Tailoring diagnosis and treatment in symptomatic gallstone disease

Association Between Triglyceride-Glucose Index and Risk of Gallstone Disease: A Prospective Cohort Study of 395 391 Individuals

OBJECTIVE

Gallstone disease (GSD) is one of the widespread gastrointestinal conditions. Triglyceride-glucose (TyG) index, a convenient surrogate for insulin resistance, may help identify and prevent gallstones. The present study aims to conduct a longitudinal study to evaluate the association between TyG index and the risk of GSD using the UK Biobank cohort.

METHOD

A total of 395 391 participants in the UK Biobank (median follow-up of 12.52 years) were included. The association between TyG index and the risk of GSD was assessed through Cox models and the restricted cubic spline model, expressed by hazard ratios (HRs) and 95% confidence intervals (CIs). Subgroup analysis was employed concerning age, gender, and body mass index (BMI) and also analyzed the mediating role of BMI in the effect of TyG index on incident GSD. Sensitivity analyses were further performed using a competing risks model and excluding participants who developed GSD in the first year of follow-up to test the stability of the results.

RESULTS

The risk of developing GSD increased in the Quartiles 2, 3, and 4 compared with Quartile 1 of TyG index (adjusted HR [aHR] 1.570 [95%CI 1.303-1.893], 1.577 [1.295-1.920], 1.489 [1.181-1.878], Ptrend < 0.001 across quartiles of TyG index). The aHR for every unit and SD increment in TyG index were 1.282 [1.100-1.494], 1.151 [1.055-1.256]. The results were consistent when participants who developed GSD in the first year of follow-up were excluded. The restricted cubic spline regression also showed an increased risk of GSD with increasing TyG index.

CONCLUSIONS

Increased TyG index is associated with an elevated risk of GSD. The TyG index might be an important indicator for identifying people at high risk of GSD.

Analgesic and hemodynamic effects of two injection approaches of dexmedetomidine in elderly cholecystolithiasis patients undergoing laparoscopic cholecystectomy: a retrospective study of 150 patients

This retrospective study investigated the effects of three dexmedetomidine (Dex) injection approaches on analgesic and hemodynamics in elderly cholecystolithiasis patients undergoing laparoscopic cholecystectomy. The clinical data of 150 elderly patients with cholecystolithiasis were collected, and they were divided into the Dex A (n=50), Dex B (n=50), and Dex C (n=50) cohorts. Patient's heart rate (HR) and mean arterial pressure (MAP) were collected at T0, T1, and T2 for blood gas analysis. The difference in oxygen content between cerebral arterial and venous blood (Da-jvO2) was calculated. The duration of surgery, occurrence of cardiovascular and respiratory suppression, and the time of spontaneous respiratory recovery and extubation were recorded. At T2, T3, and T4, HR and MAP in the Dex C group were smaller than Dex A group and Dex B group (Dex C Collapse

Key Words

• Dexmedetomidine
• heart rate
• laparoscopic cholecystectomy
• mean arterial pressure
• propofol

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MESH Headings

• Humans
• Dexmedetomidine/administration & dosage
• Dexmedetomidine/pharmacology
• Aged
• Male
• Female
• Cholecystectomy, Laparoscopic
• Hemodynamics/drug effects
• Retrospective Studies
• Cholecystolithiasis/surgery
• Aged, 80 and over
• Middle Aged
• Heart Rate/drug effects

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Affiliation(s)

Jing Zhu Department of anesthesiology, Shaanxi Provincial People's Hospital, Xi'an, China School of Clinical Medicine, Xi'an Medical University, Graduate School of Xi'an Medical University, Xi'an, China
Lijuan Zhu Department of anesthesiology, Shaanxi Provincial People's Hospital, Xi'an, China School of Clinical Medicine, Xi'an Medical University, Graduate School of Xi'an Medical University, Xi'an, China
Tao Kang Department of neurology, Shaanxi Provincial People's Hospital, Xi'an, China
Xin Li Department of anesthesiology, Shaanxi Provincial People's Hospital, Xi'an, China School of Clinical Medicine, Xi'an Medical University, Graduate School of Xi'an Medical University, Xi'an, China
Juan Wu Department of anesthesiology, Second Hospital of Shanxi Medical University, Taiyuan, China

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The carbon footprint of a laparoscopic cholecystectomy

Background

Gallbladder removal is one of the most common surgical procedures worldwide. The keyhole operation treats patients with symptomatic gallstones. This procedure uses many single-use tools and results in a lot of waste. Before we can make this operation more sustainable, we need to assess the amount of waste and CO2 emissions.

Aim

The aim of this study was to identify the types of waste and measure the CO2 emissions created by a gallbladder removal.

Method

We collected waste from 15 gallbladder operations at three hospitals. We noted the medications used and measured the surgery duration to estimate electricity consumption. We also asked all the staff how they travelled to the hospital that day.

Findings and Conclusion

The operation produces about 56.5 kg of CO2. The main sources of CO2 are single-use tools, packaging materials and disposable drapes and gowns. This study helps us understand where most CO2 is produced, so we can work on reducing it more effectively.

