Gallbladder motility, gallstones, and the surgeon

High incidence of gallstones after Roux-en-Y reconstruction gastrectomy in gastric cancer: a multicenter, long-term cohort study

BACKGROUND

Roux-en-Y reconstruction is a common anastomosis technique during gastrectomy in gastric cancer. There is a lack of studies on gallstones after Roux-en-Y reconstruction gastrectomy. This study investigated the incidence and potential risk factors associated with gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer.

METHODS

The study analyzed data from gastric cancer who underwent radical gastrectomy and Roux-en-Y reconstruction at two hospitals between January 2014 and December 2020. The patients fall into distal and total gastrectomy groups based on the extent of gastrectomy. The cumulative event probability curve was plotted using the Kaplan-Meier, and differences in gallstone between groups were evaluated using the Log-Rank. Propensity score matching was applied to construct a balanced total versus distal gastrectomies cohort. A Cox regression was employed to analyze the risk factors for gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer. Further subgroup analysis was performed.

RESULTS

Five hundred thirty-one patients were included in this study, 201 in the distal gastrectomy group and 330 in the total gastrectomy. During the follow-up, gallstones occurred in 170 cases after gastrectomy, of which 145 cases accounted for 85.29% of all stones in the first two years after surgery. Then, to reduce the impact of bias, a 1:1 propensity score matching analysis was performed on the two groups of patients. A total of 344 patients were evaluated, with each subgroup comprising 172 patients. In the matched population, the Cox regression analysis revealed that females, BMI ≥23 kg/m 2 , total gastrectomy, No.12 lymph node dissection, and adjuvant chemotherapy were risk factors for gallstones after Roux-en-Y reconstructive gastrectomy. Subgroup analysis showed that open surgery further increased the risk of gallstones after total gastrectomy.

CONCLUSION

The incidence of gallstones increased significantly within 2years after Roux-en-Y reconstructive gastrectomy for gastric cancer. Patients with these risk factors should be followed closely after gastrectomy to avoid symptomatic gallstones.

A computer study of the risk of cholesterol gallstone associated with obesity and normal weight

Obese people differ from the people of normal weight in gall bladder motility and have a higher risk of cholesterol stone formation. In this study, using a mathematical model of cholesterol homeostasis, which also considers the enterohepatic circulation of bile as well as cholesterol, we investigated the risk of cholesterol stone formation in obese and normal-weight groups who had normal blood cholesterol levels. We associated the risk of stone formation with the amount of cholesterol released into bile and the amount of de novo-synthesized cholic acid. For both groups, we determined the conditions of low and high risk. In addition, we analyzed the potential effects of changes in gall bladder motility with increased weight. The results showed that the obese group exhibited increased kinetics of enterohepatic circulation, leading to a significant increase in blood cholesterol levels, which can be reduced by increasing the amount of cholesterol in bile. Based on this finding, we suggest that for obese people, it is beneficial to reduce the amount and change the composition of circulating bile through the inhibition of cholic acid synthesis along with cholesterol synthesis. Furthermore, obese people should maintain a triglyceride-lowering diet and consume small meals containing fat, preferably in combination with agents that can reduce bile output from the gall bladder.

Physical Activity and the Biliary Tract in Health and Disease

BACKGROUND

Cholecystitis and gallstones affect a large segment of the population in developed nations, and a small proportion of affected individuals subsequently develop cancer of the gallbladder. However, little is known about the possible beneficial effects of physical activity.

OBJECTIVE

Accordingly, a systematic review examined the influence of both acute and chronic exercise on gallbladder motility, and relationships were examined between habitual physical activity, gallbladder disease, and gallbladder cancer.

METHODS

A search of Ovid/MEDLINE from 1996 to November 2014 yielded 67 articles relating to physical activity and gallbladder function or disease; 18 of these relevant to the objectives of the review were supplemented by 22 papers from personal files and other sources. Because of the limited volume of material, all were considered, although note was taken of the quality of activity measurement, care in excluding covariates, and experimental design (cross-sectional, case-control or randomized controlled trial).

