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.

Pathophysiology of severe gallstone pancreatitis:A new paradigm

Severe gallstone pancreatitis(GSP)refractory to maximum conservative therapy has wide clinical variations,and its pathophysiology remains controversial.This Editorial aimed to investigate the pathophysiology of severe disease based on Opie’s theories of obstruction,the common channel,and duodenal reflux and describe its types.Severe GSP might be a hybrid disease with pathology polarized between acute cholangitis with mild pancreatitis(biliary type)and necrotizing pancreatitis uncomplicated with biliary tract disease(pancreatic type),in which hepatobiliary and pancreatic lesion severity is inversely related to the presence or absence of impacted ampullary stones.Severe GSP is caused by stones that are persistently impacted at the ampulla with biliopancreatic obstruction(biliary type),and probably,stones that are either temporarily lodged at the duodenal orifice or passed into the duodenum,thereby permitting reflux of bile or possible duodenal contents into the pancreas(pancreas type).When the status of the stones and the presence or absence of impacted ampullary stones with biliopancreatic obstruction are determined,the clinical course and outcome can be predicted.Gallstones represent the main cause of acute pancreatitis globally,and clinicians are expected to encounter GSP more often.Awareness of the etiology and pathogenesis of severe disease is mandatory.

Development and validation of a nomogram model for predicting the risk of gallstone recurrence after gallbladder-preserving surgery

Background:The high incidence of gallstone recurrence was a major concern for laparoscopic gallbladderpreserving surgery.This study aimed to investigate the risk factors for gallstone recurrence after gallbladder-preserving surgery and to establish an individualized nomogram model to predict the risk of gallstone recurrence.Methods:The clinicopathological and follow-up data of 183 patients who were initially diagnosed with gallstones and treated with gallbladder-preserving surgery at our hospital from January 2012 to January 2019 were retrospectively collected.The independent predictive factors for gallstone recurrence following gallbladder-preserving surgery were identified by multivariate logistic regression analysis.A nomogram model for the prediction of gallstone recurrence was constructed based on the selected variables.The C-index,receiver operating characteristic(ROC)curve and calibration curve were used to evaluate the predictive power of the nomogram model for gallstone recurrence.Results:During the follow-up period,a total of 65 patients experienced gallstone recurrence,and the recurrence rate was 35.5%.Multivariate logistic regression analysis revealed that the course of gallstones>2 years[odds ratio(OR)=2.567,95%confidence interval(CI):1.270-5.187,P=0.009],symptomatic gallstones(OR=2.589,95%CI:1.059-6.329,P=0.037),multiple gallstones(OR=2.436,95%CI:1.133-5.237,P=0.023),history of acute cholecystitis(OR=2.778,95%CI:1.178-6.549,P=0.020)and a greasy diet(OR=2.319,95%CI:1.186-4.535,P=0.014)were independent risk factors for gallstone recurrence after gallbladder-preserving surgery.A nomogram model for predicting the recurrence of gallstones was established based on the above five variables.The results showed that the C-index of the nomogram model was 0.692,suggesting it was valuable to predict gallstone recurrence.Moreover,the calibration curve showed good consistency between the predicted probability and actual probability.Conclusions:The nomogram model for the prediction of gallstone recurrence might help clinicians develop a proper treatment strategy for patients with gallstones.Gallbladder-preserving surgery should be cautiously considered for patients with high recurrence risks.

Comparison of biliary protein spectrum in gallstone patients with obesity and those with normal body weight

