Gallstones, gallbladder disease, and pancreatitis: cross-sectional and 2-year data from the Swedish Obese Subjects (SOS) and SOS reference studies

Prevalence of elevated alkaline phosphatase levels among post-bariatric surgery patients

INTRODUCTION

Little is known about the prevalence of elevated alkaline phosphatase in post-bariatric surgery patients due to under-utilization of this test after surgery. Elevated alkaline phosphatase levels are caused by hepatobiliary disease or bone resorption, which can lead to gallstones and osteoporosis. Early, post-operative measurement of alkaline phosphatase can prevent complications, thus reducing morbidity and overall healthcare costs. The purpose of this study was to determine the prevalence of elevated alkaline phosphatase levels among post-operative bariatric surgery patients.

METHODS

This was a retrospective study of patients 18 years or older, who underwent laparoscopic sleeve gastrectomy (LSG) at a Midwestern Weight Management Clinic between January 1, 2002 and December 31, 2020. Alkaline phosphatase levels, weight, body mass index (BMI), gamma-glutamyl transferase (GGT), parathyroid hormone (PTH), calcitriol, and calcitonin, vitamin D and multivitamin supplementation were measured at baseline, 3, 6, and 12 months post-surgery.

RESULTS

Two hundred thirty patients with mean age of 47 years and BMI of 44.6 were included with 80.9% (n = 186) female. Alkaline phosphatase was elevated relative to baseline for 36.1% of patients (n = 52) at 3 months post-surgery, 42.4% of patients (n = 56) at 6 months, and 43.3% of patients (n = 45) at 12 months (p < 0.001). There were six cases of documented cholelithiasis post-surgery.

CONCLUSION

A significant proportion of participants experienced elevations in alkaline phosphatase following surgery, indicating that the prevalence of gallbladder pathology and bone resorption may be higher than previously thought. This merits additional investigation into these complications post-operatively to determine prevalence and avoid excess morbidity.

The potential bidirectional association between Helicobacter pylori infection and gallstone disease in adults: A two-cohort study

BACKGROUND

Previous studies have suggested that Helicobacter pylori (H. pylori) may act as a precipitating factor in gallstone formation, and the potential association between H. pylori infection and gallstone disease (GD) is still unclear and controversial. This study aimed to clarify the potential bidirectional relationship between H. pylori infection and GD.

METHODS

This retrospective cohort study was performed in a population that underwent health checkups at the hospital between 2013 and 2018. H. pylori infection status was evaluated by urea breath test (UBT), and GD was diagnosed via ultrasound. Cox regression and propensity score matching (PSM) were used.

RESULTS

Among 1011 participants without H. pylori infection at baseline, 134 participants were infected with H. pylori. Among 1192 participants without gallstones or cholecystectomy at baseline, 60 participants developed gallstones or cholecystectomy. The hazard ratio (HR) (95% CI) for incident H. pylori infection comparing the GD versus the no GD group was 1.84 (1.19, 2.85). The age- and sex-adjusted HR (95% CI) for incident GD comparing H. pylori-positive subjects to H. pylori-negative subjects was 1.74 (1.01, 2.98). Consistent results were also found with PSM and multivariate analysis.

CONCLUSIONS

This cohort study demonstrated a potential bidirectional association between H. pylori infection and GD, which provides a basis for indicating the risk of GD and implementing the clinical strategies for GD. For the prevention and treatment of GD, H. pylori infection should be carefully considered and evaluated.

Insights into modifiable risk factors of cholelithiasis: A Mendelian randomization study

BACKGROUND AND AIMS

The risk factors of cholelithiasis have not been clearly identified, especially for total cholesterol. Here, we try to identify these causal risk factors.

APPROACH AND RESULTS

We obtained genetic variants associated with the exposures at the genome-wide significance (p < 5 × 10^-8 ) level from corresponding genome-wide association studies. Summary-level statistical data for cholelithiasis were obtained from FinnGen and UK Biobank (UKB) consortia. Both univariable and multivariable Mendelian randomization (MR) analyses were conducted to identify causal risk factors of cholelithiasis. Results from FinnGen and UKB were combined using the fixed-effect model. In FinnGen, the odds of cholelithiasis increased per 1-SD increase of body mass index (BMI) (OR = 1.631, p = 2.16 × 10^-7 ), together with body fat percentage (OR = 2.108, p = 4.56 × 10^-3 ) and fasting insulin (OR = 2.340, p = 9.09 × 10^-3 ). The odds of cholelithiasis would also increase with lowering of total cholesterol (OR = 0.789, p = 8.34 × 10^-5 ) and low-density lipoprotein-cholesterol (LDL-C) (OR = 0.792, p = 2.45 × 10^-4 ). However, LDL-C was not significant in multivariable MR. In UKB, the results of BMI, body fat percentage, total cholesterol, and LDL-C were replicated. In meta-analysis, the liability to type 2 diabetes mellitus and smoking could also increase the risk of cholelithiasis. Moreover, there were no associations with other predominant risk factors.

CONCLUSIONS

Our MR study corroborated the risk factors of cholelithiasis from previous MR studies. Furthermore, lower total cholesterol level could be an independent risk factor.

