Hereditary liver disease: gallstones

The use of lidocaine infusion in laparoscopic cholecystectomy: An updated systematic review and meta-analysis

ABSTRACT

Being one of the most common abdominal surgical procedures, numerous techniques have been adapted to decrease post-operative pain post cholecystectomy. However, the efficacy of intravenous (IV) lidocaine in managing post operative pain after LC is still controversial, according to many recent studies. This study aims to detect the effectiveness of IV lidocaine compared to other medications in managing post-operative pain. PubMed, Scopes, Web of Science and Cochrane Library were searched for eligible studies from inception to June 2023, and a systematic review and meta-analysis was done. According to eligibility criteria, 14 studies (898 patients) were included in our study. The pooled results of the included studies showed that the pain score after 6, 12 and 24 h after the surgery was significantly lower in those who received IV lidocaine as a painkiller (Visual Analogue Scale [VAS] 6H, mean difference [MD] = -1.20, 95% confidence interval [CI] = -2.20, -0.20, P = 0.02; I2 = 98%, VAS 12H, MD = -0.90, 95% CI = -1.52, -0.29, P = 0.004; I2 = 96% and VAS 24H, MD = -0.86, 95% CI = -1.48, -0.24, P = 0.007; I2 = 92%). In addition, IV lidocaine is associated with a significant decrease in the opioid requirement after the surgery (opioid requirements, MD = -29.53, 95% CI = -55.41, -3.66, P = 0.03; I2 = 98%). However, there was no statistically significant difference in the incidence of nausea and vomiting after the surgery between the two groups (nausea and vomiting, relative risk = 0.91, 95% CI = 0.57, 1.45, P = 0.69; I2 = 50%). Lidocaine infusion in LC is associated with a significant decrease in post operative pain and in opioid requirements after the surgery.

Role of Secretory Mucins in the Occurrence and Development of Cholelithiasis

Cholelithiasis is a common biliary tract disease. However, the exact mechanism underlying gallstone formation remains unclear. Mucin plays a vital role in the nuclear formation and growth of cholesterol and pigment stones. Excessive mucin secretion can result in cholestasis and decreased gallbladder activity, further facilitating stone formation and growth. Moreover, gallstones may result in inflammation and the secretion of inflammatory factors, which can further increase mucin expression and secretion to promote the growth of gallstones. This review systematically summarises and analyses the role of mucins in gallstone occurrence and development and its related mechanisms to explore new ideas for interventions in stone formation or recurrence.

Genetics of Gallstone Disease and Their Clinical Significance: A Narrative Review

Gallstone (GS) disease is common and arises from a combination of genetic and environmental factors. Although genetic abnormalities specifically leading to cholesterol GSs are rare, there are clinically significant gene variants associated with cholesterol GSs. In contrast, most bilirubin GSs can be attributed to genetic defects. The pathogenesis of cholesterol and bilirubin GSs differs greatly. Cholesterol GSs are notably influenced by genetic variants within the ABC protein superfamily, including ABCG8, ABCG5, ABCB4, and ABCB11, as well as genes from the apolipoprotein family such as ApoB100 and ApoE (especially the E3/E3 and E3/E4 variants), and members of the MUC family. Conversely, bilirubin GSs are associated with genetic variants in highly expressed hepatic genes, notably UGT1A1, ABCC2 (MRP2), ABCC3 (MRP3), CFTR, and MUC, alongside genetic defects linked to hemolytic anemias and conditions impacting erythropoiesis. While genetic cases constitute a small portion of GS disease, recognizing genetic predisposition is essential for proper diagnosis, treatment, and genetic counseling.

Ten-Year Trends of Persistent Mortality With Gallstone Disease: A Retrospective Cohort Study in New Jersey

BACKGROUND AND AIMS

Recent trends in mortality with gallstone disease remain scarce in the United States. Yet multiple changes in clinical management, such as rates of endoscopy, cholecystectomy, and cholecystostomy, and insurance access at the state level, may have occurred. Thus, we evaluated recent secular trends of mortality with gallstone disease in New Jersey.

METHODS

We performed a retrospective, cohort study of mortality from 2009 to 2018 using the National Center for Health Statistics, Restricted Mortality Files. The primary outcome was any death with an International Classifications of Disease, 10th Revision, Clinical Modification diagnosis code of gallstone disease in New Jersey. Simple linear regression was used to model trends of incidence of death.

RESULTS

1580 deaths with diagnosed gallstone disease (dGD) occurred from 2009 to 2018. The annual trend of incidence of death was flat over 10 years. The incidence of death with dGD relative to all death changed only from 0.21% to 0.20% over 10 years. These findings were consistent also in 18 of 20 subgroup combinations, although the trend of death with dGD in Latinos 65 years or older increased [slope estimate 0.93, 95% confidence limit 0.42-1.43, P = .003].