Background: Obesity is a common public health issue and is currently deemed a disease. Research has shown that the risk of gallstones in individuals with obesity is elevated. This study aimed to explore the bile proteomics differences between cholelithiasis patients with obesity and normal body weight. Methods: Bile samples from 20 patients(10 with obesity and 10 with normal body weight) who underwent laparoscopic cholecystectomy at our center were subjected to tandem mass tag labeling(TMT) and liquid chromatography-tandem mass spectrometry(LC-MS/MS), followed by further bioinformatic analysis. Results: Among the differentially expressed proteins, 23 were upregulated and 67 were downregulated. Bioinformatic analysis indicated that these differentially expressed proteins were mainly involved in cell development, inflammatory responses, glycerolipid metabolic processes, and protein activation cascades. In addition, the activity of the peroxisome proliferator-activated receptor(PPAR, a subfamily of nuclear receptors) signaling pathway was decreased in the Kyoto Encyclopedia of Genes and Genomes(KEGG) enrichment analysis. Two downregulated proteins in the PPAR signaling pathway, APO A-Ⅰ and APO A-Ⅱ, were confirmed using enzyme-linked immunosorbent assay. Conclusions: The PPAR signaling pathway may play a crucial role in the development of cholelithiasis among patients with obesity. Furthermore, biliary proteomics profiling of gallstones patients with obesity is revealed, providing a reference for future research.

Cracking the silent gallstone code:Wait or operate?

The widespread availability of abdominal ultrasound has revealed the common occurrence of asymptomatic gallstones.While the treatment for symptomatic gallstones is clear,the benefits of minimally invasive laparoscopic cholecystectomy have sparked debate about the best approach to managing silent gallstones.The potential for asymptomatic gallstones to become symptomatic or lead to complications complicates the decision-making process regarding surgical intervention,as it's uncertain when or which patients might develop complications.Consequently,risk stratification appears to play a critical role in guiding decisions about silent gallstones.However,there is no definitive evidence to direct management,and a consensus-based on high-quality evidence is yet to be established.

Classification of anatomical morphology of cystic duct and its association with gallstone

BACKGROUND Gallstones are common lesions that often require surgical intervention.Laparo-scopic cholecystectomy is the treatment of choice for symptomatic gallstones.Preoperatively,the anatomical morphology of the cystic duct(CD),needs to be accurately recognized,especially when anatomical variations occur in the CD,which is otherwise prone to bile duct injury.However,at present,there is no optimal classification system for CD morphology applicable in clinical practice,and the relationship between anatomical variations in CDs and gallstones remains to be explored.AIM To create a more comprehensive clinically applicable classification of the morphology of CD and to explore the correlations between anatomic variants of CD and gallstones.METHODS A total of 300 patients were retrospectively enrolled from October 2021 to January 2022.The patients were divided into two groups:The gallstone group and the nongallstone group.Relevant clinical data and anatomical data of the CD based on magnetic resonance cholangiopancreatography(MRCP)were collected and analyzed to propose a morphological classification system of the CD and to explore its relationship with gallstones.Multivariate analysis was performed using logistic regression analyses to identify the independent risk factors using variables that were significant in the univariate analysis.RESULTS Of the 300 patients enrolled in this study,200(66.7%)had gallstones.The mean age was 48.10±13.30 years,142(47.3%)were male,and 158(52.7%)were female.A total of 55.7%of the patients had a body mass index(BMI)≥24 kg/m2.Based on the MRCP,the CD anatomical typology is divided into four types:Type I:Linear,type II:n-shaped,type III:S-shaped,and type IV:W-shaped.Univariate analysis revealed differences between the gallstone and nongallstone groups in relation to sex,BMI,cholesterol,triglycerides,morphology of CD,site of CD insertion into the extrahepatic bile duct,length of CD,and angle between the common hepatic duct and CD.According to the multivariate analysis,female,BMI(≥24 kg/m2),and CD morphology[n-shaped:Odds ratio(OR)=10.97,95%confidence interval(95%CI):5.22-23.07,P<0.001;S-shaped:OR=4.43,95%CI:1.64-11.95,P=0.003;W-shaped:OR=7.74,95%CI:1.88-31.78,P=0.005]were significantly associated with gallstones.CONCLUSION The present study details the morphological variation in the CD and confirms that CD tortuosity is an independent risk factor for gallstones.

