A previous cholecystectomy increases the risk of developing advanced adenomas of the colon. South Med J. 2009;102:1111-1115. [PMID: 19864992 DOI: 10.1097/SMJ.0b013e3181b85063]

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.

Prospective study on changes in the donor gallbladder contraction function after left lateral lobe hepatectomy

This study aimed to evaluate the feasibility of donor gallbladder preservation in liver transplantation. Conventional removal of the donor gallbladder is applied in a majority of pediatric liver transplantation. A total of 42 donors who underwent gallbladder preservation in liver transplantation from October 2013 to December 2015 at the Beijing Friendship Hospital, China, were enrolled for the study. The changes in gallbladder volume and the gallbladder EF of donors before and after surgery were measured through ultrasound, and the changes in the donor gallbladder contraction function before and after surgery were evaluated to help verify the feasibility of gallbladder preservation in living donor left lateral lobe hepatectomy. The gallbladder emptying index dropped to 42.67% in 2 weeks after surgery and gradually increased with the length of recovery time, which could reach 69.14% in 3 months after surgery. At that time, 97.6% of the donors were considered to have recovered their gallbladder contraction function. The gallbladder contraction function at an early stage after gallbladder preservation in liver transplantation is not obviously improved, but it can recover to a normal level in 1 month after surgery, indicating that the gallbladder preservation in hepatectomy of living donor can effectively guarantee the gallbladder contraction function.

The influences of cholecystectomy on the circadian rhythms of bile acids as well as the enterohepatic transporters and enzymes systems in mice

Bile acids (BAs), the most important endogenous and signaling molecules regulate the target transporters and enzymes at transcriptional level, participate in a wide variety of processes throughout the entire gastrointestinal tract to orchestrate homeostasis in vivo. BAs and their metabolism and transportation appear to follow the clear circadian rhythms, and they are recently proposed also as the potential chronobiological signals that can affect the molecular clock mechanism. Cholecystectomy are believed to affect the circadian rhythms of BAs and the relevant enterohepatic transporters and enzymes systems and their regulatory signaling pathways, for the reason that the circadian cycle of gallbladder filling and emptying play a pivotal role in controlling the flow of bile into the intestine and the enterohepatic circulation of BAs. Here, in the present study, the circadian rhythms about BAs concentration and composition and the mRNA expression of genes involved in BAs transportation, metabolism and regulation in liver and ileum of mice with or without gallbladder were evaluated. As a result, it has been found that, mice with gallbladder exhibited significant and distinct circadian oscillations in BAs concentration, mRNA expression of enterohepatic transporters and enzymes systems and farnesoid X receptor-mediated regulatory pathways both in liver and ileum during gallbladder emptying period (1:00 AM and 1:00 PM), despite food was restricted during these periods; the circadian rhythmicity of BAs pool and hepatic and ileal BAs diminished but the BAs composition had no significant alteration in liver and ileum after cholecystectomy as compared with sham-operated mice; in parallel to the alteration of BAs levels in liver and ileum after cholecystectomy, the day/night circadian oscillations in the mRNA expression of the relevant transporting and metabolic genes and the farnesoid X receptor signaling pathway-mediated “intestine-liver†regulatory axis also shifted. In conclusion, the BAs concentration and the corresponding genes exhibit significant circadian rhythms in mice with gallbladder, and the circadian oscillations of most of the investigation factors are flattened and altered following by cholecystectomy, which could mainly ascribe to the disappearance of the filling and emptying cycle of gallbladder and might result in pathological states or drug chronopharmacology alternation. We expect that this study would provide a cue for patients with cholecystectomy.

ABBREVIATIONS

Asbt: apical sodium-dependent bile acids transporter; AUC24h: area under the 24-hour BA concentration time curve; BAs: bile acids; Bsep: bile salt export pump; β-MCA: β-muricholic acid; CA: cholic acid; CDCA: chenodeoxycholic acid; Cyp3a11: cytochrome P450 3a11 (human CYP3A4); Cyp7a1: cholesterol 7α-hydroxylase cytochrome P450 7a1; DCA: deoxycholic acid; Fxr: farnesoid X receptor; Fgf15: fibroblast growth factor 15; G-: glycine conjugated bile acid; HDCA: hyodesoxycholic acid; LCA: lithocholic acid; Mrp2: multidrug resistance-associated protein 2; NDCA: demethylation deoxycholic acid; Ntcp: Na+-taurocholate co-transporting polypeptide; Oatp2: organic anion transporting polypeptide 2; Ostα/β: heterodimeric organic solute transporters alpha and beta; Shp: small heterodimer partner; T-: taurine conjugated bile acid; UDCA: ursodeoxycholic acid.