CONCLUSION

The rate of death with dGD showed little change over the recent 10 years in New Jersey. This needs to be reproduced in other states and nationally. A closer examination of the changes in clinical care and insurance access is needed to help understand why they did not result in a positive change in this avoidable cause of death.

CLINICAL AND EPIDEMIOLOGICAL EVALUATION OF COMPLICATIONS ASSOCIATED WITH GALLSTONES IN A TERTIARY HOSPITAL

BACKGROUND

Gallstones are the presence of bile clay in the gallbladder or bile ducts. The disease can be asymptomatic or symptomatic and can lead to complications and consequently a worse prognosis, such as acute cholecystitis, choledocholithiasis, cholangitis, and acute pancreatitis. The risk of complications increases after the first episode of biliary colic.

OBJECTIVE

A clinical-epidemiological evaluation of patients admitted to a gastroenterology ward of a tertiary care hospital with gallstone-related complications.

METHODS

We evaluated 158 patients admitted through discharge reports and medical records analysis from January 1, 2013, to February 24, 2021.

RESULTS

The female sex was predominant (76.6%), and the mean age of patients was 51.6 years. Men were significantly older than women (P=0.005). Most (57.6%) had some comorbidity, the most frequent being systemic arterial hypertension, diabetes mellitus, and obesity. The mean hospitalization time was 24 days, significantly longer in men (P=0.046) but without a direct relationship with age (P=0.414). The most frequent complication was choledocholithiasis, and 55.7% of patients without previous cholecystectomy had a report of biliary colic before admission, on average 1.5 years previously. A history of a prior cholecystectomy was present in 17.1% of those evaluated. Abdominal ultrasonography followed by magnetic resonance cholangiography was the most frequently performed exam for diagnostic definition. Regarding therapeutic measures, endoscopic retrograde cholangiopancreatography was necessary for 47.3% of patients without previous cholecystectomy and 81.4% of patients who have already had a cholecystectomy. Among patients not yet cholecystectomized, 84% underwent the procedure before discharge.

CONCLUSION

The female patients were predominant. Men were significantly older than women and had more extended hospital stays. The most frequent complication was choledocholithiasis, and around half of the patients reported previous biliary colic. endoscopic retrograde cholangiopancreatography has been necessary for the majority of the patients.

The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease

Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Current guidelines for treating asymptomatic common bile duct stones (CBDS) recommend stone removal, with endoscopic retrograde cholangiopancreatography (ERCP) being the first treatment choice. When deciding on ERCP treatment for asymptomatic CBDS, the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared. The incidence rate of ERCP-related complications, particularly of post-ERCP pancreatitis for asymptomatic CBDS, was reportedly higher than that of symptomatic CBDS, increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases. Although studies have reported short- to middle-term outcomes of natural history of asymptomatic CBDS, its long-term natural history is not well known. Till date, there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not. No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach, suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS. Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Factors related to residual gallbladder calculi formation using computed tomography and magnetic resonance imaging combined with clinical data

Objective

We aimed to investigate risk factors related to remnant gallbladder (RGB) stones.

Methods

This retrospective study included 73 patients with RGB, in groups with and without RGB calculi. Univariate analyses were used to identify nine variables associated with RGB calculi: sex, age, body mass index (BMI), time to detection, surgical method, length of RGB, angle of RGB and common hepatic duct (CHD), choledocholithiasis, and remnant cholecystitis. Multivariate logistic regression was performed to assess independent predictors of RGB stones. A receiver operating characteristic (ROC) curve was used to estimate model accuracy and determine cut-off values of independent predictors.

Results

We enrolled 73 patients, 33 with and 40 without RGB stones. Univariate analyses showed that age, BMI, time to detection, length of RGB, angle of RGB and CHD were predictors for RGB calculi. Multivariate analyses indicated that time to detection, length of RGB, and angle of RGB and CHD were independent predictors for RGB calculi. The area under the ROC curve of the model was 0.940. Cut-off values of the three indicators were 1.5 years, 2.25 cm, and 22.5°, respectively.

Conclusion

Time to detection, length of RGB, and angle of RGB and CHD were independent predictors of RGB calculi.