Spilled gallstone mimicking intra-abdominal seeding of gallbladder adenocarcinoma: A case report

BACKGROUND Gallbladder rupture is common in laparoscopic cholecystectomy because the gallbladder is usually in acute or chronic inflammation status.The gallstones may sometime be spilled into the peritoneal cavity,resulting in intra-abdominal ab-scess if the gallstones were not retrieved.The diagnosis of intra-abdominal ab-scess caused by unretrieved gallstone can usually be correctly identified in the routine imaging studies,such as abdominal ultrasonography or computed tomo-graphy(CT).Here we present a case of abscess formation from unretrieved gall-stone following laparoscopic cholecystectomy,which mimics the imaging findings of metastatic gallbladder ade-nocarcinoma.CASE SUMMARY This case described a 78-year-old man who received laparoscopic cholecystectomy and gallbladder adenocarcinoma was diagnosed after surgery.After adjuvant chemotherapy,the following up abdominal CT showed several small nodules at right upper abdomen and peritoneal carcinomatosis is considered.Repeated laparoscopic surgery for the excision of seeding tumor was conducted and the pathological diagnosis of the nodules and mass was inflammatory tissues and gallbladder stone.CONCLUSION Spilled gallstones are a common complication during laparoscopic cholecystectomy and some gallstones fail to be retrieved due to the size or the restricted view of laparoscopic surgery.For spilled gall bladder stones,surgeons may consider regular computerized tomography follow-up,and if necessary,laparoscopic examination can be used as a means of confirming the diagnostic and treatment.

Biliary microbiome and gallstones: A silent friendship

With increasing evidence,the biliary tract and the gallbladder mucosa are no longer considered sterile environments devoid of bacteria.Rather a profound biofilm of resident bacterial flora is associated with the mucosal surface.The bile too harbors a resident flora.It is when a dysbiotic process ensues,that this bac-terial flora either becomes opportunist or is replaced by a pathogenic one that has a strong ability to survive the challenges of the biliary environment.Although once believed a metabolic problem,recent evidence indicates a complex intera-ction between different species of bacteria and gallbladder mucosa and bile which may culminate in calculus formation.The resident microbiota and its several enzymes dictate the type of gallstone by the mere interplay of the constituting type of bacteria in the biofilm,even without any evidence of infection.Dysbiosis is often mediated by either intestinal dysbiosis or less probably by oral dysbiosis.The gallstones,in turn,provide a haven for the resident microbiota in which they can form their own defined niche enriched with the biofilm that can resist the biliary defense mechanisms and survive the hostile biliary environment in the background of biliary stasis and local infection.However,this process of silent friendship is more complex than said,and further research is needed to define the relationship between the two.

Efficacy of Laparoscopic Cholecystectomy in Treating Patients with Gallstones and Its Effect on Interleukin-6 and Tumor Necrosis Factor-α Levels

Objective:To investigate the efficacy of laparoscopic cholecystectomy in the treatment of patients with gallstones and its effect on the levels of interleukin-6(IL-6)and tumor necrosis factor-α(TNF-a).Methods:A total of 82 patients with gallstones admitted from July 2020 to July 2023 were recruited and allocated into control and observation groups using the random number table method,with 41 cases in each group.The patients were treated with laparoscopic cholecystectomy,with the anterior triangle anatomical approach to the gallbladder in the control group and the posterior triangle anatomical approach to the gallbladder in the observation group.The treatment effect and inflammatory factor levels of both groups were observed and compared.Results:When comparing the clinical outcomes of both patient groups,the key parameters evaluated included time to mobilization,duration of surgery,extubation time,and intraoperative bleeding.The observation group exhibited a significant advantage in these parameters compared to the control group(P<0.05).Regarding the levels of inflammatory factors between the two groups before and after treatment,there was no significant difference in values before treatment.However,following treatment,patients in the observation group showed significantly lower levels of IL-6,TNF-α,and C-reactive protein(CRP)compared to the control group(P<0.05).Conclusion:Patients undergoing laparoscopic cholecystectomy for gallstones can benefit from the implementation of the posterior triangular anatomical approach to the gallbladder,which not only enhances therapeutic efficacy but also offers significant advantages in reducing levels of IL-6,TNF-α,and CRP.Therefore,it is recommended for the widespread adoption of this treatment approach in clinical practice.