RESULTS

The impact of physical activity upon gallbladder function remains unclear; acute activity could augment emptying by stimulating cholecystokinin release, and one of two training experiments found a small increase in gallbladder motility. The largest and most recent cross-sectional and case-control trials show a reduced risk of gallbladder disease in active individuals. A small number of randomized controlled trials in humans and one animal study generally support these trends, although the number of cases of gallstones are too few for statistical significance. Three studies of gallbladder cancer also show a non-significant trend to benefit from physical activity.

CONCLUSIONS

Although there remains a need for further research, regular physical activity seems likely to reduce the risk of both gallstones and gallbladder cancer. A substantial number of individuals must be persuaded to exercise in order to avoid one case of gallbladder disease, but the attempt appears warranted because of the other health benefits of regular physical activity.

Cholecystokinin and gastrin receptors targeting in gastrointestinal cancer

Cholecystokinin and Gastrin are amongst the first gastrointestinal hormone discovered. In addition to classical actions (contraction of gallbladder, growth and secretion in the stomach and pancreas), these also act as growth stimulants for gastrointestinal malignancies and cell lines. Growth of these tumours is inhibited by antagonists of the cholecystokinin and gastrin receptors. These receptors provides most promising approach in clinical oncology and several specific radiolabelled ligands have been synthesized for specific tumour targeting and therapy of tumours overexpressing these receptors. Therefore, definition of the molecular structure of the receptor involved in the autocrine/paracrine loop may contribute to novel therapies for gastrointestinal cancer. Hence, this review tries to focus on the role and distribution of these hormones and their receptors in gastrointestinal cancer with a brief talk about the clinical trial using available agonist and antagonist in gastrointestinal cancers.

The prevalence of gallbladder stones is higher among patients with chronic kidney disease in Taiwan

The pathogenesis of gallstone disease is multifactorial. Few studies have focused on gallbladder stones in the chronic kidney disease population in Taiwan. We conducted the current study to determine the prevalence of gallbladder stones in populations with and without chronic kidney disease.This was a hospital-based, cross-sectional study. We retrospectively analyzed the patients receiving periodic health examinations at 1 medical center in Taiwan from 2001 to 2004. In all, 4773 patients were enrolled in the study. Chronic kidney disease was defined as a glomerular filtration rate less than 60 mL/min per 1.73 m by the Modification of Diet in Renal Disease formula. Odds ratio (OR) and 95% confidence intervals (CI) were expressed using a multivariate logistic regression analysis.We studied 2686 men (56.3%) and 2087 women (43.7%). The mean age was 49.1 +/- 12.2 years (range, 20-87 yr). The prevalence of gallbladder stones was 13.1% in the group of patients with chronic kidney disease and 4.9% in the group of patients without chronic kidney disease (p < 0.001). After controlling for the other covariates, multivariate logistic regression analysis showed that increasing age (aged 40-64 yr vs. 20-39 yr, OR = 3.06, 95% CI = 1.81-5.15; and > or =65 yr vs. 20-39 yr, OR = 6.13, 95% CI = 3.42-10.98), chronic kidney disease (OR = 1.58, 95% CI = 1.01-2.47), body mass index > or =27 kg/m (OR = 1.39, 95% CI = 1.02-1.91), metabolic syndrome (OR = 1.45, 95% CI = 1.08-1.94), and cirrhosis (OR = 4.23, 95% CI = 1.25-14.29) were significantly related to gallbladder stone disease.The prevalence of gallbladder stones in patients with chronic kidney disease is significantly higher than in those without chronic kidney disease. Our findings suggest that increasing age, chronic kidney disease, body mass index > or =27 kg/m, metabolic syndrome, and cirrhosis are the related factors for gallbladder stone formation.

The effect of moderate alcohol intake on gallblader motility a milk ultrasonographic study

OBJECTIVES

To assess the effect of periodic and moderate alcohol intake on gallbladder motility.

METHODS

The ultrasonographic ellipsoid method was used in 21 healthy male subjects: 12 non-alcohol and 9 alcohol drinkers. The stimulus for gallbladder contraction was 165 ml of half cream milk. Gallbladder dynamics were studied for 20 minutes following the ingestion of the milk. The mean percentage change in gallbladder volume after 10 and 20 minutes gave indications of gallbladder motility.