Risk Factors for Cholelithiasis

Gallstone disease is one of the most common public health problems in the United States. Approximately 10%-20% of the national adult populations currently carry gallstones, and gallstone prevalence is rising. In addition, nearly 750,000 cholecystectomies are performed annually in the United States; direct and indirect costs of gallbladder surgery are estimated to be $6.5 billion. Cholelithiasis is also strongly associated with gallbladder, pancreatic, and colorectal cancer occurrence. Moreover, the National Institutes of Health estimates that almost 3,000 deaths (0.12% of all deaths) per year are attributed to complications of cholelithiasis and gallbladder disease. Although extensive research has tried to identify risk factors for cholelithiasis, several studies indicate that definitive findings still remain elusive. In this review, predisposing factors for cholelithiasis are identified, the pathophysiology of gallstone disease is described, and nonsurgical preventive options are discussed. Understanding the risk factors for cholelithiasis may not only be useful in assisting nurses to provide resources and education for patients who are diagnosed with gallstones, but also in developing novel preventive measures for the disease.

Can gallbladder polyps predict colorectal adenoma or even neoplasia? A systematic review

OBJECTIVE

The purpose of the present systematic review is to identify whether an association between gallbladder polyps and colorectal adenoma or neoplasia exists.

DATA SOURCES

We conducted a systematic review searching the Medline (1966-2016), Scopus (2004-2016), ClinicalTrials.gov (2008-2016) and Cochrane Central Register of Controlled Trials CENTRAL (1999-2016) databases together with reference lists from included studies.

STUDY ELIGIBILITY CRITERIA

All prospective and retrospective observational cohort studies were included.

RESULTS

Four studies were finally included which included 17,437 patients. The association between gallbladder polyps and colorectal adenoma or even neoplasia is not unanimously supported. However, a possible association is clearly depicted. According to one study it seems that this correlation seems to become significant only when the gallbladder polyps exceed the size of 5 mm. However, the impact of size of gallbladder polyps was not investigated in the remaining studies.

CONCLUSION

According to the results of our systematic review there is some evidence to support the hypothesis that gallbladder polyps might adequately predict future risk of colorectal neoplasia. At present, however, current knowledge is very limited and the available data scarce. In this context further studies are necessary to be carried out, before the presence of gallbladder polyps on ultrasound can be recommended as an indication to perform a screening colonoscopy on the same patient.

Endoscopic ultrasound-assisted transmural cholecystoduodenostomy or cholecystogastrostomy as a bridge for per-oral cholecystoscopy therapy using double-flanged fully covered metal stent

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the 'gold standard' for the treatment of symptomatic gallstones. Innovative methods are being introduced, and these procedures include transgastric or transcolonic endoscopic cholecystectomy. However, before clinical implementation, instruments still need modification, and a more convenient treatment is still needed. Moreover, some gallbladders still have good functionality and cholecystectomy may be associated with various complications. The aim of this study was to evaluate the trans-gastrointestinal tract cholecystoscopy technique in the treatment of gallbladder disease without cholecystectomy.

METHOD

Endoscopic ultrasound (EUS)-guided cholecystoduodenostomy or cholecystogastrostomy with the placement of a double-flanged fully covered metal stent was performed and endoscopic sphincterotomy (EST) was also performed during this procedure for those patients with accompanying common bile duct stones. One or two weeks later the stent was removed and an endoscope was advanced into the gallbladder via the fistula, and cholecystolithotomy or polyp resection was performed. Four weeks later gallbladder was assessed by abdominal ultrasound.

RESULTS

EUS guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 4) with double flanged mental stent deployment was successfully performed in all of 7 patients. After the procedure, fistulas had formed in each of the patients and the stents were removed. Endoscopic cholecystolithotomy(7) and polyps resection(2) were successfully performed through the fistulas. Common bile duct stones were also successfully removed in 5 patients. The ultrasound examination of the gallbladder 4 weeks later showed no stones remaining and also showed satisfactory functioning of the gallbladder.

CONCLUSION

The EUS-guided placement of a novel metal stent is a safe and simple approach for performing an endoscopic cholecystoduodenostomy or cholecystogastrostomy, which can subsequently allow procedures to be performed for treating biliary disease, including cholecystolithotomy.

Feasibility of liver graft procurement with donor gallbladder preservation in living donor liver transplantation

OBJECTIVE

Cholecystectomy is routinely performed at most transplant centers during living donor liver transplantation (LDLT). This study was performed to evaluate the feasibility of liver graft procurement with donor gallbladder preservation in LDLT.

METHODS

Eighty-nine LDLTs (from June 2006 to Dec 2012) were retrospectively analyzed at our hospital. The surgical approach for liver graft procurement with donor gallbladder preservation was assessed, and the anatomy of the cystic artery, the morphology and contractibility of the preserved gallbladder, postoperative symptoms, and vascular and biliary complications were compared among donors with or without gallbladder preservation.

