European Association for the Study of the Liver (EASL). Electronic address: easloffice@easloffice.eu. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones

Risk factors for biliary tract events during elective cholecystectomy waiting time after endoscopic retrograde cholangiopancreatography for choledocholithiasis

Objectives

Endoscopic lithotripsy and elective cholecystectomy, followed by endoscopic retrograde cholangiopancreatography, are the first-line treatments for patients with common bile duct (CBD) stones (CBDS) and gallstones. However, this approach entails acute cholecystitis and recurrent cholangitis risk while patients await surgery. We aimed to identify acute cholecystitis and cholangitis risk factors during the waiting time for elective cholecystectomy.

Methods

This study comprised 151 patients with CBDS combined with gallstones who underwent cholecystectomy within 90 days of the first endoscopic retrograde cholangiopancreatography at two tertiary care centers between January 2019 and October 2021.

Results

The incidence of biliary tract events (acute cholecystitis, acute cholangitis, or any complications requiring unplanned cholangiopancreatography) was 28% (43 cases). In univariate and multivariate analyses, plastic stent placement as a bridge to surgery for the first treatment of CBDS was an independent risk factor for biliary tract events during the waiting time for surgery (odds ratio 4.25, p = 0.002). A subgroup analysis among those with plastic stent placement revealed a CBD diameter of ≤ 10 mm as an independent risk factor for acute cholecystitis (odds ratio 4.32; p = 0.027); a CBD diameter ≥ 11 mm was an independent risk factor for acute cholangitis and unplanned re-endoscopic retrograde cholangiopancreatography (odds ratio 5.66; p = 0.01).

Conclusions

Plastic stent placement for CBDS before elective cholecystectomy increases the risk of acute cholecystitis or acute cholangitis during the waiting time for elective cholecystectomy.

Unraveling factors associated with textbook outcome after cholecystectomy in patients with uncomplicated cholecystolithiasis: A posthoc analysis of individual data of 1,124 patients

BACKGROUND

A textbook outcome for the management of uncomplicated cholecystolithiasis is the targeted clinical scenario and is characterized by no recurrent biliary colic, absence of surgical and biliary complications, and absence or relief of abdominal pain. The aim of this study was to assess the incidence of textbook outcomes after cholecystectomy and identify associated baseline factors.

METHODS

Patients from 2 Dutch multicenter prospective trials between 2014 and 2019 (SECURE and SUCCESS trial) were included. The primary outcome was the proportion of patients with textbook outcomes after cholecystectomy at 6-month follow-up. Regression analysis was used to identify which factors before surgery were associated with textbook outcomes.

RESULTS

A total of 1,124 patients underwent cholecystectomy. A textbook outcome at 6-month follow-up was reached in 67.9% of patients. Persistent abdominal pain was the main reason for the failure to achieve textbook outcome. Patients who did achieve textbook outcomes more often reported severe pain attacks (89.4% vs 81.7%, P < .001) and/or biliary colic (78.6% vs 68.4%, P < .001) at baseline compared with patients without textbook outcomes. The presence of biliary colic at baseline (odds ratio = 1.56, 95% confidence interval: 1.16-2.09, P = .003) and nausea/vomiting at baseline (odds ratio = 1.33, 95% confidence interval: 1.01-1.74, P = .039) were associated with textbook outcome. The use of non-opioid analgesics (odds ratio = 0.76, 95% confidence interval: 0.58-0.99, P = .043) and pain frequency ≥1/month (odds ratio = 0.56, 95% confidence interval: 0.43-0.73, P < .001) were negatively associated with textbook outcome.

CONCLUSION

Textbook outcome is achieved in two-thirds of patients who undergo cholecystectomy for uncomplicated cholecystolithiasis. Intensity and frequency of pain, presence of biliary colic, and nausea/vomiting at baseline are independently associated with achieving textbook outcomes. A more stringent selection of patients may optimize the textbook outcome rate in patients with uncomplicated cholecystolithiasis.

The ABCG8 polymorphism increases the risk of gallbladder cancer in the general population and gallstones in obese patients from Poland

BACKGROUND

Gallstone disease (GD) is common but remains asymptomatic in most cases. However, gallstones can lead to complications like choledocholithiasis or gallbladder cancer. In this study, we analyse the common genetic risk factor for GD, the p.D19H variant in the sterol transporter ABCG8, in Polish patients with gallstones and gallbladder cancer.

METHODS

Three adult cohorts were prospectively recruited: 65 patients with gallbladder cancer, 170 obese individuals scheduled for bariatric surgery and 72 patients who underwent endoscopic retrograde cholangiopancreatography due to recurrent choledocholithiasis. The control cohort consisted of 172 gallstone-free adults. The ABCG8 p.D19H (rs11887534) polymorphism was genotyped using TaqMan assays.

RESULTS

The minor allele frequency (MAF) of the ABCG8 p.D19H polymorphism was significantly (p = .02) higher among cases with either gallstones or gallbladder cancer (MAF = 8.4%) as compared to controls (MAF = 4.0%). The highest frequency of the risk allele was detected in patients with gallbladder cancer (18.5%) and obese patients with GD (17.5%), followed by individuals with choledocholithiasis (13.9%). Notably, the p.19H variant was associated with an increased risk of developing gallbladder cancer (OR 2.76, 95% CI 1.16-6.54, p = .01) and an increased risk of GD in obese individuals scheduled for bariatric surgery (OR = 2.70, 95% CI 1.05-6.49, p = .03), but did not significantly affect the risk of choledocholithiasis.

CONCLUSIONS

The ABCG8 p.D19H common risk variant increases the risk of developing gallbladder cancer in Central Europeans and enhances the risk of gallstones in the obese. Carriers of the p.D19H variant might benefit from personalized preventive strategies, particularly regarding gallbladder cancer.

Predictive value of bile acids as metabolite biomarkers for gallstone disease: A systematic review and meta-analysis

BACKGROUND

The profiles of bile acids (BAs) in patients with gallstone disease (GSD) have been found to be altered markedly though in an inconsistent pattern. This study aims to characterize the variation of the BA profiles in GSD patients, thereby to discover the potential metabolite biomarkers for earlier detection of GSD.

METHODS

Literature search of eight electronic database in both English and Chinese was completed on May 11, 2023. The qualitative and quantitative reviews were performed to summarize the changes of BA profiles in GSD patients compared with healthy subjects. The concentrations of BAs were adopted as the primary outcomes and the weighted mean differences (WMDs) and 95% confidence interval (CI) were generated by random-effects meta-analysis models.

RESULTS

A total of 30 studies were enrolled which included 2313 participants and reported the 39 BAs or their ratios. Qualitative review demonstrated serum Taurocholic Acid (TCA), Glycochenodeoxycholic acid (GCDCA), Glycocholic acid (GCA), Taurochenodeoxycholic acid (TCDCA), Glycodeoxycholic acid (GDCA) and Deoxycholic acid (DCA) were significantly increased in GSD patients compared with healthy subjects. Meta analysis was performed in 16 studies and showed that serum Total BAs (TBA) (WMD = 1.36μmol/L, 95%CI = 0.33; 2.4) was elevated however bile TBA (WMD = -36.96mmol/L, 95%CI = -52.32; -21.6) was declined in GSD patients. GCA (WMD = 0.83μmol/L, 95%CI = 0.06; 1.6) and TCA (WMD = 0.51μmol/L; 95%CI = 0.18; 0.85) were both increased in serum sample; TCDCA (WMD = 2.64mmol/L, 95%CI = 0.16; 5.12) was rising, however GCDCA (WMD = -13.82mmol/L, 95%CI = -21.86; -5.78) was falling in bile sample of GSD patients. The level of serum DCA in the GSD patients was found to be increased by using chromatography, yet decreased by chromatography mass spectrometry.

CONCLUSION

The profiles of BAs demonstrated distinctive changes in GSD patients compared with healthy control subjects. Serum GCA, TCA and GCDCA, as the typically variant BAs, presented as a potential marker for earlier diagnosis of GSD, which could facilitate early prophylactic intervention. Yet, further validation of these biomarkers by longitudinal studies is still warranted in the future. PROSPERO registration number CRD42022339649.

Relationship of triglyceride-glucose index to gallstone prevalence and age at first gallstone surgery in American adults

The triglyceride-glucose (TyG) index is a novel marker of insulin resistance that has been strongly associated with many diseases related to metabolic disorders, such as diabetes, coronary heart disease, myocardial infarction, obesity, nonalcoholic fatty liver disease, and stroke. However, whether the TyG index is associated with the prevalence of gallstones has not been determined. Therefore, the purpose of this study was to evaluate the relationship between the TyG index and the prevalence of gallstones in American adults, as well as the age at which adults in America undergo their first gallstone surgery. We selected individuals from the National Health and Nutrition Examination Survey (NHANES) database from 2017 to March 2020. Based on the goal of our study, comprehensive inclusion and exclusion criteria were created. A logistic regression analysis, dose-response curve, and subgroup analysis were computed to assess the relationship between the TyG index and gallstone prevalence and age at first surgery for gallstone. A total of 3905 participants aged > 20 years were included in our study, of whom 421 had a self-reported history of gallstones. A total of 1884 (48.2%) males and 2021 (51.8%) females were included. After confounders adjustment, it was found single-unit increases in the TyG index were linked with a 25.0% increase in gallstone prevalence (odds ratio [OR] = 1.25, 95% confidence interval [95%CI]: 1.04, 1.51). After conversion of the TyG index values from continuous to categorical variables with tertiles, a marked 48% increase in gallstone incidence was found in tertile 3 relative to tertile 1 (OR = 1.48, 95% CI: 1.09, 1.99). The dose-response curve results indicated positive associations between gallstone prevalence and the TyG index, while the latter was negatively associated with age at first gallstone surgery. Based on subgroup analysis, the positive association between TyG index and high-incidence of gallstones was more significant in females (OR = 1.39, 95% CI: 1.09, 1.77), age < 40 years (OR = 2.02, 95% CI: 1.23, 3.29), and other race (OR = 1.46, 95% CI: 1.06, 2.02). A higher TyG index is associated with a higher incidence of gallstones and may lead to an earlier age of first gallstone surgery. However, a causal relationship between TyG and gallstones cannot be established.