RESULTS

Moderate and periodic alcohol intake did not stimulate rapid postprandial gallbladder emptying.

CONCLUSION

The protective effect of alcohol against biliary cholesterol cholelithiasis could not be due to stimulation of gallbladder emptying.

Increased prevalence of gallstone disease and impaired gallbladder motility in patients with Barrett's esophagus

The prevalence of gallstones in patients with Barrett's esophagus (BE) and their gallbladder motility relative to that of healthy volunteers and GERD patients without BE were investigated. Of the 707 patients reviewed, 203 (125 males and 78 females) had BE. The prevalence of gallstones was significantly higher in the patients with BE than in those without BE (34 vs. 20%, respectively). The gallbladder functions of 22 patients with GERD, 27 patients with BE and 21 healthy volunteers were assessed by ultrasonography before and after a test meal. The patients with BE had significantly higher fasting volume and residual volume, but lower ejection volume, ejection fraction and ejection rate values than those of the healthy controls. None of the ultrasonographic parameters of patients without BE were significantly different from those of the controls. Patients with BE have a more complex gastrointestinal motility disorder that involves the gallbladder, and this makes this subset of patients with GERD more prone to gallstone disease.

Gallbladder motor function, plasma cholecystokinin and cholecystokinin receptor of gallbladder in cholesterol stone patients

AIM: To study the interactive relationship of gallbladder motor function, plasma cholecystokinin (CCK) and cholecystokinin A receptor (CCK-R) of gallbladder in patients with cholesterol stone disease.

METHODS: Gallbladder motility was studied by ultrasonography in 33 patients with gallbladder stone and 10 health subjects as controls. Plasma CCK concentration was measured by radioimmunoassay in fasting status (CCK-f) and in 30 min after lipid test meal (CCK-30). Radioligand method was employed to analyze the amount and activity of CCK-R from 33 gallstone patients having cholecystectomy and 8 persons without gallstone died of severe trauma as controls.

RESULTS: The percentage of cholesterol in the gallstone composition was more than 70%. The cholesterol stone type was indicated for the patients with gallbladder stone in this study. Based on the criterion of gallbladder residual fraction of the control group, 33 gallstone patients were divided into two subgroups, contractor group (14 cases) and non-contractor group (19 cases). The concentration of CCK-30 was significantly higher in non-contractor group than that in both contractor group and control group (55.86±3.86 pmol/L vs 37.85±0.88 pmol/L and 37.95±0.74 pmol/L, P<0.01), but there was no difference between contractor group and control group. Meanwhile no significant difference of the concentration of CCK-f could be observed among three groups. The amount of CCK-R was lower in non-contractor group than those in both control group and contractor group (10.27±0.94 fmol/mg vs 24.59±2.39 fmol/mg and 22.66±0.55 fmol/mg, P<0.01). The activity of CCK-R shown as KD in non-contractor group decreased compared to that in control group and contractor group. Only was the activity of CCK-R lower in contractor group than that in control group. The ejection fraction correlated closely with the amount of CCK-R (r = 0.9683, P<0.01), and the concentration of CCK-30 correlated negatively with the amount of CCK-R closely (r = -0.9627, P<0.01).

CONCLUSION: The distinctive interactive relationship of gallbladder emptying, plasma CCK and CCK-R in gallbladder from this study suggested that the defect of CCK-R may be a key point leading to the impairment of gallbladder motor function and the pathogenesis of cholesterol gallstone formation may differ in two subgroups of gallstone patient, gallbladder non-contractor group or contractor group.

Sphincter of Oddi dysfunction and other functional biliary disorders: evaluation and treatment

Functional biliary disorders encompass the conditions of SOD and gallbladder dysmotility, both of which result in clinical pain syndromes. Obtaining objective diagnostic and outcomes data for both disorders has been an ongoing challenge over the last two decades. SOD, although initially believed to be strictly a biliary disorder, has now been implicated in recurrent pancreatitis. The biliary-type classification allows a clinician to stratify patients who would benefit from SOM and endoscopic sphincterotomy. Further study into the impact of endoscopic therapy for recurrent pancreatitis is needed. By the same token, the dilemma of postcholecystectomy abdominal pain, whether classified as biliary or pancreatic type III, remains challenging. The current limitations of knowledge highlight the need for prospective randomized studies to evaluate the clinical significance of SOM abnormalities to facilitate treatment of these patients.