Long-term incidence of colorectal cancer after bariatric surgery or usual care in the Swedish Obese Subjects study

Bariatric surgery in patients with obesity is generally considered to reduce cancer risk in patients with obesity. However, for colorectal cancer some studies report an increased risk with bariatric surgery, whereas others report a decreased risk. These conflicting results demonstrate the need of more long-term studies analyzing the effect of bariatric surgery on colorectal cancer risk. Therefore, data from the Swedish Obese Subjects (SOS) study, ClinicalTrials.gov identifier: NCT01479452, was used to examine the impact of bariatric surgery on long-term incidence of colorectal cancer. The SOS study includes 2007 patients who underwent bariatric surgery and 2040 contemporaneously matched controls who received conventional obesity treatment. Patients in the surgery group underwent gastric bypass (n = 266), banding (n = 376) or vertical banded gastroplasty (n = 1365). Information on colorectal cancer events was obtained from the Swedish National Cancer Registry. Median follow-up was 22.2 years (inter-quartile range 18.3–25.2). During follow up there were 58 colorectal cancer events in the surgery group and 67 colorectal cancer events in the matched control group with a hazard ratio (HR) of 0.79 (95% CI:0.55–1.12; p = 0.183). After adjusting for age, body mass index, alcohol intake, smoking status, and diabetes, the adjusted HR was 0.89 (95% CI:0.62–1.29; p = 0.551). When analyzing rectal cancer events separately- 19 events in the surgery group and 31 events in the control group-a decreased risk of rectal cancer with surgery was observed (HR = 0.56; 95% CI:0.32–0.99; p = 0.045, adjusted HR = 0.61 (95% CI:0.34–1.10; p = 0.099), while the risk of colon cancer was unchanged. To conclude- in this long-term, prospective study, bariatric surgery was not associated with altered colorectal cancer risk.

Association of Bariatric Surgery With Skin Cancer Incidence in Adults With Obesity: A Nonrandomized Controlled Trial

Importance

Obesity is a cancer risk factor, and bariatric surgery in patients with obesity is associated with reduced cancer risk. However, evidence of an association among obesity, bariatric surgery, and skin cancer, including melanoma, is limited.

Objective

To investigate the association of bariatric surgery with skin cancer (squamous cell carcinoma and melanoma) and melanoma incidence.

Design, Setting, and Participants

This nonrandomized controlled trial, the Swedish Obese Subjects (SOS) study, is ongoing at 25 surgical departments and 480 primary health care centers in Sweden and was designed to examine outcomes after bariatric surgery. The study included 2007 patients with obesity who underwent bariatric surgery and 2040 contemporaneously matched controls who received conventional obesity treatment. Patients were enrolled between September 1, 1987, and January 31, 2001. Data analysis was performed from June 29, 2018, to November 22, 2018.

Interventions

Patients in the surgery group underwent gastric bypass (n = 266), banding (n = 376), or vertical banded gastroplasty (n = 1365). The control group (n = 2040) received the customary treatment for obesity at their primary health care centers.

Main Outcomes and Measures

The SOS study was cross-linked to the Swedish National Cancer Registry, the Cause of Death Registry, and the Registry of the Total Population for data on cancer incidence, death, and emigration.

Results

The study included 4047 participants (mean [SD] age, 47.9 [6.1] years; 2867 [70.8%] female). Information on cancer events was available for 4042 patients. The study found that bariatric surgery was associated with a markedly reduced risk of melanoma (adjusted subhazard ratio, 0.43; 95% CI, 0.21-0.87; P = .02; median follow-up, 18.1 years) and risk of skin cancer in general (adjusted subhazard ratio, 0.59; 95% CI, 0.35-0.99; P = .047). The skin cancer risk reduction was not associated with baseline body mass index or weight; insulin, glucose, lipid, and creatinine levels; diabetes; blood pressure; alcohol intake; or smoking.

Conclusions and Relevance

The results of this study suggest that bariatric surgery in individuals with obesity is associated with a reduced risk of skin cancer, including melanoma.

Trial Registration

ClinicalTrials.gov identifier: NCT01479452.

Bariatric Surgery Outcomes in Appalachia Influenced by Surgery Type, Diabetes, and Depression

Background

Most effective treatment for morbid obesity and its comorbidities is bariatric surgery. However, research is limited on weight loss and associated outcomes among patients in Appalachia. The objective of this study was to examine demographic and comorbidity influence on surgical outcomes of this population including age, sex, race, state of residence, education, marital status, body mass index (BMI kg/m²), excess body weight (EBW), percent excess weight loss (%EWL), blood pressure, diagnosed depression, diagnosed type 2 diabetes (T2D), Beck Depression Inventory-II (BDI-II), and laboratory values (i.e., hemoglobin A1c).

Methods

A retrospective electronic medical record (EMR) data extraction was performed on N = 582 patients receiving bariatric surgery (laparoscopic Roux-en-Y gastric bypass [RYGB] and laparoscopic sleeve gastrectomy [SG]) between 10/2013 and 2/2017.

Results

Patient population was 92.5% Caucasian, 79.3% female, 62.8% married, 45 ± 11.1 years, 75.8% received RYGB, and 24.2% received SG. Average %EWL from baseline to 1-year follow-up was 68.5 ± 18.4% (n = 224). In final descriptive models, surgery type, diagnosed T2D, HbA1c, and depressive symptoms were significant covariates associated with lower %EWL.

