Risk factors for gallstone formation during rapid loss of weight

Association between weight-adjusted-waist index and gallstones: an analysis of the National Health and Nutrition Examination Survey

BACKGROUND

The weight-adjusted-waist index (WWI) is a novel obesity index, and gallstones are associated with obesity. This study aimed to investigate the possible relationship between WWI and gallstones.

METHODS

The datasets from the National Health and Nutrition Examination Survey (NHANES) 2017-2020 were used in a cross-sectional investigation. Multivariate linear regression models were used to examine the linear connection between WWI and gallstones incidence. Fitted smoothing curves and threshold effect analysis were used to describe the nonlinear relationship.

RESULTS

The study comprised 8004 participants over the age of 20, including 833 reported with gallstones. Participants in the higher WWI tertile tended to have a higher gallstones prevalence. In the final adjusted model, a positive association between WWI and gallstones prevalence was observed (OR = 1.34, 95% CI: 1.20‒1.49). Participants in the highest WWI tertile had a significantly 71% higher risk of gallstones than those in the lowest WWI tertile (OR = 1.71, 95% CI: 1.35‒2.17). A nonlinear correlation was found between the WWI and gallstones prevalence, with an inflection point of 12.7.

CONCLUSIONS

Our study found that higher WWI levels connected with increased prevalence of gallstones. However, more prospective studies are needed to validate our findings.

Ursodeoxycholic Acid Prophylaxis and the Reduction of Gallstone Formation After Bariatric Surgery: An Updated Meta-Analysis of Randomized Controlled Trials

Gallstone formation following bariatric surgery poses a significant clinical concern, prompting various preventive strategies, including ursodeoxycholic acid (UDCA) prophylaxis. This systematic review and meta-analysis aimed to assess the efficacy of UDCA in preventing gallstone formation after bariatric surgery. A comprehensive literature search was conducted in major databases up to September 2023, identifying 12 randomized controlled trials (RCTs) meeting the inclusion criteria. The studies, spanning from 1993 to 2022, involved 2,767 patients who underwent diverse bariatric procedures. The primary outcome was the overall incidence of cholelithiasis, with secondary outcomes encompassing gallstone occurrences at three, six, and 12 months; symptomatic cholelithiasis; and rates of cholecystectomy. The Cochrane risk-of-bias tool was utilized for evaluating study quality, and statistical analyses were conducted using the RevMan software (Cochrane Collaboration, London, UK). Patients receiving UDCA demonstrated a significantly lower overall incidence of gallstones post-bariatric surgery (risk ratio [RR] 0.13; P < 0.0001). Subgroup analyses confirmed reduced gallstone incidence at three months (P = 0.04), six months (P < 0.00001), and one year (P < 0.00001) with UDCA prophylaxis. Symptomatic cholelithiasis incidence was also lower in the UDCA group (RR 5.70; P < 0.00001), and cholecystectomy rates were significantly reduced (RR 3.05; P = 0.002). This meta-analysis supports the efficacy of UDCA prophylaxis in preventing gallstone formation after bariatric surgery. The findings suggest that UDCA administration not only lowers overall gallstone incidence but also reduces the occurrence of symptomatic cholelithiasis and mitigates the need for cholecystectomy. However, caution is warranted due to heterogeneity, diverse surgical procedures, and limited long-term follow-up in the included studies. Further research with standardized protocols and extended observational periods is recommended to strengthen the evidence base and guide clinical practice.

Risk and Prophylactic Management of Gallstone Disease in Bariatric Surgery: a Systematic Review and A Bayesian meta-analysis

BACKGROUND

The frequency and management of gallstone disease (GD) in bariatric patients, including the role of routine prophylactic concomitant cholecystectomy (CCY), are still a matter of debate. This study aims to assess the risk of de novo GD in patients undergoing bariatric surgery (BS) and their predictive factors, as well as mortality and morbidity in prophylactic CCY compared to BS alone.

METHODS

We performed a systematic review, searching PubMed, EMBASE, and Web of Science until April 2021. We performed a Bayesian meta-analysis to estimate the risk of GD development after BS and the morbidity and mortality associated with BS alone versus BS + prophylactic CCY. Sources of heterogeneity were explored by meta-regression analysis.

RESULTS

The risk of de novo post bariatric GD was 20.7% (95% credible interval [95% CrI] = 13.0-29.7%; I² = 75.4%), and that of symptomatic GD was 8.2% ([95% CrI] = 5.9-11.1%; I² = 66.9%). Pre-operative average BMI (OR = 1.04; 95% CrI = 0.92-1.17) and female patients' proportion (OR = 1.00; 95% CrI = 0.98-1.04) were not associated with increased risk of symptomatic GD. BS + prophylactic CCY was associated with a 97% probability of a higher number of postoperative major complications compared to BS alone (OR = 1.74, 95% CrI = 0.97-3.55; I² = 56.5%). Mortality was not substantially different between the two approaches (OR = 0.79; 95% CrI = 0.03-3.02; I² = 20.7%).

CONCLUSION

The risk of de novo symptomatic GD after BS is not substantially high. Although mortality is similar between groups, odds of major postoperative complications were higher in patients submitted to BS + prophylactic CCY. It is still arguable if prophylactic CCY is a fitting approach for patients with a preoperative lithiasic gallbladder.

Frequency of cholelithiasis in need of surgical or endoscopic treatment a decade or more after Roux-en-Y gastric bypass

BACKGROUND

Symptomatic cholelithiasis requiring treatment is a known side effect after Roux-en-Y gastric bypass (RYGB), but reported rates vary greatly. The objectives for this study were to evaluate the long-term frequency of surgical or endoscopic treatment for symptomatic cholelithiasis 10-15 years after RYGB and its relation to self-reported abdominal pain.

METHODS

Observational data from 546 patients who underwent RYGB at public hospitals in Central Norway between March 2003 and December 2009 were analyzed.

RESULTS

Median follow-up was 11.5 (range 9.1-16.8) years. Sixty-five (11.9%) patients had undergone cholecystectomy prior to RYGB. Out of the 481 patients with intact gallbladder, 77 (16.0%) patients underwent cholecystectomy and six (1.2%) patients had treatment for choledocholithiasis during the observation period. Median time from RYGB to cholecystectomy or treatment of choledocholithiasis was 51 (range 1-160) and 109 (range 10-151) months, respectively. Female sex was associated with an increased risk of subsequent cholecystectomy [OR (95% CI) 2.88 (1.31-7.15)], p < 0.05. There was a higher frequency of self-reported abdominal pain at follow-up [OR (95% CI) 1.92 (1.25-2.93)] among patients who underwent cholecystectomy before or after RYGB.

