Diarrhea after laparoscopic cholecystectomy: associated factors and predictors

Cholelithiasis and cholecystectomy increase the risk of gastroesophageal reflux disease and Barrett's esophagus

Background

Cholelithiasis or cholecystectomy may contribute to the development of gastroesophageal reflux disease (GERD), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC) through bile reflux; however, current observational studies yield inconsistent findings. We utilized a novel approach combining meta-analysis and Mendelian randomization (MR) analysis, to assess the association between them.

Methods

The literature search was done using PubMed, Web of Science, and Embase databases, up to 3 November 2023. A meta-analysis of observational studies assessing the correlations between cholelithiasis or cholecystectomy, and the risk factors for GERD, BE, and EACwas conducted. In addition, the MR analysis was employed to assess the causative impact of genetic pre-disposition for cholelithiasis or cholecystectomy on these esophageal diseases.

Results

The results of the meta-analysis indicated that cholelithiasis was significantly linked to an elevated risk in the incidence of BE (RR, 1.77; 95% CI, 1.37-2.29; p < 0.001) and cholecystectomy was a risk factor for GERD (RR, 1.37; 95%CI, 1.09-1.72; p = 0.008). We observed significant genetic associations between cholelithiasis and both GERD (OR, 1.06; 95% CI, 1.02-1.10; p < 0.001) and BE (OR, 1.21; 95% CI, 1.11-1.32; p < 0.001), and a correlation between cholecystectomy and both GERD (OR, 1.04; 95% CI, 1.02-1.06; p < 0.001) and BE (OR, 1.13; 95% CI, 1.06-1.19; p < 0.001). After adjusting for common risk factors, such as smoking, alcohol consumption, and BMI in multivariate analysis, the risk of GERD and BE still persisted.

Conclusion

Our study revealed that both cholelithiasis and cholecystectomy elevate the risk of GERD and BE. However, there is no observed increase in the risk of EAC, despite GERD and BE being the primary pathophysiological pathways leading to EAC. Therefore, patients with cholelithiasis and cholecystectomy should be vigilant regarding esophageal symptoms; however, invasive EAC cytology may not be necessary.

The relationship between gastrointestinal symptoms in FGID patients and D-type personality and emotion regulation strategies

This study examines the relationship between gastrointestinal symptoms in patients with functional gastrointestinal disorders (FGIDs) and type D personality traits, as well as emotion regulation strategies. Analyzing a diverse group of FGID patients, we uncover significant effects of gender and age on gastrointestinal symptoms. Negative Affectivity emerges as a key predictor, positively associated with symptom severity, whereas Social Inhibition correlates negatively with Abdominal Pain. Additionally, our findings suggest that the expressive suppression strategy predicts heightened gastrointestinal symptoms, whereas cognitive reappraisal predicts lower levels of certain symptoms. These findings provide valuable insights for precise diagnosis and tailored treatments of FGIDs. Further research is warranted to explore underlying mechanisms and inform evidence-based interventions.

Dietary Considerations in Cholecystectomy: Investigating the Impact of Various Dietary Factors on Symptoms and Outcomes

Cholecystectomy is commonly performed to address gallstone diseases, including the development of gallstones, which can lead to symptoms such as nausea, vomiting, and abdominal pain. Bile acids (BAs) produced by the liver are primarily stored and concentrated in the gallbladder (GB). After cholecystectomy, the body's ability to digest lipids is reduced due to the absence of the GB. Post-cholecystectomy syndrome (PCS) can occur when abdominal symptoms manifest after surgery. The purpose of this review is to look at the various effects of different dietary factors on patients undergoing cholecystectomy, how they affect their overall health after surgery, and how they contribute to symptoms of PCS. Some individuals may experience mild discomfort or alterations in bowel patterns, especially after consuming high-fat meals. The findings from the conducted studies suggest that, although dietary changes are a common recommendation, these measures are not sufficiently supported by evidence when it comes to alleviating symptoms and improving outcomes post-cholecystectomy. The studies found that subjects who consumed particular foods, such as processed meat and fried fatty foods, had exacerbated symptoms after cholecystectomy. Further studies are still required to understand the precise food factors that might affect post-surgical symptoms, as well as outcomes, and to develop tailored measures to enhance patient care and long-term prognosis after undergoing cholecystectomy.

[Bile Acid Diarrhea]

Diarrhea is a very common gastrointestinal symptom, and the presence of higher concentrations of bile acid in the colon leads to bile acid diarrhea (BAD). In BAD patients, a portion of bile from the small intestine that is normally controlled by enterohepatic circulation is present at a high concentration in the lumen of the large intestine, resulting in increased motility and secretion of the large intestine. The prevalence of BAD is estimated to be 1-2% of the general population, and it comprises one-third of the instances of diarrhea-predominant irritable bowel syndrome. The clinical symptoms of BAD include chronic diarrhea, increased frequency of defecation, urgency to defecate, fecal incontinence, and cramping abdominal pain. The pathophysiology of BAD has not yet been fully elucidated. However, recent studies have reported increased intestinal permeability, shortened intestinal transit time, and changes in the intestinal microbial community to be the possible causes of BAD. Although fecal and serum bile acid tests are widely used for diagnosis, new test methods that are non-invasive, inexpensive, and have high sensitivity and specificity are needed at various institutions to facilitate the diagnosis. The selenium homo-tauro-cholic acid (SeHCAT) test is the gold standard for BAD diagnosis and severity assessment. The validation of several other serum markers, such as 7-hydroxy-4-cholesten-3-one (serum 7αC4) and the fibroblast growth factor 19 (FGF19) for use in clinical practice is ongoing. Although bile acid sequestrants are the mainstay of treatment, the development of drugs that are more effective and have better compliance is required. Farnesoid X receptor (FXR) agonists are showing promising results.