Conclusions

Findings suggest patients completing surgery within an Appalachian region have successful surgical outcomes at 1-year post-surgery, as indicated by significant reductions of > 50% EWL, regardless of other covariates. Results suggest that bariatric programs should consider paying special consideration to patients with T2D or depressive symptoms to improve outcomes. Results have potential to inform future prospective studies and aid in guiding specific interventions tailored to address needs of this unique population.

Is Concomitant Cholecystectomy Necessary for Asymptomatic Cholelithiasis During Laparoscopic Sleeve Gastrectomy?

BACKGROUND

There is not any consensus on concomitant cholecystectomy for asymptomatic gallbladder stones during laparoscopic sleeve gastrectomy (LSG). The aim of this study was to evaluate the surveillance results of the LSG patients who have asymptomatic gallbladder stones and did not undergo cholecystectomy.

METHODS

Patients who underwent laparoscopic sleeve gastrectomy with preoperatively detected gallbladder stones and completed at least 6 months follow-up were included in the study. Concomitant cholecystectomy was performed for symptomatic patients while it was not performed for asymptomatic subjects. At the end of the follow-up time, symptoms and signs related to gallbladder disease were recorded. Clinical and demographic characteristics were compared between symptomatic and asymptomatic patients.

RESULTS

Between February 2012 and October 2016, 312 laparoscopic sleeve gastrectomies were performed. Among the patients, 24 were regarded as asymptomatic cholelithiasis, and cholecystectomy was not performed. The mean follow-up period was 27 (6-58) months. The mean preoperative BMI was 50.0 ± 7.6 kg/m², and at the end of the follow-up time, it decreased to 35.6 ± 8.8 kg/m². Five (20.8%) patients experienced biliary colic. Acute cholecystitis or obstructive jaundice was not observed in any of the patients. Characteristics of patients who developed symptomatic gallbladder disease (n = 5) were not significantly different from those of patients who remained asymptomatic (n = 19).

CONCLUSIONS

The risk of becoming symptomatic for asymptomatic cholelithiasis is very close to the healthy population after sleeve gastrectomy. Although further studies with a high number of cases are needed, we suggest only observation for asymptomatic gallbladder stones in patients who will undergo sleeve gastrectomy.

The Type of Bariatric Surgery Impacts the Risk of Acute Pancreatitis: A Nationwide Study

Objective

We investigated whether vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass surgery (RYGB) have a differential impact on post-operative risk of acute pancreatitis (AP).

Methods

This retrospective study uses the 2012–2014 National Readmission Database. We compared morbidly obese patients who underwent VSG (n = 205,251), RYGB (n = 169,973), and hernia repair (HR) control (n = 16,845). Our main outcome was rates of AP within 6 months post- vs. 6 months pre-surgery in VSG, RYGB, and HR. We also investigated risk factors and outcomes of AP after bariatric surgery.

Results

The rates of AP increased post- vs. pre-VSG (0.21% vs. 0.04%; adjusted odds ratio [aOR] = 5.16, P < 0.05) and RYGB (0.17% vs. 0.07%; aOR = 2.26, P < 0.05) but not post-HR. VSG was associated with a significantly greater increase in AP risk compared to RYGB (aOR = 2.28; 95% CI: 1.10, 4.73). Furthermore, when compared to HR controls, only VSG was associated with a higher AP risk (aOR = 7.58; 95% CI: 2.09, 27.58). Developing AP within 6 months following bariatric surgery was mainly associated with younger age (18–29 years old: aOR = 3.76 for VSG and aOR: 6.40 for RYGB, P < 0.05) and gallstones (aOR = 85.1 for VSG and aOR = 46 for RYGB, P < 0.05). No patients developed “severe AP” following bariatric surgery.

Conclusions

More patients develop AP within 6 months after VSG compared to RYGB and controls. This risk is highest for younger patients and those with gallstones. Prospective studies examining mechanisms and prevention are warranted.

Incidence of end-stage renal disease following bariatric surgery in the Swedish Obese Subjects Study

Background

Obesity is a major public health problem leading to co-morbidities such as diabetes, hypertension and kidney failure. Bariatric surgery results in pronounced and maintained weight loss and prevention of obesity-related diseases and their complications. Most studies of bariatric surgery on kidney disease show improvements after surgery. However, long-term studies analyzing hard end-points are lacking. Here we report on the long-term effects of bariatric surgery compared to usual obesity care on incidence of end-stage renal disease (ESRD) alone and in combination with chronic kidney disease stage 4 (CKD4/ESRD).

Methods

4047 patients were included in the Swedish Obese Subjects (SOS) study. Inclusion criteria were age 37–60 years and BMI≥34 in men and BMI≥38 in women. Patients in the bariatric surgery group (N=2010) underwent banding (18%), vertical banded gastroplasty (69%) or gastric bypass (13%); controls (N=2037) received usual obesity care. In this analysis, patients were followed up for a median time of 18 years. The incidence of ESRD and CKD4 was obtained by crosschecking the SOS database with the Swedish National Patient Register.

