Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis

The impact of virtual reality training on laparoscopic surgical skills; A prospective blinded controlled trial

Background. Laparoscopic surgery has gained popularity in the last few decades replacing open standard techniques in several procedures. While its use and scope expand, a standardized method of training and assessment in laparoscopic skills is lacking. Aim. To assess the effect of virtual reality (VR) training on laparoscopic surgical skills. Materials and Methods. It is a prospective, controlled study conducted at Sagar Hospital’s skill lab and Shanthi Hospital and Research Centre (SHRC). We included 27 post graduates in general surgery. They were divided into two groups. One group underwent training in VR Simulator for one week, 30 minutes each day. The second group received no training. Their proficiency while mobilizing the Gallbladder from its liver bed was assessed using a validated scale by a single blinded observer. Results. The statistical analysis was done using a non-parametric test (Mann-Whitney U test). Residents who underwent training in VR simulator got better scores in Overall rating and also in individual parameters when compared with the control group (P = <0.05). Conclusions. Laparoscopic surgical skills can be increased by using proficiency-based VR simulator training and it can be transferred to actual operations. VR simulators are a valid tool for laparoscopic surgical skills training.

Safety and Efficacy of Percutaneous Gallstone Extraction in High-Risk Patients: An Alternative to Cholecystectomy or Long-Term Drainage?

BACKGROUND

Acute cholecystitis in nonsurgical candidates is often managed with cholecystostomy tube drainage. After symptom resolution, management options include cholecystectomy, long-term tube drainage, or tube removal. Percutaneous cholecystolithotomy (PCCL) can offer another therapeutic option for patients who are poor operative candidates.

STUDY DESIGN

A retrospective study of PCCL performed between December 2000 and September 2017 was conducted. Demographic characteristics, procedure details, gallstone-related complications, procedure-related complications, readmission, and mortality data were collected.

RESULTS

Seventy-five patients were identified (52.0% male, 48.0% female, mean ± SD age 75.6 ± 13.9 years). Mean ± SD follow-up time was 2.8 ± 3.7 years. Most of the patients (90.7%) had an American Society of Anesthesiologists physical status classification of 3 or 4. Eleven patients (14.7%) had failed earlier cholecystectomy. A total of 96 PCCL procedures were performed, and complete gallstone removal was achieved in 68 of 75 patients (90.7%), including all patients with previously aborted cholecystectomy. The 30-day and 90-day readmission rates were 4% and 8%, respectively. Three patients (3.9%) subsequently underwent cholecystectomy after PCCL. Ten (10.4%) procedure-related complications (Clavien-Dindo grade I and II) and 17 (22.7%) gallstone-related complications occurred during the follow-up period. Postprocedural choledocholithiasis occurred in 6 patients (8.0%). Recurrent gallstones developed in 5 patients (6.3%) (3 patients undergoing cholecystectomy and 2 patients treated with cholecystostomy tube).

CONCLUSIONS

PCCL is a viable option for management of symptomatic gallbladder stones in high-risk surgical patients. There is a high technical success rate, even in patients with earlier failed cholecystectomy. Most patients (77.3%) avoided gallstone-related complications after the procedure.

Initial experience with endoscopic ultrasound-guided gallbladder drainage

Introduction

Patients with acute cholecystitis who are unsuitable for cholecystectomy undergo conservative treatment or percutaneous transhepatic gallbladder drainage. As these two methods are not always successful, further treatment options are needed. One increasingly popular method is endoscopic ultrasound-guided gallbladder drainage (EUSGBD), whereby stents are placed so as to create a permanent fistula connecting the gallbladder to the stomach or the duodenal bulb, thus enabling drainage of its contents to the gastrointestinal tract.

Aim

To present our early experience with EUSGBD for the treatment of cholecystitis in patients who are not suitable for cholecystectomy.

Material and methods

The procedure was performed in 5 patients with acute cholecystitis. Two patients also had symptoms of biliary obstruction due to pancreatic head cancer. An ultrasound endoscope was used to create a fistula between the gallbladder and the stomach or between the gallbladder and the duodenal bulb, in which a self-expandable metallic stent (SEMS) was placed.

Results

All procedures were performed with no perioperative complications. In all patients, the clinical symptoms of cholecystitis subsided within 3-15 days. In those patients who also showed symptoms of biliary obstruction, these symptoms subsided within 3-6 days following the procedure.

