Risk Factors for Gallstone Formation in Resected Gastric Cancer Patients

A Grading System for Assessing the Status of the Sphincter of Oddi During Intraoperative Choledochoscopy: A Surgeon's Perspective

BACKGROUND

The aim of this study was to establish a simple and practical grading system for evaluating the status of the sphincter of Oddi (SO) during intraoperative choledochoscopy. This system helps identify relevant variables that influence the status of the SO and provides recommendations for preventing stone recurrence.

METHODS

Ninety-three patients were selected retrospectively from a total of 316 patients diagnosed with choledocholithiasis between July 2020 and June 2023. All patients underwent common bile duct (CBD) exploration surgery and intraoperative choledochoscopy. The status of the SO was assessed during choledochoscopy. According to the severity of the condition, the patients were categorized into 4 groups. Data from each group, grades 1, 2, 3, 4, was analyzed statistically.

RESULTS

The number of patients in grade 1 was significantly lower than that of the other 3 groups. Except for grade 1, patients in grade 4 exhibited significant differences compared with the other 2 groups in terms of the diameter of the CBD, size of stones, presence of pneumobilia, and history of endoscopic retrograde cholangiopancreatography (ERCP) ( P <0.05). There were no significant differences between the groups in terms of sex, age, liver function, number of stones, history of gastrectomy, cholecystectomy, or CBD exploration.

CONCLUSIONS

The grading system helps us classify different sphincter functions and better understand the formation of choledocholithiasis by subdividing the status of the SO. Endoscopic sphincterotomy (EST) treatment can easily result in the loss of SO function, which increases the risk of stone recurrence.

High incidence of gallstones after Roux-en-Y reconstruction gastrectomy in gastric cancer: a multicenter, long-term cohort study

BACKGROUND

Roux-en-Y reconstruction is a common anastomosis technique during gastrectomy in gastric cancer. There is a lack of studies on gallstones after Roux-en-Y reconstruction gastrectomy. This study investigated the incidence and potential risk factors associated with gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer.

METHODS

The study analyzed data from gastric cancer who underwent radical gastrectomy and Roux-en-Y reconstruction at two hospitals between January 2014 and December 2020. The patients fall into distal and total gastrectomy groups based on the extent of gastrectomy. The cumulative event probability curve was plotted using the Kaplan-Meier, and differences in gallstone between groups were evaluated using the Log-Rank. Propensity score matching was applied to construct a balanced total versus distal gastrectomies cohort. A Cox regression was employed to analyze the risk factors for gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer. Further subgroup analysis was performed.

RESULTS

Five hundred thirty-one patients were included in this study, 201 in the distal gastrectomy group and 330 in the total gastrectomy. During the follow-up, gallstones occurred in 170 cases after gastrectomy, of which 145 cases accounted for 85.29% of all stones in the first two years after surgery. Then, to reduce the impact of bias, a 1:1 propensity score matching analysis was performed on the two groups of patients. A total of 344 patients were evaluated, with each subgroup comprising 172 patients. In the matched population, the Cox regression analysis revealed that females, BMI ≥23 kg/m 2 , total gastrectomy, No.12 lymph node dissection, and adjuvant chemotherapy were risk factors for gallstones after Roux-en-Y reconstructive gastrectomy. Subgroup analysis showed that open surgery further increased the risk of gallstones after total gastrectomy.

CONCLUSION

The incidence of gallstones increased significantly within 2years after Roux-en-Y reconstructive gastrectomy for gastric cancer. Patients with these risk factors should be followed closely after gastrectomy to avoid symptomatic gallstones.