Prevalence and predictors of postcholecystectomy syndrome in Nepalese patients after 1 week of laparoscopic cholecystectomy: a cross-sectional study

Postcholecystectomy syndrome (PCS) is persistent distressing symptoms which develops following a laparoscopic cholecystectomy (LC); in cases when the condition is severe, readmission may be necessary. However, research on the prevalence of PCS and potential factors associated with PCS in Nepalese patients is still limited. An observational point-prevalence, correlational predictive cross-sectional study was conducted to determine the prevalence of PCS and examine what predicting factors including preoperative anxiety, preoperative dyspepsia, smoking, alcohol consumption, and duration of preoperative symptoms are associated with PCS. A total of 127 eligible Nepalese patients who came for follow-up after 1 week of LC at outpatient department of surgery in one single university hospital, Kathmandu, Nepal, were recruited. A set of questionnaires consisting participants' information record form, Hospital Anxiety and Depression Scale (HADS), Leeds Dyspepsia Questionnaires (LDQ), Fagerstrom Test for Nicotine Dependence (FTND), and Alcohol Use Disorder Identification Test (AUDIT) was administered for data collection. The associations between influential factors and PCS were analyzed using Binary logistic regression. 43.3% of participants reported PCS after 1 week of surgery. The findings from logistic regression analysis affirmed that the patients with preoperative anxiety (OR = 6.38, 95%CI = 2.07-19.67, p < 0.01) and moderate to severe dyspepsia (OR = 4.01, 95%CI = 1.34-12.02, p < 0.05) held the likelihood to report PCS 6.38 and 4.01 times, respectively, greater than others. The implications from study results are that screening of anxiety and patients' tailored interventions to reduce anxiety should be implemented preoperatively. An appropriate health education about persistence of PCS and self-management should be provided to those postoperative patients.

Food intolerance related to gastrointestinal symptoms amongst adults living with bile acid diarrhoea: A cross-sectional study

BACKGROUND

The role of food in managing bile acid diarrhoea (BAD) is poorly understood. The present study explored the prevalence of food intolerance amongst adults with BAD.

METHODS

The study comprised a cross-sectional survey of adults with BAD determined by the 75 selenium homotaurocholic acid test (SeHCAT) living in the UK. Participants anonymously completed an online questionnaire on 39 food items. Frequency of food in general affecting BAD symptoms, as well as frequencies of diarrhoea, abdominal pain, bloating, flatulence and consequential food avoidance after food item ingestion, were assessed. Food group avoidance was also assessed.

RESULTS

There were 434 participants who completed the questionnaire between April and May 2021 of whom 80% reported moderate to severe chronic diarrhoea. Food intolerances were reported by 88.0% (95% confidence interval [CI] = 84.6-90.9) of participants. Diarrhoea was reported most frequently after take-away food, fish and chips, creamy sauces, cream and large quantities of fruit (range 41.0%-33.6%). Lowest frequencies were for potato, avocado, mango, watermelon and pear (range 3.7%-7.4%) for the foods listed in the questionnaire. Similar trends were found for abdominal pain, bloating, flatulence and consequential food avoidance. Symptom-triggering within 30 min of ingestion was more prevalence than after 30 min for almost all foods. Food group avoidance was highest for fatty foods (81.2%; 95% CI = 77.8-85.3) followed by dairy (53.9%; 95% CI = 49.1-58.7).

CONCLUSIONS

Perceived food intolerance amongst adults with BAD and persisting diarrhoeal symptoms is high. Important triggers were meals with a higher fat content and higher-fat dairy products. Diets amongst those with persisting diarrhoeal symptoms may be overly restrictive.

Diagnosis and treatment of post-cholecystectomy diarrhoea

The incidence of cholecystitis is relatively high in developed countries and may usually be attributed to gallstones, the treatment for which involves complete surgical removal of the gallbladder (cholecystectomy). Bile acids produced following cholecystectomy continue to flow into the duodenum but are poorly absorbed by the colon. Excessive bile acids in the colon stimulate mucosal secretion of water and electrolytes leading, in severe cases, to diarrhoea. Bile acid diarrhoea (BAD) is difficult to diagnose, requiring a comprehensive medical history and physical examination in combination with laboratory evaluation. The current work reviews the diagnosis and treatment of BAD following cholecystectomy.

Cholecystectomy Significantly Alters Gut Microbiota Homeostasis and Metabolic Profiles: A Cross-Sectional Study