CONCLUSION

With a median follow-up of more than 11 years after RYGB, one in six patients with an intact gallbladder at time of RYGB underwent cholecystectomy, and 1.1% of the patients needed surgical or endoscopic treatment for choledocholithiasis. Patients with a history of cholecystectomy reported a higher frequency of abdominal pain.

Prevention of Gallstones After Bariatric Surgery using Ursodeoxycholic Acid: A Narrative Review of Literatures

Obesity by itself is a factor in the development of gallstone disease, and periods of weight loss after bariatric surgery further increase the risk of gallstone formation. In patients with obesity, hypersecretion of cholesterol may increase the risk of gallstone formation, which is approximately five-fold higher than that in the general population. The incidence of gallstone formation after bariatric surgery is 10-38% and often associated with a proportional increase in the risk of developing biliary complications. Routine postoperative administration of ursodeoxycholic acid (UDCA) is recommended to prevent gallstone formation. Several randomized trials have indicated that UDCA can effectively prevent gallstones and reduce the risk of cholecystectomy after bariatric procedures. The effective daily dose of UDCA in each study ranged from 500 to 1,200 mg, and it may be considered at least during the period of rapid weight loss (first 3-6 months postoperatively) to decrease the incidence of symptomatic gallstones.

Ursodeoxycholic acid for the prevention of gallstones and subsequent cholecystectomy after bariatric surgery: a meta-analysis of randomized controlled trials

BACKGROUND

This meta-analysis aimed to compare the incidence of gallstone formation, subsequent biliary disease and the need for cholecystectomy in untreated patients and patients treated with ursodeoxycholic acid (UDCA) following bariatric surgery.

METHODS

Randomized controlled trials (RCTs) comparing UDCA and controls for the prevention of gallstone formation after bariatric surgery published until February 2022 were selected and subjected to a systematic review and meta-analysis. Articles were searched in the MEDLINE, Web of Science and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Eleven randomized controlled studies were included, with a total of 2363 randomized patients and 2217 patients analysed in the UDCA group versus 1415 randomized patients and 1257 patients analysed in the control group. Considering analysed patients, prophylactic use of UDCA was significantly associated with decreased (i) gallstone formation (OR = 0.25, 95% CI = 0.21-0.31), (ii) symptomatic gallstone disease (GD) (OR = 0.29, 95% CI = 0.20-0.42) and consequently (iii) cholecystectomy rate (OR = 0.33, 95% CI = 0.20-0.55). The results were similar in ITT analysis, in the subgroup of patients undergoing sleeve gastrectomy or considering only randomized versus placebo studies.

CONCLUSIONS

Prophylactic use of UDCA after bariatric surgery prevents both gallstone formation and symptomatic GD and reduces the need for cholecystectomy.

Comparative analysis of postoperative pain after transvaginal hybrid NOTES versus traditional laparoscopic cholecystectomy in obese patients

Purpose

Even though obesity is a known risk factor for needing cholecystectomy, most research excludes patients with higher degrees of obesity. The aim of this retrospective study was to compare postoperative pain and analgesic consumption in obese patients, who underwent either transvaginal hybrid Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy (NC) or traditional laparoscopic cholecystectomy (LC).

Methods

Between 12/2008 and 01/2017, 237 NC were performed, of which 35 (14.8%) showed a body mass index (BMI) of 35 kg/m² or more (obesity II and III according to the World Health Organization). Of these, procedural time, postoperative pain, analgesic requirements, and other early postoperative parameters were collected and compared with 35 matched LC patients from the same time period.

Results

There were no differences in the baseline characteristics between the two groups, but we found significant benefits for the hybrid NOTES technique in terms of less pain (P = 0.006), coherent with significantly less intake of peripheral (paracetamol; P = 0.005), and of centrally acting analgesics (piritramide; P = 0.047) within the first two-day post-surgery. We also found that those in the NC group had shorter hospital stays (P < 0.001). The postoperative complication rates and the procedural time did not differ between the two groups.

Conclusion

With regard to postoperative pain and analgesic requirements and without an increase in postoperative complications, obese patients experience short-term benefits from the hybrid NOTES technique compared to traditional laparoscopic cholecystectomy.

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.

Analysis of Trajectories of Care After Bariatric Surgery Using Data Mining Method and Health Administrative Information Systems

CONTEXT

The 30-day readmission rate after bariatric surgery is considered an important metric of the quality of hospital care. However, readmission rate beyond 30 days is rarely reported and does not provide any information about trajectories of care which would be of great interest for healthcare planning. The aim of this study was to analyze trajectories of care during the first year after bariatric surgery on a nationwide basis using data mining methods.

METHOD

This was a retrospective descriptive study on the trajectories of care within the first year after bariatric surgery. Data were extracted from a national administrative claims database (the PMSI database) and trajectories were defined as principal diagnosis of successive readmissions. Formal Concept Analysis was performed to find common concepts of trajectories of care.

RESULTS

We included for analysis 198,389 bariatric procedures performed on 196,323 patients. Twelve main concepts were selected. About one third of patients (32.4%) were readmitted in the first year after surgery. Most common trajectories were as follows: regular follow-up (14.9%), cholelithiasis (2.2%), abdominal pain (1.9%), and abdominal sepsis (1.3%). Important differences were found in trajectories among different bariatric procedures: 1.8% of gastric banding patients had pregnancy-related events (delivery or medical abortion), while we observed a readmission rate for abdominal sepsis in 2.7% and 5.1% of patients operated of gastric bypass and sleeve gastrectomy respectively.

CONCLUSION

Administrative claim data can be analyzed through Formal Concept Analysis in order to classify trajectories of care. This approach permits to quantify expected postoperative complications and to identify unexpected events.

Statement on additional scientific evidence in relation to the essential composition of total diet replacement for weight control

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to revise the Opinion on the essential composition of total diet replacements for weight control (TDRs) regarding the minimum content of linoleic acid (LA) and alpha-linolenic acid (ALA) and the maximum content of magnesium (Mg). Through a comprehensive literature search, human studies were retrieved reporting on LA and ALA concentrations in adipose tissue (AT), on weight loss and gallstone formation following TDR consumption and on diarrhoea after supplemental Mg intake. The distribution of the amount of LA and ALA release from AT during weight loss when consuming TDRs was estimated using statistical simulations. Using the fifth percentile, the coverage of the adequate intake (AI) for both FA was estimated. For the risk of developing diarrhoea when consuming TDRs with an Mg content of 350 mg/day, four cross-over studies using 360-368 mg Mg/day were reviewed. The Panel concludes that (1) there is no need to add LA to TDRs, as the amount released from AT during weight loss when consuming TDRs is sufficient to cover the AI for LA; (2) a minimum of 0.8 g/day ALA is needed in TDRs in order to meet the AI for ALA; (3) the minimum fat content of TDRs of 20 g/day as derived in the Panel's previous opinion is proposed to be maintained until the availability of further evidence, given the considerable uncertainty as to the amount of fat required for reducing the risk of gallstone formation; and (4) the likelihood that Mg-induced diarrhoea occurs at a severity that may be considered of concern for overweight and obese individuals consuming TDRs is low when the total maximum Mg content in TDRs is 350 mg/day.