Association of education with cholelithiasis and mediating effects of cardiometabolic factors: A Mendelian randomization study

BACKGROUND

Education, cognition, and intelligence are associated with cholelithiasis occurrence, yet which one has a prominent effect on cholelithiasis and which cardiometabolic risk factors mediate the causal relationship remain unelucidated.

AIM

To explore the causal associations between education, cognition, and intelligence and cholelithiasis, and the cardiometabolic risk factors that mediate the associations.

METHODS

Applying genome-wide association study summary statistics of primarily European individuals, we utilized two-sample multivariable Mendelian randomization to estimate the independent effects of education, intelligence, and cognition on cholelithiasis and cholecystitis (FinnGen study, 37041 and 11632 patients, respectively; n = 486484 participants) and performed two-step Mendelian randomization to evaluate 21 potential mediators and their mediating effects on the relationships between each exposure and cholelithiasis.

RESULTS

Inverse variance weighted Mendelian randomization results from the FinnGen consortium showed that genetically higher education, cognition, or intelligence were not independently associated with cholelithiasis and cholecystitis; when adjusted for cholelithiasis, higher education still presented an inverse effect on cholecystitis [odds ratio: 0.292 (95%CI: 0.171-0.501)], which could not be induced by cognition or intelligence. Five out of 21 cardiometabolic risk factors were perceived as mediators of the association between education and cholelithiasis, including body mass index (20.84%), body fat percentage (40.3%), waist circumference (44.4%), waist-to-hip ratio (32.9%), and time spent watching television (41.6%), while time spent watching television was also a mediator from cognition (20.4%) and intelligence to cholelithiasis (28.4%). All results were robust to sensitivity analyses.

CONCLUSION

Education, cognition, and intelligence all play crucial roles in the development of cholelithiasis, and several cardiometabolic mediators have been identified for prevention of cholelithiasis due to defects in each exposure.

Bibliometric Analysis on Cholecystectomy Surgery in the Nursing Field

PURPOSE

This study aimed to bibliometrically examine nursing publications regarding cholecystectomy surgery.

DESIGN

The study is a bibliometric analysis.

METHODS

The study was conducted in the Web of Science database. The keywords "cholecystectomy AND nursing" were used during the scanning. The data were evaluated in quantitative aspects.

FINDINGS

In the study, 481 publications were identified, publications were made between 1987 and 2023, the average number of years since the release of the publication was 10.2, and the annual increase rate was 8.19%. The most active country was the United States, and the journal most often published in was the "Journal of Perianesthesia Nursing." In the last 3 years, the themes of "meta-analysis, complication, pain, anxiety, quality of life" have been trending, the most working and continuing to develop our "laparoscopic cholecystectomy" and "pain" themes, and the leading theme in the field was "anxiety".

CONCLUSIONS

This study is the first bibliometric study examining nursing studies on cholecystectomy and provides a comprehensive overview of cholecystectomy and nursing issues over 36 years. In quantitative data, it was concluded that although studies in this field have a long history, the number of publications is low, and the annual growth rate is low. According to the quantitative evaluation results, it was found that the most studied topic in this field was laparoscopic cholecystectomy and pain, minimally invasive intervention and perioperative period topics remained isolated, and computerized tomography and gallbladder themes were among the newly emerging themes.

Ultraprocessed food consumption and risk of gallstone disease: analysis of 3 prospective cohorts

BACKGROUND

Majority of dietary intake in United States adults comes from ultraprocessed foods (UPFs), which have been linked to several adverse health outcomes. Gallstone disease is highly prevalent and constitutes a significant burden to the United States health system but remains understudied.

OBJECTIVES

This study aimed to investigate the association between UPF consumption and incident gallstone disease risk.

METHODS

In this analysis, 44,149 males in the Health Professionals' Follow-up Study (HPFS: 1986-2022), 71,145 females in the Nurses' Health Study (NHS: 1986-2021), and 90,932 females in the NHS II (1991-2021) were prospectively followed. Dietary intake was quadrennially assessed with semiquantitative food frequency questionnaires and used to identify UPFs. The primary outcome was defined as cholecystectomy. Cox proportional hazards model was used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

Baseline median age was 54 y in HPFS, 53 y in NHS, and 36 y in NHS II. We identified 32,374 incident gallstone disease cases over 5,077,059 person-years. Participants in the highest UPF quintile had a higher incidence of gallstone disease than those in the lowest quintile (aHR: 1.29; 95% CI: 1.24, 1.36; P < 0.001). Incremental risk of incident gallstone disease was 2.8% per daily serving (95% CI: 2.4%, 3.2%; P < 0.001). This risk was driven by sugar-sweetened beverages and artificially sweetened beverages on UPF subgroup analyses. The proportion of risk mediated by obesity was 12.8% (95% CI: 7.7%, 20.5%; P < 0.001) in HPFS, 14.3% (95% CI: 10.4%, 19.4%; P < 0.001) in NHS, and 39.4% (95% CI: 31.2%, 48.1%; P < 0.001) in NHS II. The partial population attributable risk was estimated at 15.9% (95% CI: 13.4%, 18.3%).

CONCLUSIONS

UPF consumption is associated with a higher risk of gallstone disease, particularly consumption of sugar-sweetened beverages and artificially sweetened beverages. A substantial proportion of this risk is potentially mediated by obesity in younger females.

Association between nonalcoholic fatty liver disease and gallstone risk in nonobese and lean individuals

PURPOSE

The association between nonobese/lean nonalcoholic fatty liver disease (NAFLD) and gallstone formation remains unclear. We aimed to assess whether NAFLD is an independent risk factor for gallstones, even in nonobese or lean individuals.

METHODS

We analyzed 265 353 asymptomatic adults who underwent abdominal ultrasonography. The risk of gallstone was assessed on the basis of obesity and NAFLD status.

RESULTS

The overall prevalence rates of NAFLD and gallstones were 27.1% and 2.6%, respectively. The prevalence rates of NAFLD among the 195 204 nonobese and 136 194 lean participants were 14.7% and 7.4%, respectively. Individuals with NAFLD had a significantly increased risk of gallstones (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.14-1.32). Moreover, NAFLD significantly increased the risk of gallstone (adjusted OR, 1.29; 95% CI, 1.17-1.41) among nonobese individuals. Lean individuals with NAFLD also exhibited a significantly increased risk of gallstones (adjusted OR, 1.20; 95% CI, 1.03-1.40). Furthermore, these findings remained consistent even in nonobese and lean individuals without insulin resistance.

CONCLUSION

Nonobese/lean NAFLD is an independent risk factor for gallstone formation, suggesting its role in gallstone pathogenesis, regardless of obesity status. Therefore, when hepatic steatosis is detected on abdominal ultrasonography, a more thorough evaluation of the gallstones may be necessary, even in nonobese or lean individuals.

Is Endoscopic Ultrasound-Guided Hepaticogastrostomy Safe and Effective after Failed Endoscopic Retrograde Cholangiopancreatography?-A Systematic Review and Meta-Analysis

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative option for biliary drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). Limited data exist on the safety and efficacy of EUS-HGS. In this comprehensive meta-analysis, we aim to study the safety and efficacy of EUS-HGS in cases of failed conventional ERCP. Methods: Embase, PubMed, and Web of Science databases were searched to include all studies that evaluated the efficacy and safety of EUS-HGS. Using the random effect model, the pooled weight-adjusted event rate estimate for clinical outcomes in each group were calculated with 95% confidence intervals (CIs). The primary outcomes were technical and clinical success rates. Secondary outcomes included overall adverse events (AEs), rates of recurrent biliary obstruction (RBO), and rates or re-intervention. Results: Our analysis included 70 studies, with a total of 3527 patients. The pooled technical and clinical success rates for EUS-HGS were 98.1% ([95% CI, 97.5-98.7]; I2 = 40%) and 98.1% ([95% CI, 97.5-98.7]; I2 = 40%), respectively. The pooled incidence rate of AEs with EUS-HGS was 14.9% (95% CI, 12.7-17.1), with bile leakage being the most common (2.4% [95% CI, 1.7-3.2]). The pooled incidence of RBO was 15.8% [95% CI, 12.2-19.4], with a high success rate for re-intervention (97.5% [95% CI, 94.7-100]). Conclusions: Our analysis showed high technical and clinical success rates of EUS-HGS, making it a feasible and effective alternative to ERCP. The ongoing development of dedicated devices and techniques is expected to make EUS-HGS more accessible and safer for patients in need of biliary drainage.