Cholecystectomy (CCE) is a standard clinical treatment for conditions like gallstones and cholecystitis. However, its link to post-CCE syndrome, colorectal cancer, and nonalcoholic fatty liver disease has raised concerns. Additionally, studies have demonstrated the disruptive effects of CCE on gut microbiota homeostasis and bile acid (BA) metabolism. Considering the role of gut microbiota in regulating host metabolic and immune pathways, the use of dietary and probiotic intervention strategies to maintain a stable gut ecosystem after CCE could potentially reduce associated disease risks. Inter-study variations have made it challenging to identify consistent gut microbiota patterns after CCE, a prerequisite for targeted interventions. In this study, we first meta-analyzed 218 raw 16S rRNA gene sequencing datasets to determine consistent patterns of structural and functional changes in the gut microbiota after CCE. Our results revealed significant alterations in the gut microbiota's structure and function due to CCE. Furthermore, we identified characteristic gut microbiota changes associated with CCE by constructing a random model classifier. In the validation cohort, this classifier achieved an area under the receiver operating characteristic curve (AUC) of 0.713 and 0.683 when distinguishing between the microbiota of the CCE and healthy groups at the family and genus levels, respectively. Further, fecal metabolomics analysis demonstrated that CCE also substantially modified the metabolic profile, including decreased fecal short-chain fatty acid levels and disrupted BA metabolism. Importantly, dietary patterns, particularly excessive fat and total energy intake, influenced gut microbiota and metabolic profile changes post-CCE. These dietary habits were associated with further enrichment of the microbiota related to BA metabolism and increased levels of intestinal inflammation after CCE. In conclusion, our study identified specific alterations in gut microbiota homeostasis and metabolic profiles associated with CCE. It also revealed a potential link between dietary patterns and gut microbiota changes following CCE. Our study provides a theoretical basis for modulating gut microbiota homeostasis after CCE using long-term dietary strategies and probiotic interventions.

Development of functional gastrointestinal disorder symptoms following laparoscopic cholecystectomy: a prospective cohort study

Background

The casual relationship between the role of cholecystectomy and functional gastrointestinal disorders (FGIDs) are a controversial clinical challenge. This study aimed to investigate: (1) the overlap of FGIDs before cholecystectomy and its long-term outcome after surgery in patients with symptomatic cholelithiasis, and (2) the incidence of new-onset FGIDs after cholecystectomy.

Methods

Patients with symptomatic gallstone disease who underwent elective, laparoscopic cholecystectomy were prospectively enrolled. Healthy populations who underwent medical check-ups were selected as age- and sex-matched controls. Questionnaires regarding sociodemographic characteristics, gastrointestinal symptoms and a somatization symptom checklist (SSC) were completed at baseline and 12 months thereafter.

Results

The prevalence of all FGID symptoms before cholecystectomy were significantly higher in the group of patients with symptomatic cholecystolithiasis compared to the control group. In cholecystectomy group, the preoperative FGID symptoms improved after surgery, except for chronic diarrhea. Compared to the controls, the new-onset FGIDs, including functional dyspepsia (14.8% vs. 6.9%; p = 0.040), functional diarrhea (6.6% vs. 0.2%; p < 0.001), and chronic abdominal pain (11.9% vs. 4.4%; p = 0.024), were more common at 1 year after cholecystectomy. Somatization was independent predictors of new-onset dyspepsia and abdominal pain, while newly occurring diarrhea was not realted to somatization.

Conclusion

Overlap of FGIDs was common in patients with symptomatic cholelithiasis before surgery and at follow-up 1 year after cholecystectomy. Furthermore, new-onset FGIDs could be occurred after cholecystectomy. Therefore, a delicate diagnostic approaches and appropriate treatments about co-existent FGIDs should be given in patients with cholelithiasis before and after cholecystectomy.

A High-Fat, High-Cholesterol Diet Promotes Intestinal Inflammation by Exacerbating Gut Microbiome Dysbiosis and Bile Acid Disorders in Cholecystectomy

Patients with post-cholecystectomy (PC) often experience adverse gastrointestinal conditions, such as PC syndrome, colorectal cancer (CRC), and non-alcoholic fatty liver disease (NAFLD), that accumulate over time. An epidemiological survey further revealed that the risk of cholecystectomy is associated with high-fat and high-cholesterol (HFHC) dietary intake. Mounting evidence suggests that cholecystectomy is associated with disrupted gut microbial homeostasis and dysregulated bile acids (BAs) metabolism. However, the effect of an HFHC diet on gastrointestinal complications after cholecystectomy has not been elucidated. Here, we aimed to investigate the effect of an HFHC diet after cholecystectomy on the gut microbiota-BA metabolic axis and elucidate the association between this alteration and the development of intestinal inflammation. In this study, a mice cholecystectomy model was established, and the levels of IL-Iβ, TNF-α, and IL-6 in the colon were increased in mice fed an HFHC diet for 6 weeks. Analysis of fecal BA metabolism showed that an HFHC diet after cholecystectomy altered the rhythm of the BA metabolism by upregulating liver CPY7A1, CYP8B1, and BSEP and ileal ASBT mRNA expression levels, resulting in increased fecal BA levels. In addition, feeding an HFHC diet after cholecystectomy caused a significant dysbiosis of the gut microbiota, which was characterized by the enrichment of the metabolic microbiota involved in BAs; the abundance of pro-inflammatory gut microbiota and related pro-inflammatory metabolite levels was also significantly higher. In contrast, the abundance of major short-chain fatty acid (SCFA)-producing bacteria significantly decreased. Overall, our study suggests that an HFHC diet after cholecystectomy promotes intestinal inflammation by exacerbating the gut microbiome and BA metabolism dysbiosis in cholecystectomy. Our study also provides useful insights into the maintenance of intestinal health after cholecystectomy through dietary or probiotic intervention strategies.

Associations of cholecystectomy with the risk of colorectal cancer: a Mendelian randomization study

BACKGROUND

Cholecystectomy is a standard surgery for patients suffering from gallbladder diseases, while the causal effects of cholecystectomy on colorectal cancer (CRC) and other complications are still unknown.