Predictive factors of gallstone formation after sleeve gastrectomy: a multivariate analysis of risk factors

PURPOSE

Obesity and bariatric surgery are both risk factors for cholelithiasis (CL). However, most previous studies have focused on Roux-en-Y gastric bypass, and limited published data are available for sleeve gastrectomy (SG).

METHODS

Patients were evaluated in two groups depending on the presence of gallstones (Group I, present; Group II, absent). Demographic characteristics, comorbid diseases, pre-operative blood values, and early and late weight loss rates were compared between the groups.

RESULTS

The study included 111 patients with a mean age of 38.9. The mean follow-up period was 20.6 (12-39) months. During follow-up, gallstone formation was observed in 36.9% (n = 41) of patients. Thirteen patients (31.8%) had symptomatic cholelithiasis that was resolved with laparoscopic cholecystectomy. The mean interval between sleeve gastrectomy and the detection of cholelithiasis was 210 days and the mean time of post-operative cholecystectomy was 540 days. A multivariate analysis showed that only dyslipidemia was independently and significantly associated with gallstone formation. There was no significant difference in the weight loss rate between the groups.

CONCLUSIONS

Although CL development was found to be associated with rapid weight loss in several published studies in post-SG patients, the present study showed no significant difference between the groups in terms of early or late weight loss. Pre-operative dyslipidemia may be associated with an increased risk of developing CL.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of Diets on Adipose Tissue

BACKGROUND

Obesity is a major health problem that has become a global epidemic. Overweight and obesity are commonly associated with the development of several pathologies, such as insulin resistance, cardiovascular diseases, sleep apnea and several types of cancer, which can lead to further morbidity and mortality. An increased abdominal adiposity renders overweight and obese individuals more prone to metabolic and cardiovascular problems.

OBJECTIVE

This Review aims to describe the dietary strategies to deal with excess adiposity given the medical, social and economic consequences of obesity.

METHODS

One hundred and eighty-five papers were included in the present Review.

RESULTS

Excess adiposity leads to several changes in the biology, morphology and function of the adipose tissue, such as adipocyte hypertrophy and hyperplasia, adipose tissue inflammation and fibrosis and an impaired secretion of adipokines, contributing to the onset of obesity- related comorbidities. The first approach for obesity management and prevention is the implementation of a diet combined with physical activity. The present review summarizes the compelling evidence showing body composition changes, impact on cardiometabolism and potential adverse effects of very-low calorie, low- and high-carbohydrate, high-protein or low-fat diets. The use of macronutrients during the preprandial and postprandial state has been also reviewed to better understand the metabolic changes induced by different dietary interventions.

CONCLUSION

Dietary changes should be individualised, tailored to food preferences and allow for flexible approaches to reducing calorie intake in order to increase the motivation and compliance of overweight and obese patients.

[Nutritional intervention in the control of gallstones and renal lithiasis]

INTRODUCTION

Cholelithiasis and kidney stones are frequent pathologies in developed countries. Gallstones can be pigmentary, cholesterol (75%) or mixed. Age, female sex, obesity, rapid weight loss, consumption of refined sugars, saturated fat, iron deficiency, vitamin D and low intake of fiber and vitamin C are factors associated with an increased risk of cholelithiasis. On the other hand, the intake of ω-3 fatty acids, oleic acid, calcium, magnesium, fiber, fruits and vegetables, dairy products, nuts, coffee, moderate consumption of alcohol, vitamin C supplements, physical exercise and a regular diet have a protective paper. The most frequent kidney stones are calcium oxalate followed by mixed ones (oxalate and calcium phosphate), struvite, uric acid and cystine. A high water intake is recommended (> 2.5 l / day), varying the type of recommended or unadvisable food depending on the type of calculus. In oxalic lithiasis it is recommended to reduce the consumption of meat, moderate that of spinach, Swiss chard, asparagus, chocolate and avoid excessive sodium intake. The administration of oxalate-degrading probiotics (Lactobacillus) may reduce intestinal absorption, although further studies are necessary to corroborate these results. In calcium phosphate acidifying diet is recommended and limit the consumption of coffee and tea. The prevention of uric calculus is based on hydration with alkalizing drinks and vegetarian diet, decreasing foods rich in purines (liver, kidney, fish eggs, anchovies, sardines and seafood) and in calculus of cystine diet is recommended alkalizing. Since the formation of struvite calculi is due to urinary infections, pharmacological treatment and the consumption of acidifying diets, moderation of the intake of phosphate-rich foods and limiting the contribution of fats and citrus fruits are necessary. The nutritional intervention is an effective measure in the prevention of biliary and renal lithiasis and prevent its recurrence.

Patients Remain at High Risk of Gallstones Development Late (10 y) After Sleeve Gastrectomy?

BACKGROUND

Sleeve gastrectomy (SG) is an established bariatric procedure which produces substantial and rapid weight loss and hence can lead to an increase in gallstones development.

OBJECTIVES

To demonstrate the early and late appearance of gallstones after SG.

MATERIALS AND METHODS

A prospective protocol was established in consecutive patients submitted to SG. Clinical and ultrasound evaluations were performed early (1 to 2 y) and late after surgery (over 6 y).

RESULTS

From 109 patients included, 13 (13.1%) had a previous and 10 (10.1%) had simultaneous cholecystectomy at the time of SG. Therefore, 86 patients were submitted to surveillance. Seven patients were unreachable, leaving 79 patients for late follow-up. Forty-five patients (57%) had alithiasic gallbladder late after surgery, whereas 34 patients (43%) showed appearance of gallstone. From them, 53% developed gallstones late after surgery (mean, 7.5 y). Among the group with early development of stones, 69% were symptomatic and in the latter group only 17%.

CONCLUSIONS

Study with 92% of follow-up late after SG demonstrated a 43% development of gallstones: half earlier and half late after surgery. We emphasize the need for late control to detect the real appearance of gallstones after SG.