Activation of HIF-1 signaling ameliorates liver steatosis in zebrafish atp7b deficiency (Wilson's disease) models

Wilson's disease is an autosomal recessive disease characterized by excess copper accumulated in the liver and brain. It is caused by mutations in the copper transporter gene ATP7B. However, based on the poor understanding of the transcriptional program involved in the pathogenesis of Wilson's disease and the lack of more safe and efficient therapies, the identification of novel pathways and the establishment of complementary model systems of Wilson's disease are urgently needed. Herein, we generated two zebrafish atp7b-mutant lines using the CRISPR/Cas9 editing system, and the mutants developed hepatic and behavioral deficits similar to those observed in humans with Wilson's disease. Interestingly, we found that atp7b-deficient zebrafish embryos developed liver steatosis under low-dose Cu exposure, and behavioral deficits appeared under high-dose Cu exposure. Analyses of publicly available transcriptomic data from ATP7B-knockout HepG2 cells demonstrated that the HIF-1 signaling pathway is downregulated in ATP7B-knockout HepG2 cells compared with wildtype cells following Cu exposure. The HIF-1 signaling pathway was also downregulated in our atp7b-deficient zebrafish mutants following Cu exposure. Furthermore, we demonstrate that activation of the HIF-1 signaling pathway with the chemical compound FG-4592 or DMOG ameliorates liver steatosis and reduces accumulated Cu levels in zebrafish atp7b deficiency models. These findings introduce a novel prospect that modulation of the HIF-1 signaling pathway should be explored as a novel strategy to reduce copper toxicity in Wilson's disease patients.

Depletion of hepatic forkhead box O1 does not affect cholelithiasis in male and female mice

Cholelithiasis is one of the most prevalent gastroenterological diseases and is characterized by the formation of gallstones in the gallbladder. Both clinical and preclinical data indicate that obesity, along with comorbidity insulin resistance, is a predisposing factor for cholelithiasis. Forkhead box O1 (FoxO1) is a key transcription factor that integrates insulin signaling with hepatic metabolism and becomes deregulated in the insulin-resistant liver, contributing to dyslipidemia in obesity. To gain mechanistic insights into how insulin resistance is linked to cholelithiasis, here we determined FoxO1's role in bile acid homeostasis and its contribution to cholelithiasis. We hypothesized that hepatic FoxO1 deregulation links insulin resistance to impaired bile acid metabolism and cholelithiasis. To address this hypothesis, we used the FoxO1^LoxP/LoxP-Albumin-Cre system to generate liver-specific FoxO1-knockout mice. FoxO1-knockout mice and age- and sex-matched WT littermates were fed a lithogenic diet, and bile acid metabolism and gallstone formation were assessed in these animals. We showed that FoxO1 affected bile acid homeostasis by regulating hepatic expression of key enzymes in bile acid synthesis and in biliary cholesterol and phospholipid secretion. Furthermore, FoxO1 inhibited hepatic expression of the bile acid receptor farnesoid X receptor and thereby counteracted hepatic farnesoid X receptor signaling. Nonetheless, hepatic FoxO1 depletion neither affected the onset of gallstone disease nor impacted the disease progression, as FoxO1-knockout and control mice of both sexes had similar gallstone weights and incidence rates. These results argue against the notion that FoxO1 is a link between insulin resistance and cholelithiasis.

Etiologies of Long-Term Postcholecystectomy Symptoms: A Systematic Review

BACKGROUND

Cholecystectomy does not relieve abdominal symptoms in up to 40% of patients. With 700,000 cholecystectomies performed in the US, annually, about 280,000 patients are left with symptoms, making this a serious problem. We performed a systematic review to determine the different etiologies of long-term postcholecystectomy symptoms with the aim to provide guidance for clinicians treating these patients.

METHODS

A systematic search of the literature was performed using MEDLINE, EMBASE, and Web of Science. Articles describing at least one possible etiology of long-term symptoms after a laparoscopic cholecystectomy were included in this review. Long-term symptoms were defined as abdominal symptoms that were present at least four weeks after cholecystectomy, either persistent or incident. The etiologies of persistent and incident symptoms after LC and the mechanism or hypothesis behind the etiologies are provided. If available, the prevalence of the discussed etiology is provided.

RESULTS

The search strategy identified 3320 articles of which 130 articles were included. Etiologies for persistent symptoms were residual and newly formed gallstones (41 studies, prevalence ranged from 0.2 to 23%), coexistent diseases (64 studies, prevalence 1-65%), and psychological distress (13 studies, no prevalence provided). Etiologies for incident symptoms were surgical complications (21 studies, prevalence 1-3%) and physiological changes (39 studies, prevalence 16-58%). Sphincter of Oddi dysfunction (SOD) was reported as an etiology for both persistent and incident symptoms (21 studies, prevalence 3-40%).

CONCLUSION

Long-term postcholecystectomy symptoms vary amongst patients, arise from different etiologies, and require specific diagnostic and treatment strategies. Most symptoms after cholecystectomy seem to be caused by coexistent diseases and physiological changes due to cholecystectomy. The outcome of this research is summarized in a decision tree to give clinical guidance on the treatment of patients with symptoms after cholecystectomy.