METHODS

We obtained genetic variants associated with cholecystectomy at a genome-wide significant level ( P value <5 × 10 -8 ) as instrumental variables (IVs) and performed Mendelian randomization (MR) to identify the complications of cholecystectomy. Furthermore, the cholelithiasis was also treated as the exposure to compare its causal effects to those of cholecystectomy, and multivariable MR analysis was carried out to judge whether the effect of cholecystectomy was independent of cholelithiasis. The study was reported based on Strengthening the Reporting of Observational Studies in Epidemiology Using Mendelian Randomization guidelines.

RESULTS

The selected IVs explained 1.76% variance of cholecystectomy. Our MR analysis suggested that cholecystectomy cannot elevate the risk of CRC (odds ratio [OR] =1.543, 95% confidence interval [CI]: 0.607-3.924). Also, it was not significant in either colon or rectum cancer. Intriguingly, cholecystectomy might decrease the risk of Crohn's disease (OR = 0.078, 95% CI: 0.016-0.368) and coronary heart disease (OR = 0.352, 95% CI: 0.164-0.756). However, it might increase the risk of irritable bowel syndrome (IBS) (OR = 7.573, 95% CI: 1.096-52.318). Cholelithiasis could increase the risk of CRC in the largest population (OR = 1.041, 95% CI: 1.010-1.073). The multivariable MR analysis suggested that genetic liability to cholelithiasis could increase the risk of CRC in the largest population (OR = 1.061, 95% CI: 1.002-1.125) after adjustment of cholecystectomy.

CONCLUSIONS

The study indicated that cholecystectomy might not increase the risk of CRC, but such a conclusion needs further proving by clinical equivalence. Additionally, it might increase the risk of IBS, which should be paid attention to in clinical practice.

The Symptomatic Outcomes of Cholecystectomy for Gallstones

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

Prophylactic cholecystectomy: A valuable treatment strategy for cholecystolithiasis after gastric cancer surgery

The main treatment for gastric cancer is surgical excision. Gallstones are one of the common postoperative complications of gastric cancer. To avoid the adverse effects of gallstone formation after gastric cancer surgery, we reviewed the causes and risk factors and mechanisms involved in gallstone formation after gastric cancer surgery. The evidence and value regarding prophylactic cholecystectomy (PC) during gastric cancer surgery was also reviewed. Based on previous evidence, we summarized the mechanism and believe that injury or resection of the vagus nerve or changes in intestinal hormone secretion can lead to physiological dysfunction of the gallbladder and Oddi sphincter, and the lithogenic components in the bile are also changed, ultimately leading to CL. Previous studies also have identified many independent risk factors for CL after gastric cancer, such as type of gastrectomy, reconstruction of the digestive tract, degree of lymph node dissection, weight, liver function, sex, age, diabetes and gallbladder volume are closely related to CL development. At present, there are no uniform guidelines for the selection of treatment strategies. As a new treatment strategy, PC has undeniable advantages and is expected to become the standard treatment for CL after gastric cancer in the future. The individualized PC strategy for CL after gastric cancer is the main direction of future research.

A new operation for gallstones: Choledochoscopic gallbladder-preserving cholecystolithotomy, a retrospective study of 3,511 cases

BACKGROUND

Due to the influence of traditional Chinese culture, many cholelithiasis patients refuse to undergo cholecystectomy. This has prompted surgeons to consider a new treatment option for gallstones, which preserves the gallbladder, termed as choledochoscopic gallbladder-preserving cholecystolithotomy. In this study, we reviewed the clinical outcomes of 23 years of single-center application of choledochoscopic gallbladder-preserving cholecystolithotomy.

METHODS

A total of 5,451 patients with chronic cholelithiasis were selected from 1992 to 2011 as per the inclusion criteria for the choledochoscopic gallbladder-preserving cholecystolithotomy study, and clinicopathological and follow-up data were collected from 4,340 patients who underwent successful choledochoscopic gallbladder-preserving cholecystolithotomy. The endpoints of the follow-up were recurrence of stones, loss to follow-up, patient death, removal of the gallbladder for other reasons, or end of follow-up in December 2015.

RESULTS

All 4,340 cases underwent choledochoscopic gallbladder-preserving cholecystolithotomy with a mean procedure time of 79.6 ± 35.4 minutes, among which 3,511 (80.9%) received at least 1 follow-up. The recurrence rate of gallstones gradually increased with increasing follow-up duration, with a recurrence rate of 0.83% within 1 year after surgery and a maximal cumulative recurrence rate of 7.94% at 23 years. The 5-year cumulative recurrence rate of gallstones in the age group ≤20 years was 16.80%, which was significantly higher than those of other age groups, and the 5-year recurrence rate in the single gallstone group was 2.87%, which was significantly lower than that in the multiple gallstone group. Age and number of gallstones were independent risk factors for gallstone recurrence after choledochoscopic gallbladder-preserving cholecystolithotomy.

CONCLUSION

The recurrence rate of gallstones after choledochoscopic gallbladder-preserving cholecystolithotomy is low, and most patients with recurrence are asymptomatic or have only mild symptoms. Age and number of gallstones were independent risk factors. Choledochoscopic gallbladder-preserving cholecystolithotomy is a safe and effective surgical option for gallstone removal in patients who do not wish to undergo cholecystectomy.