RESULTS

Twenty-eight donors (15 right and 13 left-liver grafts) successfully underwent liver graft procurement with gallbladder preservation. Among the 15 right lobectomy donors, for 12 cases (80.0 %) the cystic artery originated from right hepatic artery. From the left hepatic artery and proper hepatic artery accounted for 6.7 % (1/15), respectively. Postoperative symptoms among these 28 donors were slight, although donors with cholecystectomy often complained of fatty food aversion, dyspepsia, and diarrhea during an average follow-up of 58.6 (44-78) months. The morphology and contractibility of the preserved gallbladders were comparable with normal status; the rate of contraction was 53.8 and 76.7 %, respectively, 30 and 60 min after ingestion of a fatty meal. Biliary and vascular complications among donors and recipients, irrespective of gallbladder preservation, were not significantly different.

CONCLUSIONS

These data suggest that for donors compliant with anatomical requirements, liver graft procurement with gallbladder preservation for the donor is feasible and safe. The preserved gallbladder was assessed as functioning well and postoperative symptoms as a result of cholecystectomy were significantly reduced during long-term follow-up.

Risk of cancer in patients with cholecystitis: a nationwide population-based study

OBJECTIVE

The objective of this study was to evaluate the risk of cancer in patients diagnosed with cholecystitis and possible interactions between cholecystitis and cholecystectomy.

METHODS

A retrospective population-based cohort study was conducted among patients diagnosed with cholecystitis that were registered in the National Health Insurance Research Database in Taiwan between January 1, 2000 and December 31, 2010. Standardized incidence ratios (SIRs) were calculated to compare the incidence of cancer in these patients to that of the general population. Adjusted hazard ratios (HRs) were also calculated to investigate whether cholecystitis increased the risk for specific cancers.

RESULTS

During a median observation period of 5.4 years, 1541 cancers occurred in 20,431 patients with cholecystitis, yielding a SIR of 1.97 (95% confidence interval [CI], 1.88-2.07). A significantly greater risk of biliary tract cancer (adjusted HR 1.72; 95% CI, 1.08-2.75) was observed after adjusting for potential risk factors. In contrast, cholecystectomy was found to attenuate the cancer risk, with the reduction of adjusted HR from 2.34 (95% CI, 1.62-3.37) to 1.28 (95% CI, 0.76-2.14).

CONCLUSION

Cholecystitis is an independent risk factor to extrahepatic biliary tract cancers, whereas cholecystectomy can attenuate the cancer risk of cholecystitis.

Carcinoma transverse colon masquerading as carcinoma gall bladder

Colorectal cancer is one of the most common cancer worldwide .Its incidence is reported to be increasing in developing countries. It commonly presents with weight loss, anaemia, lump abdomen, change of bowel habit, obstruction or fresh rectal bleeding. Beside these common modes of presentations, there are some rare manifestations which masqueraded as different disease like obstructive jaundice, empyema gall bladder or cholecystitis. A 60-year-old male presented to hospital with right sided pain abdomen. On abdominal examination mild tenderness was present in right hypochondrium. Intra operatively gall bladder was separated from the adjoining gut, peritoneum and liver bed and was removed. On further exploration, there was a large mass in the vicinity of the gall bladder related to transverse colon. Extended right hemicolectomy was done. Histopathological examination of gut mass revealed adenocarcinoma of transverse colon with free margins and gall bladder showed cholecystitis with no evidence of malignancy. We present an interesting case of colon cancer colon that caused diagnostic confusion by mimicking as cholecystitis. Colorectal cancer constitutes a major public health issue globally. Therefore, public awareness, screening of high-risk populations, early diagnosis and effective treatment and follow-up will help to reduce its occurance and further complications.

Gallstones are associated with colonic adenoma: a meta-analysis

BACKGROUND

Increased levels of secondary bile acids after gallstone disease and cholecystectomy are believed to increase the risk of colorectal cancer. It remains unclear whether there is a similar risk of developing adenomas. The aim of this meta-analysis was to determine the risk of developing colonic adenomas following gallstone disease or cholecystectomy.

METHODS

The study was based on a systematic search of PubMed, MEDLINE, EMBASE, and Current Contents (1950-2012). Selection criteria were developed to sort for studies exploring the relationship between cholelithiasis, cholecystectomy, and colonic adenoma in an adult population. A random-effects model was used to generate pooled odds ratios (OR) and 95 % confidence intervals (CI). Publication bias and heterogeneity were assessed.

RESULTS

Of the 1,276 studies identified, 14 were suitable for final analysis. There were 253,059 subjects in total, 42,543 of whom were diagnosed with colonic adenoma, and 28,281 of whom had gallstones or underwent cholecystectomy. There was a significant risk of developing colonic adenoma if gallstones were present (OR = 2.26; 95 % CI = 1.83-2.81). A risk was also seen with cholecystectomy (OR = 1.15; 95 % CI = 1.04-1.26), but this risk was negated when only adjusted odds were selected (OR = 1.01; 95 % CI = 0.91-1.12). No publication bias and only low levels of heterogeneity existed.

