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

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.

The necessity and safety of simultaneous cholecystectomy during gastric surgery for patients with asymptomatic cholelithiasis

OBJECTIVES

The incidence of cholelithiasis is higher among individuals who have undergone gastric surgery. The benefits of concomitant gallbladder removal in asymptomatic gallstone patients remain uncertain. The aim was to investigate the necessity and safety of simultaneous cholecystectomy in this particular patient population.

METHODS

We performed a systematic review and meta-analysis to assess the incidence of asymptomatic cholelithiasis converting to symptomatic after gastric surgery and the complication rate associated with simultaneous cholecystectomy. PubMed, Embase, and the Cochrane Library were searched for relevant articles published until 10 March 202210 March 2022.

RESULTS

Patients with asymptomatic cholelithiasis after gastric surgery were at a higher risk of developing symptomatic cholelithiasis compared to those without cholelithiasis (relative risk [RR] 2.28, 95% confidence interval [CI] 1.23-4.25) and those with unknown gallbladder conditions (RR 2.70, 95% CI 1.54-4.73). Additionally, patients who underwent simultaneous cholecystectomy did not face a higher risk of complications compared to those who only underwent gastric surgery (RR 0.86, 95% CI 0.48-1.53).

CONCLUSIONS

Simultaneous cholecystectomy is both necessary and safe for patients with asymptomatic cholelithiasis undergoing gastric surgery. It is crucial to assess the gallbladder's condition before gastric surgery, and if the gallbladder status is unknown, simultaneous cholecystectomy should be avoided.

Individualized Choice of Simultaneous Cholecystectomy in Patients with Gastric Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing gastrectomy for gastric cancer are more likely to develop gallstones than the general population. Prophylactic cholecystectomy remains controversial.

METHODS

Studies from 2000-2022 were systematically searched in the PubMed, EMBASE, and Cochrane Library databases. The search included simultaneous cholecystectomy or risk factors for gallstone formation with gastrectomy alone. Major prognostic factors included complications and mortality, and risk factor analyses included age, sex, TNM stage, gastrectomy type, lymph node dissection, diabetes, and duodenal exclusion. Random effects regression models were used to analyze risk estimates and data were presented as odds ratios (ORs) with corresponding 95% confidence intervals (CIs).

RESULTS

There were no significant differences in postoperative morbidity (OR 1.12, 95% CI 0.90-1.39; p = 0.33, I² = 11%) and mortality (OR 1.23, 95% CI 0.62-2.43; p = 0.56, I² = 0%) between gastrectomy alone and simultaneous cholecystectomy. Older age (OR 1.48, 95% CI 1.36-1.59; p < 0.001, I² = 59%), male sex (OR 1.38, 95% CI 1.10-1.71; p = 0.004, I² = 77%), total gastrectomy (OR 1.50, 95% CI 1.25-1.81; p < 0.001, I² = 72%), diabetes mellitus (OR 1.38, 95% CI 1.17-1.63; p < 0.001, I² = 8%), and duodenal exclusion (OR 1.77, 95% CI 1.47-2.15; p < 0.001, I² = 30%) were risk factors for cholecystolithiasis.

CONCLUSIONS

Simultaneous cholecystectomy did not increase the incidence of postoperative complications or mortality. Older age, male sex, total gastrectomy, duodenal exclusion, and diabetes were risk factors for gallstone development after gastrectomy.

Clinical Characteristics of Symptomatic Cholecystitis in Post-Gastrectomy Patients: 11 Years of Experience in a Single Center

Background and Objectives: Gallbladder (GB) stones, a major cause of symptomatic cholecystitis, are more likely to develop in post gastrectomy people. Our purpose is to evaluate characteristics of symptomatic cholecystitis after gastrectomy. Materials and Method: In January 2011−December 2021, total 1587 patients underwent operations for symptomatic cholecystitis at our hospital. We reviewed the patients’ general characteristics, operation results, pathologic results, and postoperative complications. We classified the patients into non-gastrectomy and gastrectomy groups, further divided into subtotal gastrectomy and total gastrectomy groups. Result: The patients’ ages, male proportion, and the open surgery rate were significantly higher (127/1543 (8.2%) vs. 17/44 (38.6%); p < 0.001), and the operation time was longer (102.51 ± 52.43 vs. 167.39 ± 82.95; p < 0.001) in the gastrectomy group. Extended surgery rates were significantly higher in the gastrectomy group (56/1543 (3.6%) vs. 12/44 (27.3%); p < 0.001). The period from gastrectomy to symptomatic cholecystitis was significantly shorter in the total gastrectomy group (12.72 ± 10.50 vs. 7.25 ± 4.80; p = 0.040). Conclusion: GB stones were more likely to develop in post-gastrectomy patients and extended surgery rates were higher. The period to cholecystitis was shorter in total gastrectomy. Efforts to prevent GB stones are considered in post-gastrectomy patients.

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.

Experience of endoscopic retrograde cholangiopancreatography with side-viewing duodenoscope in patients with previous gastric surgery

OBJECTIVES

Endoscopic Retrograde Cholangiopancreatography (ERCP) with conventional side-viewing duodenoscope can be challenging and unsuccessful at altered anatomy in the gastrointestinal tract. This study aimed to evaluate our experience with ERCP in patients with previous gastric surgery.