Follow-up study of gallbladder stones in 44 children

BACKGROUND

Cholesterol stones affect a certain subpopulation of children. Concerns have been raised on the impact of gallbladder surgery on the growth of children and adolescents.

AIM

To study the population characteristics, clinical features, treatment, and prognosis of gallstones in children.

METHODS

The clinical data of 44 children with gallstones admitted to The First Affiliated Hospital of Naval Medical University from August 2009 to August 2021 were collected, the children were followed up by telephone to monitor their prognoses. The follow-up ended in August 2023. The shortest follow-up time was 2 years and 6 months, whereas the longest was 13 years and 11 months. The population characteristics, general clinical characteristics, and treatments were retrospectively analyzed. The children were divided according to whether they underwent surgical gallbladder removal into an operation group (n = 28) and a non-operation group (n = 16), The effects of surgical gallbladder resection on the growth and development of children were analyzed.

RESULTS

The male-female ratio in the population was 6:5 and 84.09% of the children had onset in adolescence. Furthermore, 29.55% of the children were overweight or obese. The study identified 26 cases with metabolic abnormalities, 9 with hemolytic anemia, and 4 with choledochal cyst. Of the population, 68.18% had recurrent symptomatic cholecystolithiasis. Surgical treatment accounted for 63.64%, with laparoscopic cholecystectomy accounting for 71.43% of surgical treatment. No significant differences were observed in symptoms and complications between the surgery and non-surgery groups. Furthermore, no significant differences were found between the two groups in the attainment of genetic height target and the rightward shift of height curve during follow-up.

CONCLUSION

The sex characteristics of gallstones in children were not observed. Most gallstones occurred in adolescents and rarely in young children. A considerable proportion of children have inborn causes, which are often concurrent with metabolic abnormalities and hemolytic anemia. Most children had recurrent symptomatic gallstones. Surgical treatment, especially laparoscopic cholecystectomy, is still the main treatment for gallstones in children. Surgical treatment did not affect the growth and development of children who underwent gallstone removal.

Association between sarcopenia-related markers and cholelithiasis: A prospective and Mendelian randomization study

Cholelithiasis is a common digestive disease that drives a myriad of adverse complications. The correlation between sarcopenia and various digestive disorders has been extensively researched, whereas its association with cholelithiasis remains unreported. We aimed to investigate the association through prospective and Mendelian randomization (MR) analyses and establish a quantitative score reflecting the impact of sarcopenia-related markers on cholelithiasis. The prospective study involved 448 627 participants from the UK Biobank. Cox proportional hazard models were employed to investigate the correlation between sarcopenia-related markers and cholelithiasis. To quantitatively assess cholelithiasis risk, the SARCHO score was derived from a multivariable Cox model. Bidirectional two-sample MR analysis was conducted to validate the causal association. A total of 16 738 individuals developed cholelithiasis during a median follow-up of 12 years. Hazard ratios (HRs) of cholelithiasis decreased stepwise over skeletal muscle index tertiles (highest tertile: reference; middle tertile: 1.23, p < .001; lowest tertile: 1.33, p < .001). The tertiles of grip strength showed a similar pattern. Individuals with slow walking pace had a higher risk of cholelithiasis compared to those with normal walking pace (HR 1.23; p < .001). Our SARCHO score better quantifies the risk of cholelithiasis. MR analysis showed a causal relationship between muscle mass and cholelithiasis (OR 0.81; p < .001). No causal effect of cholelithiasis on lean mass was observed. Prospective and MR analyses have consistently demonstrated an increased risk of cholelithiasis in individuals with decreased muscle mass. Additionally, SARCHO score further quantified the cholelithiasis occurrence risk. These findings provide compelling evidence for muscle strengthening in preventing cholelithiasis.

Bouveret's syndrome: A rare case of gallstone causing gastric outlet obstruction

Key Clinical Message

The case highlights the importance of decisive action in addressing large gallstones causing gastric outlet obstruction. The chosen single-stage surgical approach reflects the need to manage both obstruction and the gallstone simultaneously.

Abstract

Bouveret's syndrome is a rare cause of gastric outlet obstruction secondary to gallstones entering the enteric system through an acquired cholecystoduodenal fistula. Here, we present the case of an 85-year-old female who presented to our emergency department with gastric outlet obstruction secondary to a large gallstone in the third part of the duodenum. Abdominal X-ray did not demonstrate air-fluid levels but revealed a dilated gastric shadow, suggesting gastric outlet obstruction. EGD showed a dilated stomach and a hard, golf ball-sized gallstone in the duodenum. CT scan showed a distended stomach with a large gallstone obstructing the DJ junction and air in the biliary tree. Findings were suggestive of perforation of the gallbladder with stone impaction in the duodenojejunal (DJ) junction. The patient was managed surgically with a one-stage procedure comprising enterotomy, fistula closure, and cholecystectomy. Although Bouveret's syndrome is rare, it is important for practicing surgeons to have a high index of suspicion for this condition due to the high mortality associated with it.

Safety of cholecystectomy performed by surgeons who prefer fundus first versus surgeons who prefer a standard laparoscopic approach

Background

An alternative method to standard laparoscopic cholecystectomy (SLC) is the "fundus first" method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level.

Method

In GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006-2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20-79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time.

Results

No difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14-0.86]) and gallbladder perforation (OR 0.61 [0.45-0.82]) were significantly lower in the "fundus first > 80% group" and the operative time was shorter (OR 0.76 [0.69-0.83]).

Conclusion

In this study including >160,000 cholecystectomies, both methods was found to be equally safe.

Key message

During laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

Prediction for post-ERCP pancreatitis in non-elderly patients with common bile duct stones: a cross-sectional study at a major Chinese tertiary hospital (2015-2023)

BACKGROUND

Post-ERCP pancreatitis is one of the most common adverse events in ERCP-related procedures. The purpose of this study is to construct an online model to predict the risk of post-ERCP pancreatitis in non-elderly patients with common bile duct stones through screening of relevant clinical parameters.

METHODS

A total of 919 cases were selected from 7154 cases from a major Chinese tertiary hospital. Multivariable logistic regression model was fitted using the variables selected by the LASSO regression from 28 potential predictor variables. The internal and external validation was assessed by evaluating the receiver operating characteristic curve and the area under curve. Restricted cubic spline modelling was used to explore non-linear associations. The interactive Web application developed for risk prediction was built using the R "shiny" package.

RESULTS

The incidence of post-ERCP pancreatitis was 5.22% (48/919) and significantly higher in non-elderly patients with female, high blood pressure, the history of pancreatitis, difficult intubation, endoscopic sphincterotomy, lower alkaline phosphatase and smaller diameter of common bile duct. The predictive performance in the test and external validation set was 0.915 (95% CI, 0.858-0.972) and 0.838 (95% CI, 0.689-0.986), respectively. The multivariate restricted cubic spline results showed that the incidence of pancreatitis was increased at 33-50 years old, neutrophil percentage > 58.90%, hemoglobin > 131 g/L, platelet < 203.04 or > 241.40 × 109/L, total bilirubin > 18.39 umol / L, aspartate amino transferase < 36.56 IU / L, alkaline phosphatase < 124.92 IU / L, Albumin < 42.21 g / L and common bile duct diameter between 7.25 and 10.02 mm. In addition, a web server was developed that supports query for immediate PEP risk.

CONCLUSION

The visualized networked version of the above model is able to most accurately predict the risk of PEP in non-elderly patients with choledocholithiasis and allows clinicians to assess the risk of PEP in real time and provide preventive treatment measures as early as possible.

Gastrointestinal side effects of somatostatin analogs in neuroendocrine tumors: a focused review

Neuroendocrine tumors (NETs) are a group of well-differentiated heterogeneous neoplasms characterized by slow progression and distinct clinical and biological behavior. In the majority of patients with NET, first-line treatment is represented by somatostatin analogs (SSAs) that, despite being drugs with high tolerability (even at high doses) and providing to carcinoid symptoms control and anti-proliferative effects, may present some side effects, with potential impact on quality of life and nutritional status. The most frequent side effects are represented by gastrointestinal events in particular alterations in bowel habits (diarrhea and constipation), abdominal pain, exocrine pancreatic insufficiency, and cholelithiasis. Considering the relative rarity of NETs, literature about frequency and standard clinical management of adverse events SSA-related is still lacking and heterogeneous. The aim of this review is to arm gastroenterologists and other physicians treating NET patients with essential knowledge on the side effects of SSAs. By identifying and managing these adverse events early, healthcare professionals can offer optimal care, avert foreseeable complications, and ensure the best outcomes for patients. Without such early recognition, there is a risk of diminishing the patient's quality of life and their ability to sustain treatment over time.

Association between dietary inflammatory index and gallstones in US adults

Introduction

Previous studies have found that diet's inflammatory potential is related to various diseases. However, little is known about its relationship with gallstones. The present study aims to investigate the relationship between dietary inflammatory index (DII) and gallstones.

Methods

Data were obtained from the 2003-2020 National Health and Nutrition Examination Survey (NHANES). We used the nearest neighbor propensity score matching (PSM) with a ratio of 1:1 to reduce selection bias. Logistic regression models estimated the association between DII and gallstones. The non-linear relationship was explored with restricted cubic splines (RCS). BMI subgroup stratification was performed to explore further the connection between DII and gallstones in different populations.