Alternative treatment of gallbladder disease

Major risk factors for gallbladder disease include a sedentary lifestyle and a diet rich in refined sugars. In genetically prone individuals, these two factors lead to an abnormal bile composition, altered gut microflora, and hyperinsulinemia, with resulting gallstone formation. As a large percentage of gallbladder patients have continued digestive complaints following cholecystectomy, the author examines complementary and alternative medicine (CAM) treatments to counteract gallstone formation. Herbal medicine such as turmeric, oregon grape, bupleurum, and coin grass may reduce gallbladder inflammation and relieve liver congestion. Elimination of offending foods, not necessarily 'fatty' foods, is often successful and recommended by many holistic physicians. Regular aerobic exercise has a beneficial effect on hyperinsulinemia, which is often associated with gallbladder disease. Dietary changes that lower plasma insulin levels, such as a change in dietary fats and substitution of unrefined carbohydrates for refined carbohydrates, may also be helpful.

The effect of cholecystectomy on plasma cholecystokinin

OBJECTIVE

Gallbladder removal is associated with an increased incidence of gastroesophageal reflux, but the mechanism is unclear. Cholecystokinin (CCK) release, which causes gallbladder contraction, is inhibited by bile in the duodenum. This study investigates the effect of cholecystectomy on meal-stimulated CCK secretion.

METHODS

Three groups of patients were studied. Group 1 (n = 15) were normal controls. Group 2 (n = 27) were patients with symptomatic gallstones. Group 3 (n = 25) were patients who had undergone cholecystectomy. Meal-stimulated CCK levels were measured by radioimmunoassay at defined time points for 60 min after a standard corn oil-based meal.

RESULTS

Fasting CCK levels were similar in all three groups. In postcholecystectomy patients, meal-stimulated plasma CCK levels were significantly elevated compared with controls: median (range) integrated CCK values for 60 min were 116 (28-209) in controls, 123 (20-501) in gallstone patients, and 176 (63-502) after cholecystectomy.

CONCLUSIONS

This study suggests that cholecystectomy causes an exaggerated meal-stimulated CCK response. Because CCK is known to relax the lower esophageal sphincter. these findings may help explain the increased incidence of gastroesophageal reflux seen after cholecystectomy.

Opioid agonists inhibit excitatory neurotransmission in ganglia and at the neuromuscular junction in Guinea pig gallbladder

BACKGROUND & AIMS

Opiates administered therapeutically could have an inhibitory effect on the neuromuscular axis of the gallbladder, and thus contribute to biliary stasis and acalculous cholecystitis.

METHODS

Intracellular recordings were made from gallbladder neurons and smooth muscle, and tension measurements were made from muscle strips. Opioid receptor-specific agonists tested: delta, DPDPE; kappa, U-50488H; and mu, DAMGO.

RESULTS

Opioid agonists had no effect on gallbladder neurons or smooth muscle. Each of the opioid agonists potently suppressed the fast excitatory synaptic input to gallbladder neurons, in a concentration-dependent manner with half-maximal effective concentration values of about 1 pmol/L. Also, each agonist caused a concentration-dependent reduction in the amplitude of the neurogenic contractile response (half-maximal effective concentration values: DPDPE, 189 pmol/L; U-50488H, 472 pmol/L; and DAMGO, 112 pmol/L). These ganglionic and neuromuscular effects were attenuated by the highly selective opioid-receptor antagonist, naloxone. Opioid-receptor activation also inhibited the presynaptic facilitory effect of cholecystokinin in gallbladder ganglia. Immunohistochemistry with opioid receptor-specific antisera revealed immunostaining for all 3 receptor subtypes in nerve bundles and neuronal cell bodies within the gallbladder, whereas opiate-immunoreactive nerve fibers are sparse in the gallbladder.