Liver Cirrhosis in a Patient with Crigler Najjar Syndrome

INTRODUCTION

Crigler Najjar (CN) disease is a genetic disorder which results in increased unconjugated bilirubin level. Liver parenchyma was previously considered structurally normal. Recent reports describe significant fibrosis in the liver parenchyma of patients with CN syndrome.

CASE REPORT

We present a patient with persistent unconjugated hyperbilirubinemia, clinically diagnosed as CN-2, with a UGT1 A1 p. H39D (c.115C > G) (His → Asp) mutation. She required hepatic transplantation at the age of 17.5 years for biliary cirrhosis. Explanted liver histopathology revealed regenerative cirrhotic nodules with dilated bile ducts filled with bile plugs.

CONCLUSION

CN can develop significant hepatic fibrosis/cirrhosis requiring liver transplantation.

Hepatic Parenchymal Injury in Crigler-Najjar Type I

BACKGROUND

Crigler-Najjar syndrome type I (CNI) arises from biallelic variants of UGT1A1 that abrogate uridine diphosphate glucuronosyltransferase (UGT1A1) activity resulting in unconjugated hyperbilirubinemia. Historically, liver parenchyma in CNI was considered structurally and histologically normal. Recent review of CNI liver explants revealed fibrosis. Our aim was to investigate the association between hepatic histology and disease phenotype in CNI.

METHODS

We extracted data from the medical record at the time of liver transplant from 22 patients with CNI at the Children's Hospital of Pittsburgh, and reviewed explant histology. Continuous data were normally distributed, are presented as mean (±1 SD), and analyzed using two-tailed Student t-test. Categorical data were analyzed using the Chi-square test.

RESULTS

Both alanine transaminase (ALT; mean 87.4 IU/L) and aspartate transaminase (AST; mean 54.6 IU/L) were elevated. Nine (41%) of 22 explants had significant fibrosis. Pericentral (n = 5), periportal (n = 2), and mixed (n = 2) patterns of fibrosis occurred. A significant difference in mean age of subjects with fibrotic versus non-fibrotic livers (16.1 years vs 10.5 years; P = 0.02) was seen. There were no indices of synthetic liver dysfunction or portal hypertension. Neither a history of gallstone disease nor excess weight appeared to contribute to the development of fibrosis.

CONCLUSIONS

For the first time, we report a 41% prevalence of clinically silent, yet histologically significant fibrosis among subjects with Crigler-Najjar type 1. Risk for fibrosis appears to accrue with time, indicating that earlier intervention may be prudent whenever considering alternative treatments such as hepatocyte transplant, auxiliary liver transplant, or viral gene therapy.

Chemical and structural analysis of gallstones from the Indian subcontinent

Representative gallstones from north and southern parts of India were analyzed by a combination of physicochemical methods: X-ray diffraction (XRD), infrared spectroscopy (IR), scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), CHNS analysis, thermal analysis and Nuclear Magnetic Resonance (NMR) spectroscopy (¹H and ¹³C). The stones from north Indian were predominantly consisting of cholesterol monohydrate and anhydrous cholesterol which was confirmed by XRD analysis. FTIR spectroscopy confirmed the presence of cholesterol and calcium bilirubinate in the south Indian gallstones. EDX spectroscopy revealed the presence of carbon, nitrogen, oxygen, calcium, sulfur, sodium and magnesium and chloride in both south Indian and north Indian gallstones. FTIR and NMR spectroscopy confirmed the occurrence of cholesterol in north Indian gallstones. The respective colour of the north Indian and south Indian gallstones was yellowish and black. The morphology of the constituent crystals of the north Indian and south Indian gallstones were platy and globular respectively. The appreciable variation in colour, morphology and composition of south and north Indian gallstones may be due to different food habit and habitat.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Role of the Free Radicals in Mechanisms of Gallstone Formation: An EPR Study

The mechanism of gallstone formation is not well understood. Abnormal regulation of hepatic cholesterol, bile acid synthesis or esterification, deposition of cholesterol monohydrate crystals and gall bladder dysfunction are thought to be the principal metabolic aberrations that may cause gallstone formation. One plausible mechanism leading to these abnormalities is the role of free radicals, whose presence can be investigated using Electron Paramagnetic Resonance (EPR). Surgically removed gall bladder stones were used to obtain purified bilirubin, which was irradiated in vitro with visible light and measured with EPR in the presence of and without oxygen. EPR detected oxidized bilirubin free radical (BFR) (g = 2.003, ΔH = 1.0 mTl) in the gallstones. In vitro exposure of bilirubin to visible light in the presence of oxygen induced BFR formation; its intensity was radiation time dependent and decreased under the influence of β-carotene; irradiation in a vacuum did not generate BFRs. These results indicate the important role of oxidative processes (oxidation of bilirubin) in the gallstone formation. In oxidative stress, bilirubin acting as a second type photosensitizer undergoes rapid oxidation and free radical polymerization that plays an important role in the nucleation and deposition of gallstones.