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

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

The Role of Diet in the Pathogenesis of Cholesterol Gallstones

Cholesterol gallstone disease is a major health problem in Westernized countries and depends on a complex interplay between genetic factors, lifestyle and diet, acting on specific pathogenic mechanisms. Overweigh, obesity, dyslipidemia, insulin resistance and altered cholesterol homeostasis have been linked to increased gallstone occurrence, and several studies point to a number of specific nutrients as risk- or protective factors with respect to gallstone formation in humans. There is a rising interest in the identification of common and modifiable dietetic factors that put the patients at risk of gallstones or that are able to prevent gallstone formation and growth. In particular, dietary models characterized by increased energy intake with highly refined sugars and sweet foods, high fructose intake, low fiber contents, high fat, consumption of fast food and low vitamin C intake increase the risk of gallstone formation. On the other hand, high intake of monounsaturated fats and fiber, olive oil and fish (ω-3 fatty acids) consumption, vegetable protein intake, fruit, coffee, moderate alcohol consumption and vitamin C supplementation exert a protective role. The effect of some confounding factors (e.g., physical activity) cannot be ruled out, but general recommendations about the multiple beneficial effects of diet on cholesterol gallstones must be kept in mind, in particular in groups at high risk of gallstone formation.

Ursodeoxycholic acid for the prevention of symptomatic gallstone disease after bariatric surgery: study protocol for a randomized controlled trial (UPGRADE trial)

Background

The number of bariatric interventions for morbid obesity is increasing worldwide. Rapid weight loss is a major risk factor for gallstone development. Approximately 11 % of patients who underwent Roux-en-Y gastric bypass develop symptomatic gallstone disease. Gallstone disease can lead to severe complications and often requires hospitalization and surgery. Ursodeoxycholic acid (UDCA) prevents the formation of gallstones after bariatric surgery. However, randomized controlled trials with symptomatic gallstone disease as primary endpoint have not been conducted. Currently, major guidelines make no definite statement about postoperative UDCA prophylaxis and most bariatric centers do not prescribe UDCA.

Methods

A randomized, placebo-controlled, double-blind multicenter trial will be performed for which 980 patients will be included. The study population consists of consecutive patients scheduled to undergo Roux-en-Y gastric bypass or sleeve gastrectomy in three bariatric centers in the Netherlands. Patients will undergo a preoperative ultrasound and randomization will be stratified for pre-existing gallstones and for type of surgery. The intervention group will receive UDCA 900 mg once daily for six months. The placebo group will receive similar-looking placebo tablets. The primary endpoint is symptomatic gallstone disease after 24 months, defined as admission or hospital visit for symptomatic gallstone disease. Secondary endpoints consist of the development of gallstones on ultrasound at 24 months, number of cholecystectomies, side-effects of UDCA and quality of life. Furthermore, cost-effectiveness, cost-utility and budget impact analyses will be performed.

Discussion

The UPGRADE trial will answer the question whether UDCA reduces the incidence of symptomatic gallstone disease after Roux-en-Y gastric bypass or sleeve gastrectomy. Furthermore it will determine if treatment with UDCA is cost-effective.

Trial registration

Netherlands Trial Register (trialregister.nl) 6135. Date registered: 21-Nov-2016.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Telocytes: New Players in Gallstone Disease

Cholesterol gallstone disease is highly prevalent in Western countries, particularly in women and some specific ethnic groups. The mechanisms behind the formation of gallstones are not clearly understood, but gallbladder dysmotility seems to be a key factor that triggers the precipitation of cholesterol microcrystals from supersaturated lithogenic bile.Given that newly described interstitial cells, telocytes, are present in the gallbladder and they are located in close vicinity of smooth muscle cell and neural fibers possibly interfering with gallbladder motility or contractility, authors are trying to summarize the current knowledge on the role of telocytes with respect to disturbed gallbladder function in gallstone disease.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Frequency of cholecystectomy and associated sociodemographic and clinical risk factors in the ELSA-Brasil study

CONTEXT AND OBJECTIVE

There are few data in the literature on the frequency of cholecystectomy in Brazil. The frequency of cholecystectomy and associated risk factors were evaluated in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

DESIGN AND SETTING

Cross-sectional study using baseline data on 5061 participants in São Paulo.

METHODS

The frequency of cholecystectomy and associated risk factors were evaluated over the first two years of follow-up of the study and over the course of life. A multivariate regression analysis was presented: odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

A total of 4716 individuals (93.2%) with information about cholecystectomy were included. After two years of follow-up, 56 had undergone surgery (1.2%: 1.7% of the women; 0.6% of the men). A total of 188 participants underwent cholecystectomy during their lifetime. The risk factors associated with surgery after the two-year follow-up period were female sex (OR, 2.85; 95% CI, 1.53-5.32), indigenous ethnicity (OR, 2.1; 95% CI, 2.28-15.85) and body mass index (BMI) (OR, 1.10; 95% CI, 1.01-1.19 per 1 kg/m2 increase). The risk factors associated over the lifetime were age (OR, 1.03; 95% CI, 1.02-1.05 per one year increase), diabetes (OR, 1.92; 95% CI, 1.34-2.76) and previous bariatric surgery (OR, 5.37; 95% CI, 1.53-18.82). No association was found with parity or fertile age.

CONCLUSION

Female sex and high BMI remained as associated risk factors while parity and fertile age lost significance. New factors such as bariatric surgery and indigenous ethnicity have gained importance in this country.

Ursodeoxycholic acid and diets higher in fat prevent gallbladder stones during weight loss: a meta-analysis of randomized controlled trials

BACKGROUND & AIMS

The prevalence of gallstones is increasing in association with the obesity epidemic, but rapid weight loss also increases the risk of stone formation. We conducted a systematic review of the efficacy of strategies to prevent gallbladder stones in adults as they lose weight.

METHODS

Randomized controlled trials of nonsurgical strategies to prevent gallstones were identified by electronic and manual searches. Our final analysis included 13 trials, comprising 1836 participants undergoing weight loss through dieting (8 trials) or bariatric surgery (5 trials). The trials compared ursodeoxycholic acid (UDCA) or high-fat weight loss diets with control interventions. We performed random-effects meta-analyses and evaluated heterogeneity and bias with subgroup, sensitivity, regression, and sequential analysis.