Gallstones in patients with liver cirrhosis:Incidence,etiology,clinical and therapeutical aspects

Gallstones occur in about one third of the patients having liver cirrhosis.Pigment gallstones are the most frequent type,while cholesterol stones represent about15%of all stones in cirrhotics.Increased secretion of unconjugated bilirubin,increased hydrolysis of conjugated bilirubin in the bile,reduced secretion of bile acids and phospholipds in bile favor pigment lithogenesis in cirrhotics.Gallbladder hypomotility also contributes to lithogenesis.The most recent data regarding risk factors for gallstones are presented.Gallstone prevalence increases with age,with a ratio male/female higher than in the general population.Chronic alcoholism,viral C cirrhosis,and non-alcoholic fatty liver disease are the underlying liver diseases most often associated with gallstones.Gallstones are often asymptomatic,and discovered incidentally.If asymptomatic,expectant management is recommended,as for asymptomatic gallstones in the general population.However,a closer follow-up of these patients is necessary in order to earlier treat symptoms or complications.For symptomatic stones,laparoscopic cholecystectomy has become the therapy of choice.Child-Pugh class and MELD score are the best predictors of outcome after cholecystectomy.Patients with severe liver disease are at highest surgical risk,therefore gallstone complications should be treated using noninvasive or minimally invasive procedures,until stabilization of the patient condition.

Metabolic syndrome and gallstone disease

AIM： To investigate the association between metabolic syndrome （NetS） and the development of gallstone disease （GSD）. METHODS： A cross-sectional study was conducted in 7570 subjects （4978 men aged 45.0：1：8.8 years, and 2592 women aged 45.3：1：9.5 years） enrolled from the physical check-up center of the hospital. The subjects included 918 patients with gallstones （653 men and 265 women） and 6652 healthy controls （4325 men and 2327 women） without gallstones. Body mass index （BII）, waist circumference, blood pressure, fasting plasma glucose （FPG） and serum lipids and lipoproteins levels were measured. Colorimetric method was used to measure cholesterol, high-density lipoprotein cho- lesterol （HDL-C） and low-density lipoprotein cholesterol （LDL-C）. Dextrose oxidizing enzyme method was used to measure FPG. Subjects were asked to complete a questionnaire that enquired about the information on demographic data, age, gender, histories of diabetes mellitus, hypertension, and chronic liver disease and so on. Metabolic syndrome was diagnosed according to the Adult Treatment Panel HI （ATP ]3） criteria. Gall- stones were defined by the presence of strong intralu- minal echoes that were gravity-dependent or attenu- ated ultrasound transmission. RESULTS： Among the 7570 subjects, the prevalence of the gallstone disease was 12.1% （13.1% in men and 10.2% in women）. BMI, waist circumference, systolic blood pressure, diastolic blood pressure, fasting blood glucose and serum triglyceride （TG） in cases group were higher than in controls, while serum high-density lipid was lower than in controls. There were significant differences in the waist circumference, blood pressure, FPG and TG between cases and controls. In an age- adjusted logistic regression model, metabolic syndrome was associated with gallstone disease. The age-adjust- ed odds ratio of MetS for GSD in men was 1.29 [95% confidence interval （CI）, 1.09-1.52; P = 0.0030], and 1.68 （95% CI, 1.26-2.25; P = 0.0004） in women; the overall age-adjusted odds ratio of NetS for GSD was 1.42 （95% CI, 1.23-1.64; P 〈 0.0001）. The men with more metabolic disorders had a higher prevalence of gallstone disease, the trend had statistical significance （P 〈 0.0001）. The presence of 5 components of the MetS increased the risk of gallstone disease by 3.4 times （P 〈 0.0001）. The prevalence of GSD in women who had 5 components of NetS was 5 times higher than in those without Nets component. The more the components of Mets, the higher the prevalence of GSD （P 〈 0.0001）. The presence of 5 components of the Mets increased the risk of gallstone disease by 4.0 times. CONCLUSION： GSD appears to be strongly associated with MetS, and the more the components of NetS, the higher the prevalence of GSD.