Comparison Study between ERCP and PTBD for Recurrent Choledocholithiasis in Patients Following Gastrectomy

The recurrence rate of choledocholithiasis in the general population has been reported to exceed 10%. The incidence of cholelithiasis was reported to be higher in patients following gastrectomy than that in the general population. However, there is no study for recurrent choledocholithiasis incidence in patients following gastrectomy. This study aimed to evaluate the recurrence rate of choledocholithiasis and identify risk factors for recurrent choledocholithiasis in patients following gastrectomy. A retrospective analysis was performed on patients with gastrectomy history who underwent choledocholithiasis removal in Kyungpook National University Hospital between January 2011 and December 2019. Choledocholithiases were treated by endoscopic retrograde cholangiopancreatography (ERCP) (n = 41) or percutaneous transhepatic biliary drainage (PTBD) (n = 90). The gastrectomy type was classified as subtotal gastrectomy with Billroth I (18.3%), Billroth II (45.0%), and total gastrectomy with Roux-en-Y (36.6%). During a median follow-up period of 31.5 (range, 6-105) months, choledocholithiasis recurrence was noted in 19 of 131 patients (14.5%). In subgroup analysis, the ERCP group (24.4%) had higher choledocholithiasis recurrence than the PTBD group (10.0%). Stone removal modality (ERCP), no use of balloon sphincteroplasty, and the presence of periampullary diverticulum were significant risk factors for recurrent choledocholithiasis. In multivariate analysis, ERCP (hazard ratio (HR), 3.597; 95% confidence interval (CI): 1.264-10.204) CBD stricture (HR, 3.823; 95% CI: 1.118-13.080) and no use of balloon sphincteroplasty (HR, 4.830; 95% CI: 1.669-13.889) were risk factors for recurrent choledocholithiasis following stone removal. The incidence of CBD stones in patients who underwent gastrectomy is similar to that of the general population. ERCP, CBD stricture, and no use of balloon sphincteroplasty are potential risk factors for recurrent CBD stones following gastrectomy. When we consider PTBD disadvantages, the ERCP procedure with active use of balloon sphincteroplasty is recommended to decrease recurrent CBD stones.

Comparison of one-step laparoscopy and two-step endolaparoscopy in the treatment of secondary choledocholithiasis: A multicenter retrospective clinical study

BACKGROUND

There are two minimally invasive ways of treating cholecystolithiasis combined with choledocholithiasis, but there remains some controversy regarding which technique is better, since they both have advantages and disadvantages. The one-step method involves laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and primary close (LC + LCBDE + PC), while the two-step procedure consists of endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and laparoscopic cholecystectomy (ERCP + EST + LC).

OBJECTIVE

This multicenter retrospective study aimed to analyze and compare the effects of the two techniques.

METHODS

The data of patients who underwent either one-step LCBDE + LC + PC or two-step ERCP + EST + LC treatment for gallstones in the gallbladder and bile duct at the Shanghai Tenth People's Hospital, Shanghai Tongren Hospital, and Taizhou Fourth People's Hospital between January 1, 2015 and December 31, 2019 were collected, and the preoperative indicators of the two groups were compared.

RESULTS

The surgical success rate of the one-step laparoscopic group was 96.23% (664/690), the transit abdominal opening rate was 2.03% (14/690), and there were 21 cases of postoperative bile leakage. The success rate of the two-step endolaparoscopic surgery was 78.95% (225/285), the transit opening rate was 2.46% (7/285), and there were 43 postoperative cases of pancreatitis and five of cholangitis. Postoperative cholangitis, pancreatitis, postoperative stone recurrence, postoperative hospitalization, and treatment costs were significantly lower (P< 0.05) in the one-step laparoscopic group than in the two-step endolaparoscopic group. However, the amount of intraoperative bleeding, the postoperative extraction time of the abdominal drainage tube, and the incidence of bile leakage were higher (P< 0.05) in the one-step laparoscopic group than in the two-step endolaparoscopic group.

CONCLUSION

The two methods of treating choledocholithiasis combined with choledocholithiasis that were analyzed in this study were safe and effective, and each method had its own advantages.