A randomized controlled trial to compare a restrictive strategy to usual care for the effectiveness of cholecystectomy in patients with symptomatic gallstones (SECURE trial protocol)

Background

Five to 22 % of the adult Western population has gallstones. Among them, 13 to 22 % become symptomatic during their lifetime. Cholecystectomy is the preferred treatment for symptomatic cholecystolithiasis. Remarkably, cholecystectomy provides symptom relief in only 60-70 % of patients. The objective of this trial is to compare the effectiveness of usual (operative) care with a restrictive strategy using a standardized work-up with stepwise selection for cholecystectomy in patients with gallstones and abdominal complaints.

Design and methods

The SECURE-trial is designed as a multicenter, randomized, parallel-arm, non-inferiority trial in patients with abdominal symptoms and ultrasound proven gallstones or sludge. If patients meet the inclusion criteria they will be randomized to either usual care or the restrictive strategy.

Patients in the usual care group will be treated according to the physician’s knowledge and preference. Patients in the restrictive care group will be treated with interval evaluation and stepwise selection for laparoscopic cholecystectomy. In this stepwise selection, patients strictly meeting the preselected criteria for symptomatic cholecystolithiasis will be offered a cholecystectomy. Patients not meeting these criteria will be assessed for other diagnoses and re-evaluated at 3-monthly intervals. Follow-up consists of web-based questionnaires at 3, 6, 9 and 12 months.

The main end point of this trial is defined as the proportion of patients being pain-free at 12 months follow-up. Pain will be assessed with the Izbicki Pain Score and Gallstone Symptom Score.

Secondary endpoints will be the proportion of patients with complications due to gallstones or cholecystectomy, the association between the patients’ symptoms and treatment and work performance, and ultimately, cost-effectiveness.

Discussion

The SECURE trial is the first randomized controlled trial examining the effectiveness of usual care versus restrictive care in patients with symptomatic gallstones. The outcome of this trial will inform clinicians whether a more restrictive strategy can minimize persistent pain in post-operative patients at least as good as usual care does, but at a lower cholecystectomy rate. (The Netherlands National Trial Register NTR4022, 17th December 2012)

Trial registration

The Netherlands National Trial Register NTR4022

http://www.zonmw.nl/nl/projecten/project-detail/scrutinizing-inefficient-use-of-cholecystectomy-a-randomized-trial-concerning-variation-in-practi/samenvatting/

Consistency of patient-reported outcomes after cholecystectomy and their implications on current surgical practice: a prospective multicenter cohort study

Background

Persistent postoperative pain (up to 41 %) and significant practice variation necessitate better patient selection for cholecystectomy. Patient-reported outcome measures (PROMs) are nowadays known to serve as a tool for better patient selection, although variability within these subjective outcomes may be a point for debate. This study determines associations of both the preoperative pain and patient characteristics with PROMs at 24 weeks after cholecystectomy. In order to evaluate variability of PROMs, we also determined consistency of these outcomes in time.

Methods

This prospective multicenter cohort study included adult patients diagnosed with uncomplicated symptomatic cholecystolithiasis. Twenty-four weeks after surgery, a questionnaire study was carried out, containing Gastrointestinal Quality of Life Index (GIQLI) and Patients’ Experience of Surgery Questionnaire. Results were compared to preoperative data and results 12 weeks post-cholecystectomy. Logistic regression analyses were performed to determine associations. Additional post hoc analysis on associations between preoperative selection criteria and PROMs was done.

Results

A total of 360 patients (85 %) responded. Postoperative absence of pain was reported by 59.2 %. Associated characteristics were symptoms ≤1 year prior to surgery [OR 1.85 (95 % CI 1.11–3.09)] and high baseline GIQLI score [OR 1.04 (95 % CI 1.02–1.05)]. General improvement in abdominal symptoms and positive result of surgery were found in 90 %; no preoperative variables were significantly associated. PROMs showed consistency at 12 and 24 weeks postoperatively. Post hoc analysis showed no significant associations.

Conclusion

PROM-based preoperative selection criteria need to be considered to select those patients who achieve freedom of pain after surgical treatment of uncomplicated symptomatic cholecystolithiasis. Other patients might consider cholecystectomy as successful, but are less likely to be free of pain. Usefulness of PROMs is underscored as they proved to be consistent in time in evaluating surgical outcome.