Bile Acid Diarrhea in Adults and Adolescents

BACKGROUND

Bile acids are central to enterohepatic signaling pathways activated through natural receptors, farnesoid X receptor [FXR mediates synthesis of fibroblast growth factor-19 (FGF-19)], and G protein-coupled bile acid receptor 1 (GPBAR1, also known as TGR5). Although bile acid diarrhea (BAD) is more commonly encountered in ileal resection or disease, there is evidence documenting "idiopathic" BAD in about 20% of adolescents and 30% of adults presenting with chronic, non-bloody diarrhea often attributed to irritable bowel syndrome. Mechanism(s) leading to increased hepatic synthesis and colonic bile acid levels in "idiopathic" BAD include reduced synthesis of FGF-19 by the ileal mucosa, or genetic variation in hepatocyte proteins klotho β and FGF receptor 4 (FGFR4) that mediate negative feedback of bile acid synthesis.

PURPOSE

The objective of this review is to summarize the diagnosis of BAD in adults and adolescents. In addition to ⁷⁵ SeHCAT retention for diagnosis of BAD, studies have validated fasting serum 7αC4 and FGF-19, respectively, by-product and inhibitor of hepatic bile acid synthesis, as well as fecal bile acid measurements. These assays are widely available through reference laboratories, and they are being simplified (eg, measurement of primary fecal bile acids in a random stool sample). BAD has also been identified as a co-factor contributing to persistent diarrhea in other diseases in remission including inflammatory bowel disease, microscopic colitis, celiac disease, and neuroendocrine tumors. In summary, advances in diagnosis of BAD provide opportunities for generalists and pediatric and adult gastroenterologists to provide targeted treatment for BAD presenting as chronic non-bloody diarrhea.

Postcholecystectomy diarrhoea rate and predictive factors: a systematic review of the literature

OBJECTIVES

Cholecystectomy is one of the most common surgical procedures performed worldwide to treat gallstone-related disease. Postcholecystectomy diarrhoea (PCD) is a well-reported phenomenon, however, the actual rate, predictive factors and mechanism of action have not been well determined. A systematic review was undertaken to determine the rate and predictive factors associated with diarrhoea in the postcholecystectomy setting.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. Databases searched included Medline, Embase, Pubmed, Cochrane and Google Scholar up to 29 September 2020. The inclusion criteria consisted of cohort studies or randomised trials which investigated the rate of PCD and predictive factors. Case reports, case series, conference abstracts and expert opinion pieces were excluded as were other systematic reviews as all the original articles from those reviews were included in this review. Papers that did not include PCD as a separate entity were excluded. Bias assessment was performed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomised controlled trials as appropriate. Data were extracted by two authors (AF and JAA) and an overall rate of PCD was calculated. Predictive factors were also extracted and compared between studies.

RESULTS

1204 papers were obtained and 21 were found to contain relevant information about PCD, including the number of patients developing diarrhoea, method of symptom assessment and time of onset postcholecystectomy. A pooled total of 3476 patients were included across the identified studies with 462 (13.3%) patients developing PCD. Possible predictive factors varied across all studies, with characteristics such as gender, age and weight of patients postulated as being predictive of PCD, with no agreement across studies.

DISCUSSION

PCD is therefore relatively common (13.3%). This has important implications for patient consent. Patients ought to be investigated early for bile acid diarrhoea in suspected PCD. More studies are required to determine the possible predictive factors for PCD. Limitations of the study included that most studies were not powered for calculation of PCD, and assessment methods between studies varied.

PROSPERO REGISTRATION NUMBER

CRD42019140444.

Rates of Bile Acid Diarrhoea After Cholecystectomy: A Multicentre Audit

INTRODUCTION

Bile acid diarrhoea (BAD) can occur due to disruption to the enterohepatic circulation, e.g. following cholecystectomy. Post-cholecystectomy diarrhoea has been reported in 2.1-57.2% of patients; however, this is not necessarily due to BAD. The aim of this study was to determine the rates of bile acid diarrhoea diagnosis after cholecystectomy and to consider investigation practices.

METHODS

A retrospective analysis of electronic databases from five large centres detailing patients who underwent laparoscopic cholecystectomy between 2013 and 2017 was cross-referenced with a list of patients who underwent 75SeHCAT testing. A 7-day retention time of <15% was deemed to be positive. Patient demographics and time from surgery to investigation were collected and compared for significance (p < 0.05).

RESULTS

A total of 9439 patients underwent a laparoscopic cholecystectomy between 1 January 2013 and 31 December 2017 in the five centres. In total, 202 patients (2.1%) underwent investigation for diarrhoea via 75SeHCAT, of which 64 patients (31.6%) had a 75SeHCAT test result of >15%, while 62.8% of those investigated were diagnosed with bile acid diarrhoea (BAD). In total, 133 (65.8%) patients also underwent endoscopy and 74 (36.6%) patients had a CT scan. Median time from surgery to 75SeHCAT test was 672 days (SD ± 482 days).

DISCUSSION/CONCLUSION

Only a small proportion of patients, post-cholecystectomy, were investigated for diarrhoea with significant time delay to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher, and clinicians need to have an increased awareness of this condition due to its amenability to treatment. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea.

Changes in gut microbiota composition and diversity associated with post-cholecystectomy diarrhea

BACKGROUND

Post-cholecystectomy diarrhea (PCD) frequently occurs in patients following gallbladder removal. PCD is part of the post-cholecystectomy (PC) syndrome, and is difficult to treat. After cholecystectomy, bile enters the duodenum directly, independent of the timing of meals. The interaction between the bile acids and the intestinal microbes is changed. Therefore, the occurrence of PCD may be related to the change in microbiota. However, little is known about the relationship between the gut microbiota and PCD.

AIM

To better understand the role of the gut microbiota in PCD patients.