Conclusions

The EUSGBD seems to be an effective and safe treatment for acute cholecystitis in patients unsuitable for cholecystectomy. It can also be used to treat jaundice caused by obstruction of the common bile duct, when no other methods can be used. The method is particularly promising in cases of concurrent acute cholecystitis and common bile duct obstruction.

Increased Risk of Acute Cholecystitis in Patients With Spinal Cord Injury: A Nationwide Population-Based Cohort Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the risk of acute cholecystitis (AC) in patients with spinal cord injury (SCI) based on a nationwide sample.

SUMMARY OF BACKGROUND DATA

Prior research evaluating the risk of AC in patients with SCI is limited. Moreover, since most previous studies on the association between AC and SCI used case-series designs, little is known about the relative risk of SCI patients developing AC from a longitudinal follow-up, compared with individuals without SCI.

METHODS

We used the data from Taiwan's National Health Insurance Research Database. The SCI group consisted of 11,523 patients with SCI aged between 20 and 90 years. Propensity score matching procedure was employed to minimize potential confounding effects arising from the imbalance in the baseline characteristics. A total of 23,046 propensity score-matched patients without SCI were enrolled in the non-SCI group. We compared the incidence of AC between these two groups, and assessed the impact of SCI on the risk of developing AC.

RESULTS

In the SCI and non-SCI groups, the respective incidence rates of AC were 36.9 (95% confidence interval [CI], 30.0-44.8) and 25.2 (95% CI, 21.2-29.8) per 10,000 person-years. As compared with the non-SCI group, the hazard ratio for the SCI group of AC was 1.71 (95% CI, 1.22-2.41, P = 0.0018); and the cumulative incidence of AC of the SCI group was higher than that of the non-SCI group (P = 0.0036).

CONCLUSION

This population-based cohort study showed that there was an increased risk of AC in patients with SCI.

LEVEL OF EVIDENCE

3.

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.

Optimum cystic duct closure: a comparative study using metallic clips, ENSEAL, and ENDOLOOP in swine

BACKGROUND

Metal clips are commonly used to secure the cystic duct during cholecystectomy, although use of an ENDOLOOP (Ethicon Endo-Surgery, Blue Ash, OH) is often touted as a more secure closure when postoperative endoscopic retrograde cholangiopancreatography (ERCP) is anticipated. The objective of this study was to test the strength of 3 different cystic duct closure methods in a model simulating postoperative biliary insufflation.

METHODS

The extrahepatic biliary system, including common bile duct, gallbladder, and cystic duct, was harvested en bloc from 22 swine postmortem. A cholecystectomy was performed and the cystic duct was secured using 1 of 3 randomly assigned methods: metallic clips (Ethicon Endo-Surgery), an ENDOLOOP (Ethicon Endo-Surgery), or an ENSEAL tissue sealing device (Ethicon Endo-Surgery). The common bile duct was cannulated with a pressure-monitoring system and insufflated with air. The burst pressures, location of rupture, and size of the common bile duct and cystic duct were recorded and compared.

RESULTS

There were 7 pigs each in the ENDOLOOP and ENSEAL groups and 8 in the metallic clip group, with no statistical significance between cystic and common bile duct size. Mean burst pressure was 432 mm Hg for metallic clips, 371 mm Hg for the ENDOLOOP, and 238 mm Hg for the ENSEAL device (P = .02). Post hoc analysis revealed clips to be statistically superior when compared with the ENSEAL (P= .01). There was no statistical difference between the ENDOLOOP and metal clips or between the ENDOLOOP and the ENSEAL.

CONCLUSIONS

All 3 closure methods successfully secured the cystic duct, with mean burst pressures exceeding 195 mm Hg. Metallic clips demonstrated the highest burst pressures and no cystic duct stump leaks. This study challenges the traditional dogma of additionally securing the cystic duct with an ENDOLOOP when postoperative biliary instrumentation is expected and also suggests that an adequately secure closure may be obtained with thermal sealing devices.

Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel

BACKGROUND AND AIMS

Cholecystokinin-cholescintigraphy (CCK-CS) provides a physiologic, noninvasive, and quantitative method for assessing gallbladder contraction and calculation of a gallbladder ejection fraction (GBEF). At present, it is used most commonly to identify patients with suspected functional gallbladder disorder. However, the methodology of CCK infusion and normal values differ markedly among imaging centers.