CONCLUSIONS

These results show that opiates can cause presynaptic inhibition of excitatory neurotransmission at 2 sites within the wall of the gallbladder: vagal preganglionic terminals in ganglia and neuromuscular nerve terminals. These findings support the concept that opiates can contribute to gallbladder stasis by inhibiting ganglionic activity and neurogenic contractions.

An ultrasonographic evaluation of gallbladder emptying in patients with cholelithiasis

Impaired gallbladder emptying producing biliary stasis may provide potent carcinogen, which comes in contact with gallbladder mucosa for a prolonged period, inducing carcinogenesis. The aim was to study gallbladder emptying pattern in cholelithiasis. Postprandial gallbladder emptying was measured ultrasonographically in terms of fasting volume (FV), postprandial residual volume at 30 minutes (PP30), 60 minutes (PP60), and 90 minutes (PP90), residual fraction, and ejection volume (EV) in 58 patients with gallstones. Patients were divided into two groups of poor and good contractors on the basis of 50% maximal postprandial gallbladder emptying. Malonaldehyde level was estimated in 15 patients with cholelithiasis. Twenty-nine patients (50%) were poor contractors. The FV in patients with cholelithiasis (mean, 30.08 mL) was larger than the controls (mean, 17.55 mL) and the difference was statistically significant (p < 0.02). The FV in the cholelithiasis group correlated significantly with the PP30 (r = 0.85, p < 0.001), PP60 (r = 0.85, p < 0.001), PP90 (r = 0.78, p < 0.001), and EV (r = 0.65, p < 0.001). Ejection volume was significantly less in poor contractors (p <0.001). Residual fraction was significantly higher in poor contractors (p < 0.001). The biliary malonaldehyde in poor contractors (2.27 micromol/mL) was higher than in good contractors (1.78 micromol/mL), but the difference was statistically not significant. Significantly larger volumes of PP30, PP60, PP90, and residual fraction and a low EV indicate poor contraction leading to biliary stasis.

Genetic determinants of variation in gallbladder disease in the Mexican-American population

Since there have not been any studies that quantify the influence of genetic factors on gallbladder disease (GBD) in humans using information from families, we utilized pedigree data to explore the genetic control of variation in liability to GBD. Using an extension of a variance components approach, we performed genetic analyses of GBD using information from 32 low-income Mexican-American families with two slightly different general models incorporating several sex-specific GBD risk factors. After evaluating the relative magnitudes of the covariate effects from these two models, we identified a parsimonious model including only significant predictors of GBD. According to this model, heritability for GBD was high (h2 = 0.44+/-0.18), after accounting for the significant effects of age, leptin in both sexes, total cholesterol, and HDL cholesterol in males only. We have shown quantitatively that variation in GBD is under strong genetic control. However, there are two major limitations to our findings: (1) since GBD was defined by a self-reported clinical history rather than an ultrasound examination, the prevalence of GBD could have been underestimated; and (2) since our design did not allow for shared environmental effects, our estimate of heritability may have been inflated.