Prevention of gallstones by Lidan Granule: Insight into underlying mechanisms using a guinea pig model

The aim of the study was to examine the mechanism of action of Lidan Granule (LDG) for the prevention of gallstones using a guinea pig model. One hundred guinea pigs were divided into five groups randomly: control (standard diet and saline), model [lithogenic diet (LD) and saline], LDG-H (LD and 2 g/kg of LDG), LDG-L (LD and 1 g/kg of LDG), and ursodeoxycholic acid (UDCA) (LD and UDCA) as the positive control. At 6 weeks, the rate of gallstone formation and weight of the adrenal gland were recorded and serum levels of inflammatory cytokines were measured. Levels of corticotrophin-releasing hormone (CRH) in the hypothalamus, adrenocorticotropic hormone (ACTH) in the hypophysis, and serum cortisol were determined. Bile components were tested with colorimetry. At 6 weeks, the rate of gallstone formation was significantly decreased in the LDG-H (14.29%) and LDG-L (21.43%) groups compared to the model group (81.25%; P<0.01). LDG treatment decreased the serum levels of interleukin (IL)-1, IL-6, and tumor necrosis factor-α (P<0.01). LDG decreased bile cholesterol and increased bile acid and phospholipid levels in the bile (P<0.01). LDG treatment recovered the function of the hypothalamic-pituitary-adrenal (HPA) axis by increasing the expression of CRH (P<0.01) and ACTH (P<0.05). LDG made the bile less lithogenic, improved the function of the HPA axis, and regulated the expression of inflammatory cytokines for the prevention of cholelithiasis.

Estrogen and G protein-coupled estrogen receptor agonist G-1 cause relaxation of human gallbladder

OBJECTIVE

Estrogen interacts with a membrane receptor, G protein-coupled estrogen receptor (GPER). It was reported that 17β-estradiol was able to inhibit contraction of the human colon and cause relaxation of the guinea pig gallbladder, however, the involvement of GPER was not clarified. The aim of the present study was to investigate the effect of estrogen on human gallbladder motility and the possible role of GPER.

MATERIALS AND METHODS

Relaxation of human gallbladder strips were measured using isometric transducers. Expression of GPER was evaluated by reverse transcription polymerase chain reaction (PCR), realtime PCR, and immunohistochemistry.

RESULTS

In human gallbladder strips, 17β-estradiol and G-1 elicited marked and rapid relaxation, whereas tamoxifen produced mild concentration-dependent relaxation. The relative efficacies to cause relaxation were as follows: 17β-estradiol = G-1 > tamoxifen. The relaxant response of 17β-estradiol was not attenuated by tetrodotoxin or conotoxin GVIA. This implies that nerve stimulation was not involved in the 17β-estradiol-induced gallbladder relaxation. Analysis by reverse transcription PCR and real-time PCR showed that GPER was expressed in the human gallbladder. Further analysis by immunohisto-chemistry revealed that GPER was expressed in the gallbladder muscle. This suggests that 17β-estradiol relaxes the human gallbladder via GPER.

CONCLUSION

These results demonstrate for the first time that 17β-estradiol and GPER agonist G-1 cause relaxation of the human gallbladder, probably through GPER. Estrogen might play an important role in the control of human gallbladder motility.

Acute cholangitis in an old patient with Crigler-Najjar syndrome type II - a case report

Background

Crigler-Najjar syndrome (CN) is a very rare genetic disorder characterized by an inability to conjugate bilirubin. Contrary to CN type I, patients with CN II exhibit residual capacity to conjugate bilirubin and may present a normal life expectancy.

Case presentation

We report an unusual late diagnosis of CN type II in an 80-year-old female admitted with severe acute cholangitis. While the patient present typical clinical and radiologic signs of bile duct obstruction and cholangitis, her blood analysis showed severe unconjugated hyperbilirubinemia. Endoscopic retrograde cholangiopancreatography confirmed the diagnosis and allowed therapeutic intervention. The anatomopathologic examination of her gallbladder following cholecystectomy showed signs of chronic cholecystitis.

Conclusion

The risk of gallstone disease may be increased in patients with CN syndrome. While unusual, we alert to this curious and potential life-threatening presentation.

Restriction fragment length polymorphism effectively identifies exon 1 mutation of UGT1A1 gene in patients with Gilbert's Syndrome

BACKGROUND & AIMS

Gilbert's syndrome causes pharmacological variation in drug glucuronidation and unexpected toxicity from therapeutic agents. The two common genotypes of Gilbert's syndrome are a dinucleotide polymorphism (TA)7 in TATA-Box as well as the 211G>A mutation in the coding exon 1, particularly in Asians, of human UGT1A1 gene. In this study, we aimed to establish an effective method to detect the 211G>A mutation.

