid crystals were distributed in bile in the form of global grains. Their polychroism and absorption were slight, but the edge and Becke*Line were very clear. Its refractive index was larger than that of the bile. These liquid crystals were uniaxial positive crystals. The interference colors were the first order grey-white. The double refractive index of the liquid crystals was Δn = 0.011-0.015.

Effect of apolipoprotein E gene Hha I restricting fragment length polymorphism on serum lipids in cholecystolithiasis

AIM: To investigate the role of apolipoprotein E (apoE) polymorphism in the lithogenesis of gallstone and the hereditary pathogenesis of the disease.

METHODS: Polymerase chain reaction (PCR) was used to study apoE phenotypes and allele frequencies in patients with gallstones and control, and the fasting serum lipids of subjects were also measured by enzymatic methods.

RESULTS: The levels of triglyceride (TG) and very low density lipoprotein cholesterol (VLDL-C) were much higher in E_2/3 patients than that in E_2/3 control. E_3/3 patients were accompanied with remarkably low levels of high density lipoprotein cholesterol(HDL-C) and its subforms. But in E_3/4 patients there were only slight changes in levels of VLDL-C and low density lipoprotein cholesterol (LDL-C).

CONCLUSION: Different apoE phenotype patients with gallstones have different cheracteristics of dyslipidemia and the average level of serum lipids in patients with gallstones are higher than subjects without gallstones in the same apoE gene phenotype. ε2 allele is possibly one of the dangerous factors in the lithogenesis of chole-cystolithiasis.