Incidence of gallstone disease in Italy:Results from a multicenter,population-based Italian study (the MICOL project)

AIM:To evaluate gallstone incidence and risk factors in a large population-based study. METHODS: Gallstone incidence and risk factors, were evaluated by structured questionnaire and physical examination, respectively, in 9611 of 11 109 (86.5%) subjects who were gallstone-free at the cross-sectional study. RESULTS: Six centers throughout Italy enrolled 9611 subjects (5477 males, 4134 females, aged 30-79 years), 9517 of whom were included into analysis: 424 subjects (4.4%) had gallstones and 61 (0.6%) had been cholecystectomized yielding a cumulative incidence of 0.67% per year (0.66% in males, 0.81% in females). Increasing age, a high body mass index (BMI), a history of diabetes, peptic ulcer and angina, and low cholesterol and high triglyceride levels were identifi ed as risk factors in men while, in females, the only risk factors were increasing age and a high BMI.Increasing age and pain in the right hypocondrium in men and increasing age in females were identifi ed as predictors of gallstones. Pain in the epigastrium/ right hypocondrium was the only symptom related to gallstones; furthermore, some characteristics of pain (forcing to rest, not relieved by bowel movements) were significantly associated with gallstones. No correlation was found between gallstone characteristics and clinical manifestations, while increasing age in men and increasing age and BMI in females were predictors of pain. CONCLUSION:Increasing age and BMI represent true risk factors for gallstone disease (GD); pain in the right hypocondrium and/or epigastrium is confi rmed as the only symptom related to gallstones.

Gallstone recurrence after successful percutaneous cholecystolithotomy:a 10-year follow-up of 439 cases

BACKGROUND: Stone recurrence is a major problem in the medication of gallstones with gallbladder preservation. The aim of this study was to determine the long-term recurrence rate of gallstones and the clinical outcome after successful percutaneous cholecystolithotomy (PCCL) treatment, and to investigate the possible risk factors for gallstone recurrence. METHODS: After successful PCCL for gallstones, 439 patients were followed up during a 10-year period. The long-term gallstone recurrence rate and clinical outcome were evaluated. Risk factors associated with stone recurrence were identified. RESULTS: Gallstone recurrence was detected in 182 of 439 PCCL patients, giving an overall recurrence rate of 41.46%. The cumulative gallstone recurrence rate for each of the 10 post-operative years was 9.57%, 18.91%, 27.33%, 34.14%, 37.59%, 39.86%, 41.90%, 42.73%, 42.85%, and 43.21%, respectively. Among these recurrent patients, 94 were asymptomatic, 80 suffered from nonspecific upper gastrointestinal symptoms and 8 suffered from abdominal pain or biliary colic. Thirty-eight of the 182 patients were retreated with cholecystectomy. The risk factors for stone recurrence included a family history of gallstones, preference for fatty food, accompanying liver disease, multiple stones and poor gallbladder function pre-PCCL. CONCLUSIONS: In this study, the overall recurrence rate of gallstone was 41.46% during a 10-year period. The highest frequency of gallstone recurrence was during the 5th to 6th postoperative years and then continued to slowly increase. Risk factors for stone recurrence varied. We suggest that the use of PCCL in patients with gallstones should be considered carefully because of stone recurrence.

Gender and metabolic differences of gallstone diseases

AIM： To investigate the risk factors for gallstone disease in the general population of Chengdu, China. METHODS： This study was conducted at the West China Hospital. Subjects who received a physical examination at this hospital between January and December 2007 were included. Body mass index, blood pressure, fasting plasma glucose, serum lipid and lipoproteins concentrations were analyzed. Gallstone disease was diagnosed by ultrasound or on the basis of a history of cholecystectomy because of gallstone disease. Unconditional logistic regression analysis was used to investigate the risk factors for gallstone disease, and the Chi-square test was used to analyze differences in the incidence of metabolic disorders between subjects with and without gallstone disease. RESULTS： A total of 3573 people were included, 10.7% （384/3573） of whom had gallstone diseases. Multiple logistic regression analysis indicated that the incidence of gallstone disease in subjects aged 40-64 or ≥65 years was significantly different from that in those aged 18-39 years （P 〈 0.05）; the incidence was higher in women than in men （P 〈 0.05）. In men,a high level of fasting plasma glucose was obvious in gallstone disease （P 〈 0.05）, and in women, hypertriglyceridemia or obesity were significant in gallstone disease （P 〈 0.05）. CONCLUSION： We assume that age and sex are profoundly associated with the incidence of gallstone disease; the metabolic risk factors for gallstone disease were different between men and women.