Short-term outcomes after simultaneous gastrectomy plus cholecystectomy in gastric cancer: A pooling up analysis

The purpose of this study was to evaluate the short-term outcomes after simultaneous gastrectomy plus cholecystectomy in gastric cancer patients. PUBMED, EMBASE, and the Cochrane Library were searched from inception to Apr 15, 2021. Short-term surgical outcomes were compared between the simultaneous gastrectomy plus cholecystectomy group and the gastrectomy only group. Five retrospective studies with 3,315 patients and 1 randomized controlled trial with 130 patients were included. There was no significant difference in age, sex, surgical methods, or reconstruction. In terms of short-term outcomes, no significance was found in postoperative complications (odds ratio, OR = 1.08, I ² = 24%, 95% CI = 0.78-1.50, P = 0.65), postoperative biliary complications (OR = 0.98, I ² = 0%, 95% CI = 0.43-2.25, P = 0.96), mortality (OR = 1.28, I ² = 0%, 95% CI = 0.49-3.37, P = 0.61), and postoperative hospital stay (MD = -0.10, I ² = 0%, 95% CI = -0.73-0.54, P = 0.77) between the two groups. Simultaneous gastrectomy plus cholecystectomy in gastric cancer patients is safe and does not increase the short-term outcomes.

Late complication after gastrectomy for clinical stage I cancer: supplementary analysis of JCOG0912

BACKGROUND

Late complications following gastric cancer surgery, including postgastrectomy syndromes, are complex problems requiring a solution. Reported risk factors for developing late complications include surgery-related factors, such as the surgical approach and the extent of resection and reconstruction. However, this has not been assessed in a prospective study with a large sample size. Therefore, this study aimed to evaluate associations between surgery-related factors and the development of late complications. Data from the JCOG0912 trial were used. It compared laparoscopy-assisted distal gastrectomy (LADG) to open distal gastrectomy (ODG) in clinical stage I gastric cancer patients.

METHODS

This study included 881/921 patients enrolled in the JCOG0912 trial. The incidence of late complications was compared between the ODG and the LADG arms. In addition, associations between surgery-related factors and the development of late complications were assessed by multivariable analyses using the proportional odds model to identify relevant risk factors.

RESULTS

There was no difference in the type or number of patients with late complications between the LADG and the ODG arms. The multivariable analysis for each late complication revealed that the Billroth-I reconstruction (vs. R-en-Y or Billroth-II) had a lower risk of cholecystitis [odds ratio (OR) 0.187, 95% confidence interval (CI) 0.039-0.905, P = 0.037] or ileus (OR 0.116, 95%CI 0.033-0.406, P < 0.001), and pylorus-preserving gastrectomy (vs. R-en-Y or Billroth-II) had a higher risk of reflux esophagitis (OR 3.348, 95% CI 1.371-8.176, P = 0.008). The surgical approach was not a risk factor for any late complications.

CONCLUSION

Differences in surgical approaches did not constitute a risk for developing late complications after gastrectomy. Billroth-I reconstruction reduced the risk of ileus and cholecystitis, but pylorus-preserving gastrectomy carried a risk for reflux esophagitis.

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

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

New common bile duct morphological subtypes: Risk predictors of common bile duct stone recurrence

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment for removing common bile duct (CBD) stones. The risk factors for CBD stone recurrence after ERCP have been discussed for many years. However, the influence of CBD morphology has never been noticed.

AIM

To evaluate CBD morphology and other predictors affecting CBD stone recurrence in average patients.

METHODS

A retrospective analysis of 502 CBD stone patients who underwent successful therapeutic ERCP for stone extraction at our centre from February 2020 to January 2021 was conducted. CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis.

RESULTS

CBD morphology (P < 0.01), CBD diameter ≥ 1.5 cm [odds ratio (OR) = 2.20, 95%CI: 1.08-4.46, P = 0.03], and endoscopic biliary sphincterotomy with balloon dilation (ESBD) (OR = 0.35, 95%CI: 0.17-0.75, P < 0.01) are three independent risk factors for CBD stone recurrence. Furthermore, the recurrence rate of patients with the S type was 6.61-fold that of patients with the straight type (OR = 6.61, 95%CI: 2.61-16.77, P < 0.01). The recurrence rate of patients with the polyline type was 2.45-fold that of patients with the straight type (OR = 2.45, 95%CI: 1.14-5.26, P = 0.02). The recurrence rate of S type patients was 2.70-fold that of patients with the polyline type (OR = 2.70, 95%CI: 1.08-6.73, P = 0.03). Compared with no-ESBD, ESBD could decrease the risk of recurrence.