Results

10,779 participants were included. Before and after PSM, gallstone group individuals had higher DII scores than non-gallstone group individuals (p < 0.05). Matched logistic regression analysis showed that DII scores were positively correlated with gallstone risk (adjusted OR = 1.14, 95% CI 1.01, 1.29). The stratified analysis showed that this association was stronger in overweight or obese people (adjusted OR = 1.18, 95% CI 1.03, 1.34). RCS analysis suggested that DII and gallstones showed a "J"-shaped non-linear dose-response relationship (p non-linear <0.001).

Conclusion

Higher DII score is positively associated with the risk of gallstones, particularly in overweight or obese population, and this relationship is a "J"-shaped non-linear relationship. These results further support that avoiding or reducing a pro-inflammatory diet can be an intervention strategy for gallstone management, particularly in the overweight or obese population.

Opioid Prescribing Variation After Laparoscopic Cholecystectomy in the US Military Health System

INTRODUCTION

After laparoscopic cholecystectomy (LC), there is a wide variation in opioid prescription miligram morphine equivalent dose (MED) and refills across US medical institutions. Given wide variation and opioid prescription guidelines, it is essential to conduct thorough health services research across medical, surgical, and patient-level factors that can be implemented to improve system-wide prescribing practices. Therefore, this study describes discharge MED variation and opioid refill probability after emergent and nonemergent LC.

MATERIALS AND METHODS

This retrospective cohort study included medical record data of adult patients (N = 20,025) undergoing LC from January 2016 to June 2021 in the US Military Health System. Data visualizations and bivariate analyses examined prescription patterns across hospitals and evaluated the relationship between patient-level, care-level, and system-level factors and each outcome: discharge MED and opioid refill probability. Two generalized additive mixed models evaluated the relationship between predictors and each outcome.

RESULTS

There was a significant variation in opioid and nonopioid pain medication prescribing practices across hospitals. While several factors were associated with discharge MED and opioid refill probability, the strongest effects were related to time period (before versus after a June 2018 Defense Health Agency policy release) and receipt of an opioid/nonopioid combination medication. Despite decreases in MED, the MED remained almost twice the recommended dose per prior research.

CONCLUSIONS

Variation by hospital suggests the need for system-level changes that target genuine practice change and opioid stewardship. Inclusion of patient-reported outcomes, electronic health record decision support tools, and academic detailing programs may support system-level improvements.

Comparative Risks of Post-ERCP Adverse Events in Patients with Asymptomatic and Symptomatic Choledocholithiasis: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients.

METHODS

We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel-Haenszel method within a random-effect model.

RESULTS

Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56-4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups.

CONCLUSIONS

Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients.

The effects of pks+ Escherichia coli and bile acid in colorectal tumorigenesis among people with cholelithiasis or cholecystectomy

BACKGROUND AND AIM

Patients with cholelithiasis (CL) or cholecystectomy (CE) would have more chances of getting colorectal adenoma (CRA) or cancer (CRC). We aimed to figure out the effects of gut microbiota and bile acid on colorectal neoplasm in CL and CE patients.

METHODS

This was a retrospective observational study that recruited 514 volunteers, including 199 people with normal gallbladders (normal), 152 CL, and 163 CE patients. Discovery cohort was established to explore the difference in gut microbiota through 16S rRNA and metagenomics sequencing. Validation cohort aimed to verify the results through quantitative polymerase chain reaction (qPCR).

RESULTS

Significant enrichment of Escherichia coli was found in patients with cholelithiasis or cholecystectomy both in the discovery cohort (16S rRNA sequencing, PNormal-CL = 0.013, PNormal-CE = 0.042; metagenomics sequencing, PNormal-CE = 0.026) and validation cohort (PNormal-CL < 0.0001, PNormal-CE < 0.0001). Pks+ E. coli was found enriched in CL and CE patients through qPCR (in discovery cohort: PNormal-CE = 0.018; in validation cohort: PNormal-CL < 0.0001, PNormal-CE < 0.0001). The differences in bile acid metabolism were found both through Tax4Fun analysis of 16S rRNA sequencing (Ko00120, primary bile acid biosynthesis, PNormal-CE = 0.014; Ko00121, secondary bile acid biosynthesis, PNormal-CE = 0.010) and through metagenomics sequencing (map 00121, PNormal-CE = 0.026). The elevation of serum total bile acid of CE patients was also found in validation cohort (PNormal-CE < 0.0001). The level of serum total bile acid was associated with the relative abundance of pks+ E. coli (r = 0.1895, P = 0.0012).

CONCLUSIONS

E. coli, especially pks+ species, was enriched in CL and CE patients. Pks+ E. coli and bile acid metabolism were found associated with CRA and CRC in people after cholecystectomy.

Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones

BACKGROUND

Common bile duct (CBD) stones commonly occur in cholecystectomy cases. The management options include laparoscopic CBD exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Although ERCP is fully developed, it has complications, and LCBDE is a proven alternative. This study aimed to evaluate the safety and efficacy of these treatments in elderly individuals aged ≥70 years.

METHODS

A retrospective study between January 2015 and July 2022 included 160 elderly patients (aged ≥70 years) diagnosed with cholelithiasis and choledocholithiasis. The patients were divided into 1-stage (LCBDE [n = 80]) or 2-stage (ERCP followed by LC [n = 80]) treatment groups. Data collected encompassed comorbidities, symptoms, bile duct clearance, postoperative complications, and long-term outcomes for systematic analysis.

RESULTS

This study analyzed 160 patients treated for CBD stones, comparing 1-stage and 2-stage groups. The 1-stage group had more female patients than the 2-stage group (57.5% vs 37.5%, respectively). The 1-stage group had a mean age of 80.55 ± 7.00 years, which was higher than the mean age in the 2-stage group. American Society of Anesthesiologists classification, Charlson Comorbidity Index, and laboratory findings were similar. Pancreatitis and cholangitis occurred after ERCP in the 2-stage group. Stone clearance rates (92.35% [1-stage group] vs 95.00% [2-stage group]) and biliary leakage incidence (7.5% [1-stage group] vs 3.0% [2-stage group]) were similar, as were postoperative complications and long-term recurrence rates (13.0% [1-stage group] vs 12.5% [2-stage group]).

CONCLUSION

Our research indicates that both the combination of LCBDE and LC and the sequence of ERCP followed by LC are equally efficient and secure when treating CBD stones in elderly patients. Consequently, the 1-stage procedure may be considered the preferred treatment approach for this demographic.

Hepatolithiasis: Epidemiology, presentation, classification and management of a complex disease

The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts, above the hilar confluence of the hepatic ducts. The disease is more prevalent in Asia, mainly owing to socioeconomic and dietary factors, as well as the prevalence of biliary parasites. In the last century, owing to migration, its global incidence has increased. The main pathophysiological mechanisms involve cholangitis, bile infection and biliary strictures, creating a self-sustaining cycle that perpetuates the disease, frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of "recurrent pyogenic cholangitis". Furthermore, long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma. Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment. The management of symptomatic patients and those with complications can be complex, and relies upon a multidisciplinary team of hepatologists, endoscopists, interventional radiologists and hepatobiliary surgeons, with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications. This comprehensive review provides insight on various aspects of hepatolithiasis, with a focus on epidemiology, new evidence on pathophysiology, most important clinical aspects, different classification systems and contemporary management.

The association between trajectory of serum cholesterol, statin dosage, and the risk of recurrent biliary stone diseases

BACKGROUND

Statins may reduce the risk of recurrent gallstone disease by decreasing bile cholesterol saturation and pathogenicity. However, limited studies have investigated this issue. This study aimed to assess whether statin doses and serum cholesterol levels were associated with a decreased risk of recurrent biliary stone diseases after the first event index, with a follow-up time of 15 years.

METHODS

Based on the Chang Gung Research Database (CGRD) between January 1, 2001, and December 31, 2020, we enrolled 68,384 patients with the International Classification of Diseases, Ninth and Tenth Revision codes of choledocholithiasis. After exclusions, 32,696 patients were divided into non-statin (<28 cDDD, cumulative defined daily doses) (n = 27,929) and statin (≥28 cDDD) (n = 4767) user groups for analysis. Serum cholesterol trajectories were estimated using group-based trajectory modeling (n = 8410).

RESULTS

The statin users had higher Charlson Comorbidity Index (CCI) scores than the non-statin users. Time-dependent Cox regression analysis showed that statin use >365 cDDD was associated with a significantly lower risk of recurrent biliary stones (adjusted hazard ratio [aHR] = 0.28, 95% CI, 0.24-0.34; p < 00.0001), acute pancreatitis (aHR = 0.24, 95% CI, 0.17-0.32, p < 00.0001), and cholangitis (aHR = 0.28, 95% CI, 0.25-0.32, p < 00.0001). Cholecystectomy was also a protective factor for recurrent biliary stones (aHR = 0.41, 95% CI, 0.37-0.46; p < 00.0001). The higher trajectory serum cholesterol group (Group 3) had a lower risk trend for recurrent biliary stones (aHR = 0.79, p = 0.0700) and a lower risk of cholangitis (aHR = 0.79, p = 0.0071).