METHODS

Fecal DNA was isolated. The diversity and profiles of the gut microbiota were analyzed by performing high-throughput 16S rRNA gene sequencing. The gut microbiota were characterized in a healthy control (HC) group and a PC group. Subsequently, the PC group was further divided into a PCD group and a post-cholecystectomy non-diarrhea group (PCND) according to the patients' clinical symptoms. The composition, diversity and richness of microbial communities were determined and compared.

RESULTS

In the PC and HC groups, 720 operational taxonomic units (OTUs) were identified. The PC group had fewer OTUs than the HC group. β-diversity was decreased in the PC group. This indicated decreased microbial diversity in the PC group. Fifteen taxa with differential abundance between the HC and PC groups were identified. In the PCD group compared to the PCND group, significant decreases in microbial diversity, Firmicutes/Bacteroidetes ratio, and richness of probiotic microbiota (Bifidobacterium and Lactococcus), and an increase in detrimental microbiota (Prevotella and Sutterella) were observed. Moreover, a negative correlation was found between Prevotella and Bifidobacterium. Using a Kyoto Encyclopedia of Genes and Genomes functional analysis, it was found that the abundances of gut microbiota involved in lipid metabolism pathways were markedly lower in the PCD group compared to the PCND group.

CONCLUSION

This study demonstrated that gut dysbiosis may play a critical role in PCD, which provides new insights into therapeutic options for PCD patients.

The Role of Bile Acids in Chronic Diarrhea

Bile acids (BAs) are the central signals in enterohepatic communication, and they also integrate microbiota-derived signals into enterohepatic signaling. The tissue distribution and signaling pathways activated by BAs through natural receptors, farsenoid X receptor and G protein-coupled BA receptor 1 (GPBAR1, also known as Takeda G-coupled receptor 5), have led to a greater understanding of the mechanisms and potential therapeutic agents. BA diarrhea is most commonly encountered in ileal resection or disease, in idiopathic disorders (with presentation similar to functional diarrhea or irritable bowel syndrome with diarrhea), and in association with malabsorption such as chronic pancreatitis or celiac disease. Diagnosis of BA diarrhea is based on Se-homocholic acid taurine retention, 48-hour fecal BA excretion, or serum 7αC4; the latter being a marker of hepatic BA synthesis. BA diarrhea tends to be associated with higher body mass index, increased stool weight and stool fat, and acceleration of colonic transit. Biochemical markers of increased BA synthesis or excretion are available through reference laboratories. Current treatment of BA diarrhea is based on BA sequestrants, and, in the future, it is anticipated that farsenoid X receptor agonists may also be effective. The optimal conditions for an empiric trial with BA sequestrants as a diagnostic test are still unclear. However, such therapeutic trials are widely used in clinical practice. Some national guidelines recommend definitive diagnosis of BA diarrhea over empirical trial.

Fecal Bile Acid Testing in Assessing Patients With Chronic Unexplained Diarrhea: Implications for Healthcare Utilization

INTRODUCTION

Bile acid (BA) diarrhea is the cause in ∼26% of chronic unexplained (nonbloody) diarrhea (CUD) based on SeHCAT testing. To assess fecal BA excretion and healthcare utilization in patients with CUD.

METHODS

In a retrospective review of 1,071 consecutive patients with CUD who completed 48-hour fecal BA testing, we analyzed the symptoms, diagnostic tests performed, and final diagnoses.

RESULTS

After 135 patients were excluded because of mucosal diseases, increased BA excretion was identified in 476 (51%) of the 936 patients with CUD: 29% with selective increase in primary BA and 22% with increased total BA excretion (35% with normal primary BA excretion). There were no differences in demographics, clinical symptoms, or history of cholecystectomy in patients with elevated total or selective primary fecal BA excretion compared with patients with normal excretion. Before the 48-hour fecal BA excretion test was performed, patients completed on average 1.2 transaxial imaging, 2.6 endoscopic procedures, and 1.6 miscellaneous tests/person. Less than 10% of these tests identified the etiology of CUD. Total fecal BAs >3,033 µmol/48 hour or primary BAs >25% had a 93% negative predictive value to exclude mucosal disease. Among patients with increased fecal BA excretion, >70% reported diarrhea improved with BA sequestrant compared with 26% with normal fecal BA excretion. Patients with selective elevation in primary fecal BAs were 3.1 times (95% confidence interval, 1.5-6.63) more likely to respond to BA sequestrant therapy compared with those with elevated total fecal BAs.

DISCUSSION

Increased fecal BA excretion is frequent (51%) in patients with CUD. Early 48-hour fecal BA evaluation has the potential to decrease healthcare utilization in CUD.

Low-fat diet after cholecystectomy: Should it be systematically recommended?

INTRODUCTION

Even though evidence is lacking, a low-fat diet has been traditionally recommended after cholecystectomy. The main aim of this study was to assess the potential correlation between postoperative symptoms and type of diet after cholecystectomy.

METHODS

Symptoms were prospectively assessed by the Gastrointestinal Quality of Life Index (GIQLI) score at baseline, one month and 6 months after cholecystectomy in 83 patients operated on at our institution. Patients completed a questionnaire about their diet and were classified into 4 groups according to the amount of fat intake. Differences in the GIQLI score depending on the type of diet were assessed over time.

RESULTS

The overall GIQLI score and most subdomains significantly increased after surgery compared to baseline, regardless of the intake of dietary fat. Constipation improved after cholecystectomy compared to baseline, whereas diarrhea and bowel urgency got worse. More than 50% of patients experienced a change in their bowel habit after surgery, which persisted 6 months later in 23% of cases.