METHODS

This document represents the consensus opinion of an interdisciplinary panel that gathered to assess the current optimal method for performing CCK-CS in adults, potential uses and limitations of CCK-CS, and questions that require further investigation.

RESULTS

The panel recommended the use of a single, standardized, recently described CCK-CS protocol that involves infusion of 0.02 μg/kg of sincalide over 60 minutes with a normal GBEF defined as ≥38%. The panel emphasized the need for a large, multicenter, prospective clinical trial to establish the utility of CCK-CS in the diagnosis of functional gallbladder disease. Although not without controversy regarding its clinical utility, the primary indication for CCK-CS at present is the well-selected patient with suspected functional gallbladder disorder.

CONCLUSION

Agreement was reached that the adoption of this standardized protocol is critical to improve how CCK-CS is used to direct patient care and will represent an improvement over the diverse methods currently in use by eliminating the current lack of uniformity and adding both reliability and credibility to the results.

Clipless cholecystectomy: which sealer should be used?

BACKGROUND

The use of the Harmonic Scalpel (HS) for cystic duct ligation began with little data about its efficacy or safety. On the other hand, there is not any literature available about the use of PlasmaKinetic Sealer (PK) for closing the cystic duct in laparoscopic cholecystectomy (LC). Therefore, this study was designed to compare the efficacy and safety of HS and PK for achieving safe closure of the cystic ducts after LC.

METHODS

Ninety patients with symptomatic gallstone disease were enrolled in this prospective case control study. The patients were operated with laparoscopic technic and divided into three groups (n = 30) randomly. After the dissection of Calot's triangle, proximal cystic ducts on common bile ducts were sealed with single surgical clips (SC) in all groups, and in the first group, distal of the cystic ducts also was sealed with single SC and the gallbladders were removed with SC. In the second and third groups, distal of the cystic ducts were sealed with HS and PK, respectively. The gallbladders were removed as sealed cystic ducts with HS and PK. Then, gallbladders were connected to a transducer set and increasing pressure with saline was applied. The bursting pressures of gallbladders were measured and differences between the groups were calculated by using Student's t test. The value of P < 0.05 was accepted as significant.

RESULTS

In this study, the mean cystic duct bursting pressures were 332.46 ± 4.62 mmHg with SC, 326.56 ± 4.53 mmHg with PK, and 343.06 ± 4.28 mmHg with HS. Differences of the mean cystic duct bursting pressures between the groups were indicated the superior results of HS.

CONCLUSIONS

The results of this study indicated that HS is more effective than PK and as safe and effective as SC for cystic duct closure.

Gallstone disease: current therapeutic practice

Most asymptomatic gallstone carriers require no therapy. Laparoscopic cholecystectomy is the best definitive therapy for symptomatic gallstone disease. Selective laparoscopic cholecystectomy can provide secondary prevention of symptoms and complications in certain instances (in a complex clinical setting such as sickle cell disease or to prevent gallbladder carcinoma from developing in those at risk with large gallstones or with a calcified gallbladder). Primary prevention is unproven but focuses on early identification and risk alteration to decrease the possibility of developing gallstones. Ursodeoxycholic acid has a limited role for stone dissolution but can prevent stone development in severe obesity during rapid weight reduction with diet or after bariatric surgery. Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy represents the therapeutic cornerstone for managing severe pancreatitis and cholangitis.

Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel

BACKGROUND & AIMS

Cholecystokinin-cholescintigraphy (CCK-CS) provides a physiologic, noninvasive, and quantitative method for assessing gallbladder contraction and calculation of a gallbladder ejection fraction (GBEF). At present, it is used most commonly to identify patients with suspected functional gallbladder disorder. However, the methodology of CCK infusion and normal values differ markedly among imaging centers.

METHODS

This document represents the consensus opinion of an interdisciplinary panel that gathered to assess the current optimal method for performing CCK-CS in adults, potential uses and limitations of CCK-CS, and questions that require further investigation.

