Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery?

Chinese consensus on the management of liver cirrhosis

Liver cirrhosis, characterized by diffuse necrosis, insufficient regeneration of hepatocytes, angiogenesis, severe fibrosis, and the formation of pseudolobules, is a progressive, chronic liver disease induced by a variety of causes. It is clinically characterized by liver function damage and portal hypertension, and many complications may occur in its late stage. Based on the updated practice guidelines, expert consensuses, and research advances on the diagnosis and treatment of cirrhosis, the Chinese Society of Gastroenterology of Chinese Medical Association established the current consensus to standardize the clinical diagnosis and management of liver cirrhosis and guide clinical practice. This consensus contains 43 statements on the etiology, pathology and pathogenesis, clinical manifestations, major complications, diagnosis, treatment, prognosis, and chronic disease control of liver cirrhosis. Since several practice guidelines and expert consensuses on the complications of liver cirrhosis have been published, this consensus emphasizes the research progress of liver cirrhosis itself.

Elevated LDL-c may warn of the risk of gallbladder stones in the patients with metabolic dysfunction-associated steatotic liver disease: A case-control study

PURPOSE

This study aimed to explore the relationship between metabolic dysfunction-associated steatotic liver disease (MASLD) and the development of new-onset gallbladder stone disease (GSD) and to identify factors that influence the occurrence of new-onset GSD in patients with MASLD.

METHODS

In this retrospective case-control study, patients who underwent asymptomatic GSD screening during annual routine health check-ups at two hospitals in China between August 2017 and July 2022 were included. Patients with new-onset GSD and controls without GSD were matched 1:1 based on age, sex, race, occupation, diet, drinking habits, systolic blood pressure, diastolic blood pressure, and fasting blood glucose levels.

RESULTS

The study comprised 1200 patients with new-onset GSD and 1200 controls without GSD. Patients with new-onset GSD had higher rates of MASLD (33.8% vs. 22.2 %, P < 0.001) and hypercholesterolemia (12.6% vs. 7.2 %, P < 0.001) compared to controls. Waist circumference (WC) (OR = 1.042, 95 % CI: 1.022-1.063, P < 0.001), high-density lipoprotein cholesterol (HDL-c) (OR = 0.048, 95 % CI: 0.037-0.062, P < 0.001), triglycerides (OR = 0.819, 95 % CI: 0.699-0.958, P = 0.013), and hypercholesterolemia (OR = 5.023, 95 % CI: 2.735-9.225, P < 0.001) were independently associated with new-onset GSD. Among patients with MASLD, WC (OR = 1.075, 95 % CI: 1.026-1.127, P = 0.003), total cholesterol (TC) (OR = 2.094, 95 % CI: 1.259-3.484, P = 0.004), HDL-c (OR = 0.088, 95 % CI: 0.054-0.142, P < 0.001), and low-density lipoprotein cholesterol (LDL-c) (OR = 4.056, 95 % CI: 2.669-6.163, P < 0.001) were independently associated with new-onset GSD.

CONCLUSIONS

The findings indicate that hypercholesterolemia is independently associated with GSD. Among patients with MASLD, hypercholesterolemia also showed an independent association with GSD. Notably, this study is the first to identify serum LDL-c levels as potentially the most significant risk factor for GSD, highlighting that elevated LDL-c could serve as an important indicator for individuals with MASLD.

Altered microbiome of serum exosomes in patients with acute and chronic cholecystitis

BACKGROUND

This study aimed to investigate the differences in the microbiota composition of serum exosomes from patients with acute and chronic cholecystitis.

METHOD

Exosomes were isolated from the serum of cholecystitis patients through centrifugation and identified and characterized using transmission electron microscopy and nano-flow cytometry. Microbiota analysis was performed using 16S rRNA sequencing.