CONCLUSIONS

A low fat diet does not seem to have an influence on the improvement of symptoms after cholecystectomy. However, a randomized study is ongoing at our institution to confirm the results of this prospective study.

Measurement of patient-reported outcomes after laparoscopic cholecystectomy: a systematic review

BACKGROUND

Patient-reported outcome (PRO) measures (PROMs) are increasingly used as endpoints in surgical trials. PROs need to be consistently measured and reported to accurately evaluate surgical care. Laparoscopic cholecystectomy (LC) is a commonly performed procedure which may be evaluated by PROs. We aimed to evaluate the frequency and consistency of PRO measurement and reporting after LC.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting PROs of LC, between 2013 and 2016. Data on the measurement and reporting of PROs were extracted.

RESULTS

A total of 281 studies were evaluated. Forty-five unique multi-item questionnaires were identified, most of which were used in single studies (n = 35). One hundred and ten unique rating scales were used to assess 358 PROs. The visual analogue scale was used to assess 24 different PROs, 17 of which were only reported in single studies. Details about the type of rating scale used were not given for 72 scales. Three hundred and twenty-three PROs were reported in 162 studies without details given about the scale or questionnaire used to evaluate them.

CONCLUSIONS

Considerable variation was identified in the choice of PROs reported after LC, and in how they were measured. PRO measurement for LC is focused on short-term outcomes, such as post-operative pain, rather than longer-term outcomes. Consideration should be given towards the development of a core outcome set for LC which incorporates PROs.

Routine Pathology and Postoperative Follow-Up are Not Cost-Effective in Cholecystectomy for Benign Gallbladder Disease

INTRODUCTION

The incidence of gallstone disease is increasing and represents a strain on healthcare systems worldwide. Following cholecystectomy, gallbladder specimens are generally submitted for histopathologic examination and the diagnostic yield of this strategy remains questionable. This study aimed to evaluate the usefulness of routine pathologic examination of the gallbladder specimens and investigate the results of routine postoperative follow-up visits.

METHODS

All cholecystectomies performed between January 2011 and July 2017 at a single center were evaluated. All gallbladder specimens were routinely pathologically examined. The outcome parameters were the macro- and microscopic gallbladder anomalies at pathology and the reported symptoms during routine follow-up visits 2-6 weeks after surgery.

RESULTS

In the study period a total of 2763 patients underwent cholecystectomy, of which 2615 had a postoperative visit in the outpatient clinic. Seventy-three patients (3%) complained of persistent abdominal pain, and 29 of these patients were referred for further treatment, resulting in a resolution of symptoms in 97%. Of all gallbladder specimens, 199 (7%) displayed macroscopic anomalies and in four (2%) of these, gallbladder carcinoma was diagnosed.

DISCUSSION

Selective pathologic examination of gallbladder specimens in case of macroscopic anomalies appears justified. Also routine follow-up after cholecystectomy appears not useful since 97% of patients do not report any symptoms at follow-up. A selective pathology and follow-up strategy could save significant healthcare costs.

Association between dietary intake and postlaparoscopic cholecystectomic symptoms in patients with gallbladder disease

BACKGROUND/AIMS

After cholecystectomy, patients have reported postcholecystectomic syndromes such as abdominal symptoms, dyspepsia, and diarrhea, which suggest a relationship between cholecystectomic symptoms and diet, although the details of this association remain unclear. The present study investigated the hypothesis that dietary intake of nutrients and foods was significantly associated with postcholecystectomic syndromes.

METHODS

Gallstone patients (n = 59) who underwent laparoscopic cholecystectomy were enrolled, and dietary intake and clinical parameters were assessed immediately postcholecystectomy and 3 months later.

RESULTS

There were no significant differences in biochemical measurements or characteristics between symptomatic and asymptomatic patients. Immediately postcholecystectomy, there were no significant differences in consumption of nutrients or foods between symptomatic and asymptomatic patients. However, 3 months after cholecystectomy, symptomatic patients consumed more animal protein, cholesterol, and eggs, and fewer vegetables than did asymptomatic patients. Multivariable-adjusted regression analyses also indicated that the risk for symptoms was positively associated with intake of animal protein, cholesterol, and eggs, but negatively associated with intake of vegetables after adjusting for confounders. In addition, symptomatic patients consumed more bread-based breakfast foods, while asymptomatic patients consumed more rice.

CONCLUSIONS

Postcholecystectomic syndromes were positively associated with intake of cholesterol, animal protein, and eggs, and negatively associated with intake of vegetables, suggesting that diet was plays a role in postcholecystectomic syndromes.

Update on Bile Acid Malabsorption: Finally Ready for Prime Time?

PURPOSE OF REVIEW

To provide an update on the prevalence, pathophysiology, disease associations, and treatment options for bile acid malabsorption (BAM).

RECENT FINDINGS

•Molecular mechanisms-BAs prevent water reabsorption and increase water secretion by intracellular mediators, increasing aquaporin channels and intracellular permeability. •Inflammatory bowel disease-new molecular mechanisms of BAM are identified in patients without ileal disease, including changes in expression of ileal BA transporter and nuclear receptors involved in BA homeostasis. •Microscopic colitis-BAM is one of the mechanisms leading to microscopic colitis. •Diagnostic testing-new diagnostic tests have been launched in the USA (serum C4 and fecal 48-h BA excretion); stimulated FGF19 has higher detection of BAM compared to fasting sample alone. •Treatment-investigational FXR agonists may provide a daily, oral option for treatment of BAM instead of BA sequestrants. There is a greater appreciation of the biological role of bile acids across multiple fields of medicine, including gastrointestinal indications.