CONCLUSION

This study supports the potential benefits of statin use and the role of cholecystectomy in reducing the risk of recurrent biliary stone diseases.

The association between intakes of dietary trace minerals and gallstone disease: A cross-sectional study from National Health and Nutrition Examination Survey 2017 to 2018

The gallstone disease is becoming increasingly prevalent worldwide. Dietary trace minerals have been proven to be closely related to many metabolic diseases, and this study aims to explore the association between intakes of dietary trace minerals (copper, iron, selenium, and zinc) and gallstone disease (GSD). Using the National Health and Nutrition Examination Survey (NHANES) from 2017 to 2018, intakes of dietary trace minerals and GSD data were obtained through a 24-hour recall and diagnostic questionnaire, respectively. Weighted logistic regression models were used to identify the association between intakes of dietary trace minerals and the prevalence of GSD, and the results were presented as odds ratios (OR) and 95% confidence intervals (95% CI). A total of 4077 participants were included in the final analysis, of which 456 participants had GSD and 3621 participants serving as the control group. No significant associations between GSD and intakes of dietary trace minerals (iron, selenium, and zinc) were found. However, after adjusting for all covariates, significant association was demonstrated between dietary copper (Cu) intake and GSD (OR = 0.66, 95% CI = 0.45-0.98). After conducting a weighted quantile logistic regression, a significant negative correlation was also found between dietary Cu intake and highest GSD quartile (Q4) (OR = 0.45, 95% CI = 0.26-0.80). Following the research outlined above, no association was found between intakes of dietary trace minerals (iron, selenium, and zinc) and GSD; however, a linear negative association was identified between dietary Cu intake and GSD.

Application of Data Mining Technology in the Screening for Gallbladder Stones: A Cross-Sectional Retrospective Study of Chinese Adults

PURPOSE

The purpose of this study was to use data mining methods to establish a simple and reliable predictive model based on the risk factors related to gallbladder stones (GS) to assist in their diagnosis and reduce medical costs.

MATERIALS AND METHODS

This was a retrospective cross-sectional study. A total of 4215 participants underwent annual health examinations between January 2019 and December 2019 at the Physical Examination Center of Shengjing Hospital Affiliated to China Medical University. After rigorous data screening, the records of 2105 medical examiners were included for the construction of J48, multilayer perceptron (MLP), Bayes Net, and Naïve Bayes algorithms. A ten-fold cross-validation method was used to verify the recognition model and determine the best classification algorithm for GS.

RESULTS

The performance of these models was evaluated using metrics of accuracy, precision, recall, F-measure, and area under the receiver operating characteristic curve. Comparison of the F-measure for each algorithm revealed that the F-measure values for MLP and J48 (0.867 and 0.858, respectively) were not statistically significantly different (p>0.05), although they were significantly higher than the F-measure values for Bayes Net and Naïve Bayes (0.824 and 0.831, respectively; p<0.05).

CONCLUSION

The results of this study showed that MLP and J48 algorithms are effective at screening individuals for the risk of GS. The key attributes of data mining can further promote the prevention of GS through targeted community intervention, improve the outcome of GS, and reduce the burden on the medical system.

The Accuracy of Point-of-Care Ultrasound in the Detection of Gallbladder Disease: A Meta-analysis

RATIONALE AND OBJECTIVES

The aim of this meta-analysis was to systematically assess the diagnostic value of point of care ultrasound (POCUS) in the detection of gallbladder diseases.

MATERIALS AND METHODS

Pubmed, Web of Science, Embase, and the Cochrane Library were searched for studies up to May 22, 2023. Pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio, diagnostic odds ratio, area under the curve of summary receiver operating characteristic were calculated using the bivariate model. Subgroup analysis based on cholecystitis and cholelithiasis was conducted.

RESULTS

A total of seven studies with 1464 participants were identified in this meta-analysis. The pooled sensitivity of POCUS for the detection of gallbladder disease was 0.86 (95% CI: 0.75, 0.93) and the pooled specificity was 0.92 (95% CI: 0.87, 0.96). The pooled sensitivity and specificity of POCUS for the detection of acute cholecystitis were 0.73 (95% CI: 0.55, 0.86) and 0.93 (95% CI: 0.82, 0.98). The pooled sensitivity and specificity of POCUS for the detection of gallstones were 0.94 (95% CI: 0.91, 0.96) and 0.93 (95% CI: 0.91, 0.95).

CONCLUSION

POCUS was a favorable modality for the detection of patients suspected of gallbladder disease, especially for cholelithiasis. Physicians are advised to use POCUS in clinical practice as a non-invasive test to detect gallbladder disease.

Feasibility and safety of intraoperative bile duct clearance by antegrade transcystic balloon sphincteroplasty: A prospective observational pilot study

BACKGROUND

Concomitant cholecystolithiasis and choledocholithiasis are common. Standard treatments are endoscopic retrograde cholangiography (ERC) followed by cholecystectomy or laparoendoscopic rendezvous. Endoscopic retrograde cholangiography has drawbacks, such as post-ERC pancreatitis or bleeding, and potentially more than one intervention is required to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with balloon sphincteroplasty and pushing of stones to the duodenum has not been evaluated prospectively. The aim of this pilot study was to evaluate this procedure regarding safety, feasibility, and stone clearance rate.

METHODS

Prospective single-center intervention study (SUPER Reporting-Guideline). Main inclusion criterion was confirmed choledocholithiasis (stones ≤6 mm) at intraoperative cholangiography. Success of the procedure was defined as CBD stone clearance at intraoperative control cholangiography, absence of symptoms and no elevated cholestasis parameters at 6 weeks follow-up. Simon's two-stage design was used to determine sample size.

RESULTS

From January 2021 to April 2022, a total of 57 patients fulfilled the final inclusion criteria and were included. Mild pancreatitis or cholangitis were present upon admission in 15 (26%) and 15 (26%) patients, respectively. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Common bile duct stone clearance was achieved in 54 patients (94%). The main reason for failed CBD clearance was the inability to push the guidewire along the biliary stone into the duodenum. Median intervention time was 28 minutes (14-129 minutes). While there was no postoperative pancreatitis, two patients (3.5%) had asymptomatic hyperlipasemia 4 hours postoperatively.

CONCLUSION

Intraoperative CBD stone clearance by antegrade balloon sphincteroplasty appears to be safe and highly feasible. Its overall superiority to the current standards warrants evaluation by a randomized controlled trial.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level V.

Mendelian randomization study on the causal relationship between food and cholelithiasis

Background

Cholelithiasis, commonly referred to as gallstones, is a prevalent medical condition influenced by a combination of genetic factors, lifestyle choices, and dietary habits. Specific food items have been associated with an increased susceptibility to cholelithiasis, whereas others seem to offer a protective effect against its development.

Methods

In this study, we conducted a Mendelian randomization (MR) analysis using a large-scale genetic dataset comprising individuals with European ancestry to explore the potential causal relationship between diet and cholelithiasis. The analysis incorporated 17 food-related variables, which were considered as potential factors influencing the occurrence of this condition.

Results

Our findings indicate that a higher consumption of cooked vegetables, dried fruit, and oily fish is associated with a reduced risk of cholelithiasis. Conversely, a higher consumption of lamb is associated with an increased risk of developing the condition. Importantly, these associations proved robust to sensitivity and heterogeneity tests, and the pleiotropic test results further supported the hypothesis of a causal relationship between diet and cholelithiasis.

Conclusion

Through our study, we provide compelling evidence for the existence of a causal relationship between diet and cholelithiasis. Adopting a dietary pattern enriched with cooked vegetables, dried fruit, and oily fish, while minimizing lamb intake, may contribute to the prevention of cholelithiasis. Recognizing diet as a modifiable risk factor in the prevention and management of this condition is of paramount importance, and our study offers valuable insights in this regard.

Antiobesity pharmacotherapy to facilitate living kidney donation

Obesity is a chronic, relapsing disease that increases the risks of living kidney donation; at the same time, transplant centers have liberalized body mass index constraints for donors. With the increasing number of antiobesity medications available, the treatment of obesity with antiobesity medications may increase the pool of potential donors and enhance donor safety. Antiobesity medications are intended for long-term use given the chronic nature of obesity. Cessation of treatment can be expected to lead to weight regain and increase the risk of comorbidity rebound/development. In addition, antiobesity medications are meant to be used in conjunction with-rather than in replacement of-diet and physical activity optimization. Antiobesity medication management includes selecting medications that may ameliorate any coexisting medical conditions, avoiding those that are contraindicated in such conditions, and being sensitive to any out-of-pocket expenses that may be incurred by the potential donor. A number of questions remain regarding who will and should shoulder the costs of long-term obesity treatment for donors. In addition, future studies are needed to quantify the degree of weight loss and duration of weight loss maintenance needed to normalize the risk of adverse kidney outcomes relative to comparable nondonors and lower-weight donors.

A Surgeon's Challenge: Diagnosing and Managing Hidden Bile Duct Stones Post-cholecystectomy

This case report details the diagnostic and management challenges encountered with hidden bile duct stones post-cholecystectomy in a 58-year-old female patient. Despite a successful laparoscopic cholecystectomy, the patient developed sudden upper abdominal pain and jaundice, leading to the discovery of an impacted bile duct stone. The case underscores the limitations of conventional preoperative diagnostics and highlights the importance of advanced imaging techniques and a multidisciplinary approach for optimal outcomes. The successful extraction of the stone via endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy demonstrates the efficacy of this therapeutic strategy. This report emphasizes the need for heightened vigilance and comprehensive evaluation in the postoperative management of gallstone disease, contributing valuable insights into the complexities of choledocholithiasis post-cholecystectomy.