Prevalence of and risk factors for gallstones in Uighur and Han Chinese

AIM:To perform a single-centre survey of the prevalence of and possible risk factors for gallstones in Uighur and Han Chinese.METHODS:Complete medical data for 9455 patients were collected from the medical centre of our hospital,and the overall prevalence of gallstones as well as the prevalence in different ethnic groups was studied.The risk factors for gallstones in different ethnic groups were identified in a univariate analysis,and variables with statistical significance were analysed by unconditional multiple logistic regression,to primarily explore the similarities and differences in gallstone risk factors between different ethnic groups.RESULTS:The prevalence of gallstones was significantly higher in the Uighur population than in the Hanpopulation(22.87%vs 11.64%,P<0.05).Further analysis of risk factors for gallstones based on the different ethnic areas revealed that age was a risk factor for gallstones in both groups;triglycerides,body-mass index(BMI)and high-density lipoprotein were risk factors for gallstones in the Han population,while total cholesterol(TC),gender and fatty liver were risk factors in the Uighur population.The Uighur patients were older than the Han patients,and had higher BMI,TC,low-density lipoprotein,female rate and fatty liver rate,while the incidence of hypertension was lower than that in the Han patients.CONCLUSION:The prevalence of and risk factors for gallstones differ between the Uighur and Han populations.

Surgical anatomy of innervation of the gallbladder in humans and Suncus murinus with special reference to morphological understanding of gallstone formation after gastrectomy

AIM： To clarify the innervation of human gallbladder,with special reference to morphological understanding of gallstone formation after gastrectomy.METHODS： The liver, gallbladder and surrounding structures were immersed in a 10 mg/L solution of alizarin red S in ethanol to stain the peripheral nerves in cadavers （n = 10）. Innervation in the areas was completely dissected under a binocular microscope. Similarly,innervation in the same areas of 10 Suncus murinus （S. murinus） was examined employing whole mount immunohistochemistry.RESULTS： Innervation of the gallbladder occurred predominantly through two routes. One was from the anterior hepatic plexus, the innervation occurred along the cystic arteries and duct. Invariably this route passed through the hepatoduodenal ligament. The other route was from the posterior hepatic plexus, the innervation occurred along the cystic duct ventrally. This route also passed through the hepatoduodenal ligament dorsally.Similar results were obtained in S. murinus.CONCLUSION： The route from the anterior hepatic plexus via the cystic artery and/or duct is crucial for preserving gallbladder innervation. Lymph node dissection specifically in the hepatoduodenal ligament may affect the incidence of gallstones after gastrectomy.Furthermore, the route from the posterior hepatic plexus via the common bile duct and the cystic duct to the gallbladder should not be disregarded. Preservation of the plexus may attenuate the incidence of gallstone formation after gastrectomy.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.