CONCLUSION

CBD diameter ≥ 1.5 cm and CBD morphology, especially S type and polyline type, were associated with increased recurrence of CBD stones. In addition, ESBD was related to decreased recurrence. Patients with these risk factors should undergo periodic surveillance and standard prophylactic therapy.

Compared With a Nasointestinal Route, Pre-operative Enteral Nutrition via a Nasogastric Tube Reduced the Incidence of Acalculous Acute Cholecystitis After Definitive Surgery for Small Intestinal Fistula

Purpose: This study aimed to investigate the difference in the efficacy of pre-operative enteral nutrition (EN) via a nasogastric tube (NGT) and pre-operative EN via a nasointestinal tube (NIT) in reducing the incidence of post-operative acalculous acute cholecystitis (AAC) after definitive surgery (DS) for small intestinal fistulas.

Methods: Patients with a small intestinal fistula, who had a DS for the disease between January 2015 and March 2021, were enrolled in this study. They were divided into the NIT group and the NGT group based on the pre-operative routes of feeding they received. The clinical characteristics of the two groups were analyzed, and the incidences of post-operative AAC in the two groups were evaluated.

Results: A total of 200 patients were enrolled in the study, 85 in the NGT group and 115 in the NIT group. Thirty-one patients developed post-operative AAC (8 in the NGT group and 23 in the NIT group). The incidence of post-operative AAC was 15.5%. EN via the NGT route was associated with a reduction in the incidence of post-operative AAC (adjusted HR = 0.359; 95% CI: 0.139–0.931; P = 0.035).

Conclusion: Pre-operative EN via the NGT may reduce the incidence of post-operative AAC in patients who received a DS for small intestinal fistulas.

The Effect of Minimally Invasive Gastrectomy for Gastric Cancer on Postoperative Gallstone Formation

BACKGROUND

Gallstones are known to occur quite frequently after gastrectomy. Most of the studies about postoperative cholelithiasis have focused on open gastrectomy, whereas laparoscopic gastrectomy has recently gained popularity as a type of minimally invasive surgery (MIS). Hence, the efficacy of MIS in preventing post-gastrectomy gallstone formation remains to be elucidated. This study aimed to evaluate the risk of gallstone formation after MIS for clinical stage I/IIA gastric cancer.

METHODS

A total of 1166 patients undergoing gastrectomy for clinical stage I/IIA gastric cancer between 2009 and 2016 were included in this study. Gallstones were detected on abdominal ultrasound and/or computed tomography. Multivariate logistic regression analysis was used to determine factors associated with postoperative gallstone formation.

RESULTS

Gallstone formation was observed in 174 patients (15%), of whom 22 (2%) experienced symptomatic cholelithiasis. In multivariate analysis, the following were identified as risk factors for post-gastrectomy gallstone formation: open approach with an odds ratio (OR) of 1.670 and a 95% confidence interval (CI) of 1.110-2.510 (P = 0.014), older age (OR 1.880; 95% CI 1.290-2.730; P < 0.001), high body mass index (OR 1.660; 95% CI 1.140-2.420; P = 0.008), Roux-en-Y (RY) reconstruction (OR 1.770; 95% CI 1.230-2.530; P = 0.002), hepatic branch vagotomy (OR 1.600; 95% CI 1.050-2.440; P = 0.029), and intra-abdominal infectious complications (OR 3.040; 95% CI 1.680-5.490; P < 0.001).

CONCLUSION

Our study suggested that MIS along with the preservation of the hepatic vagus nerve and non-RY reconstruction could help prevent post-gastrectomy gallstone development.