CLINICAL AND PATHOLOGIC FINDINGS IN IGUANIDS WITH SODIUM URATE CHOLELITHIASIS

Four green iguanas (Iguana iguana) and one blue iguana (Cyclura lewisi) from five facilities were diagnosed with sodium urate cholelithiasis. One case was diagnosed antemortem via ultrasonography, and the iguana underwent a choledochotomy for treatment. The other four cases were identified at necropsy. Pathologic hepatic and biliary changes were present in four of the five cases at necropsy. Histologically, four iguanas had hepatic fibrosis, three had bile duct hyperplasia, and one had cholangiohepatitis and pancreaticocholedochitis. Two iguanas had pathologic renal changes. This is the first report of sodium urate cholelithiasis in reptiles. This case series highlights the potential significant clinical disease caused by sodium urate cholelithiasis and the importance of biliary system evaluation. Further investigation is recommended to explore the pathogenesis of reptilian sodium urate cholelith formation.

Outcomes of laparoscopic choledochotomy using cholangioscopy via percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis: A preliminary Vietnamese study

Backgrounds/Aims

Hepatolithiasis and choledocholithiasis are frequent pathologies and unfortunately, with the current treatment strategies, the recurrence incidence is still high. This study aimed to assess the outcomes of laparoscopic choledochotomy using cholangioscopy via the percutaneous-choledochal tube for the treatment of hepatolithiasis and choledocholithiasis in Vietnamese patients.

Methods

A cross-sectional study of patients with hepatolithiasis and/or choledocholithiasis who underwent laparoscopic choledochotomy using intraoperative cholangioscopy via percutaneous-choledochal tube at the Department of Hepatopancreatobiliary Surgery, 108 Military Central Hospital, from June 2017 to March 2020.

Results

A total of 84 patients were analyzed. Most patients were females (56.0%) with a median age of 55.56 years. Among them, 41.8% of patients had previous abdominal operations, with 33.4% having choledochotomy. All patients underwent successful laparoscopic common bile duct exploration followed by T-tube drainage without needing to convert to open surgery. Most patients (64.3%) had both intrahepatic and extrahepatic stones. The rate of stones ≥ 10 mm in diameter was 64.3%. Biliary strictures were observed in 19.1% of patients during cholangioscopy. Complete removal of stones was achieved in 54.8% of patients. Intraoperative complications were encountered in two patients, but there was no need to change the strategy. The mean operating time was 121.85 ± 30.47 minutes. The early postoperative complication rate was 9.6%, and all patients were managed conservatively. The residual stones were removed through the T-tube tract by subsequent choledochoscopy in 34/38 patients, so the total success rate was 95.2%.

Conclusions

Laparoscopic choledochotomy combined with cholangioscopy through the percutaneous-choledochal tube is a safe and effective strategy for hepatolithiasis and/or choledocholithiasis, even in patients with a previous choledochotomy.

Can Lipid-Lowering Drugs Reduce the Risk of Cholelithiasis? A Mendelian Randomization Study

Background and Aims

Cholelithiasis etiology intricately involves lipid metabolism. We sought to investigate the plausible causal link between genetically proxied lipid-lowering medications-specifically HMGCR inhibitors, PCSK9 inhibitors, and NPC1L1 inhibitors-and cholelithiasis risk.

Methods

Our study utilized two genetic instruments for exposure to lipid-lowering drugs. These instruments encompassed genetic variants linked to low-density lipoprotein (LDL) cholesterol within or in proximity to drug target genes, along with loci governing gene expression traits of these targets. Effect estimates were derived through Inverse-variance-weighted MR (IVW-MR) and summary-data-based MR (SMR) methods.

Results

Higher HMGCR-mediated LDL cholesterol levels (IVW-MR, OR = 2.15, 95% CI = 1.58-2.94; P = 0.000) and increased HMGCR expression (SMR, OR = 1.19, 95% CI = 1.04-1.37; P = 0.014) are linked to elevated cholelithiasis risk, suggesting potential benefits of HMGCR inhibition. In contrast, higher PCSK9-mediated LDL cholesterol levels (IVW-MR, OR = 0.72, 95% CI = 0.56-0.94; P = 0.015) and increased PCSK9 expression (SMR, OR = 0.90, 95% CI = 0.82-0.99; P = 0.035) both correlate with lower cholelithiasis risk, indicating that PCSK9 inhibition may elevate this risk. Nevertheless, no substantial link emerged between NPC1L1-mediated LDL cholesterol or NPC1L1 expression and cholelithiasis in both IVW-MR and SMR analyses.

Conclusion

This MR investigation affirms the causal link between the utilization of HMGCR inhibitors and a diminished risk of cholelithiasis. Additionally, it indicates a causal link between PCSK9 inhibitors use and increased cholelithiasis risk. However, no significant correlation was found between NPC1L1 inhibitors use and cholelithiasis risk.

Modified dietary fat intake for treatment of gallstone disease in people of any age

BACKGROUND

The prevalence of gallstones varies between less than 1% and 64% in different populations and is thought to be increasing in response to changes in nutritional intake and increasing obesity. Some people with gallstones have no symptoms but approximately 2% to 4% develop them each year, predominantly including severe abdominal pain. People who experience symptoms have a greater risk of developing complications. The main treatment for symptomatic gallstones is cholecystectomy. Traditionally, a low-fat diet has also been advised to manage gallstone symptoms, but there is uncertainty over the evidence to support this.

OBJECTIVES

To evaluate the benefits and harms of modified dietary fat intake in the treatment of gallstone disease in people of any age.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE ALL Ovid, Embase Ovid, and three other databases to 17 February 2023 to identify randomised clinical trials in people with gallstones. We also searched online trial registries and pharmaceutical company sources, for ongoing or unpublished trials to March 2023.

SELECTION CRITERIA

We included randomised clinical trials (irrespective of language, blinding, or status) in people with gallstones diagnosed using ultrasonography or conclusive imaging methods. We excluded participants diagnosed with another condition that may compromise dietary fat tolerance. We excluded trials where data from participants with gallstones were not reported separately from data from participants who did not have gallstones. We included trials that investigated other interventions (e.g. trials of drugs or other dietary (non-fat) components) providing that the trial groups had received the same proportion of drug or other dietary (non-fat) components in the intervention.

DATA COLLECTION AND ANALYSIS

We intended to undertake meta-analysis and present the findings according to Cochrane recommendations. However, as we identified only five trials, with data unsuitable and insufficient for analyses, we described the data narratively.

MAIN RESULTS

We included five trials but only one randomised clinical trial (69 adults), published in 1986, reported outcomes of interest to the review. The trial had four dietary intervention groups, three of which were relevant to this review. We assessed the trial at high risk of bias. The dietary fat modifications included a modified cholesterol intake and medium-chain triglyceride supplementation. The control treatment was a standard diet. The trial did not report on any of the primary outcomes in this review (i.e. all-cause mortality, serious adverse events, and health-related quality of life). The trial reported on gallstone dissolution, one of our secondary outcomes. We were unable to apply the GRADE approach to determine certainty of evidence because the included trial did not provide data that could be used to generate an estimate of the effect on this or any other outcome. The trial expressed its finding as "no significant effect of a low-cholesterol diet in the presence of ursodeoxycholic acid on gallstone dissolution." There were no serious adverse events reported. The included trial reported that they received no funding that could bias the trial results through conflicts of interest. We found no ongoing trials.

AUTHORS' CONCLUSIONS

The evidence about the effects of modifying dietary fat on gallstone disease versus standard diet is scant. We lack results from high-quality randomised clinical trials which investigate the effects of modification of dietary fat and other nutrient intakes with adequate follow-up. There is a need for well-designed trials that should include important clinical outcomes such as mortality, quality of life, impact on dissolution of gallstones, hospital admissions, surgical intervention, and adverse events.

The gut microbiome predicts response to UDCA/CDCA treatment in gallstone patients: comparison of responders and non-responders

The treatment of gallbladder (GB) stones depends on condition severity. Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (CDCA) are commonly used to treat GB stones, but the factors affecting response rates have not been fully identified. Therefore, we investigated the relationship between response to UDCA/CDCA treatment and changes in the gut microbiomes of patients with GB stones with the intention of identifying gut microbiomes that predict susceptibility to UDCA/CDCA treatment and treatment response. In this preliminary, prospective study, 13 patients with GB stones were treated with UDCA/CDCA for 6 months. Patients were classified into responder and non-responder groups based on treatment outcomes. Gut microbiomes were analyzed by 16S rDNA sequencing. Taxonomic compositions and abundances of bacterial communities were analyzed before and after UDCA/CDCA treatment. Alpha and beta diversities were used to assess similarities between organismal compositions. In addition, PICRUSt2 analysis was conducted to identify gut microbial functional pathways. Thirteen patients completed the treatment; 8 (62%) were assigned to the responder group and the remainder to the non-responder group. Low abundances of the Erysipelotrichi lineage were significantly associated with favorable response to UDCA/CDCA treatment, whereas high abundances of Firmicutes phylum indicated no or poor response. Our results suggest that a low abundance of the Erysipelotrichi lineage is significantly associated with a favorable response to UDCA/CDCA and that a high abundance of Firmicutes phylum is indicative of no or poor response. These findings suggest that some gut microbiomes are susceptible to UDCA/CDCA treatment and could be used to predict treatment response in patients with GB stones.