Effects of sphincter of Oddi motility on the formation of cholesterol gallstones

AIM: To investigate the mechanisms and effects of sphincter of Oddi(SO) motility on cholesterol gallbladder stone formation in guinea pigs.METHODS: Thirty-four adult male Hartley guinea pigs were divided randomly into two groups, the control group(n = 10) and the cholesterol gallstone group(n = 24), which was sequentially divided into four subgroups with six guinea pigs each according to time of sacrifice. The guinea pigs in the cholesterol gallstone group were fed a cholesterol lithogenic diet and sacrificed after 3, 6, 9, and 12 wk. SO manometry and recording of myoelectric activity were obtained by a multifunctional physiograph at each stage. Cholecystokinin-A receptor(CCKAR) expression levels in SO smooth muscle were detected by quantitative real-time PCR(q RT-PCR) and serum vasoactive intestinal peptide(VIP), gastrin, and cholecystokinin octapeptide(CCK-8) were detected by enzyme-linked immunosorbent assay at each stage in the process of cholesterol gallstone formation.RESULTS: The gallstone formation rate was 0%, 0%, 16.7%, and 83.3% in the 3, 6, 9, and 12 wk groups, respectively. The frequency of myoelectric activity in the 9 wk group, the amplitude of myoelectric activity in the 9 and 12 wk groups, and the amplitude and the frequency of SO in the 9 wk group were all significantly decreased compared to the control group. The SO basal pressure and common bile duct pressure increased markedly in the 12 wk group, and the CCKAR expression levels increased in the 6 and 12 wk groups compared to the control group. Serum VIP was elevated significantly in the 9 and 12 wk groups and gastrin decreased significantly in the 3 and 9 wk groups. There was no difference in serum CCK-8 between the groups.CONCLUSION: A cholesterol gallstone-causing diet can induce SO dysfunction. The increasing tension of the SO along with its decreasing activity may play an important role in cholesterol gallstone formation. Expression changes of CCKAR in SO smooth muscle and serum VIP and CCK-8 may be important causes of SO dysfunction.

XbaⅠpolymorphisms of apolipoprotein B gene:Another risk factor of gallstone formation after radical gastrectomy

AIM:To prospectively investigate the association between the XbaⅠpolymorphisms of apolipoprotein B (APOB)gene and gallstone formation following gastrectomy.METHODS:The study was conducted between January 2005 and December 2006.A total of 186 gastric cancer patients who had undergone radical gastrectomy were grouped according to XbaⅠpolymorphisms of APOB gene(X+X-group,n=24 and X-X-group,n =162)and compared.The XbaⅠpolymorphisms of APOB gene were detected by polymerase chain reaction-restriction fragment length polymorphism(PCRRFLP).RESULTS:The incidence of gallstone was significantly higher in the X + X-group than in the X-X-group[54.2% vs 9.3%,RR=5.85(2.23-15.32),P<0.001].The serum levels of total cholesterol(TC)and low-density lipoprotein(LDL)were higher in the X + X-than in the X-X-group(4.02±1.12 vs 3.48±0.88,P=0.004 before surgery and 3.88±1.09 vs 3.40±0.86,P=0.008 after surgery).LDL was 2.21±0.96 vs 1.89±0.84(P =0.042)before surgery and 2.09±0.95 vs 1.72±0.85 (P=0.029)after surgery in the two groups.No relationship was found between XbaⅠpolymorphisms and gallbladder motility.CONCLUSION:In Chinese patients after radical gastrectomy,X + allele of APOB gene is another risk factor for the development of gallstone besides the gallbladder motility disorder after surgery.

Metabolic syndrome as a risk factor for gallstone disease

AIM: To establish an association between the presence of metabolic syndrome and the development of gallstone disease. METHODS: We carried out a cross-sectional study in a check-up unit in a university hospital in Mexico City. We enrolled 245 subjects, comprising 65 subjects with gallstones (36 women, 29 men) and 180 controls (79 women and 101 men without gallstones). Body mass index, waist circumference, blood pressure, plasma insulin, and serum lipids and lipoproteins levels were measured. Insulin resistance was calculated by homeostasis model assessment. Unconditional logistic regression analysis (univariate and multivariate) was used to calculate the risk of gallstone disease associated with the presence of at least three of the criteria (Adult Treatment Panel Ⅲ). Analyses were adjusted for age and sex. RESULTS: Among 245 subjects, metabolic syndrome was present in 40% of gallstone disease subjects, compared with 17.2% of the controls, adjusted by age and gender (odds ratio (OR) = 2.79; 95%CI, 1.46-5.33; P= 0.002), a dose-dependent effect was observed with each component of metabolic syndrome (OR=2.36, 95%CI, 0.72-7.71; P= 0.16 with one component and OR = 5.54, 95%CI, 1.35-22.74; P = 0.02 with four components of metabolic syndrome). Homeostasis model assessment was significantly associated with gallstone disease (adjusted OR = 2.25; 95%CI, 1.08-4.69; P= 0.03). CONCLUSION: We conclude that as for cardiovascular disease and diabetes mellitus, gallstone disease appears to be strongly associated with metabolic syndrome.