CONCLUSIONS

Gallstones increase the risk of colonic adenoma. No association exists with cholecystectomy.

Laparoscopic cholelithotomy and polypectomy of gallbladder polyps for cholelithiasis and/or cholecystic polyps: An analysis of 53 cases

AIM: To discuss the indications, methods, and therapeutic effect of laparoscopic cholelithotomy and polypectomy in treating cholecystolithiasis and polyps.

METHODS: The clinical data for 53 patients with cholelithiasis and cholecystic polyps who were treated by laparoscopic cholelithotomy and polypectomy between January 2009 and September 2011 were analyzed. Of the 53 patients, 39 suffered from only cholecystolithiasis (including 12 with a single stone and 27 with multiple stones), 8 suffered from cholecystic polyps (including 3 with adenomatous polyps and 5 with cholesterol polyps), and 6 simultaneously suffered from cholecystolithiasis and cholecystic polyps. Of 39 patients suffering from cholecystolithiasis, 2 had liver cirrhosis, 1 had primary hepatocellular carcinoma, and 3 had acute cholecystitis. Before the stones were removed, the bottom of the gallbladder was incised in 37 of 39 cases with cholelithiasis, and the neck of the gallbladder was incised in the remaining two patients. Of 8 patients with cholecystic polyps, 5 had cholesterol polyps and underwent polyp removal, and the other 3 had adenomas of the gallbladder and underwent partial cholecystectomy around the adenoma. In six patients with combined cholecystolithiasis and cholecystic polyps, the bottom of the gallbladder was excised to remove the stones and polyps. The incisions were sutured continuously with a 4/0 prolene suture in 10 cases, and interrupted or continuous suturing was performed with a 3/0 absorption suture in the other 43 cases. Both choledochoscopy and laparoscopy were used in 33 cases, and only laparoscopy was used in the other 20 patients during operation to see if the stones and polyps had been removed. Celiac drainage tube was placed under the right hepatic lobe in 19 cases during operation and was removed one to five days later. Thirty-three patients with cholecystolithiasis took choleretic drugs for one week to 4 weeks after operation, and the other 12 cases with cholecystolithiasis did not take choleretic drugs.

RESULTS: The operation had been performed successfully in all the cases, and none of them was converted to celiotomy. The operation time was 80 to 200 (109 ± 33) minutes. One case whose gallbladder neck had been cut and sutured developed upper abdominal pain after operation, with about 15 mL of yellow fluid drained a day due to mild bile leakage. Ultrasonic examination showed small amount of fluid in the lesser omentum cavity of the patient. Five days later, the patient's upper abdominal pain relieved, with no fluid in the drainage tube, and then the tube was pulled out. The rest cases recovered smoothly. All the patients were cured and their mean postoperative hospital stay was 2 to 10 (3.8±2.2) days. Postoperative follow-up period ranged from 3 to 36 months. Only one case had muddy stone recurrence 12 months postoperatively, and his stone disappeared after taking choleretic and calculus-removing drugs for one month.

CONCLUSION: Laparoscopic cholelithotomy and polypectomy allow preserving gallbladder function and maintaining normal digestive function in patients with cholelithiasis and/or cholecystic polyps. If the size, wall thickness, and function of the gallbladder are nearly normal and cholecystic malignancies are excluded, laparoscopic cholelithotomy and polypectomy can be performed in patients with cholelithiasis and/or cholecystic polyps.

Meta-analysis of observational studies on cholecystectomy and the risk of colorectal adenoma

AIM

Cholecystectomy has been suggested as a risk factor for colorectal cancer. However, the association of cholecystectomy and the risk of colorectal adenoma (CRA) remains unclear. We conducted a meta-analysis of observational studies to explore this relationship.

METHODS

We identified studies by a literature search of MEDLINE and EMBASE through 30 September 2011, and by searching the reference lists of pertinent articles. Summary relative risks (SRRs) with their 95% confidence intervals (CIs) were calculated with a random-effects model. Between-study heterogeneity was assessed using Cochran's Q statistic and the I2.

RESULTS

A total of 10 studies (including 4061 CRA cases) were included in this meta-analysis. Analysis of these 10 studies found that no effect of cholecystectomy on the risk of CRAs was shown (SRR, 1.17; 95% CI: 0.93-1.48), with no significant heterogeneity among these studies (P heterogeneity=0.106, I2=37.9%). This null association was seen in both men and women (men: SRR=1.00, 95% CI: 0.58-1.73; women: SRR=1.39, 95% CI: 0.95-2.04).

CONCLUSION

The results of this meta-analysis suggest that there is no positive association between previous cholecystectomy and the risk of CRA development in both men and women.