RESULTS

The panel recommended the use of a single, standardized, recently described CCK-CS protocol that involves infusion of 0.02 μg/kg of sincalide over 60 minutes with a normal gallbladder ejection fraction defined as ≥38%. The panel emphasized the need for a large, multicenter, prospective clinical trial to establish the utility of CCK-CS in the diagnosis of functional gallbladder disease. Although not without controversy regarding its clinical utility, the primary indication for CCK-CS at present is the well-selected patient with suspected functional gallbladder disorder.

CONCLUSIONS

Agreement was reached that the adoption of this standardized protocol is critical to improve how CCK-CS is used to direct patient care and will represent an improvement over the diverse methods currently in use by eliminating the current lack of uniformity and adding both reliability and credibility to the results.

Pravastatin activates PPARalpha/PPARgamma expression in the liver and gallbladder epithelium of hamsters

BACKGROUND

Our earlier study with cultured gallbladder epithelial cells demonstrated that statins (HMG-CoA reductase inhibitors) activate the expression of PPARalpha and PPARgamma, consequently blocking the production of pro-inflmmatory cytokines. The present study used hamsters to investigate the effects of pavastatin on PPARalpha/PPARgamma expression in the liver and gallbladder epithelium, and to determine whether pravastatin suppresses cholesterol crystal formation in the gallbladder.

METHODS

A total of 40 Golden Syrian male hamsters (4 weeks old) were randomly assigned to four groups (basal diet control; basal diet+pavastatin; high cholesterol diet; high cholesterol diet+pravastatin). All hamsters were 11 weeks old at the end of the experiment. The liver, gallbladder and bile were harvested. Immunohistochemical staining and Western blotting for PPARalpha and PPARgamma were performed in the liver and gallbladder. A drop of fresh bile was examined for cholesterol crystals under a microscope.

RESULTS

In the gallbladder and liver of the hamsters, pravastatin activated the PPARalpha and PPARgamma expression of gallbladder epithelial cells and hepatocytes, and particularly the response of PPARgamma was much stronger than that of PPARalpha. Pravastatin suppressed the formation of cholesterol gallstones or crystals in the gallbladder.

CONCLUSION

Pravastatin is an effective medication to activate PPARs (especially PPARgamma) in the liver and the gallbladder epithelium of hamsters, and contributes to the prevention of gallstone formation.

Assessment of positive perioperative cholangiography in patients undergoing elective laparoscopic cholecystectomy

OBJECTIVE

To evaluate the positivity of cholangiography in patients without formal indication of this exam undergoing elective cholecystectomy.

METHODS

We included, in the study, 100 patients whose clinical, laboratory and imaging not older than 10 days before the operation showed no change and therefore kept us unsuspicious of choledocholithiasis. The cholangiographies were analyzed and examined by the surgical team, the radiologist and the authors. The reports were compared and correlated with patients' previous clinical and laboratory findings.

RESULTS

The incidence of preoperatively unsuspected choledocholithiasis was only one case (1%).

CONCLUSION

The use of selective cholangiography is safe and should be used in the treatment of calculous cholecystitis.

Verification of clipless closure of cystic duct by harmonic scalpel

INTRODUCTION

The excellent results of harmonic scalpel (HS) for closure of blood vessels encouraged surgeons to use these instruments for cystic ducts. The use of HS on tissues other than blood vessels was started with little data about its efficacy or safety. Therefore, this study was designed to verify the safety and efficacy of HS for achieving safe closure of the cystic ducts after laparoscopic cholecystectomy.

MATERIALS AND METHODS

Sixty patients with symptomatic gallstone disease were enrolled in this prospective case control study. The patients were operated with laparoscopic technic and divided into two groups (n = 30). After the dissection of Calot's triangle, proximal cystic ducts on common bile ducts were sealed with single surgical clips (SC) in both groups. In the first group, distal of the cystic ducts was sealed with single SC and the gallbladders were removed with SC. In the second group, distal of the cystic ducts was sealed with HS and the gallbladders were removed as sealed cystic ducts with HS. Twenty-gauge catheters were inserted into the fundus of gallbladders in vitro and connected to the arterial line transducer set. A gradually increasing pressure was applied through a sphygmomanometer. The bursting pressures of the gallbladders were measured, and differences between HS and single SC groups were calculated with independent samples t-test. The value of P < 0.05 was accepted as significant.

RESULTS

The mean cystic duct bursting pressures in single SC and HS groups were 332.46 +/- 4.62 and 343.06 +/-4.28 mmHg, respectively. The mean values between the groups were found significant and indicated the superior results of HS.