RESULTS

UDCA reduced the risk of ultrasound-verified gallstones compared with control interventions (risk ratio, 0.33; 95% confidence interval [CI], 0.18-0.60; number needed to treat, 9). This effect was significantly larger in trials of diets alone (risk ratio, 0.17; 95% CI, 0.11-0.25) than in trials of patients who underwent bariatric surgery (risk ratio, 0.42; 95% CI, 0.21-0.83) (test for subgroup differences, P =.03). UDCA reduced the risk of cholecystectomy for symptomatic stones (risk ratio, 0.20; 95% CI, 0.07-0.53). Diets high in fat content also reduced gallstones, compared with those with low fat content (risk ratio, 0.09; 95% CI, 0.01-0.61). The meta-analyses were confirmed in trials with a low risk of bias but not in sequential analysis. No additional beneficial or harmful outcomes were identified.

CONCLUSIONS

On the basis of a meta-analysis of randomized controlled trials, during weight loss, UDCA and/or higher dietary fat content appear to prevent formation of gallstones.

Gallstones

Gallstone disease is a worldwide medical problem, but the incidence rates show substantial geographical variation, with the lowest rates reported in African populations. Publications in English language on gallstones which were obtained from reprint requests and PubMed database formed the basis for this paper. Data extracted from these sources included authors, country, year of publication, age and sex of patients, pathogenesis, risk factors for development of gallstones, racial distribution, presenting symptoms, complications and treatment. Gallstones occur worldwide, however it is commonest among North American Indians and Hispanics but low in Asian and African populations. High biliary protein and lipid concentrations are risk factors for the formation of gallstones, while gallbladder sludge is thought to be the usual precursor of gallstones. Biliary calcium concentration plays a part in bilirubin precipitation and gallstone calcification. Treatment of gallstones should be reserved for those with symptomatic disease, while prophylactic cholecystectomy is recommended for specific groups like children, those with sickle cell disease and those undergoing weight-loss surgical treatments. Treatment should be undertaken for a little percentage of patients with gallstones, as majority of those who harbor them never develop symptoms. The group that should undergo cholecystectomy include those with symptomatic gallstones, sickle cell disease patients with gall stones, and patients with morbid obesity who are undergoing laparotomy for other reasons.

Gallstone disease in severely obese children participating in a lifestyle intervention program: incidence and risk factors

INTRODUCTION

Cholelithiasis is increasingly encountered in childhood and adolescence due to the rise in obesity. As in adults, weight loss is presumed to be an important risk factor for cholelithiasis in children, but this has not been studied.

METHODS

In a prospective observational cohort study we evaluated the presence of gallstones in 288 severely obese children and adolescents (mean age 14.1±2.4 years, body mass index (BMI) z-score 3.39±0.37) before and after participating in a 6-month lifestyle intervention program.

RESULTS

During the lifestyle intervention, 17/288 children (5.9%) developed gallstones. Gallstones were only observed in those losing >10% of initial body weight and the prevalence was highest in those losing >25% of weight. In multivariate analysis change in BMI z-score (odds ratio (OR) 3.26 (per 0.5 s.d. decrease); 95% CI:1.60-6.65) and baseline BMI z-score (OR 2.32 (per 0.5 s.d.); 95% CI: 1.16-4.70) were independently correlated with the development of gallstones. Sex, family history, OAC use, puberty and biochemistry were not predictive in this cohort. During post-treatment follow-up (range 0.4-7.8 years) cholecystectomy was performed in 22% of those with cholelithiasis. No serious complications due to gallstones occurred.

CONCLUSION

The risk of developing gallstones in obese children and adolescents during a lifestyle intervention is limited and mainly related to the degree of weight loss and initial body weight.

Optimal diabetes management during medical weight loss for cardiovascular risk reduction

Obesity has long been recognized as a significant risk factor for type 2 diabetes. Both obesity and type 2 diabetes are associated with an increase in cardiovascular risk. As cardiovascular disease continues to be the number one killer in the USA and western adult populations, the rise in prevalence of obesity and type 2 diabetes is alarming. This is especially disturbing in the tripling of overweight children and adolescents, accompanied by the increase in prevalence of pediatric type 2 diabetes. Optimal strategies for long-term diabetes management aim at effectively controlling, reducing and ultimately preventing obesity. This review explores the clinical recommendations in place, new clinical investigations, diet therapy, medical nutrition therapy, meal replacements, behavior therapy, exercise therapy, pharmacotherapy and surgical therapy as strategies to achieve weight-loss success in diabetic patients and ultimately reduce cardiovascular disease.

Risk of symptomatic gallstones and cholecystectomy after a very-low-calorie diet or low-calorie diet in a commercial weight loss program: 1-year matched cohort study

Background:

Concern exists regarding gallstones as an adverse event of very-low-calorie diets (VLCDs; <800 kcal per day).

Objective:

To assess the risk of symptomatic gallstones requiring hospital care and/or cholecystectomy in a commercial weight loss program using VLCD or low-calorie diet (LCD).

Design:

A 1-year matched cohort study of consecutively enrolled adults in a commercial weight loss program conducted at 28 Swedish centers between 2006 and 2009. A 3-month weight loss phase of VLCD (500 kcal per day) or LCD (1200–1500 kcal per day) was followed by a 9-month weight maintenance phase. Matching (1:1) was performed by age, sex, body mass index, waist circumference and gallstone history (n=3320:3320). Gallstone and cholecystectomy data were retrieved from the Swedish National Patient Register.

Results:

One-year weight loss was greater in the VLCD than in the LCD group (−11.1 versus −8.1 kg; adjusted difference, −2.8 kg, 95% CI −3.1 to −2.4; P<0.001). During 6361 person–years, 48 and 14 gallstones requiring hospital care occurred in the VLCD and LCD groups, respectively, (152 versus 44/10 000 person–years; hazard ratio, 3.4, 95% CI 1.8–6.3; P<0.001; number-needed-to-harm, 92, 95% CI 63–168; P<0.001). Of the 62 gallstone events, 38 (61%) resulted in cholecystectomy (29 versus 9; hazard ratio, 3.2, 95% CI 1.5–6.8; P=0.003; number-needed-to-harm, 151, 95% CI 94–377; P<0.001). Adjusting for 3-month weight loss attenuated the hazard ratios, but the risk remained higher with VLCD than LCD for gallstones (2.5, 95% CI 1.3–5.1; P=0.009) and became borderline for cholecystectomy (2.2, 95% CI 0.9–5.2; P=0.08).

Conclusion:

The risk of symptomatic gallstones requiring hospitalization or cholecystectomy, albeit low, was 3-fold greater with VLCD than LCD during the 1-year commercial weight loss program.

Weight loss and dropout during a commercial weight-loss program including a very-low-calorie diet, a low-calorie diet, or restricted normal food: observational cohort study

BACKGROUND

The effectiveness of commercial weight-loss programs consisting of very-low-calorie diets (VLCDs) and low-calorie diets (LCDs) is unclear.