MATERIAL AND METHODS

Patients on whom ERCP was performed from January 2017 to August 2021 and who had previous gastric surgery were included into the study. Age, sex, comorbidity, Charlson's Comorbidity Index (CCI), ERCP indication, previous gastric surgery (indication, type of resection and reconstruction), history of cholecystectomy, and MRCP results were evaluated retrospectively. The results were compared as successful ERCP (SERCP) or unsuccessful ERCP (USERCP). Also, odds ratio ERCP failure was also evaluated.

RESULTS

Forty-three patients were included into study. Mean age was 68.8 ± 13.6 years. The most common sex was female (51.2%). The most common ERCP indication was choledocholithiasis with 44.2%, gastric surgery indication was peptic ulcer with 72.1%, gastric resection was subtotal with 67.4%, and reconstruction was gastrojejunostomy with 58.1%. The success rate of ERCP was 44.2%. Mean CCI was 4.16 ± 2.28. Only malignancy history was significantly higher in the USERCP group (p= 0.026). Male sex, non-choledocholithiasis indication, history of malignancy, CCI> 4, total gastrectomy, Roux-NY (RNY) reconstruction, history of cholecystectomy, and intercalarily to the bile duct dilatation in MRCP were likelihood for USERCP.

CONCLUSION

While history of malignancy and cholecystectomy were the only significant factor for unsuccessful ERCP, male sex, total gastrectomy, RNY anastomosis result in a higher likelihood of ERCP failure in patients with previous gastric surgery. Alternative devices to side-viewing duodenoscope will increase success in selected patients.

Spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after gastrectomy for gastric cancer: A case report

INTRODUCTION AND IMPORTANCE

Spontaneous gallbladder (GB) perforation is a rare and severe condition. Herein, we present a case of spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after a subtotal gastrectomy for gastric cancer.

CASE PRESENTATION

An 83-year-old woman underwent a radical subtotal gastrectomy for advanced gastric cancer. On postoperative day 5, mild leukocytosis was observed. A computed tomography (CT) scan revealed a slightly distended non-thickened GB with minimal air and fluid collection near the duodenal stump, and fluid collection in the abdominal and pelvic cavities. We considered a duodenal stump leak. The effluent of the Barovac located in the abdominal cavity was serosanguinous and the patient was stable, thus we observed and continued using antibiotics. On day 13, the Barovac stopped functioning properly, so we replaced it with a percutaneous catheter drain (PCD) under ultrasonography guidance, aided by the Barovac tract. The PCD drained over 1000 cc of bile daily. On day 16, a follow-up CT showed an increased fluid collection in the abdominopelvic cavity. After comparing this with the previous CT, we rediagnosed as spontaneous GB perforation. An emergency cholecystectomy was performed. Postoperatively, the patient's condition returned to normal and antibiotic therapy continued until day 14. The patient recovered without other complications and was discharged on day 28.

CLINICAL DISCUSSION

Spontaneous GB perforation is a rare but serious complication immediately after gastrectomy which should be looked out for.

CONCLUSION

We report a rare case of spontaneous GB perforation mimicking duodenal stump leak after radical subtotal gastrectomy in gastric cancer.

Important risk factors for gallstones after laparoscopic gastrectomy: a retrospective study

Background

The frequency of gallstones is higher in patients who have undergone gastrectomy than in the general population. While there have been some studies of gallstone formation after open gastrectomy, there are few reports of gallstones after laparoscopic gastrectomy (LG). Therefore, this study aimed to evaluate the incidence of gallstones after LG.

Methods

We retrospectively reviewed the records of 184 patients who underwent LG between January 2011 and May 2016 at Saiseikai Utsunomiya Hospital. After gastrectomy, abdominal ultrasonography was generally performed every 6 months for 5 years. Patients who underwent cholecystectomy before LG, underwent simultaneous cholecystectomy, and did not undergo abdominal ultrasonography, with an observation period of < 24 months, were excluded from the study. Finally, 90 patients were analyzed. Laparoscopic cholecystectomy was performed whenever biliary complications occurred. Patient characteristics were compared using the two-tailed Fisher’s exact test or Chi-square test. In addition, the risk factors for postoperative gallstones were analyzed using logistic regression analysis.

Results

Among the 90 patients included in this study, 60 were men (78%), and the mean age was 65.5 years. Laparoscopic total gastrectomy was performed for 15 patients and laparoscopic distal gastrectomy for 75 patients. D2 lymph node dissection was performed for 8 patients (9%), whereas 68 patients underwent LG with Roux-en-Y reconstruction (76%). Gallstones were detected after LG in 27 of the 90 (30%) patients. Multivariate analysis identified Roux-en-Y reconstruction and male sex as significant risk factors of gallstones after gastrectomy. The incidence of gallstones was significantly higher (53%) in male patients who underwent Roux-en-Y reconstruction. Symptomatic gallstones after laparoscopic cholecystectomy were found in 6 cases (6/27, 22%), and all patients underwent laparoscopic cholecystectomy.

Conclusion

Roux-en-Y reconstruction and male sex were identified as significant risk factors for gallstones after LG.

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.

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.

Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention

Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.