Results

During follow-up, ESRD occurred in 13 patients in the surgery group and in 26 patients in the control group (adjusted hazard ratio (HR) = 0.27; 95% CI 0.12 – 0.60; p=0.001). The number of CKD4/ESRD events was 23 in the surgery group and 39 in the control group (adjusted HR = 0.33; 95% CI 0.18 – 0.62; p<0.001). In both analyses, bariatric surgery had a more favorable effect in patients with baseline serum insulin levels above median compared to those with lower insulin levels (interaction p=0.010). Treatment benefit of bariatric surgery was also greater in patients with macroalbuminuria at baseline compared to those without macroalbuminuria (interaction p<0.001).

Conclusions

Our study showed for the first time that bariatric surgery is associated with a long-term protection against ESRD and CKD4/ESRD.

Treatment of Common Bile Duct Stones in Gastric Bypass Patients with Laparoscopic Transgastric Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass excludes the biliary tree from traditional evaluation and treatment with endoscopic retrograde cholangiopancreatography (ERCP). Due to the initial rapid weight loss, gastric bypass patients have an increased risk of developing gallstones in the gallbladder as well as in the common bile duct. Various techniques to access the biliary tree have been described. The techniques are characterised by complexity and varying results. The aim of the present study was to assess both feasibility and outcome of laparoscopic-assisted transgastric ERCP in patients with gastric bypass.

METHODS

We retrospectively reviewed all laparoscopic transgastric ERCPs performed at Zealand University Hospital during the period January 2010 to January 2016. The main outcome was cannulation of the common bile duct. Secondary outcomes were length of hospital stay and surgical complications.

RESULTS

Thirty-one laparoscopic assisted transgastric ERCP procedures were performed in 29 patients. Indication was choledocholithiasis. All planned procedures were conducted with a 100% success in cannulation of the common bile duct. Median hospital stay was 2 days (range 1-22). Perforation of the wall of the gastric remnant occurred in two patients. The overall postoperative complication rate was 36%. Surgical complications were bleeding, haematoma and intra-abdominal abscesses.

CONCLUSION

Laparoscopic assisted transgastric ERCP is feasible, but there are several complications related to the procedure. Thus, until better alternative treatments are developed, it is recommended that the procedure should be performed at centres with both high endoscopic and bariatric expertise.

Long-term incidence of female-specific cancer after bariatric surgery or usual care in the Swedish Obese Subjects Study

OBJECTIVE

To examine the long-term effects of bariatric surgery on female-specific cancer in women with obesity.

METHODS

The prospective, matched Swedish Obese Subjects (SOS) study was designed to examine outcomes after bariatric surgery. This study includes 1420 women from the SOS cohort that underwent bariatric surgery and 1447 contemporaneously matched controls who received conventional obesity treatment. Age was 37-60years and BMI was ≥38kg/m². Information on cancer events was obtained from the Swedish National Cancer Registry. Median follow-up time was 18.1years (interquartile range 14.8-20.9years, maximum 26years). This study is registered with ClinicalTrials.gov, NCT01479452.

RESULTS

Bariatric surgery was associated with reduced risk of overall cancer (hazard ratio=0.71; 95% CI 0.59-0.85; p<0.001). About half of the observed cancers were female-specific, and the incidence of these were lower in the surgery group compared with the control group (hazard ratio=0.68; 95% CI 0.52-0·88; p=0.004). The surgical treatment benefit with respect to female-specific cancer was significantly associated with baseline serum insulin (interaction p value=0.022), with greater relative treatment benefit in patients with medium or high insulin levels. Separate analyses of different types of female-specific cancers showed that bariatric surgery was associated with reduced risk of endometrial cancer (hazard ratio=0.56: 95% CI 0.35-0.89; p=0.014).

CONCLUSIONS

In this long-term study, bariatric surgery was associated with reduced risk of female-specific cancer, especially in women with hyperinsulinemia at baseline.

FUNDING

This project was supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number R01DK105948 (the content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health), the Swedish Research Council K2013-99X-22279-01, K2013-54X-11285-19, Sahlgrenska University Hospital ALF research grant and Swedish Diabetes Foundation.

Obesity Not Necessary, Risk of Symptomatic Cholelithiasis Increases as a Function of BMI

INTRODUCTION

Obesity is a well-established risk factor for cholelithiasis. But most of the studies have actually tried to establish the risk of cholelithiasis in overweight and obese people. Very few studies have addressed the issue of cholelithiasis in patients with otherwise normal Body Mass Index (BMI). In this study we have tried to establish if there is any relationship between increasing BMI and cholelithiasis.

AIM

To establish a relationship between increasing BMI and risk of cholelithiasis.

MATERIALS AND METHODS

Retrospective analysis was carried out after doing a prospective pilot study. Ten years data of patients admitted to surgery ward with complaints of pain abdomen was reviewed. Patients with cholelithiasis were segregated as cases and patients with some other diagnosis were selected as controls. Patients with incidental diagnosis of cholelithiasis were excluded. Appropriate analytical tools were used to draw the results using SPSS^© 20.