METHODS

The coding exon 1 sequence of human UGT1A1 gene was analysed by Vector NTI software. The 211G>A mutation in the coding exon 1 of UGT1A1 gene was determined by restriction fragment length polymorphism (RFLP) method. Serum total bilirubin level was measured as well.

RESULTS

A newly identified BsmBI site was located in the coding exon 1 of UGT1A1 gene. The 211G>A mutation in the coding exon 1 of UGT1A1 gene was determined by DNA RFLP. Furthermore, we reported our present work on genetic analysis of mutations of UGT1A1 gene, and the correlation of UGT1A1 mutations with serum total bilirubin levels in Taiwanese population. The results showed that 15 subjects carried 211G>A mutation in 23 subjects related with Gilbert's syndrome. The homozygous 211G>A mutant as well as simultaneously heterozygous mutants both in TATA-Box and 211G>A significantly increased the risk of Gilbert's syndrome similar to subjects carrying homozygous TATA-Box mutant.

CONCLUSIONS

BsmBI RFLP is an effective method to detect 211G>A mutation in the coding exon 1 of UGT1A1 gene. The common 211G>A mutation is one of the causes of Gilbert's syndrome in Taiwanese population.

Patient-reported outcomes of symptomatic cholelithiasis patients following cholecystectomy after at least 5 years of follow-up: a long-term prospective cohort study

BACKGROUND

Up to 41% of patients report pain after cholecystectomy and in most studies follow-up for these symptoms did not exceed 5 years. The episodic nature of abdominal pain associated with symptomatic cholelithiasis warrants long-term follow-up studies. We assessed which patient and surgical factors were associated with absence of pain and patient-reported success of surgery after ≥ 5 years of follow-up.

METHODS

Patients of ≥ 18 years of age with symptomatic cholelithiasis, classified as ASA I or II, who had previously returned a preoperative questionnaire were sent a questionnaire consisting of the gastrointestinal quality of life index (GIQLI) and patient ratings of current versus presurgical abdominal symptoms and of surgery result. Logistic regression analysis was performed to determine associations.

RESULTS

Questionnaires were sent to 197 patients and returned by 126 (64.0%) patients (73.8 % female, mean age at surgery 47.5 ± 12.2 years) at a mean of 10.0 ± 1.0 years after cholecystectomy. Absence of abdominal pain was reported by 60.3% of the patients. Patients classified as ASA II as opposed to ASA I were less likely to report absence of pain (OR 0.41, 95% CI 0.17-0.99). A positive rating of long-term postsurgical versus presurgical abdominal symptoms was given by 89.7% of the patients and 90.5% considered the cholecystectomy result to be good. No variables were significantly associated with these latter two outcome measures.

CONCLUSIONS

We found a high patient-reported surgery success rate after >5 years of follow-up after cholecystectomy despite residual abdominal pain in some of these patients. None of the patient and surgery-related characteristics were consistently associated with all three outcome measures. This discrepancy between patient' outcomes highlights the need for realistic expectations prior to cholecystectomy.

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.

An analysis of the role of the indigenous microbiota in cholesterol gallstone pathogenesis

BACKGROUND AND AIMS

Cholesterol gallstone disease is a complex process involving both genetic and environmental variables. No information exists regarding what role if any the indigenous gastrointestinal microbiota may play in cholesterol gallstone pathogenesis and whether variations in the microbiota can alter cholesterol gallstone prevalence rates.

METHODS

Genetically related substrains (BALB/cJ and BALB/cJBomTac) and (BALB/AnNTac and BALB/cByJ) of mice obtained from different vendors were compared for cholesterol gallstone prevalence after being fed a lithogenic diet for 8 weeks. The indigenous microbiome was altered in these substrains by oral gavage of fecal slurries as adults, by cross-fostering to mice with divergent flora at <1 day of age or by rederiving into a germ-free state.

RESULTS

Alterations in the indigenous microbiome altered significantly the accumulation of mucin gel and normalized gallbladder weight but did not alter cholesterol gallstone susceptibility in conventionally housed SPF mice. Germ-free rederivation rendered mice more susceptible to cholesterol gallstone formation. This susceptibility appeared to be largely due to alterations in gallbladder size and gallbladder wall inflammation. Colonization of germ-free mice with members of altered Schaedler flora normalized the gallstone phenotype to a level similar to conventionally housed mice.

CONCLUSIONS

These data demonstrate that alterations in the gastrointestinal microbiome may alter aspects of cholesterol gallstone pathogenesis and that in the appropriate circumstances these changes may impact cholesterol cholelithogenesis.