Higher levels of systemic immune-inflammatory index are associated with the prevalence of gallstones in people under 50 years of age in the United States: a cross-sectional analysis based on NHANES

Introduction

Inflammation plays a significant role in gallstones formation. The prognosis of various illnesses was initially predicted using the systemic immune-inflammatory index (SII). We performed an updated analysis on the impact of SII and gallstones.

Methods

To investigate the connection between the SII and gallstones occurrence in a sample of individuals from the National Health and Nutrition Examination Survey (NHANES) database from 2017 to 2020, we employed logistic regression analysis, subgroup analysis, and smoothing curve fitting.

Results

In our study, an aggregate of 4,950 individuals over the age of 20 were enrolled, and 429 of them claimed to have gallstones. A fully adjusted model showed that the third and fourth quartiles of SII was parallel associated with gallstones in adults (OR = 2.43, 95% CI = 1.39-4.26; OR = 2.97, 95% CI = 1.72-5.16) under 50 years. Subgroup analysis and smoothed curve fitting provided evidence in favor of this finding.

Conclusion

According to our research, gallstones are more likely to occur in US adults younger than 50 years.

Clinical application of magnetic anchor technique in laparoscopic cholecystectomy: the first retrospective study in China

Background and objectives

Magnetic anchor technique (MAT) is frequently used in laparoscopic cholecystectomy. However, there are few reports on its clinical application in China. In this study, we retrospectively analyzed the clinical application of MAT in laparoscopic cholecystectomy in China.

Materials and methods

25 patients (4 males, 21 females) who underwent laparoscopic cholecystectomy assisted by MAT at the First Affiliated Hospital of Xi'an Jiaotong University were enrolled from November 2020 to March 2021. Their records were retrospectively analyzed. The magnetic anchor device was independently designed and developed by the authors and consisted of the anchor magnet and magnetic grasping apparatus. Surgical time, intraoperative blood loss, intraoperative accidents, operator experience, postoperative incision pain score, postoperative complications, and other indicators were evaluated and analyzed.

Results

All patients successfully underwent laparoscopic cholecystectomy, including 3 cases of MAT-assisted transumbilical single-port LC, 16 cases of MAT-assisted 2-port LC and 6 cases of conventional 3-port LC. The median operation time was 50 min (range 30-95 min); intraoperative bleeding was less than 30 ml. The median score of surgical incision on day 1 and 3 after the operation was 3 (range 1-4) and 1 (range 1-3), respectively. All patients had no intraoperative bile duct injury, vascular injury, postoperative bleeding, bile leakage, biliary stricture and other complications. No adverse events (such as injury to adjacent organs or failure of the magnetic anchor device) occurred either during or after the operation.

Conclusions

The MAT-assisted laparoscopic cholecystectomy appears to be safe, feasible and effective and exhibits unique assistance in transumbilical single-port laparoscopic cholecystectomy.

Cholecystectomy and ERCP in pregnancy: a nationwide register-based study

OBJECTIVE

The objective was to examine the outcomes of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy and compare these outcomes with those in nonpregnant women of fertile age.

SUMMARY BACKGROUND DATA

Although both laparoscopic cholecystectomy and ERCP are considered safe and feasible in pregnant patients, there is still concern and uncertainty regarding gallstone intervention during pregnancy. This study aimed to investigate outcomes in pregnant patients compared to outcomes in nonpregnant patients.

METHODS

Data on all female patients aged 18-45 years were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography. The patients were divided into groups according to intervention: cholecystectomy, ERCP, or a combination thereof. Differences between pregnant and nonpregnant patients were analyzed.

RESULTS

A total of 21 328 patients were included, with 291 cholecystectomy and 63 ERCP procedures performed in pregnant patients. At the 30-day follow-up, more complications after cholecystectomy were registered for pregnant patients. However, pregnancy was not a significant risk factor for adverse events when adjusting for previous complicated gallstone disease, intraoperative complications, emergency surgery, and common bile duct stones. There were no differences in outcomes when comparing cholecystectomy among the different trimesters. ERCP had no significant effect on outcomes at the 30-day follow-up.

CONCLUSION

Cholecystectomy, ERCP, and combinations thereof are safe during pregnancy.

Referral practices are associated with a delay in treatment of symptomatic cholelithiasis and cholecystitis

BACKGROUND

The project was performed to determine if referrals to non-surgical providers after an initial presentation of symptomatic cholelithiasis are associated with a delay in surgical management.

METHODS

A single institution chart review of all adult patients who underwent a cholecystectomy from 2015 to 2019 was completed. Quantitative data was analyzed using independent t-tests.

RESULTS

Of 574 reviewed, 482 patients met criteria. Following initial presentation, 295 (61.2%) received a referral to surgery and 187 (38.8%) received follow up with a non-surgical provider. Those in the latter group had a significantly longer time from initial symptom presentation to surgical evaluation (65.7 days vs. 10.3 days, p ​< ​0.001) and cholecystectomy (102.0 days vs 39.1 days, p ​< ​0.001) when compared to the surgery referral group.

CONCLUSIONS

This study demonstrated that cholecystectomy was significantly delayed for patients who had been referred to non-surgical providers after initial presentation, prolonging symptoms and increasing use of healthcare resources.

Systematic Appraisal of Guidelines for the Diagnosis and Treatment of Choledocholithiasis

BACKGROUND

To systematically evaluate the methodological quality of the current up-to-date guidelines pertaining to choledocholithiasis, we conducted a comprehensive analysis of key recommendations and corresponding evidence, focusing on the heterogeneity among these guidelines.

METHOD

Systematic searches across various databases were performed to identify the latest guidelines. The identified guidelines, which met the inclusion criteria, underwent evaluation using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The key recommendations and evidence from the included guidelines were extracted and reclassified using the Oxford Centre for Evidence-Based Medicine (OCEBM) grading system, and the obtained results were analyzed.

RESULTS

Nine guidelines related to choledocholithiasis were included in this study, out of which 4 achieved an overall standardized score of more than 60%, indicating their suitability for recommendation. Upon closer examination of the main recommendations within these guidelines, we discovered significant discrepancies concerning the utilization of similar treatment techniques for different diseases or different treatment methods under comparable conditions, and discrepancies in the recommended treatment duration. High-quality research evidence was lacking, and some recommendations either failed to provide supporting evidence or cited inappropriate and low-level evidence.

CONCLUSION

The quality of guidelines pertaining to choledocholithiasis is uneven. Recommendations for the treatment of choledocholithiasis demonstrate considerable disparities among the guidelines, particularly regarding the utilization of endoscopic retrograde cholangiopancreatography as a treatment method and the management approaches for difficult stone cases. Improvements by guideline developers for these factors contributing to the heterogeneity would be a reasonable approach to further update the guidelines for cholangiolithiasis.

Prevalence and clinical relevance of cholelithiasis in cats: A multicenter retrospective study of 98 cases

BACKGROUND

Cholelithiasis is an uncommon and mainly incidental finding in dogs; current literature on this topic is scarce in cats.

HYPOTHESIS

Report prevalence, clinical presentation, management, and outcome of cholelithiasis in cats.

ANIMALS

Ninety-eight cats with cholelithiasis.

METHODS

Retrospective multicenter case series. Electronic databases from 3 hospitals were searched for cats diagnosed with cholelithiasis by ultrasonography (US). Cholelithiasis was classified as incidental (IC) or symptomatic (SC) depending on clinicopathological signs, biliary tract US appearance, and presence of another disease potentially explaining the clinical presentation. Multivariate analysis was used to investigate factors associated with clinical expression of cholelithiasis and, within the SC group, survival.

RESULTS

The observed prevalence of cholelithiasis was 0.99% (95% confidence interval [CI], 0.79%-1.19%) among cats that underwent abdominal US. Cholelithiasis was classified as IC in 41% and SC in 59%. Choleliths found in multiple locations within the biliary tract (odds ratio [OR], 8.11; 95% CI, 2.32-34.15; P = .001) or associated with US signs of obstruction (OR, 18.47; 95% CI, 2.13-2413.34; P = .004) were significantly associated with SC. Concurrent hepatobiliary diseases were suspected or confirmed in 83% of cases with SC. Forty-three cats (74%) with SC survived to discharge. Biliary tract obstruction (BTO) was negatively associated with survival (OR, 13.87; 95% CI, 1.54-124.76; P = .001). None of the cats with IC that had available follow-up (47%) developed clinicopathological signs related to cholelithiasis.

CONCLUSIONS AND CLINICAL IMPORTANCE

Cholelithiasis is uncommon and can be asymptomatic in cats. Symptomatic cholelithiasis frequently is associated with another hepatobiliary disease or BTO or both. Biliary tract obstruction is associated with poorer outcome.

Abdominal obesity mediates the causal relationship between depression and the risk of gallstone disease: retrospective cohort study and Mendelian randomization analyses

OBJECTIVE

Our study aimed to explore the causal effect of depression on the risk of gallstone disease, and the mediation effects of metabolic traits.