RESULTS

Over 11,000 patients data was reviewed and 7,182 patients were selected for inclusion into the study. Major exclusion was due to incomplete availability of data. Cholelithiasis group had 2,872 patients and rest of the patients served as controls against them. Female patients outnumbered their male counterparts in cholelithiasis group. Mean age of the gallstone patients was 37.09 years, almost 2 years younger than their controls. Mean BMI of all patients was 23.55 kg/m² and in cholelithiasis and control group was 24.93 and 22.62, respectively (df=1, F>1635.395, p<0.001). Gender specific comparison also yielded a significant difference df=3, F=547.238, p<0.001). The difference in the way the patients were distributed among the ethnic groups (Nepalis, Bhutias, Lepchas and others) was also significant (df=3, F=34.234, p<0.001). Most important outcome was that the majority of the patients in the cholelithiasis group were within the normal BMI range.

CONCLUSION

We concluded that it's not only the overweight or obese patients who develop symptomatic cholelithiasis but also the individuals with normal BMI. The risk of symptomatic cholelithiasis increases with every increase in BMI. Risk of symptomatic cholelithiasis also increases in women and as the age advances.

INCIDENCE OF ACUTE PANCREATITIS IN ALBANIAN POPULATION

Background:

Acute Pancreatitis (AP) is an inflammatory pathology with large regional variations in incidence and etiology

Aim:

The aim of the study was to provide a description of the epidemiologic situation of AP in Albanian population, regarding incidence, etiology and severity of the disease

Methods:

We have studied all the files of all patients with acute pancreatitis admitted at the UHC ‘Mother Theresa” during an eight year period (2005-2012).

The results:

We had 964 admissions with the diagnosis acute pancreatitis, making an incidence of 5.64 per 100 000 inhabitants per year. Mean age of patients was 54.5 ± 16.93 years old. Among risk factors, alcohol consumption was found in 382 patients (39.6%), gallstone in 362 patients (37.6%), and others in 220 patients (22.8%).

Conclusion:

The incidence of acute pancreatitis in Albania ranges from 3.6 – 5.64 new cases per 100 000 inhabitants per year, with an increasing trend during the last years. The incidence of AP among females almost doubles during 2005-2012. Alcohol consumption is the predominating etiologic factor among young males.

Obesity: impact of infections and response to vaccines

Obesity is a common condition that has rapidly increased in both the industrialised and developing world in recent decades. Obese individuals show increased risk factors for severe infections and significant immune system dysregulation that may impair the immune response to vaccines. The main aim of this paper was to review the current knowledge regarding the association between obesity and the risk and outcome of infections as well as immune response to vaccines. The results showed that obesity is a highly complex clinical condition in which the functions of several organ and body systems, including the immune system, are modified. However, only a small minority of the biological mechanisms that lead to reduced host defences have been elucidated. Relevant efforts for future research should focus on obese children, as the available data on this population are scarce compared with the adult population. Even if most vaccines are given in the first months of life when obesity is rare, some vaccines require booster doses at preschool age, and other vaccines, such as the influenza vaccine, are recommended yearly in the obese population, but it is not known whether response to vaccines of obese patients is impaired. The reduced immune response of obese patients to vaccination can be deleterious not only for the patient but also for the community.

Prevalence of cholelithiasis among persons undergoing abdominal ultrasound at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

BACKGROUND

The prevalence of gallstones among Ghanaians is unknown. We aimed to determine the prevalence of gallstones among persons undergoing abdominal ultrasound at the Komfo Anokye Teaching Hospital (KATH).

METHODS

We performed a cross-sectional study of patients aged ≥14years presenting to KATH for abdominal ultrasound between 2009 and 2012. Patient demographics were recorded. The gallbladder was assessed by ultrasonography. Cholelithiasis was defined as presence of gallstones or absence of gallbladder. Data was expressed as descriptive and inferential statistics.

RESULTS

There were 2824 participants. 55% were females. Mean age was 47±18 years. Mean body mass index (BMI) was 24.0±5.5. Mean parity among females was 3±3. Prevalence of cholelithiasis was 5.9 (95%C.I:5.0,6.8). Females had a high prevalence compared to males (6.8 vs 4.7). Prevalence increased steadily by age. Prevalence was 6.6, 5.1 and 8.8 for patients with BMI <18.5, 18.5-24.9 and ≥30 respectively. Prevalence among women with parity of 0,1-5 and >5 was 3.1, 6.7 and 6.4 respectively.On multivariate regression analysis, female sex (AOR=1.55;p<0.05), age≥40 years (AOR=2.05;p<0.01), BMI<18.5 (AOR=1.25;p>0.05) or BMI≥30 (AOR=1.39;p>0.05) and family history of gallstones (AOR=11.9;p<0.01) increased the odds of cholelithiasis.

CONCLUSIONS

Prevalence of cholelithiasis among patients undergoing ultrasonography at KATH was 5.9. Patient age, sex and family history significantly influenced the prevalence.

Concomitant cholecystectomy during laparoscopic sleeve gastrectomy

BACKGROUND

The prevalence of cholelithiasis in morbidly obese individuals is 19-45%. Laparoscopic sleeve gastrectomy (LSG) has become one of the most performed procedures worldwide. The management of gallstones at the time of LSG is under debate. We herein report our experience with concomitant LSG and cholecystectomy.