RESULTS

Compared to patients with chronic cholecystitis, those with acute cholecystitis exhibited lower richness and diversity. Beta diversity analysis revealed significant differences in the microbiota composition between patients with acute and chronic cholecystitis. The relative abundance of Proteobacteria was significantly higher in exosomes from patients with acute cholecystitis, whereas Actinobacteria, Bacteroidetes, and Firmicutes were significantly more abundant in exosomes from patients with chronic cholecystitis. Furthermore, functional predictions of microbial communities using Tax4Fun analysis revealed significant differences in metabolic pathways such as amino acid metabolism, carbohydrate metabolism, and membrane transport between the two patient groups.

CONCLUSIONS

This study confirmed the differences in the microbiota composition within serum exosomes of patients with acute and chronic cholecystitis. Serum exosomes could serve as diagnostic indicators for distinguishing acute and chronic cholecystitis.

Non-operative management of cirrhotic patients with acute calculous cholecystitis: How effective is it?

INTRODUCTION

Nonoperative management (NOM) of acute calculous cholecystitis (ACC) in patients with cirrhosis was proposed. We examined the outcomes of cirrhotic patients with ACC treated with cholecystectomy compared to NOM.

METHODS

We analyzed the 2017-Nationwide Readmissions Database including cirrhotic patients with ACC. Patients were stratified: cholecystectomy, percutaneous cholecystostomy (PCT), and antibiotics only.

PRIMARY OUTCOMES

complications, failure of NOM.

SECONDARY OUTCOMES

mortality, length of stay (LOS), and charges.

RESULTS

3454 patients were identified. 1832 underwent cholecystectomy, 360 PCT, and 1262 were treated with antibiotics. PCT patients had higher mortality 16.9% vs. the antibiotics group 10.9% vs. cholecystectomy group 4.2%. PCT patients had longer LOS, but lower charges compared to the operative group. Failure of NOM was 28.2%. On regression, PCT was associated with mortality.

CONCLUSION

ACC remains a morbid disease in cirrhosis patients. One in three failed NOM, had longer LOS, and higher mortality. Further studies are warranted to identify predictors of NOM failure.

LEVEL OF EVIDENCE

Level III, prognostic.

Colorectal Surgery in Patients with Liver Cirrhosis: A Systematic Review

BACKGROUND

Colorectal surgery in patients with liver cirrhosis poses a significant challenge due to the associated peri-operative morbidity and mortality risks. The aim of this systematic review was to evaluate the outcomes in this cohort of patients following colorectal surgery.

METHODS

The PubMed, Embase and Cochrane databases and references were searched up to October 2022 using the PRISMA guidelines. The data collated included: patient demographics, pathology or type of colorectal operation performed, severity of liver cirrhosis, post-operative complication rates, mortality rates and prognostic factors. A quality assessment of included studies was performed with the Newcastle-Ottawa scale.

RESULTS

Sixteen studies reporting the outcomes of colorectal surgery in patients with liver cirrhosis were identified, including the results of 8646 patients. The indications, pathologies and/or type of operations varied. The overall complication rate ranged from 29 to 75%, minor complication ranged 14.5-37% and major complication ranged 6.7-59.3%. The mortality rates ranged from 0 to 37%.

CONCLUSION

Colorectal surgery in patients with liver cirrhosis still carries considerable morbidity and mortality rates. This group of patients needs to be managed in a multidisciplinary setting to achieve excellent outcomes. Future research should focus on uniform definitions to enable interpretable outcomes.

Gallstone and Gallbladder Disease: Biliary Tract and Cholangiopathies

Cholestatic liver diseases are named primarily due to the blockage of bile flow and buildup of bile acids in the liver. Cholestasis can occur in cholangiopathies, fatty liver diseases, and during COVID-19 infection. Most literature evaluates damage occurring to the intrahepatic biliary tree during cholestasis; however, there may be associations between liver damage and gallbladder damage. Gallbladder damage can manifest as acute or chronic inflammation, perforation, polyps, cancer, and most commonly gallstones. Considering the gallbladder is an extension of the intrahepatic biliary network, and both tissues are lined by biliary epithelial cells that share common mechanisms and properties, it is worth further evaluation to understand the association between bile duct and gallbladder damage. In this comprehensive article, we discuss background information of the biliary tree and gallbladder, from function, damage, and therapeutic approaches. We then discuss published findings that identify gallbladder disorders in various liver diseases. Lastly, we provide the clinical aspect of gallbladder disorders in liver diseases and ways to enhance diagnostic and therapeutic approaches for congruent diagnosis. © 2023 American Physiological Society. Compr Physiol 13:4909-4943, 2023.