The causal relationship between diet habits and cholelithiasis: a comprehensive Mendelian randomization (MR) study

Background

Epidemiological studies show dietary habits can have an impact on the risk of cholelithiasis, but the relationship is still unclear. We used a comprehensive Mendelian randomization (MR) study to explore the relationship between dietary habits and cholelithiasis.

Methods

The 18 dietary habits were divided into six categories: meat foods, cereals, vegetables, fruits, dairy products, beverages, and condiments. Cholelithiasis data came from a GWAS meta-analysis and the FinnGen consortium. The inverse variance weighted (IVW), the weighted median (WM), and MR-Egger approaches were used as the main MR analysis methods. In addition, multiple sensitivity analysis and meta-analysis were performed to verify the robustness of the results.

Results

Dried fruit intake [odds ratio (OR) = 0.568; 95% confidence interval (CI), 0.405-0.797; p = 0.001] was discovered to reduce the risk of cholelithiasis. The sensitivity analysis and meta-analysis showed reliable results for the relationship between dried fruit intake and cholelithiasis.

Conclusion

Our study found that dried fruit intake is a protective factor in the development of cholelithiasis. However, the mechanisms of action need to be further explored.

Inhibition of PCSK9 prevents and alleviates cholesterol gallstones through PPARα-mediated CYP7A1 activation

BACKGROUND & AIMS

Dysregulated cholesterol metabolism is the major factor responsible for cholesterol gallstones (CGS). Proprotein convertase subtilisin/kexin type 9 (PCSK9) plays a critical role in cholesterol homeostasis and its inhibitors secure approval for treating various cholesterol metabolic disorders such as hypercholesterolemia and cardiovascular diseases, but its role in CGS remains unclear. Our study aims to clarify mechanisms by which PCSK9 promotes CGS formation and explore the application of the PCSK9 inhibitor, alirocumab, in preventing and treating CGS.

APPROACH & RESULTS

The expressions of PCSK9 were notably increased in CGS patients' serum, bile, and liver tissues compared to those without gallstones. Moreover, among CGS patients, hepatic PCSK9 was positively correlated with hepatic cholesterol and negatively correlated with hepatic bile acids (BAs), suggesting PCSK9 was involved in disrupted hepatic cholesterol metabolism related to CGS. Mechanistically, in vitro experiments demonstrated that inhibition of PCSK9 enhanced nuclear expression of PPARα by diminishing its lysosomal degradation and subsequently activated CYP7A1 transcription. Finally, inhibition of PCSK9 prevented CGS formation and dissolved the existing stones in CGS mice by elevating the conversion of cholesterol into BAs through PPARα-mediated CYP7A1 activation. Additionally, serum PCSK9 level may function as a prognostic signature to evaluate the therapeutic efficacy of PCSK9 inhibitors.

CONCLUSIONS

Inhibition of PCSK9 exerts preventive and therapeutic effects on CGS by activating PPARα-mediated CYP7A1 expression and facilitating the conversion of cholesterol into BAs, which highlights the potential of PCSK9 inhibition as a promising candidate for preventing and treating CGS in clinical applications.

IMPACT AND IMPLICATIONS

PCSK9 plays a pivotal role in cholesterol metabolism and its inhibitors are approved for clinical use in cardiovascular diseases. Our study observes inhibition of PCSK9 prevents and dissolves CGS by activating PPARα-mediated CYP7A1 expression and facilitating the conversion of cholesterol into BAs. Mechanistically, PCSK9 inhibition enhanced the nuclear expression of PPARα by diminishing its lysosomal degradation and subsequently activated CYP7A1 transcription. Our study sheds light on the new function and mechanism of PCSK9 in CGS, providing a novel preventive and therapeutic target with potential clinical applications.

Clinical study on the necessity and feasibility of routine MRCP in patients with cholecystolithiasis before LC

BACKGROUND

In the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis.

METHODS

According to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups.

RESULTS

Among the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05).

CONCLUSIONS

The preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

A mixed-methods study to define Textbook Outcome for the treatment of patients with uncomplicated symptomatic gallstone disease with hospital variation analyses in Dutch trial data

BACKGROUND

International consensus on the ideal outcome for treatment of uncomplicated symptomatic gallstone disease is absent. This mixed-method study defined a Textbook Outcome (TO) for this large group of patients.

METHODS

First, expert meetings were organised with stakeholders to design the survey and identify possible outcomes. To reach consensus, results from expert meetings were converted in a survey for clinicians and for patients. During the final expert meeting, clinicians and patients discussed survey outcomes and a definitive TO was formulated. Subsequently, TO-rate and hospital variation were analysed in Dutch hospital data from patients with uncomplicated gallstone disease.

RESULTS

First expert meetings returned 32 outcomes. Outcomes were distributed in a survey among 830 clinicians from 81 countries and 645 Dutch patients. Consensus-based TO was defined as no more biliary colic, no biliary and surgical complications, and the absence or reduction of abdominal pain. Analysis of individual patient data showed that TO was achieved in 64.2% (1002/1561). Adjusted-TO rates showed modest variation between hospitals (56.6-74.9%).

CONCLUSION

TO for treatment of uncomplicated gallstone disease was defined as no more biliary colic, no biliary and surgical complications, and absence or reduction of abdominal pain.TO may optimise consistent outcome reporting in care and guidelines for treating uncomplicated gallstone disease.