OBJECTIVE

The aim of the study was to quantify weight loss and dropout during a commercial weight-loss program in Sweden (Itrim; cost: $1300/€1000; all participants paid their own fee).

DESIGN

This observational cohort study linked commercial weight-loss data with National Health Care Registers. Weight loss was induced with a 500-kcal liquid-formula VLCD [n = 3773; BMI (in kg/m(2)): 34 ± 5 (mean ± SD); 80% women; 45 ± 12 y of age (mean ± SD)], a 1200-1500-kcal formula and food-combination LCD (n = 4588; BMI: 30 ± 4; 86% women; 50 ± 11 y of age), and a 1500-1800-kcal/d restricted normal-food diet (n = 676; BMI: 29 ± 5; 81% women; 51 ± 12 y of age). Maintenance strategies included exercise and a calorie-restricted diet. Weight loss was analyzed by using an intention-to-treat analysis (baseline substitution).

RESULTS

After 1 y, mean (±SD) weight changes were -11.4 ± 9.1 kg with the VLCD (18% dropout), -6.8 ± 6.4 kg with the LCD (23% dropout), and -5.1 ± 5.9 kg with the restricted normal-food diet (26% dropout). In an adjusted analysis, the VLCD group lost 2.8 kg (95% CI: 2.5, 3.2) and 3.8 kg (95% CI: 3.2, 4.5) more than did the LCD and restricted normal-food groups, respectively. A high baseline BMI and rapid initial weight loss were both independently associated with greater 1-y weight loss (P < 0.001). Younger age and low initial weight loss predicted an increased dropout rate (P < 0.001). Treatment of depression (OR: 1.4; 95% CI: 1.1, 1.9) and psychosis (OR: 2.6; 95% CI: 1.1, 6.3) were associated with an increased dropout rate in the VLCD group.

CONCLUSION

A commercial weight-loss program, particularly one using a VLCD, was effective at reducing body weight in self-selected, self-paying adults.

Epidemiology of gallbladder disease: cholelithiasis and cancer

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.

Disruption of the murine protein kinase Cbeta gene promotes gallstone formation and alters biliary lipid and hepatic cholesterol metabolism

The protein kinase C (PKC) family of Ca(2+) and/or lipid-activated serine-threonine protein kinases is implicated in the pathogenesis of obesity and insulin resistance. We recently reported that protein kinase Cβ (PKCβ), a calcium-, diacylglycerol-, and phospholipid-dependent kinase, is critical for maintaining whole body triglyceride homeostasis. We now report that PKCβ deficiency has profound effects on murine hepatic cholesterol metabolism, including hypersensitivity to diet-induced gallstone formation. The incidence of gallstones increased from 9% in control mice to 95% in PKCβ(-/-) mice. Gallstone formation in the mutant mice was accompanied by hyposecretion of bile acids with no alteration in fecal bile acid excretion, increased biliary cholesterol saturation and hydrophobicity indices, as well as hepatic p42/44(MAPK) activation, all of which enhance susceptibility to gallstone formation. Lithogenic diet-fed PKCβ(-/-) mice also displayed decreased expression of hepatic cholesterol-7α-hydroxylase (CYP7A1) and sterol 12α-hydroxylase (CYP8b1). Finally, feeding a modified lithogenic diet supplemented with milk fat, instead of cocoa butter, both increased the severity of and shortened the interval for gallstone formation in PKCβ(-/-) mice and was associated with dramatic increases in cholesterol saturation and hydrophobicity indices. Taken together, the findings reveal a hitherto unrecognized role of PKCβ in fine tuning diet-induced cholesterol and bile acid homeostasis, thus identifying PKCβ as a major physiological regulator of both triglyceride and cholesterol homeostasis.

The prevalence and risk factors for gallstone disease

Gallstone disease is one of the most prevalent gastrointestinal disorders. In addition, the costs associated with the diagnosis and treatment of gallstone disease have been rapidly increasing. The etiology and pathogenesis of gallstone disease remains incompletely understood. Gallstone formation may result from a complex interaction of genetic and environmental factors. This article reviews the prevalence and risk factors associated with gallstone disease. Understanding the pathogenesis of gallstone disease could lead to the development of better therapeutic and preventive strategies for dealing with this disease.

Predictors of gallstone formation after bariatric surgery: a multivariate analysis of risk factors comparing gastric bypass, gastric banding, and sleeve gastrectomy

BACKGROUND

Risk factors for gallstone formation in the general population have been well studied while those after weight reduction surgery are unknown. The aim of this study was to identify the risk factors for the development of symptomatic gallstones after bariatric surgery.

METHOD

Retrospective review was performed for patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), adjustable gastric banding (LAGB) or sleeve gastrectomy (LSG) between 2004 and 2006. Statistical evaluation was performed using a univariate and multivariate analysis. Risk factors, including age, gender, preoperative body mass index (BMI), BMI > 45 kg/m(2), diabetes mellitus, hyperlipidemia, types of operation, and weight loss >25% of original weight, were analyzed for their association with postoperative symptomatic gallstones formation.

RESULTS

670 laparoscopic RYGBP, 47 LAGB, and 79 LSG were performed in our institute. Preoperative gallbladder disease, as indicated by presence of gallstones or sludge on preoperative transabdominal ultrasound, or previous cholecystectomy, were found in 25.3, 14.9, and 30.4% of patients who subsequently had RYGBP, LAGB, and LSG, respectively. A total of 586 patients were included for analysis. Mean follow-up was 25.9 (range 12-42) months. Overall rate of symptomatic gallstone formation was 7.8% and mean time for its development was 10.2 (range 2-37) months. Incidence of symptomatic gallstones with complications as initial presentation was found in 1.9% of the patients. Logistic regression analysis showed that only postoperative weight loss of more than 25% of original weight was associated with symptomatic gallstones formation [B = 1.482, SE = 0.533, odds ratio 4.44, 95% confidence interval (CI) 1.549-12.498, p = 0.005].

CONCLUSIONS

Traditional risk factors for gallstone formation in the general population are not predictive of symptomatic gallstone formation after bariatric surgery. Weight loss of more than 25% of original weight was the only postoperative factor that can help selecting patients for postoperative ultrasound surveillance and subsequent cholecystectomy once gallstones were identified.