CONCLUSIONS

HS sealer could be an alternative method for cystic duct closure, especially for avoiding the clip displacement and migration of the clip. Results of this study indicated that HS sealer was as reliable as single SC and it could be accepted as a standard closure technic.

Risk assessment in cholelithiasis: is cholecystectomy always to be preferred?

BACKGROUND

As many patients with gallstone disease do not benefit from cholecystectomy, preoperative recognition of such high-risk patients is important. The aim of the study is to identify predictors of persisting symptoms at 6 months after cholecystectomy for patients with different preoperative symptomatology.

METHOD

Participants in this prospective study were consecutive patients (n = 172), age 18-65 years, with symptomatic cholelithiasis, undergoing a laparoscopic cholecystectomy. Predictors were identified using uni- and multivariate regression analyses.

RESULTS

At 6 months postcholecystectomy, patients with only preoperative biliary symptoms were most often free of symptoms (62.5%). Patients with only dyspeptic symptoms most often reported persistence of preexisting symptoms (63.2%). Preoperative non-specific symptoms predicted the report of postoperative biliary and/or dyspeptic symptoms (OR = 4.5-6.1). Persistence of preexisting pattern of symptoms was predicted by the use of psychotropic medication (OR = 5.3) and dyspeptic symptoms (OR = 4.5). Postoperative biliary symptoms were predicted by High Trait Anxiety (HTA) (OR = 10.6).

CONCLUSION

Surgeons should take account of individual risks of patients in the management of cholelithiasis. Instead of cholecystectomy, expectative management should be the first choice in patients with non-specific symptoms, with dyspeptic symptoms only, with HTA and in patients using psychotropic medication.

HMG-CoA reductase inhibitors (statins) activate expression of PPARalpha/PPARgamma and ABCA1 in cultured gallbladder epithelial cells

In gallbladder epithelial cells (GBEC), PPARalpha and PPARgamma ligands modulate inflammation by suppression of TNFalpha production and prevent excessive accumulation of cholesterol by ABCA1 activation. Recently, HMG-CoA reductase inhibitors (statins) were shown to activate PPARalpha and PPARgamma in various cells but no studies of their effects in GBEC have been conducted. The objective of this study was, therefore, to determine the effects of statins on PPAR and ABCA1 expression and the anti-inflammatory effect of statins in GBEC. Canine GBEC were cultured on Petri dishes. Expression of the proteins PPARalpha, PPARgamma, and ABCA1 was measured by western blotting analysis after treatment with simvastatin, pravastatin, NO-pravastatin, PPARalpha ligand, or PPARgamma ligand in the culture media. Expression of ABCA1 and LXRalpha mRNAs was estimated by RT-PCR. Expression of TNFalpha mRNA was measured by RT-PCR after 24 h pre-treatment with the statins, preceding 1 h of lipopolysaccharide (LPS) loading. Simvastatin, pravastatin, and NO-pravastatin increased expression of the proteins PPARalpha, PPARgamma, and ABCA1, and expression of the mRNA of ABCA1 and LXRalpha in GBEC. Pre-treatment with simvastatin, pravastatin, and NO-pravastatin suppressed the production of TNFalpha mRNA induced by LPS. In conclusion, statins probably contribute to the preservation of GBEC function by activation of PPARalpha and PPARgamma, which have anti-inflammatory effects by suppression of pro-inflammatory cytokines, and ABCA1 activation mediated by LXRalpha, which prevents the accumulation of cholesterol in GBEC.

Trait anxiety predicts unsuccessful surgery in gallstone disease

OBJECTIVE

To identify predictors of negative symptomatic outcomes at 6 months after cholecystectomy, surgical removal of the gallbladder, which is the preferred treatment for gallstone disease. After cholecystectomy, a substantial number of patients report persistence of symptoms.

METHODS

In this prospective follow-up study, consecutive patients (n = 172) diagnosed with symptomatic gallstone disease and indicated for elective cholecystectomy were investigated. Preoperatively and at 6 months, patients completed self-report symptom checklists. The Spielberger State-Trait Anxiety Inventory scale was completed preoperatively and patients with a score of > or = P 80 were considered having High Trait Anxiety (HTA). Multivariate regression analyses were used to investigate independent predictors of persisting symptoms.