Diet After Cholecystectomy

Patients with gallstones are often affected by alimentary disorders contributing to the onset of gallstones disease. Cholecystectomy can have nutritional and metabolic consequences in the short-term (diarrhea, abdominal pain and bloating) and in the long-term (increased Body Mass Index with metabolic syndrome, gastritis, liposoluble vitamin deficiency). Pathogenic mechanisms behind these disturbances are reviewed and the need for an early post-operative nutritional intervention based on low-lipid, high-fibers diet, is highlighted.

PREVALENCE AND PREDICTORS OF CHANGES IN BOWEL HABITS AFTER LAPAROSCOPIC CHOLECYSTECTOMY

BACKGROUND:

The incidence of cholecystolithiasis is approximately 15% of the population. It is believed that between 30-40% of cholecystectomy patients have symptoms after surgery, being changes in bowel habits the most common among them.

AIM:

1) Defining the prevalence, and 2) identifying predictors of changes in bowel habits after laparoscopic cholecystectomy.

METHODS:

This is a retrospective cross-sectional study with an initial sample of 150 patients diagnosed with cholecystolithiasis operated between July and September 2014. Patients were submitted to a questionnaire about the presence of gastrointestinal symptoms and changes in stools consistency before and after the surgical procedure. They were divided into two groups (with or without changes in bowel habits) being combined with the following variables: high blood pressure, body mass index, hypothyroidism, adherence to postoperative dietary orientations, previous abdominal and bariatric surgery.

RESULTS:

The prevalence of changes in bowel habits in the study population was 35.1%. The association between it and gastrointestinal symptoms was demonstrated to be statistically significant (‰2=7.981; p=0.005), and people who did not have gastrointestinal symptoms had 2.34 times the odds of not presenting changes in bowel habits. None of the other investigated factors had shown to be a predictor of risk for post-cholecystectomy changes in bowel habits.

CONCLUSION:

1) There was a high prevalence of changes in bowel habits, and 2) there was association between changes in bowel habits and the presence of gastrointestinal symptoms.

RACIONAL:

A incidência da colecistopatia calculosa é de aproximadamente 15% da população brasileira. Acredita-se que entre 30-40% dos pacientes colecistectomizados apresentem sintomas pós-operatório, sendo a alteração do hábito intestinal o mais comum.

OBJETIVO:

1) Determinar a prevalência, e 2) identificar preditores de mudanças do hábito intestinal pós-colecistectomia videolaparoscópica.

MÉTODOS:

Estudo transversal retrospectivo com amostra inicial de 150 pacientes diagnosticados com colecistopatia calculosa, operados entre julho e setembro de 2014. Os pacientes foram submetidos a um questionário sobre a presença de sintomas gastrointestinais após a operação, e a alterações do aspecto das fezes antes e depois do procedimento. A amostra foi dividida em dois grupos (com ou sem mudanças do hábito intestinal) sendo realizadas associações com as seguintes variáveis: hipertensão arterial, IMC, hipotireoidismo, seguimento de dieta no pós-operatório, operação abdominal prévia e operação bariátrica.

RESULTADOS:

A prevalência de mudanças do hábito intestinal na população estudada foi de 35,1%. A associação entre elas e sintomas gastrointestinais demonstrou-se estatisticamente significativa (‰2=7,981; p=0,005), sendo que as pessoas que não apresentavam os sintomas tinham 2,34 vezes mais chances de não apresentarem mudanças do hábito intestinal. Nenhum dos demais fatores investigados demonstrou ser preditor de risco para mudanças do hábito intestinal pós-colecistectomia.

CONCLUSÕES:

1) Observou-se alta prevalência de mudanças do hábito intestinal, e 2) houve associação entre mudança do hábito intestinal e a presença de sintomas gastrointestinais.

Predictors of Diarrhea after Hepatectomy and Its Impact on Gastrointestinal Quality of Life in Living Donors

Background

Donor safety and preservation of donor health after living liver donation are of paramount importance. Diarrhea has a significant influence on gastrointestinal quality of life among donors who have undergone living donor hepatectomy. Thus, we aimed to investigate predictors of diarrhea after hepatectomy and its impact on gastrointestinal quality of life in living donors.

Methods

We retrospectively examined the medical records of 204 living liver donors who underwent hepatectomy during the period January 2010 to June 2013 at a single medical center. Diarrhea was defined as the passing of three or more liquid stools per day. The Chinese version of the Gastrointestinal Quality of Life Index (GIQLI) was used to assess the influence of diarrhea on quality of life in donors.

Results

During the study period, diarrhea was diagnosed in 62 (30.3%) of the 204 donors and the duration of diarrhea in the majority of them (n = 46, 74%) was <12 months. Risk factors associated with diarrhea included age [risk ratio (RR) = 0.84, 95% confidence interval (CI): 0.79–0.89, risk difference = 16%], and chronic cholecystitis (RR = 0.48, 95% CI: 0.24–0.99, risk difference = 52%). Compared to donors without diarrhea, donors with diarrhea had lower GIQLI scores in the following GIQLI domains: GI symptoms (1.8 vs. 3.6), physical function (2.1 vs. 3.5), emotional function (3.0 vs. 3.6), social function (3.3 vs. 3.7), and treatment reaction (2.6 vs. 3.7).

Conclusions

Our findings show that younger donors and those without chronic cholecystitis are at increased risk for diarrhea after living donor hepatectomy and that diarrhea is associated with lower GIQLI scores after hepatectomy.