METHODS

Patients undergoing LSG, between 2006 and 2014 with symptomatic cholelithiasis (SC), underwent concomitant cholecystectomy (SGC), and were compared to those who had LSG alone. Gender, age, and BMI were noted. Preoperative ultrasonography was performed for all patients and gallstone presence was recorded. Operative time, intraoperative mishaps, perioperative complications, length of hospital stay (LOS), and the incidence of subsequent symptomatic gallbladder disease were collected as well.

RESULTS

SC was present in 180 patients who underwent SGC. LSG was performed in 2,383, of whom 43 (2%) had asymptomatic cholelithiasis (AC). SGC patients had a higher percentage of females and were older (79% and 46 years vs. 62% and 43 years, respectively). BMI, LOS, and complications were similar. Operative time was prolonged by 35 min in SGC. Two patients with SGC had bile leakage. Of patients with AC, 9.3% required cholecystectomy during the first post-operative year after LSG due to evolution of symptoms, compared to only 2.7% of those with normal preoperative gallbladders. Presenting symptoms and severity of the disease were worse in the first group.

CONCLUSIONS

For SC, LSC is safe and warranted. Prophylactic cholecystectomy when gallstones are absent is unnecessary. Management of AC at the time of LSG is still debatable.

Relative risk of acute pancreatitis in initiators of exenatide twice daily compared with other anti-diabetic medication: a follow-up study

AIMS

Previously, a retrospective cohort study found no increased risk of acute pancreatitis with current or recent use of exenatide twice daily compared with use of other anti-diabetic drugs. This follow-up study investigated incident acute pancreatitis, with the use of a different data source and analytic method, in patients exposed to exenatide twice daily compared with patients exposed to other anti-diabetic medications.

METHODS

A large US health insurance claims database was used. Eligible patients had ≥ 9 months continuous enrollment without a claim for pancreatitis and a claim for a new anti-diabetic medication on or after 1 June 2005 to 31 March 2009. Cases of acute pancreatitis were defined as hospitalized patients with an Internation Classification of Disease 9 code of 577.0 in the primary position. A discrete time survival model was used to evaluate the relationship between exenatide twice daily and acute pancreatitis.

RESULTS

Of 482,034 eligible patients, 24,237 initiated exenatide twice daily and 457,797 initiated another anti-diabetic medication. Initiators of exenatide twice daily had more severe diabetes compared with initiators of other anti-diabetic medications. After adjustments for propensity score, insulin and use of medication potentially associated with acute pancreatitis, the odds ratio with exenatide twice daily exposure was 0.95 (95% CI 0.65-1.38). A secondary analysis that examined current, recent and past medication exposure found no increased risk of acute pancreatitis with exenatide twice daily, regardless of exposure category.

CONCLUSION

This study indicates that exposure to exenatide twice daily was not associated with an increased risk of acute pancreatitis compared with exposure to other anti-diabetic medications. These results should be interpreted in light of potential residual confounding and unknown biases.

Relative risk of acute pancreatitis in initiators of exenatide twice daily compared with other anti-diabetic medication: a follow-up study

AIMS

Previously, a retrospective cohort study found no increased risk of acute pancreatitis with current or recent use of exenatide twice daily compared with use of other anti-diabetic drugs. This follow-up study investigated incident acute pancreatitis, with the use of a different data source and analytic method, in patients exposed to exenatide twice daily compared with patients exposed to other anti-diabetic medications.

METHODS

A large US health insurance claims database was used. Eligible patients had ≥ 9 months continuous enrollment without a claim for pancreatitis and a claim for a new anti-diabetic medication on or after 1 June 2005 to 31 March 2009. Cases of acute pancreatitis were defined as hospitalized patients with an Internation Classification of Disease 9 code of 577.0 in the primary position. A discrete time survival model was used to evaluate the relationship between exenatide twice daily and acute pancreatitis.

RESULTS

Of 482,034 eligible patients, 24,237 initiated exenatide twice daily and 457,797 initiated another anti-diabetic medication. Initiators of exenatide twice daily had more severe diabetes compared with initiators of other anti-diabetic medications. After adjustments for propensity score, insulin and use of medication potentially associated with acute pancreatitis, the odds ratio with exenatide twice daily exposure was 0.95 (95% CI 0.65-1.38). A secondary analysis that examined current, recent and past medication exposure found no increased risk of acute pancreatitis with exenatide twice daily, regardless of exposure category.

CONCLUSION

This study indicates that exposure to exenatide twice daily was not associated with an increased risk of acute pancreatitis compared with exposure to other anti-diabetic medications. These results should be interpreted in light of potential residual confounding and unknown biases.

Safety and tolerability of exenatide twice daily in patients with type 2 diabetes: integrated analysis of 5594 patients from 19 placebo-controlled and comparator-controlled clinical trials

BACKGROUND

Exenatide twice daily is a first-in-class glucagon-like peptide receptor agonist approved for the treatment of type 2 diabetes. The objective of this analysis was to evaluate the safety profile of exenatide twice daily and to compare its profile with that of a pooled comparator (placebo and insulin) in patients with type 2 diabetes.

METHODS

Data from 19 completed, randomized, controlled clinical trials of exenatide twice daily (5 μg and 10 μg) were pooled and analyzed; the pooled data included 5594 intent-to-treat patients who were followed for 12-52 weeks. Incidence rates, exposure-adjusted incidence rates, and 95% confidence intervals around risk differences between groups were calculated.