RESULTS

Six months after cholecystectomy, patients with HTA were more likely to report persisting biliary symptoms than patients without HTA (NHTA) (45.5% versus 14.3%; chi(2) = 8.78, p = .002). HTA was identified as an independent predictor of persisting biliary symptoms at 6 months (odds ratio [OR], 3.08, p = .047; 95% confidence interval [CI], 1.02-9.34), in addition to the report of nonspecific symptoms (OR, 6.16, p = .024; 95% CI, 1.27-29.82), and the use of psychotropic medication (OR, 4.76, p = .023; 95% CI, 1.24-18.34).

CONCLUSION

Patients with HTA have a three times higher risk at persisting biliary symptoms at 6 months after cholecystectomy than NHTA patients. Both clinical factors and the patient's personality should be considered in clinical decision making and risk estimation in elective cholecystectomy.

Effect of virtual reality training on laparoscopic surgery: randomised controlled trial

OBJECTIVE

To assess the effect of virtual reality training on an actual laparoscopic operation.

DESIGN

Prospective randomised controlled and blinded trial.

SETTING

Seven gynaecological departments in the Zeeland region of Denmark.

PARTICIPANTS

24 first and second year registrars specialising in gynaecology and obstetrics.

INTERVENTIONS

Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls).

MAIN OUTCOME MEASURE

The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes.

RESULTS

The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers' inter-rater agreement was 0.79.

CONCLUSION

Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00311792.

Risk factors for bile duct injury during laparoscopic cholecystectomy: a case-control study

Common bile duct injury is a serious but uncommon complication of laparoscopic cholecystectomy. A case-control epidemiologic study of patients who had undergone cholecystectomy in Ontario, Canada, between 1991 and 1997 was performed. Four patients who had undergone a laparoscopic cholecystectomy at the same hospital 2 months prior to a case were selected as controls. The risk of bile duct injury associated with various exposures was estimated by unconditional logistic regression. There were 28 cases and 88 controls. Emergency operation (adjusted odds ratio = 5.0; 95% confidence interval, 1.4-17.8) and failure to identify the cystic duct (adjusted odds ratio = 13.7; 95% confidence interval, 2.5-76.3) were statistically significant risk factors for operative bile duct injury. No other characteristics were independent risk factors for bile duct injury. Failure to identify the cystic duct and the emergency surgery are independent risk factors for bile duct injury.

Expression of estrogen-metabolizing enzymes and estrogen receptors in cholelithiasis gallbladder

BACKGROUND

Estrogen exposure is a risk factor for gallstone disease (cholelithiasis), which often leads to chronic inflammation (cholecystitis). Studies in various estrogen-sensitive tissues showed that key enzymes involved in the inactivation and activation of estrogens as well as expression of estrogen receptors alpha and beta determine the amount of active estrogen. In estrogen-sensitive tissues, e.g. the female breast, estrone sulfate (E1S), present at high concentrations in the circulation, is converted into the biologically active estrone (E1) by steroid sulfatase (STS) and again reverted into E1S by estrogen sulfotransferase (SULT1E1) providing a local estrogen storage.

AIMS

To assess whether this might also apply for gallbladder epithelia, we determined expression of these two enzymes and of ERalpha and ERbeta in 15 cholelithiasis specimens from tissues with/or without inflammation.

METHODS

Quantitative (Real-time) PCR and immunofluorescence were used as methods.

RESULTS

We demonstrate mRNA expression of SULT1E1, STS, and ERalpha in all specimens with mean enrichment of 3.53- vs. 1.72-fold (n.s.), 3.5- vs. 0.91-fold (n.s.), and 3.04- vs. 1.6-fold (n.s.) in the inflammatory and non-inflammatory groups, respectively. Although high expression levels were seen in many specimens (means 4.88-fold vs. 5.77-fold), ERbeta mRNA was below the detection limit in two specimens from cholecystitis patients. To further investigate this varying expression pattern of ERbeta, immunohistological studies were performed, which indeed showed low expression levels of ERbeta in the damaged mucosa, while in specimens with well preserved mucosa, high ERbeta levels were seen in the cytosol and in the nucleus.

CONCLUSION

The data show expression of an estrogen network of activating STS and inactivating SULT1E1. Together with ERalpha and ERbeta, these enzymes could regulate estrogen concentrations in human gallbladder.