The Relationship between Diabetes Mellitus and Gastric Cancer and the Potential Benefits of Metformin: An Extensive Review of the Literature

The objective of this review is to summarize the findings of published research that investigated the relationship between diabetes mellitus and gastric cancer (GCa) and the potential benefits of metformin on GCa. Related literature has been extensively reviewed, and findings from studies investigating the relationship between diabetes mellitus and GCa suggest that hyperglycemia, hyperinsulinemia and insulin resistance are closely related to the development of GCa. Although not supported by all, most observational studies suggest an increased risk of GCa in patients with type 2 diabetes mellitus, especially in women and in Asian populations. Incidence of second primary malignancy diagnosed after GCa is significantly higher in diabetes patients. Diabetes patients with GCa may have more complications after gastrectomy or chemotherapy and they may have a poorer prognosis than patients with GCa but without diabetes mellitus. However, glycemic control may improve in the diabetes patients with GCa after receiving gastrectomy, especially after procedures that bypass the duodenum and proximal jejunum, such as Roux-en-Y gastric bypass or Billroth II reconstruction. The potential links between diabetes mellitus and GCa may involve the interactions with shared risk factors (e.g., obesity, hyperglycemia, hyperinsulinemia, insulin resistance, high salt intake, smoking, etc.), Helicobacter pylori (HP) infection, medications (e.g., insulin, metformin, statins, aspirin, proton pump inhibitors, antibiotics, etc.) and comorbidities (e.g., hypertension, dyslipidemia, vascular complications, heart failure, renal failure, etc.). With regards to the potential benefits of metformin on GCa, results of most observational studies suggest a reduced risk of GCa associated with metformin use in patients with T2DM, which can be supported by evidence derived from many in vitro and animal studies. Metformin use may also reduce the risk of HP infection, an important risk factor of GCa. In patients with GCa, metformin users may have improved survival and reduced recurrence. More studies are required to clarify the pathological subtypes/anatomical sites of GCa associated with type 2 diabetes mellitus or prevented by metformin, to confirm whether GCa risk can also be increased in patients with type 1 diabetes mellitus and to explore the possible role of gastric microbiota in the development of GCa.

Preservation of hepatic branch of the vagus nerve reduces the risk of gallstone formation after gastrectomy

BACKGROUND

Injury to the vagus nerve has been proposed to be associated with occurrence of gallstones after gastrectomy. We investigated the effect of preservation of hepatic branch of the vagus nerve on prevention of gallstones during laparoscopic distal (LDG) and pylorus-preserving gastrectomy (LPPG).

METHODS

Preservation of the vagus nerve was reviewed of cT1N0M0 gastric cancer patients underwent LDG (n = 323) and LPPG (n = 144) during 2016-2017. Presence of gallstones was evaluated by ultrasonography (US) and computed tomography (CT). Incidences of gallstones were compared between the nerve preserved (h-DG, h-PPG) group and sacrificed (s-DG, s-PPG) group. Clinicopathological features were also compared.

RESULTS

The 3-year cumulative incidence of gallstones was lower in the h-DG (2.7%, n = 85) than the s-DG (14.6%, n = 238) (p = 0.017) and lower in the h-PPG (1.6%, n = 123) than the s-PPG (12.9%, n = 21) (p = 0.004). Overall postoperative complication rate was similar between the h-DG and s-DG (p = 0.861) as well as between the h-PPG and s-PPG (p = 0.768). The number of retrieved lymph nodes station #1 and 3-year recurrence-free survival were not significantly different between the preserved group and sacrificed group. Injury to the vagus nerve (p = 0.001) and high body mass index (BMI) (≥ 27.5 kg/m²) (p = 0.040) were found to be independent risk factors of gallstone formation in multivariate analysis.

CONCLUSIONS

Preservation of hepatic branch of the vagus nerve can be recommended for LDG as well as LPPG of early gastric cancer patients to reduce postoperative gallstone formation.

Mirizzi syndrome in a patient with partial gastrectomy with Billroth II anastomosis: A case report

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Obstructive jaundice may be a challenge for differential diagnosis.

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Mirizzi Syndrome may simulate clinical and radiological presentation of common bile duct stones.

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ERCP hardly achieves cannulation of biliary duct in altered anatomy, so gastroscope may be a correct choice in these cases.

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Surgical treatment is essential in Mirizzi Syndrome.

Introduction

Mirizzi Syndrome (MS) is a common bile duct (CBD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Radiological evaluation may mistake it for CBD stones in jaundiced patient, especially in those who have altered anatomy of upper gastrointestinal (e.g. sub-total gastrectomy – STG – with Billroth I or II anastomosis).