Review: pathogenesis of gallstones

The aim of this article is to review selected aspects of the pathogenesis of cholesterol-rich, gall-bladder stones (GBS)--with emphasis on recent developments in biliary cholesterol saturation, cholesterol microcrystal nucleation, statis within the gall-bladder and, particularly, on the roles of intestinal transit and altered deoxycholic acid (DCA) metabolism, in GBS development. In biliary cholesterol secretion, transport and saturation, recent developments include evidence in humans and animals, that bile lipid secretion is under genetic control. Thus in mice the md-2 gene, and in humans the MDR-3 gene, encodes for a canalicular protein that acts as a 'flippase' transporting phospholipids from the inner to the outer hemi-leaflet of the canalicular membrane. In the absence of this gene, there is virtually no phospholipid or cholesterol secretion into bile. Furthermore, when inbred strains of mice that have 'lith genes' are fed a lithogenic diet, they become susceptible to high rates of GBS formation. The precipitation/nucleation of cholesterol microcrystals from supersaturated bile remains a critical step in gallstone formation. methods of studying this phenomenon have now been refined from the original 'nucleation time' to measurement of cholesterol appearance/detection times, and crystal growth assays. Furthermore, the results of recent studies indicate that, in addition to classical Rhomboid-shape monohydrate crystals, cholesterol can also crystallize, transiently, as needle-, spiral- and tubule-shaped crystals of anhydrous cholesterol. A lengthy list of promoters, and a shorter list of inhibitors, has now been defined. There are many situations where GB stasis in humans is associated with an increased risk of gallstone formation--including iatrogenic stone formation in acromegalic patients treated chronically with octreotide (OT). As well as GB stasis, however, OT-treated patients all have 'bad' bile which is supersaturated with cholesterol, has excess cholesterol in vesicles, rapid microcrystal mulceation times and a two-fold increase in the percentage DCA in bile. This increase in the proportion of DCA seems to be due to OT-induced prolongation of large bowel transit time (LBTT). Thus LBTT is linearly related to (i) the percentage of DCA in serum; (ii) the DCA pool size; and (III) the DCA input or 'synthesis' rate. Furthermore, the intestinal prokinetic, cisapride, counters the adverse effects of OT on intestinal transit, and 'normalizes' the percentage of DCA in serum/bile. Patients with spontaneous gallstone disease also have prolonged LBTTs, more colonic gram-positive anaerobes, increased bile acid metabolizing enzymes and higher intracolonic pH values, than stone-free controls. Together, these changes lead to increased DCA formation, solubilization and absorption, Thus, in addition to the 'lithogenic liver' and 'guilty gall-bladder' one must now add the 'indolent intestine' to the list of culprits in cholesterol gallstone formation.

Nonsurgical management of gallstone disease

Cholelithiasis is a common disease in the United States associated with significant morbidity. Surgical treatment with cholecystectomy has been increasing with a significant cost to the health care system. Surgical management is not without risk. Cholecystectomy has also been associated with a significant morbidity and mortality in elderly patients. Cholecystectomies are often performed unnecessarily in gallstone patients for nonspecific symptoms. Many patients with nonspecific pain, which may have a psychogenic component, continue to experience similar pain after cholecystectomy. There are problems in determining the symptom status of patients. Patients who believe surgery will relieve symptoms may maximize their symptoms, whereas patients who are reluctant to undergo surgery may minimize their symptoms. Although cholecystectomy is the mainstay of gallstone treatment, bile acid therapy and, if available, ESWL and topical dissolution are nonsurgical treatment alternatives in selected patients. In selected cases, in particular in the elderly and in other patients at increased risk from surgery, nonsurgical management offers lower morbidity and mortality than does operative treatment. The decision for surgical versus nonsurgical management should be based on both objective selection criteria and patient choice.

Abdominal symptoms and food intolerance related to gallstones

We have evaluated the association between gallstones and abdominal symptoms, comparing two different study designs. We asked questions on abdominal pain, dyspeptic symptoms, and food intolerance in (1) surgery patients referred for conditions unrelated to gallstones, screened by ultrasound (screening study, n = 892, 63 with gallstones); and in (2) symptomatic patients referred for gallbladder ultrasound (clinical study, n = 336, 71 with gallstones). Gallstones were associated with mid upper abdominal pain in the screening study, and with mid upper abdominal pain, biliary pain, and colic (each independently) in the clinical study. When these symptoms were absent (and only dyspeptic symptoms or food intolerance was present), gallstones were not more common than expected from the general population prevalence (estimated from the screening study). When upper abdominal pain symptoms are accounted for, other symptoms (dyspeptic; food intolerance; pain related to food intake) have no additional diagnostic value. The results are discussed, contrasting different types of studies.

The study on the relationship between the expression of calponin and gallstone formation

In order to understand the molecular mechanisms of gallstone formation, the expression of calponin in animal model of gallstone disease was studied. High-cholesterol diet was given to the guinea pigs to induce gallstone formation. RT-PCR and Western-blotting were used to evaluate expression level of calponin gene. Down-regulation of calponin gene expression was observed in animals with gallstone, while myosin expression was relatively stable. Our results indicated that the decrease of calponin could increase the pressure of Oddi's sphincter, aggravate the stasis of bile and promote the gallstone formation.