Iatrogenic Injury of Biliary Tree-Single-Centre Experience.

Cholecystolithiasis is among the most prevalent gastrointestinal disorders requiring surgical intervention, and iatrogenic damage to the bile tree is a severe complication. We aimed to present the frequency of bile duct injuries and how our facility handles these complications. We retrospectively analyzed bile duct injuries in patients undergoing surgery. We concentrated on factors such as sex, age, indications for surgery, type of surgery, primary procedure, bile tree injury, repair, and timing as well as early and late complications. There were 22 cases of bile duct injury in the studied material, primarily affecting women-15 individuals (68.2%). Eleven cases (45.7%) of acute cholecystitis were the primary reason for surgery, and an injury to the common bile duct that extended up to 2 cm from the common hepatic duct was the most common complication (European Association for Endoscopic Surgery grade 2). Roux-en-Y hepaticojejunostomy was the most common repair procedure in 14 cases (63.6%). Eleven patients (50%) experienced early complications following reconstruction surgery, whereas five patients (22.7%) experienced late complications. An annual mortality rate of 22.7% (five patients) was observed. Iatrogenic bile duct injury is a severe complication of surgical treatment for cholecystolithiasis. Reconstruction procedures are characterized by high complication rates and high mortality.

Risk Assessment of Laparoscopic Cholecystectomy in Liver Cirrhotic Patients with Clinically Significant Portal Hypertension: A Retrospective Cohort Study.

Objective: This study was aimed to evaluate the correlation between clinically significant portal hypertension (CSPH) and postoperative complications and risk predictors of postoperative complications. Methods: The retrospective study was conducted to identify the effect. The cirrhotic patients were divided into two groups, those with or without CSPH. The intraoperative and postoperative conditions were evaluated. Multivariate logistic regression analysis was performed to identify potential risk predictors for postoperative complications in cirrhotic patients with CSPH. Results: The cirrhotic patients with CSPH who underwent laparoscopic cholecystectomy (LC) had postoperative hospitalization than the patients without CSPH. However, the incidence of postoperative complications between two groups showed no significant difference. The results of multivariate analysis showed that male, gallbladder wall >3 mm, size of stones ≥1 cm, scores of Model for end-stage liver disease (MELD) ≥10, and operation time >60 minutes were the potential risk predictors for postoperative complications. Conclusions: CSPH did not increase the incidence of postoperative complications in cirrhotic patients who underwent LC, but increased conversion rate and prolonged postoperative hospitalization. Furthermore, our study showed that gender, sizes of gallbladder wall and stones, scores of MELD, and operation time were the important postoperative risk predictors for cirrhotic patients with CSPH.

Gallstone recurrence after minimally-invasive cholecystolithotomy with gallbladder reservation: a follow-up of 720 cases.

OBJECTIVE: To discuss the hazards of cholecystolithiasis recrudesce after cholecystolithotomy with gallbladder reservation; To provide a theoretical basis for reducing the recurrence rate of gallstone. PATIENTS AND METHODS: The patients who were followed up for at least one year after minimally-invasive operation with gallbladder reservation because of cholecystolithiasis were selected. In this population, the patients with recurrence after surgery were as the case group, those patients with no recurrence after surgery were as the control group. Through collection of general data of selected cases, relevant information of Ultrasound Examinations of gallbladder and history data of the patients questionnaires were completed. Relevant factors of gallstone recurrence of patients, were observed through statistic analysis. Main factors go as follows: gender, age, nation, career, BMI, whether or not the patient had the history of chronic superficial gastritis, and regulation of gallbladder emptying function, family history, etc. The information of selected cases is complete. RESULTS AND CONCLUSIONS: The main hazards of cholecystolithiasis recurrence were BMI, family history of gallstone disease, and emptying function of gallbladder.

[Clinical review and case report of ceftriaxone-associated gallbladder pseudolithiasis in adult].