Risk factors for pancreatitis occurrence after gallstone treatment using endoscopic retrograde cholangiopancreatography

Background

Patients with gallstones are prone to pancreatitis after treatment using endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to explore the risk factors for pancreatitis occurrence after gallstone treatment using ERCP.

Methods

A total of 193 patients treated from October 2017 to October 2020 were assigned into pancreatitis group (n=55) and non-pancreatitis group (n=138). Multivariate logistic regression analysis was utilized to analyse the risk factors for post-ERCP pancreatitis. The discrimination and accuracy of an established nomogram model were evaluated using receiver operating characteristic and calibration curves, respectively.

Results

The incidence rate of pancreatitis was 28.50% (55/193). Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, number of intubation ≥2 and absence of pancreatic duct stenting were risk factors for post-ERCP pancreatitis (P<0.05). The established model had high discrimination and accuracy. The incidence rates of pancreatitis in patients with and without pancreatic duct stenting were 11.84% (9/76) and 39.31% (46/117), respectively. The patients undergoing pancreatic duct stenting had lower serum amylase levels 6, 12 and 24 h after ERCP than those of patients who did not.

Conclusion

Patients with gallstones have a higher risk of developing pancreatitis. Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, pancreatic duct visualization and number of intubation ≥2 are risk factors for post-ERCP pancreatitis.

Minimally invasive treatment of cirrhotic secondary hypersplenism with high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) has been reported to be a minimally invasive effective method for the treatment of secondary hypersplenism. However, neither the short-term efficacy nor the indications and/or contraindications have been described in patients with cirrhosis. From October 2019 to May 2021, eleven cases of patients with cirrhotic secondary hypersplenism were enrolled. The blood counts, liver function tests and abdominal ultrasound and/or MRI scans of all patients were closely evaluated. Among these 11 patients, eight (72.7%) patients were classified as Child-Pugh A, and the other 3 (27.3%) patients were Child-Pugh B; Five (45%) patients were diagnosed with gallstone, including multiple small stones in 2 patients and single stone in 3 patients. HIFU was performed successfully in all 11 patients. After HIFU, hematologic parameters and liver function were significantly improved in all 11 patients (p < 0.05). The HIFU ablated volume to spleen volume rate was 35-61%. Complications were ecchymosis of the waist in 7 (63.3%) patients, ablated area pain in 3 (27.3%) patients, and choledocholithiasis in 2 (18.2%) patients with multiple small gallstones. All of them recovered smoothly without additional treatment except for 2 patients with choledocholithiasis recovered with risky endoscopic retrograde cholangiopancreatography (ERCP) treatment. This series suggested that HIFU is an effective and safe treatment for cirrhotic secondary hypersplenism in patients classified as Child-Pugh A or B. However, multiple small gallstones could be a relative contraindication for it.

Association of gallstone and polymorphisms of UGT1A1*27 and UGT1A1*28 in patients with hepatitis B virus-related liver failure

Genetic variation in UDP-glucuronosyltransferase 1A1 gene (UGT1A1) is a lithogenic risk factor for gallstone formation. This study aimed to assess genotype and allele frequencies of common UGT1A1 variants in patients with gallstone and hepatitis B virus (HBV)-related hepatic failure. This study enrolled 113 healthy individuals (CTRL), 54 patients with HBV infection (HBV), 134 patients with gallstone-free hepatic failure and HBV infection, and 34 patients with gallstone-related hepatic failure and HBV infection (GRHF). Peripheral venous blood samples were collected for genomic DNA isolation. Polymerase chain reaction amplification was carried out for UGT1A1, followed by direct sequencing. Analysis for genotype and allele frequencies of UGT1A1 variants (UGT1A1*6, UGT1A1*27, UGT1A1*28, and UGT1A1*60) was performed. The allele distributions of the four groups did not deviate from Hardy–Weinberg equilibrium. Allele (A) and genotype (CA) frequency distributions of UGT1A1*27 were significantly different between GRHF and CTRL, or between GRHF and HBV. GRHF and CTRL exhibited significant differences in allele (A) and genotype (CA) frequency distributions of UGT1A1*28. Linkage disequilibrium analysis suggested that haplotype G-G-[TA]7-T may be associated with gallstone in HBV-related hepatic failure. Our data reveal that UGT1A1*27 and UGT1A1*28 variants are significantly observed in patients with GRHF compared to healthy individuals.