Genetics of gallstone disease

Gallstone disease (GSD) is one of the most common biliary tract disorders worldwide. The prevalence, however, varies from 5.9-21.9% in Western society to 3.1-10.7% in Asia. Most gallstones (75%) are silent. Approximately half of symptomatic gallstone carriers experience a second episode of biliary pain within 1 year. These individuals are at increased risk of developing acute cholecystitis, acute cholangitis, and biliary pancreatitis. As can be expected, these complications burden health care systems because of their invasive nature and surgical cost. Factors that contribute to gallstone formation include supersaturation of cholesterol in bile, gallbladder hypomotility, destabilization of bile by kinetic protein factors, and abnormal mucins. Epidemiologic studies have implicated multiple environmental factors and some common genetic elements in gallstone formation. Genetic factors that influence gallstone formation have been elaborated from linkage studies of twins, families, and ethnicities. Accumulating evidence suggests that genetic factors play a role in GSD.

Current views on genetics and epigenetics of cholesterol gallstone disease

Cholesterol gallstone disease, one of the commonest digestive diseases in western countries, is induced by an imbalance in cholesterol metabolism, which involves intestinal absorption, hepatic biosynthesis, and biliary output of cholesterol, and its conversion to bile acids. Several components of the metabolic syndrome (e.g., obesity, type 2 diabetes, dyslipidemia, and hyperinsulinemia) are also well-known risk factors for gallstones, suggesting the existence of interplay between common pathophysiological pathways influenced by insulin resistance, genetic, epigenetic, and environmental factors. Cholesterol gallstones may be enhanced, at least in part, by the abnormal expression of a set of the genes that affect cholesterol homeostasis and lead to insulin resistance. Additionally, epigenetic mechanisms (mainly DNA methylation, histone acetylation/deacetylation, and noncoding microRNAs) may modify gene expression in the absence of an altered DNA sequence, in response to different lithogenic environmental stimuli, such as diet, lifestyle, pollutants, also occurring in utero before birth. In this review, we will comment on various steps of the pathogenesis of cholesterol gallstones and interaction between environmental and genetic factors. The epigenomic approach may offer new options for therapy of gallstones and better possibilities for primary prevention in subjects at risk.

Persistent and de novo symptoms after cholecystectomy: a systematic review of cholecystectomy effectiveness

BACKGROUND

Cholecystectomy is the preferred treatment option for symptomatic gallstones, but the exact relationship between cholecystectomies and symptoms still is unclear. This study aimed to assess the effectiveness of elective cholecystectomy for patients with cholecystolithiasis in terms of both persistent and de novo symptoms.

METHODS

A systematic literature search was conducted in Pubmed and Embase. The search included studies comprising patients 18 years of age or older undergoing elective cholecystectomy for symptomatic cholecystolithiasis. The proportions of symptoms after cholecystectomy were calculated and then subdivided into persistent and de novo symptoms.

RESULTS

A total of 38 studies reported the presence of postcholecystectomy symptoms. The results showed that upper abdominal pain, the main indication for cholecystectomy in the majority of the patients, mostly disappeared after surgery. However, it persisted in up to 33 % of the patients and arose de novo in up to 14 %. Diarrhea (85 %) and constipation (76 %) were the persistent symptoms most often reported, whereas upper abdominal pain and vomiting were the least often reported. Flatulence (62 %) was the most often reported new symptom. However, large variations in symptoms were found between studies.

CONCLUSIONS

The review indicates that cholecystectomy often is ineffective with regard to persistent and de novo symptoms. The finding that the types and proportions of persistent symptoms differ from those that arise de novo suggests that this distinction may be useful in predicting which patients would and which would not benefit from a cholecystectomy.

Mucin genes in gallstone disease

Gallstone disease is a complex disorder that can be caused by environmental influences, common genetic factors and their interactions. Three major pathogenic abnormalities are considered to involve in gallstone formation: cholesterol supersaturation in bile, precipitation and nucleation of excess cholesterol, and gallbladder hypomotility, while, mucin takes part in the cholesterol nucleation process. Up to date, more than 20 mucin genes have been reported, 9 of them are identified at the mRNA and/or protein level in native gallbladder and its associated diseases. In the gallbladder, mucin is essential for best protection against detergent effect of high concentration of bile acids. Over the past decade, the properties, expressions and functions of the gallbladder mucins are delineated in animal and human studies. Alteration expressions of mucins are thought to response during the pathogenesis of gallstone formation. Moreover, recent genetic association study demonstrated mucin gene polymorphisms may also influence susceptibility to gallstone disease. This review is not to provide a complete coverage of all the aspects of mucin glycoproteins, but focus on the role and expression of mucins involve in the regulation of cholelithogenesis.