Although ceftriaxone can be used safely in most instances, it can sometimes induce biliary sludge or stone formation. Most of the patients remain asymptomatic and children are more susceptible to develop this condition, but adults can be affected as well. Because sludge or stones disappear after discontinuing ceftriaxone, this condition is referred to as ceftriaxone-associated pseudolithiasis. A 54-year-old woman was admitted to a local clinic for management of ileus. During admission, she had received ceftriaxone and metronidazole, and had been on nil per os for the past 6 days. She was then referred to our hospital for cholecystectomy due to persistent right upper quadrant pain. Although imaging studies showed gallbladder sludge, pseudolithiasis was suspected because of ceftriaxone administration history and prolonged fasting. After careful watch-and-wait, the condition resolved spontaneously after ceftriaxone discontinuation. Our clear understanding on ceftriaxone-associated gallbladder pseudolithiasis allowed us to avoid an unnecessary cholecystectomy. Herein, we report the case of a 54-year-old woman with ceftriaxone-associated gallbladder pseudolithiasis that was successfully managed by ceftriaxone discontinuation alone.

Acute abdominal complications following hip surgery.

Hip surgeries are some of the most common and successful orthopedic procedures. Although rarely, abdominal complications do occur and are associated with unfavorable outcomes.We aimed to identify and describe the severe abdominal complications that appear in patients under-going elective or traumatic hip surgery. A four year retrospective electronic database research identified 408 elective primary hip replacements,51 hip revisions and 1040 intra and extracapsular proximal femur fractures. Out of these, three males and 4 females between 64 - 84 years old were identified to have developed acute abdominal complications: perforated acute ulcer (3),acute cholecystitis (2), volvulus (1), toxic megacolon with peritonitis (1) and acute colonic pseudo-obstruction (1).Complications debuted 3 - 10 days after index orthopedic surgery. Acute perioperative abdominal complications are rarely encountered during orthopedic surgery. When these do occur, they do so almost exclusively in patients with hippathology, comorbidities and most often lead to life threatening situations. We thus emphasize the need for early identification and appropriate management by both orthopedic and general surgery doctors in order to improve patient safety.

Symptomatic cholecystolithiasis after cholecystectomy.

A 43-year-old woman was admitted to the gastroenterology department with colicky pain in the upper abdomen. Four years earlier, she had undergone a laparoscopic cholecystectomy because of cholecystitis. She recognised her current complaints from that previous episode. An endoscopic retrograde cholangiopancreatography showed a cavity with a diameter of 2 cm which contained multiple concrements near the liver hilus. An elective surgical exploration was performed. Near the clip of the previous cholecystectomy a bulging of the biliary tract with its own duct was visualised and resected. Histological examination of this "neo" gallbladder showed that the bulging was consistent with the formation of a reservoir secondary to bile leakage, probably caused by a small peroperative lesion of the common bile duct during the previous cholecystectomy. In conclusion, our patient presented with colicky pain caused by concrements inside a 'neo' gallbladder.

Cholecystectomy due to symptomatic gallbladder disease after orthotopic liver transplantation: report of three cases.

Although biliary stones and sludge are relatively common after liver transplantation (OLT), symptomatic cholecystolithiasis or acute cholecystitis have rarely been reported. Until the early 1990s few transplant centers preserved the donor's gallbladder for transplantation with the liver graft. This technique allows one to perform procedures, such as cholecystojejunostomy or a donor gallbladder conduit for biliary tract reconstruction, to treat posttransplant biliary complications. Herein we have reported three cases of successful either laparoscopic or open cholecystectomy for symptomatic cholecystolithiasis or acute cholecystitis between 14 and 19 years after OLT, as well as a systematic literature review.

Cholecystolithiasis is associated with Clonorchis sinensis infection.

BACKGROUND: The objective of this study was to analyze gallbladder stones for direct evidence of a relationship between Clonorchis sinensis infection and gallbladder stones formation. METHODOLOGY: We investigated one hundred eighty-three gallbladder stones for the presence of Clonorchis sinensis eggs using microscopy, and analyzed their composition using Fourier transform infrared spectroscopy. We confirmed the presence of Clonorchis sinensis eggs in the gallbladder stones using real-time fluorescent PCR and scanning electron microscopy. PRINCIPAL FINDINGS: Clonorchis sinensis eggs were detected in 122 of 183 gallbladder stones based on morphologic characteristics and results from real-time fluorescent PCR. The proportion of pigment stones, cholesterol stones and mixed gallstones in the egg-positive stones was 79.5% (97/122), 3.3% (4/122) and 17.2% (21/122), respectively, while 29.5% (18/61), 31.1% (19/61) and 39.3% (24/61) in the egg-negative stones. The proportion of pigment stone in the Clonorchis sinensis egg-positive stones was higher than in egg-negative stones (P<0.0001). In the 30 egg-positive stones examined by scanning electron microscopy, dozens or even hundreds of Clonorchis sinensis eggs were visible (×400) showing a distinct morphology. Many eggs were wrapped with surrounding particles, and in some, muskmelon wrinkles was seen on the surface of the eggs. Also visible were pieces of texture shed from some of the eggs. Some eggs were depressed or without operculum while most eggs were adhered to or wrapped with amorphous particles or mucoid matter (×3000). CONCLUSION: Clonorchis sinensis eggs were detected in the gallbladder stones which suggests an association between Clonorchis sinensis infection and gallbladder stones formation, especially pigment stones.