Effectiveness of Laparoscopic Cholecystectomy in Patients with Gallbladder Stones with Chronic Cholecystitis

Objective

To assess the effectiveness of laparoscopic cholecystectomy in patients with gallbladder stones and chronic cholecystitis.

Methods

From July 2018 to January 2020, 90 patients with gallbladder stones and chronic cholecystitis assessed for eligibility were recruited and concurrently assigned (1 : 1) to receive either small-incision cholecystectomy (observation group) or laparoscopic cholecystectomy (experimental group). Outcome measures included operation time, intraoperative bleeding volume, postoperative hospital stay, c-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor-α (TNF-α), gastrin (GAS), vasoactive intestinal peptide (VIP), motilin (MOT), and adverse events.

Results

Patients given laparoscopic cholecystectomy showed lower levels of operation-related indices versus those receiving small-incision cholecystectomy (P < 0.05). Laparoscopic cholecystectomy resulted in lower postoperative levels of CRP, IL-6, and TNF-α in the patients versus small-incision cholecystectomy (P < 0.05). Patients receiving laparoscopic cholecystectomy showed better GAS, VIP, and MOT levels than those receiving small-incision cholecystectomy (P < 0.05). The eligible patients after laparoscopic cholecystectomy had a significantly lower incidence of adverse events versus those after small-incision cholecystectomy (P < 0.05).

Conclusion

Laparoscopic cholecystectomy effectively shortens the operative time and length of hospital stay in patients with gallbladder stones and chronic cholecystitis, reduces intraoperative bleeding, attenuates the inflammatory response, and enhances the gastrointestinal function, with less surgical trauma and high safety. Clinical trials are, however, required prior to promotion.

Value of Auricular Point Pressing in Postoperative Pain Nursing Care of Laparoscopic Cholecystectomy Under the Guidance of Nano-Probe

This work aimed to investigate and analyse the application value of auricular point pressing (APP) in pain nursing care after laparoscopic cholecystectomy guided by nano-probe. In this study, 100 patients who underwent laparoscopic cholecystectomy guided by nanoprobes were selected. According to the difference in admission time and intervention measures, 100 patients meeting the inclusion criteria were enrolled into an observation group (n = 50) and a control group (n = 50). Then, patients as controls after surgery were treated with routine preventive nursing intervention measures, and patients for observation received APP on the basis of routine nursing. Anal exhaust time (AET), bowel sound recovery time (BSRT), incidence of abdominal distension, and clinical efficacy were compared. In addition, the degree of abdominal pain was evaluated at the 24th hour, 48th hour, and 72nd hour after surgery, as well as the degree of gastrointestinal reaction. There was no marked difference in the general data of patients from the two groups. The time of first exhaust defecation in the observation group was shorter (P <0.05), indicating that the exhaust effect was better. The differences in degree of abdominal pain in patients were statistically marked between the 24th and 48th hours and the 48th and 72nd hours (P <0.05), indicating that postoperative abdominal pain symptoms of both groups could be effectively improved. The degree of gastrointestinal reaction of patients showed obvious difference between the 24th and 48th hour and the 24th and 72nd hour (P <0.05). However, there was no huge difference in the degree of gastrointestinal reaction between 72 hours and 48 hours (P >0.05), suggesting that the gastrointestinal symptoms were improved after 48 hours. In conclusion, postoperative APP could effectively alleviate postoperative pain in patients.