RESULTS

Baseline demographics and exposure time were comparable between groups (exenatide, N = 3261; pooled comparator, N = 2333; mean exposure time 166-171 days). Transient, mild- to-moderate nausea was the most frequent adverse event with exenatide (36.9% versus 8.3% in the pooled comparator). The incidence of hypoglycemia (minor or major) with concomitant sulfonylurea (exenatide 26.5%, pooled comparator 20.7%) was higher than that without sulfonylurea (exenatide 3.1%, pooled comparator 2.7%) in all groups. Serious adverse events, discontinuations due to serious adverse events, and deaths were reported with similar frequency in the exenatide and pooled comparator groups. Composite exposure-adjusted incidence rates were not statistically different between groups for pancreatitis, renal impairment, or major adverse cardiac events; there was a difference in incidence rates for benign thyroid neoplasm (0.3% versus 0%).

CONCLUSION

Overall, this analysis, representing over 1500 patient-years of exposure, demonstrated that exenatide twice daily was safe and generally well tolerated in patients with type 2 diabetes. The incidence of most adverse events, including serious adverse events, was similar in both exenatide-treated and comparator-treated patients. The most distinct differences between groups were in gastrointestinal-related adverse events, which is consistent with other therapies within the glucagon-like peptide class.

Prophylactic cholecystectomy in midgut carcinoid patients

BACKGROUND

Patients with midgut carcinoid (MGC) tumors are commonly treated with somatostatin analogs. Adverse effects of these drugs include impairment of gallbladder function, formation of gallstones, and cholecystitis. Prophylactic cholecystectomy has been advocated, but data to support this recommendation are sparse. We have analyzed a cohort of 235 patients with MGC focusing on the risk for gallstone formation and complications thereof.

METHODS

Forty-eight of the 235 patients had been cholecystectomized before surgery for MGC. Of the remaining 187 patients, 144 were treated with somatostatin analogs. Eighteen of the 187 patients had their gall bladder removed during the primary carcinoid surgery.

RESULTS

Twenty-two of the 144 somatostatin-analog-treated patients developed complications, such as gallbladder empyema (n = 1), cholangitis (n = 2), acute cholecystitis (n = 6), acute pancreatitis (n = 1) or acute pancreatitis and cholecystitis (n = 1), or biliary colic (n = 11). Ninety-two of the 144 were examined during surgery, by computed tomography, or by ultrasound, most for reasons other than gallbladder-related indications, and 63% (58/92) of these examinations revealed gallstones. Of the 43 patients not treated with somatostatin analogs, only 3 patients suffered from biliary colic and underwent cholecystectomy.

CONCLUSIONS

In our study the incidence of gallstone-related complications seems to be higher than in the general population. We recommend that prophylactic cholecystectomy is liberally performed during laparotomy for MGC if patients are planned to undergo treatment with somatostatin analogs.

Increased risk of acute pancreatitis and biliary disease observed in patients with type 2 diabetes: a retrospective cohort study

OBJECTIVE

The objective of this study was to assess the risk of acute pancreatitis in patients with type 2 diabetes compared with that in patients without diabetes. We also examined the risk of biliary disease (defined as occurrence of cholelithiasis, acute cholecystitis, or cholecystectomy), which is a major cause of pancreatitis.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study using a large, geographically diverse U.S. health care claims database. Eligible patients (>or=18 years) were enrolled for at least 12 continuous months (1999-2005), with no incident events of pancreatitis or biliary disease during that 1 year baseline period. ICD-9 codes and prescription data were used to identify patients with type 2 diabetes; ICD-9 codes were also used to identify cases of pancreatitis and biliary disease. Overall, 337,067 patients with type 2 diabetes were matched on age and sex with 337,067 patients without diabetes. Incidence rates of disease and 95% CI were calculated per 100,000 person-years of exposure.

RESULTS

The type 2 diabetic cohort had a 2.83-fold (95% CI 2.61-3.06) greater risk of pancreatitis and 1.91-fold (1.84-1.99) greater risk of biliary disease compared with the nondiabetic cohort. Relative to patients of corresponding age without diabetes, younger type 2 diabetic patients had the highest risk of pancreatitis (<45 years: incidence rate ratio [IRR] 5.26 [95% CI 4.31-6.42]; >or=45 years: 2.44 [2.23-2.66]).

CONCLUSIONS

These data suggest that patients with type 2 diabetes may have an increased risk of acute pancreatitis and biliary disease.