Gallstone formation and weight loss

Obesity is associated with increased bile stasis and cholesterol saturation, and an increased risk of gallstone development. Conversely, bile composition is normalized following reduction in body weight. It would appear advantageous to promote weight loss in obesity, which would reduce the predisposition to gallstone formation. Despite the potential health benefits of weight reduction, very-low-calorie diets appear to increase the risk for cholesterol crystal and gallstone formation. The incidence of gallstone formation seems to be dependent on the degree of caloric restriction, the rate of weight loss, and the duration of the dietary intervention. Thus, faster rates of weight loss for longer periods of time are associated with increased risk. Available data obtained from prospective studies of subjects during active weight loss suggest that newly formed gallstones occur within 4 weeks and with incidence rates 15 to 25-fold higher than in the general obese population. The stones produce symptoms in approximately one-third of the subjects, of whom approximately one-half will undergo surgery. Proposed mechanisms underlying gallstone formation during weight reduction include bile stasis due to reduced caloric intake, increased biliary cholesterol saturation secondary to increased cholesterol mobilization, and increased nucleation due to changes in bile arachidonate and glycoprotein concentrations. Data are lacking on the effects of gradual rates of weight loss and risk of gallstone formation.

Genetic analysis of cholesterol gallstone formation: searching for Lith (gallstone) genes

The genetics of cholesterol cholelithiasis is complex because a number of interacting genes regulate biliary cholesterol homeostasis. Quantitative trait locus (QTL) analysis is a powerful method for identifying primary rate-limiting genetic defects and discriminating them from secondary downstream lithogenic effects caused by mutations of the primary genes. The subsequent positional cloning of such genes responsible for QTLs may lead to the discovery of pathophysiologic functions of Lith (gallstone) genes. In this review, we present a map of candidate genes for Lith genes that may determine gallstone susceptibility in mice. The physical-chemical, pathophysiologic, and genetic studies of Lith genes in bile, liver, gallbladder, and intestine will be crucial for elucidating the genetic mechanisms of cholesterol gallstone disease in mice and in humans. Because exceptionally close homology exists between mouse and human genomes, the orthologous human LITH genes can often be recognized after mouse genes are identified.

Lipase inhibition by orlistat: effects on gall-bladder kinetics and cholecystokinin release in obesity

BACKGROUND

Obese subjects are at risk of developing gallstones as a result of the obese state and during weight reduction.

AIM

To study whether orlistat, by lipase inhibition, impairs gall-bladder emptying, thus further predisposing weight-losing obese subjects to gallstone formation.

METHODS

Patients entering a randomized clinical trial of 1 month of diet, followed by treatment with placebo, 3 x 60 mg orlistat or 3 x 120 mg orlistat, underwent gall-bladder emptying studies measured by ultrasound. Meal-induced cholecystokinin release and gall-bladder emptying were investigated at the start, at randomization and after 1 and 12 months.

RESULTS

One month of dieting did not change gall-bladder emptying and cholecystokinin release. After 1 month, placebo treatment resulted in a decreased fasting volume of 11%, compared with increases of 26% and 47% with 60 and 120 mg orlistat, respectively. Gall-bladder emptying increased by 9% with placebo and decreased by 15% and 53% with 60 and 120 mg orlistat, respectively. Fasting cholecystokinin values and cholecystokinin release decreased significantly in the orlistat group. After 1 year, a persistent but attenuated effect of orlistat on gall-bladder emptying and cholecystokinin release remained. Three of 40 patients developed gallstones, two on placebo with major weight loss and one on 60 mg orlistat.

CONCLUSIONS

One month of lipase inhibition by orlistat significantly impaired gall-bladder motility, which persisted to some extent after 1 year. Obese subjects with diabetes or hyperlipidaemia, who are more at risk of gallstones, should be followed carefully.

Gallstone formation prophylaxis after gastric restrictive procedures for weight loss: a randomized double-blind placebo-controlled trial

OBJECT

To determine if a 6-month regimen of prophylactic ursodeoxycholic acid is effective in the prevention of gallstones.

SUMMARY BACKGROUND DATA

Rapid weight loss after surgery for the treatment of morbid obesity is associated with a high incidence of gallstone formation.

METHODS

Patients with vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB) were enrolled in this study. A single-center, randomized, double-blind, prospective trial evaluated 500 mg of ursodeoxycholic acid versus placebo, beginning within 3 days after surgery and continuing for 6 months or until gallstone development, for patients with morbid obesity. Transabdominal sonography or abdominal CT scan was obtained preoperatively at 3, 6, 12, and 24 months after surgery or until gallstone formation.

RESULTS

From March 1997 to April 2000, 262 patients were submitted to surgery. Seventy-seven patients refused to participate in the study; 43 patients with previous gallstone operation or verified gallstones preoperatively were excluded. Of 152 patients, 76 were randomized to placebo and 76 to 500 mg of ursodeoxycholic acid daily. Preoperative age, sex, weight, BMI, and postoperative weight loss were not significantly different between groups. Gallstone formation was significantly less (P = 0.0018, Fisher exact test) frequent with ursodeoxycholic acid than with placebo at 12 months, 3% versus 22%, and 8% versus 30% (P = 0.0022) at 24 months, cholecystectomy in 4.7% versus 12%, respectively (P < 0,02, Fisher exact test).

CONCLUSION

A daily dose of 500 mg of ursodeoxycholic acid for 6 months is effective prophylaxis for gallstone formation following gastric restrictive procedures.

N/A

N/A

Acute-phase response and immunological markers in morbid obese patients and patients following adjustable gastric banding

OBJECTIVE

We measured markers of acute-phase response and immunological markers in morbid obese patients and in formerly morbid obese patients after a massive weight loss following adjustable gastric banding (GB).

SUBJECTS

A total of 49 morbid obese female patients with a body mass index (BMI) above 40 kg/m(2) were investigated during a study period of 6 months. Of these, 24 patients received a gastric banding (GB) and lost a minimum of 20 kg in 1 y (GB group) and 25 patients maintained their weight (obese group). In sum, 13 normal weight subjects (BMI<24 kg/m(2)) were taken for controls.

METHOD

Plasma concentration of the acute-phase proteins, C-reactive protein (CRP), orosomucoid, complement factors C3 and C4 and white blood cell count, lymphocyte subsets and serum immunoglobulins were analyzed.

RESULTS

Acute-phase proteins were significantly lower in GB compared to morbid obese patients and remained significantly elevated in GB compared to controls. In addition, leukocytes, polymorphonuclear leukocytes and lymphocytes were significantly lower after GB and reached levels comparable to controls (except PMN). No difference in CD3 counts was observed in the three groups. CD4 increased and CD8 decreased in obese and GB patients when compared to controls whereas no statistical difference was found between obese and GB patients.

CONCLUSION

Our results confirm the positive effect of GB followed by a massive weight loss without apparent malnutrition. Subclinical chronical inflammation in morbid obese patients leads to irregularities in leukocyte and lymphocyte subsets. These alterations can be positively influenced by GB.