Presentation of case

A 69-year-old male with a history of STG Billroth-II 25 years prior, accessed hospital for abdominal pain and jaundice with increasing in hepatic laboratory tests. Ultrasound of abdomen, CT scan and MRCP diagnosed CBD stones, so endoscopic retrograde cholangiopancreatography (ERCP) was performed, using a gastroscope to reach papillary region and to achieve cannulation of biliary duct. During cholangiography patient resulted affected by Mirizzi syndrome type I, so laparoscopic cholecystectomy was performed and cystic duct was moved away.

Discussion

This rare case shows how it’s easy to delay the correct treatment when a wrong radiological diagnosis is made. Moreover, ERCP remains a challenging procedure in patients with altered anatomy, such as STG B–II, and in this case gastroscope was needed for cannulation, due to the need of frontal view.

Conclusion

This rare case report highlights the importance of not forgetting MS in the differential diagnosis of biliary obstruction, especially in those patients with upper GI altered anatomy. Physicians with expertise in ERCP should always consider altered anatomy as a factor which may confuse radiologist in diagnosis, so in this case MS may be discovered or confirmed at ERCP.

Risk Factors for Gallbladder Stone Formation after Gastric Cancer Surgery

Purpose

Although an increased incidence of gallbladder (GB) stone formation after gastrectomy has been reported, its etiology remains uncertain. The goal of this study was to explore the incidence of gallstone formation after gastrectomy in gastric cancer patients and investigate the risk factors therein.

Materials and Methods

Medical records of patients who underwent curative gastrectomy, performed by a single surgeon between August 2012 and December 2015 at the Asan Medical Center, were retrospectively reviewed. Baseline characteristics and surgical outcomes, including GB stone gallstone formation after gastrectomy, were analyzed.

Results

Of 561 patients included in the study, 36 presented with GB stone formation after gastrectomy for gastric cancer. The incidence of gallstone formation was 6.4%. The mean interval between gallstone formation and gastrectomy was 21.9 months. In multivariate analyses, the incidence of gallstone formation increased in patients 63 years or older, with greater than 6.2 kg weight loss in the first 6 months after the procedure, a preoperative serum total bilirubin level greater than 0.5 mg/dL, and in patients who did not receive adjuvant chemotherapy.

Conclusions

This study presented risk factors for GB stone formation after gastric cancer surgery, and special attention should be afforded to patients with such risk factors.

Clinical analysis of prophylactic cholecystectomy during gastrectomy for gastric cancer patients: a retrospective study of 1753 patients

Background

Performance of gastrectomy in gastric cancer patients can lead to an increased incidence of cholecystolithiasis (CL) and a higher morbidity rate. However, the value of prophylactic cholecystectomy performed during gastric cancer surgery is still being debated.

Methods

We carried out a retrospective study on patients with gastric cancer who underwent subtotal or total gastrectomy, with preservation of the gallbladder or simultaneous cholecystectomy from January 2010 to March 2018.

Results

Cholecystolithiasis occurred in 152 of 1691 (8.98%) patients after gastric cancer surgery, with 45 (2.67%) patients undergoing subsequent cholecystectomy. Postoperative body mass index (BMI) decrease > 5% in 3 months was an independent risk factor for cholecystolithiasis [BMI decrease > 5%/≤5%: OR (95%CI): 1.812 (1.225–2.681), p = 0.003). Gastrectomy method and diabetes mellitus were independent risk factors for both cholecystolithiasis [gastrectomy method (no-Billroth I/Billroth I): OR (95%CI): 1.801 (1.097–2.959), p = 0.002; diabetes mellitus (yes/no): OR (95%CI): 1.544 (1.030–2.316), p = 0.036] and subsequent cholecystectomy [gastrectomy method (no-Billroth I/Billroth I): OR (95%CI): 5.432 (1.309–22.539), p = 0.020; diabetes mellitus (yes/no): OR (95%CI): 2.136 (1.106–4.125), p = 0.024]. Simultaneous cholecystectomy was performed in 62 of 1753 (3.5%) patients. The mortality and morbidity rates did not differ significantly between the combined surgery group and the gastrectomy only group (8.1% vs. 8.9 and 1.6% vs. 2.2%, respectively, p > 0.05).