Gallstone formation after pancreas and/or kidney transplantation: an analysis of risk factors

Pancreas and kidney transplantation (SPK) is the treatment of choice for patients with type 1 diabetes mellitus and end-stage renal failure. Gallstones are common after SPK transplantation but little is known about the true incidence and etiology of gallstones in this group. We therefore evaluated the incidence of gallstones and the presence of transplant-related risk factors in patients after SPK and kidney transplantation alone (KTA). Data were evaluated of 56 consecutive patients who underwent SPK transplantation and compared the results with those of 91 consecutive nondiabetic patients who underwent KTA transplantation at the Leiden University Medical Center between 1987 and 1994. Of the 58 evaluable KTA patients, 20.7% developed gallstones during 7.7 yr of follow-up and in the SPK group 43.9% of the 41 evaluable patients developed gallstones during 7.1 yr of follow-up. Postoperative weight loss and cyclosporin A-related hepatotoxicity correlated with gallstone formation both in SPK and KTA patients. In addition, the duration of postoperative fasting and autonomic neuropathy correlated with gallstones in SPK patients. It is concluded that both in patients after SPK transplantation and in patients after KTA transplantation, the risk to develop gallstones is significantly increased. Physicians should be aware of the high incidence of gallstones in SPK recipients.

Body mass index, alcohol, tobacco and symptomatic gallstone disease: a Swedish twin study

BACKGROUND/AIMS

Both genetic and environmental factors are involved in the pathogenesis of gallstone disease (GD). We aimed to examine the association between symptomatic GD and overweight (body mass index, BMI, 25-30 kg m(-2)), obesity (BMI > 30 kg m(-2)), alcohol, smoking and smoke-free tobacco by analysing a large twin population.

METHODS

The Swedish Twin Registry (STR) was linked to the Swedish Hospital Discharge and Causes of Death Registries for GD and GD-surgery related diagnoses. Weight, height, use of alcohol, smoking and smoke-free tobacco were provided by STR and analysed for possible associations by conditional logistic regression.

RESULTS

Overweight and obesity were associated with a significantly higher risk for symptomatic GD in the whole study population (OR 1.86 and OR 3.38; CI: 1.52-2.28 and 2.28-5.02 respectively). High alcohol consumption was associated with a lower risk for GD in the whole population (OR 0.62; CI: 0.51-0.74) with no difference between discordant monozygotic and dizygotic twins (OR 1.08 and OR 0.96; CI: 0.82-1.42 and 0.79-1.16). Smoking or smoke-free tobacco was not correlated with GD.

CONCLUSION

Consistent with epidemiological studies, we found positive associations between BMI and the development of symptomatic GD. High alcohol consumption was associated with a decreased risk against GD. Tobacco use has no impact on GD.

Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines

This article discusses the definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis. Acute cholangitis and cholecystitis mostly originate from stones in the bile ducts and gallbladder. Acute cholecystitis also has other causes, such as ischemia; chemicals that enter biliary secretions; motility disorders associated with drugs; infections with microorganisms, protozoa, and parasites; collagen disease; and allergic reactions. Acute acalculous cholecystitis is associated with a recent operation, trauma, burns, multisystem organ failure, and parenteral nutrition. Factors associated with the onset of cholelithiasis include obesity, age, and drugs such as oral contraceptives. The reported mortality of less than 10% for acute cholecystitis gives an impression that it is not a fatal disease, except for the elderly and/or patients with acalculous disease. However, there are reports of high mortality for cholangitis, although the mortality differs greatly depending on the year of the report and the severity of the disease. Even reports published in and after the 1980s indicate high mortality, ranging from 10% to 30% in the patients, with multiorgan failure as a major cause of death. Because many of the reports on acute cholecystitis and cholangitis use different standards, comparisons are difficult. Variations in treatment and risk factors influencing the mortality rates indicate the necessity for standardized diagnostic, treatment, and severity assessment criteria.

Gene-environment factors that contribute to alcoholic pancreatitis in humans

Alcohol-associated acute and chronic pancreatitis occur in a minority of alcohol users, suggesting that most drinkers are protected from pancreatic diseases while a subset is susceptible. Ongoing studies suggest that the pathophysiology is complex and can involve multiple genetic and environmental pathways and stochastic events. Both rat models and human genetic epidemiology studies have been used to understand susceptibility and modifying factors in humans. Rat studies suggest that different types of altered pancreatic physiology occur depending on dose, they occur rapidly and that alcohol changes the immune response to recurrent pancreatic injury. Human studies suggest that PRSS1 and SPINK1 mutation increase the pancreas' susceptibility to alcohol-associated pancreatitis, and that tobacco smoking, and some factors, affect disease progression.

Weight gain after laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (LC) relieves symptomatic cholelithiasis (SC) but may facilitate postoperative gluttony.

AIM

To examine changes in body mass index (BMI) and general health of a cohort of patients three years after uncomplicated LC for SC.

METHODS

Patients were studied three years after uncomplicated LC and compared to age- and gender-matched controls who had undergone non-biliary surgery.

RESULTS

Forty-two patients and 42 controls were studied. The mean age of the patients was 55 years (range 29-82) versus 54 years (25-82) for controls. Patients undergoing LC increased their mean BMI by 1.8 kg/m2. Females were particularly likely to gain weight (mean change in BMI=+2.1), with no significant difference being found between premenopausal and postmenopausal women. Of the 24 LC patients who claimed to continue their low fat diet, the mean BMI changed from 27.6 to 29.6 kg/m2. The mean BMI of the 17 people who claimed regular exercise changed less markedly (+1.4) than those who admitted infrequent exercise (+2.1).

CONCLUSION

Selection for LC may identify patients at risk of continuing or resumed aetiological contributors to obesity. Follow-up long after the surgery may therefore be necessary to facilitate additional healthcare interventions.