METHODS

A retrospective cohort study on Chinese elderly from the Dongfeng-Tongji cohort (including 18,141 individuals) was conducted to estimate the adverse effect of probable depression on the risk of gallstone disease. Two-sample Mendelian randomization was performed in European and East-Asian ancestries, to verify the causal relationship between major depression and gallstone disease. We further applied two-step Mendelian randomization to explore the mediation effects of metabolic traits.

RESULTS

In the cohort study, probable depression was associated with an increased risk of gallstone disease within 5 years, with RR (95% CI) of 1.33 (1.12, 1.58) in multivariable regression, and 1.34 (1.11, 1.61) following propensity score weighting. Bidirectional Mendelian randomization in European ancestry revealed a positive causal effect (OR: 1.21; 95% CI: 1.07 to 1.37) of genetically predicted major depression liability on gallstone disease, based on the inverse variance weighted method. Little evidence was presented from other complementary approaches, and the analysis in East-Asian ancestry (IVW estimated OR: 1.03; 95% CI: 0.92 to 1.15). The indirect effect via waist circumference and HDL-C were 1.06 (95% CI: 1.02 to 1.10) and 1.01 (95% CI: 1.00 to 1.01) respectively, which mediated 25.8% and 3.78% of the causal relationship.

CONCLUSIONS

Our study suggested a higher risk of gallstone disease in the population with probable depression, while the two-sample Mendelian randomization provided weak evidence for the causal relationship, which was moderately mediated by abdominal obesity.

Causal effect of gallstone disease on the risk of coronary heart disease or acute myocardial infarction: a Mendelian randomization study

Gallstone disease (GSD) is thought to be associated with the risk of coronary heart disease (CHD) or acute myocardial infarction (AMI), which may be due to abnormal cholesterol metabolism. We used multiple Mendelian randomization (MR) methods based on publicly available genome-wide association study data to assess whether this association is genetically causal and to search for loci driving causality. Pooled data for GSD were obtained from FinnGen Biobank and Biobank Japan, while CHD and AMI were obtained as pooled data from the CARDIoGRAMplusC4D consortium. In this MR study, we found a significant negative causal effect of genetic susceptibility to GSD on AMI in the Finnish population, but no causal effect was found on CHD. This causal effect was not confounded by reverse causality and the same findings were obtained in the Japanese population. Furthermore, the negative causal effect of GSD on AMI risk may be driven by the rs4245791-regulated ABCG5/8 protein. In conclusion, the results of this MR study support a negative causal effect of GSD on AMI and suggest that rs4245791 is the causal driver locus of this effect, which provides new ideas and evidence for the prevention and etiologic study of AMI in patients with GSD.

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.

Learning curve of laparoscopic cholecystectomy: a risk-adjusted cumulative summation (RA-CUSUM) analysis of six general surgery residents

BACKGROUND

Laparoscopic cholecystectomy (LapC) is one of the most frequently performed surgical procedures worldwide. Reaching technical competency in performing LapC is considered one essential task for young surgeons. Investigating the learning curve for LapC (LC-LapC) may provide important information regarding the learning process and guide the training pathway of residents, improving educational outcomes. The present study aimed to investigate LC-LapC among general surgery residents (GSRs).

METHODS

Operative surgical reports of consecutive patients undergoing LapC performed by GSRs attending the General Surgery Residency Program at the University of Milan were analysed. Data on patient- and surgery-related variables were obtained from the ICD-9-CM diagnosis codes and gathered. A multidimensional assessment of the LC was performed through Cumulative Sum (CUSUM) and Risk-Adjusted (RA)-CUSUM analysis.

RESULTS

340 patients operated by 6 GSRs were collected. The CUSUM and RA-CUSUM graphs based on surgical failures allowed to distinguish two defined phases for all GSRs: an initial phase ending at the peak, so-called learning phase, followed by a phase in which there was a significant decrease in failure incidence, so-called proficiency phase. The learning phase was completed for all GSRs at most within 25 procedures, but the trend of the curves and the number of procedures needed to achieve technical competency varied among operators ranging between 7 and 25.

CONCLUSIONS

The present study suggested that at most 25 procedures might be sufficient to acquire technical competency in LapC. The variability in the number of procedures needed to complete the LC, ranging between 7 and 25, could be due to the heterogeneous scenarios in which LapC was performed, and deserves to be investigated through a prospective study involving a larger number of GSRs and institutions.

Pancreatitis Prevention in Tabuk City, Kingdom of Saudi Arabia: Evaluating Public Knowledge and Raising Awareness of Risk Factors and Symptoms

INTRODUCTION

Pancreatitis is an inflammation of the pancreas. The pancreas is a flat, elongated gland situated in the upper abdomen, beyond the stomach. It produces digestive enzymes and hormones that regulate glucose absorption in the body. Pancreatitis can be acute, developing rapidly and lasting for several days, or chronic, persisting over an extended period and affecting specific individuals. While treatment can improve mild cases of pancreatitis, severe cases can be fatal.

METHOD

This study utilizes a cross-sectional survey design with 549 participants, allowing data collection from a representative sample of Tabuk City's adult population.

RESULTS

The participants' knowledge about the risk factors and symptoms of pancreatitis was inadequate. Among those who did not receive any information about pancreatitis and its risk factors, the count was 352 (64.1%). On the other hand, there was increased awareness of pancreatitis and its risk factors, which would lead to early detection and prevention. A total of 483 participants (88%) expressed adequate agreement, and 305 participants (55.6%) demonstrated an adequate response regarding seeking medical attention if they experienced any symptoms of pancreatitis.

CONCLUSION

Our findings revealed a lack of knowledge about the risk factors and symptoms of pancreatitis. Furthermore, there was inadequate awareness regarding governmental initiatives or programs that support access to pancreatitis knowledge and awareness in Tabuk City.

Invalidity of Tokyo guidelines in acute biliary pancreatitis: A multicenter cohort analysis of 944 pancreatitis cases

BACKGROUND

There is a noteworthy overlap between the clinical picture of biliary acute pancreatitis (AP) and the 2018 Tokyo guidelines currently used for the diagnosis of cholangitis (AC) and cholecystitis (CC). This can lead to significant antibiotic and endoscopic retrograde cholangiopancreatography (ERCP) overuse.

OBJECTIVES

We aimed to assess the on-admission prevalence of AC/CC according to the 2018 Tokyo guidelines (TG18) in a cohort of biliary AP patients, and its association with antibiotic use, ERCP and clinically relevant endpoints.

METHODS

We conducted a secondary analysis of the Hungarian Pancreatic Study Group's prospective multicenter registry of 2195 AP cases. We grouped and compared biliary cases (n = 944) based on the on-admission fulfillment of definite AC/CC according to TG18. Aside from antibiotic use, we evaluated mortality, AC/CC/AP severity, ERCP performance and length of hospitalization. We also conducted a literature review discussing each criteria of the TG18 in the context of AP.

RESULTS

27.8% of biliary AP cases fulfilled TG18 for both AC and CC, 22.5% for CC only and 20.8% for AC only. Antibiotic use was high (77.4%). About 2/3 of the AC/CC cases were mild, around 10% severe. Mortality was below 1% in mild and moderate AC/CC patients, but considerably higher in severe cases (12.8% and 21.2% in AC and CC). ERCP was performed in 89.3% of AC cases, common bile duct stones were found in 41.1%.

CONCLUSION

Around 70% of biliary AP patients fulfilled the TG18 for AC/CC, associated with a high rate of antibiotic use. Mortality in presumed mild or moderate AC/CC is low. Each of the laboratory and clinical criteria are commonly fulfilled in biliary AP, single imaging findings are also unspecific-AP specific diagnostic criteria are needed, as the prevalence of AC/CC are likely greatly overestimated. Randomized trials testing antibiotic use are also warranted.

Diagnostic performance of laparoscopic transcystic common bile duct exploration for the detection of choledocholithiasis in patients with negative MRCP

There is little research to evaluate laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) as a diagnostic test to identify choledocholithiasis undergoing laparoscopic cholecystectomy (LC). This study aimed to assess the technical success and safety of LTCBDE in patients with suspected choledocholithiasis but negative magnetic resonance cholangiopancreatography (MRCP) undergoing LC. We did an ambispective cohort study in patients with gallstones and suspected CBD stones but negative MRCP undergoing LC. The primary outcomes were the rate of complications in the hospital. Between January 2010 and December 2018, 620 patients (median age, 58 years; 58.4% female) were eligible for the study. The success rate of LTCBDE was 91.8% and CBD stones were observed in 53.3% with a stone clearance rate of 99.3%. The overall postoperative complication rate was 0.65% and no death was recorded in the total cohort. Notably, the morbidity in LTCBDE is 0.53%. Retained CBD stones were diagnosed in 2 patients and managed by ERCP successfully. In the LTCBDE cohort, the median duration of operation was 78 (60-100) min and the median postoperative hospital stay was 1 (1-2) days. Overall, at a mean follow-up of 4.1 (2.3-6.1) years, recurrent CBD stones occurred in 1.1% and all-cause mortality in 0.6%. LTCBDE should be considered the favored choice in the diagnostic algorithm for patients with suspected choledocholithiasis but negative MRCP undergoing LC.