Conclusions

Prophylactic cholecystectomy may be necessary in gastric cancer patients without Billroth I gastrectomy and with diabetes mellitus. Simultaneous cholecystectomy during gastric cancer surgery does not increase the postoperative mortality and morbidity rates.

Increased risk of gallstones after gastrectomy: A longitudinal follow-up study using a national sample cohort in korea

This study sought to evaluate the association between gastrectomy and the occurrence of gallstones using a national sample cohort from Korea.Data from 2002 to 2013 were collected for individuals ≥20 years of age in the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC). We extracted data for patients who had undergone gastrectomy (n = 1998) and a 1:4 matched control group (n = 7992) and then analyzed the occurrence of gallstones. The patients were matched according to age, sex, income, region of residence, hypertension, diabetes mellitus, and history of dyslipidemia. Gastrectomies were identified using operation codes (Q2533-Q2537, Q2594-Q2596, and Q2598). Gallstones were diagnosed if the corresponding International Classification of Disease-10 code (K80) was reported ≥2 times. Crude (simple) and adjusted hazard ratios (HRs) were analyzed using Cox proportional hazard models, and 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed based on age and sex.The adjusted HR for gallstones was 1.77 (95% CI = 1.34-2.35, P < .001) in the gastrectomy group compared to control. Consistent HRs were found in the analyses of all of the subgroups determined using age and sex.The occurrence of gallstones was increased in the patients who had undergone gastrectomy compared to their matched control group.

The Cholegas trial: long-term results of prophylactic cholecystectomy during gastrectomy for cancer-a randomized-controlled trial

BACKGROUND

The incidence of cholelithiasis has been shown to be higher for patients after gastrectomy than for the general population, due to vagal branch damage and gastrointestinal reconstruction. The aim of this trial was to evaluate the need for routine concomitant prophylactic cholecystectomy (PC) during gastrectomy for cancer.

METHODS

A multicenter, randomized, controlled trial was conducted between November 2008 and March 2017. Of the total 130 included patients, 65 underwent PC and 65 underwent standard gastric surgery only for curable cancers. The primary endpoint was cholelithiasis-free survival after gastrectomy for gastric adenocarcinoma. Cholelithiasis was detected by ultrasound exam.

RESULTS

After a median follow-up of 62 months, eight patients (12.3%) in the control group developed biliary abnormalities (four cases of gallbladder calculi and four cases of biliary sludge), with only three (4.6%) being clinically relevant (two cholecystectomies needed, one acute pancreatitis). One patient in the PC group had asymptomatic biliary dilatation during sonography after surgery. The cholelithiasis-free survival did not show statistical significance between the two groups (P = 0.267). The number needed to treat with PC to avoid reoperation for cholelithiasis was 1:32.5.

CONCLUSIONS

Concomitant PC during gastric surgery for malignancies, although reducing the absolute number of biliary abnormalities, has no significant impact on the natural course of patients.

Clinical analysis of treatment strategies to cholecystocholedocholithiasis patients with previous subtotal or total gastrectomy: a retrospective cohort study

Background

Previous gastrectomy can lead to an increased incidence of cholecystocholedocholithiasis (CCL) and increased morbidity rate. However, the appropriate treatment strategy for patients with CCL and a history of gastrectomy remains unclear.

Methods

We performed a retrospective cohort study of patients with CCL and a history of gastrectomy who underwent either one-stage laparoscopic common bile duct (CBD) exploration with stone clearance and laparoscopic cholecystectomy (LCBDE+LC) or two-stage endoscopic retrograde cholangiopancreatography followed by LC (ERCP+LC) from May 2010 to March 2018.

Results

The success rate of ERCP for CBD stone clearance was 81.2% in patients with a history of Billroth I gastrectomy and 23.7% in patients with a history of Billroth II or Roux-en-Y esophagojejunostomy [χ² = 97.67, P < 0.001, risk ratio (RR) = 3.43]. The success rate of second-step LC after successful ERCP for removal of CBD stones and the success rate of LCBDE+LC after ERCP treatment failure were 96.8 and 87.7%, respectively, in patients with preoperative intra-abdominal adhesion evaluation scores of ≤3 points. These success rates were 28.6 and 27.6%, respectively, in patients with scores of > 3 points (χ² = 59.70, P < 0.001, RR = 3.38 and χ² = 53.41, P < 0.001, RR = 3.27, respectively).