Gallstones in spinal cord injury (SCI): a late medical complication?

STUDY DESIGN

Prospective controlled study.

OBJECTIVES

To assess the prevalence of cholelithiasis among chronic spinal spinal cord injured (SCI) male patients of the ACHS (Asociación Chilena de Seguridad). To evaluate statistically the prevalence of cholelithiasis among SCI patients compared to a control group and to the general male Chilean population. To assess the correlation between cholelithiasis in chronic SCI patients and usual risk factors such as age, obesity and diabetes mellitus. To assess the association of cholelithiasis in chronic SCI patients and the duration of the spinal cord injury.

SETTING

Rehabilitation Service at the Hospital del Trabajador, in Santiago, Chile.

METHODS

One hundred SCI patients followed up at the Hospital del Trabajador on a regular basis were included in the study; one group consisted of 76 subjects rated ASIA A or B and the other group consisted of 24 subjects rated ASIA C and D. They were all male, older than 20 years old (average age: 41,9 and 42,6 respectively), and suffered from a spinal cord injury greater than one year of evolution. The control group (CG) consisted of 100 male volunteers, without both SCI and history of biliary disease, aged 40.3 years old in average. All three groups underwent ultrasonographic imaging evaluation of the gallbladder and the biliary tract between 1998 and 2000.

RESULTS

The prevalence of cholelithiasis among the groups was the following: 25% in the SCI patients ASIA A and B (19/76), 25% in the SCI patients ASIA C and D (6/24) and 9% (1/100) in the CG. The statistical analysis showed a value of P=0.0037, thus establishing a significant association between cholelithiasis and SCI, both complete and incomplete. The difference was not statistically significant when correlating the presence of cholelithiasis with the neurological level of the injury--above and below T10 (24,1 and 25%, respectively)--with the duration of the SCI, with age, obesity and diabetes mellitus.

CONCLUSIONS

SCI represents a major risk factor for the development of cholelithiasis, and it should be considered a late, secondary complication of a spinal cord injury.

SPONSORSHIP

The present work is sponsored by the Fundación Científica y Tecnológica of the ACHS, grant No 2899.

Gallstones, cholecystectomy, and the risk for developing pancreatic cancer

We examined the relation between gallstones, cholecystectomy, and the development of pancreatic cancer in the Nurses' Health Study and the Health Professionals Follow-up Study. Among 104,856 women and 48,928 men without cancer at baseline, we documented 349 cases of pancreatic cancer during up to 16 years of follow-up. Participants were classified according to a history of gallstones or cholecystectomy. The age-adjusted relative risk of pancreatic cancer following cholecystectomy or diagnosis of gallstones was 1.31 (95% CI, 0.93-1.83). However, adjustment for other pancreatic cancer risk factors attenuated the association (RR=1.11, 95% CI, 0.78-1.56); this risk did not increase with increasing time following cholecystectomy or gallstones. Gallstones or cholecystectomy do not appear to be significant risk factors for pancreatic cancer.

Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study

INTRODUCTION

An increased risk of gallstone (GS) formation has been linked to obesity and to episodes of rapid and significant weight loss. Previous reports have suggested that bile salt therapy (ursodeoxycholic acid) or prostaglandin inhibition (ibuprofen) may prevent gallstone formation in this high-risk group. The purpose of this study was to investigate GS prevention following bariatric surgery.

DESIGN

Randomized double blind controlled trial.

METHODS

Sixty patients without gallstones preoperatively (gender, 9 male, 51 female; average preop wt, 349.6 lb; mean age, 38 years) were randomly assigned to receive urso (600 mg/day, n = 20), ibuprofen (600 mg/d, n = 20), or placebo (n = 20). At the time of standard open gastric bypass, intraoperative ultrasonography confirmed the absence of stones or microcalculi, and bile samples were collected via puncture of the gallbladder for bile lipid analysis. Following recovery and resumption of a bariatric diet, study medication was prescribed for the first 6 months postop. Gallbladder emptying and GS formation were assessed using ultrasonograms preop and at 3, 6, 9, and 12 months postop (gallbladder emptying following a high-fat liquid test meal was assessed preop, and at 3 and 6 months postop).

RESULTS

Forty-one (68.3%, 8 male, 33 female) of the original 60 patients completed all phases of the study (15 urso, 15 ibuprofen, 11 placebo). The average weight loss was 98.5 +/- 7.2 lb over the 12-month period following bariatric surgery. Twenty-nine (71%) of 41 patients who completed the study developed GS. Of those who formed stones, 12 (41%) developed symptomatic GS and 8/12 (67%) underwent cholecystectomy (4 refused operation). Preoperative gallbladder emptying studies showed no differences in emptying between groups (urso 29%, ibuprofen 32%, and placebo 30%). There was no correlation found between the cholesterol saturation index (CSI mean 205.15, range 67-360) and the incidence of GS. There was a statistical difference (P < 0.01) between the ursodeoxycholic acid group and the ibuprofen group with respect to the incidence of stone formation. There was correlation between weight loss (mean 99 lb, range 21-278 lb) and GS formation, in that patients who lost more weight had a greater tendency to form gallstones. Complete medical compliance was achieved in only 17/60 (28%) of patients originally enrolled.

CONCLUSIONS

This pilot study confirms the high incidence of gallstone formation (71% of assessed patients) associated with rapid weight loss in patients undergoing gastric bypass. Despite active enrollment in a supervised prevention trial, the two therapies investigated to reduce gallstone formation were not efficacious, likely because compliance with medical therapy was poor. These findings highlight the significant risk of gallstone formation in this patient cohort even when prevention strategies are utilized.

Obstáculos diagnósticos e desafios terapêuticos no paciente obeso

Obesidade é uma doença complexa, de mútiplas etiologias e suficientemente comum para constituir um problema de saúde pública, assim como um dilema clínico importante. Especialistas da área clínica e cirúrgica são freqüentemente desafiados pelas alterações fisiopatológicas associadas com a obesidade. Essas alterações comprometem virtualmente todos os sistemas do organismo, podendo apresentar-se como barreiras no diagnóstico e na terapêutica. Há evidências marcantes de que obesidade acarreta risco excessivo para a saúde; de fato, a mortalidade aumenta de forma aguda quando o índice de massa corporal ultrapassa 30 kg/m2, principalmente quando há distribuição central de tecido adiposo concomitante. O autor discute os efeitos da obesidade nos sistemas respitatório, cardiovascular, digestório e geniturinário. Os obstáculos enfrentados em procedimentos diagnósticos ordinários, prescrição de medicamentos, traumas, assim como descrições patológicas raras de lipomas, são apresentados.