Conclusions

Based on the results of this study, ERCP+LC seems to be an attractive strategy for treatment of CCL in patients with a history of Billroth I gastrectomy, and LCBDE+LC appears to be suitable for patients with a history of Billroth II or Roux-en-Y esophagojejunostomy. Preoperative evaluation of intra-abdominal adhesions helps to reduce the conversion rate of laparoscopic surgery.

Analysis of gallstone disease after gastric cancer surgery

BACKGROUND

The incidence rate of newly developed gallstone disease after gastrectomy for gastric cancer is thought to be higher than that in the general population. However, the presentation and management of these gallstones remain under debate, and the role of prophylactic cholecystectomy remains questionable.

METHODS

Data on adult patients who were diagnosed with gastric cancer and received gastrectomy between 2000 and 2011 were extracted from the Taiwan National Health Insurance Research Database. A patient was excluded if he or she had gallstone disease or received cholecystectomy before the index date. The incidence of newly developed gallstone disease and its subsequent management were recorded. Data were analyzed to evaluate the factors associated with gallstone development and treatment options.

RESULTS

A total of 17,325 gastric cancer patients who underwent gastrectomy were eligible for analysis. During the follow-up period (mean 4.1 years; median, 2.9 years), 1280 (7.4%) patients developed gallstone disease and 560 (3.2%) patients subsequently underwent cholecystectomy. The in-hospital mortality for cholecystectomy was 1.8% (10/560). Development of gallstone disease was associated with older age, total gastrectomy, duodenal exclusion, diabetes, cirrhosis, and more comorbidities. Factors associated with the use of cholecystectomy to treat gallstone disease included younger age, fewer comorbidities, medical center admission, and presentation as cholecystitis.

CONCLUSIONS

Although few patients required further gallbladder removal after gastrectomy for gastric malignancy, the increased mortality rate for subsequent cholecystectomy was worth noting. The decision to undergo prophylactic cholecystectomy might be individualized based upon patient characteristics and the surgeon's discretion.

Incidence of gallstones after gastric resection for gastric cancer: a nationwide claims-based study

Purpose

Gallstone formation is one of the most common problems after gastrectomy. This retrospective cohort study used the South Korean nationwide claims database to evaluate the incidence and risk factors of gallstone after gastrectomy for gastric cancer.

Methods

All consecutive patients who underwent gastrectomy for gastric cancer in South Korea in 2008-2010 were identified. Incidence of gallstone formation 5 years after gastrectomy in males and females, in various age groups, and after different types of gastrectomy was determined. Multivariate logistic regression analysis served to identify gallstone risk factors.

Results

Of the 47,752 patients, 2,506 (5.2%) developed gallstone during the 5-year follow-up period. At 12, 24, 36, and 48 months, the cumulative incidences were 1.2%, 2.2%, 3.3%, and 4.3%, respectively. Males had a higher incidence than females (5.8% vs. 4.1%, P < 0.001). Older patients (60-89 years) had a higher incidence than younger patients (30-59 years) (6.1% vs. 4.3%, P < 0.001). Gallstone was most common after total gastrectomy (6.6%), followed by proximal gastrectomy (5.4%), distal gastrectomy (4.8%), and pylorus-preserving distal gastrectomy (4.0%) (P < 0.001). Multivariate analysis showed that male sex (odds ratio [OR], 1.39), an older age (OR, 1.44), and total gastrectomy (OR, 1.40 vs. distal gastrectomy) were significant independent risk factors for postgastrectomy gallstone.

Conclusion

The cumulative incidence of gallstone 5 years after gastrectomy for gastric cancer was 5.2%. Male sex, an older age, and total gastrectomy were significant risk factors. More careful monitoring for gallstone may be necessary in patients with such risk factors.