Cholecystolithiasis after gastric bypass: a clinical, biochemical, and ultrasonographic 3-year follow-up study.

BACKGROUND: Cholecystolithiasis (CL) is a common occurrence after bariatric surgery. Few studies have prospectively analyzed not only gallstone formation after Roux-en-Y gastric bypass (RYGBP), but also its complications and symptoms. This study aimed to identify the incidence of CL itself and symptomatic CL after RYGBP as well as the presence of predictive factors for CL. METHODS: A prospective observational study was performed on 40 morbidly obese patients free of gallbladder disease undergoing RYGBP at a public hospital in Brazil between February and October 2007. They were followed up clinically, biochemically (lipid profile), and ultrasonographically at 6 months and 1, 2, and 3 years after surgery. Postoperative prophylactic bile salt therapy (ursodiol) was not prescribed. Of the 40 patients, 38 completed the 3-year follow-up. They were divided into two groups: those who formed gallstones and those who did not. These groups were compared with respect to gender, age, preoperative body mass index (BMI) and lipid profile results, and postoperative percentage of excess BMI lost (%EBL) and lipid profile results. RESULTS: The overall postoperative incidence of CL was 28.9 % (11 out of 38), with a 15.7 % incidence of symptomatic CL (6 out of 38). Gender, age, preoperative BMI, postoperative %EBL, and preoperative and postoperative lipid profile results were not identified as predictive factors for CL after RYGBP. CONCLUSIONS: There was a high incidence of CL after RYGBP, occurring primarily in the first 2 years postoperatively. There was no identified predictive factor for gallstone formation after RYGBP. Most patients who formed gallstones were symptomatic, some with potentially severe complications.

Limits and perspective of oral therapy with statins and aspirin for the prevention of symptomatic cholesterol gallstone disease.

The prevalence of gallstones disease in Western countries is 10 - 15%. Gallstones can be one of two types - cholesterol or pigment - with cholesterol gallstones representing nearly the 80% of the total. Cholesterol and pigment gallstones have different predisposing factors: cholesterol gallstones are related to supersaturated bile in cholesterol, whereas black pigment gallstones are related to hyperbilirubinbilia factors (hemolysis, etc.); these are necessary, but not sufficient, factors to produce gallstones in vivo. Gall bladder mucosa factors (gall bladder secretion of mucin, local bile stasis and production of endogenous biliary ß-glucuronidase) may coexist with the aforementioned factors and facilitate gallstone nucleation and growth. The gold-standard treatment for symptomatic gallstones is laparoscopic cholecystectomy. Several studies have reported a significant reduction in the onset of symptomatic gallstones disease in patients undergoing chronic therapy with statins, which can reduce bile cholesterol saturation. Aspirin, which has been shown to reduce the local production of gall bladder mucins (mucosal or parietal factors of gallstone formation) in animal experimental models, does not appear to reduce the risk of symptomatic gallstones disease when tested alone. The new horizon of oral therapy for the prevention of symptomatic gallstone disease needs to evaluate the long-term effect of statins and chronic aspirin administration in patients with dyslipidemia and/or atherosclerosis.

Prophylactic cholecystectomy, a mandatory step in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass?

BACKGROUND: The aim of this study was to determine the incidence of symptomatic gallstone disease requiring cholecystectomy (CCE) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and to identify the peri-operative risk factors associated with postoperative symptomatic gallstone disease. METHODS: Between August 2003 and November 2009, 724 patients underwent LRYGBP at the Groeninge Hospital. Preoperative ultrasound was performed in 600 of 641 patients without history of CCE and 120 (20.0%) were diagnosed with cholecystolithiasis. RESULT: Six hundred twenty-five patients were included, 43(6.9%) developed delayed symptoms related to biliary disease. Of these 43 patients, 39 underwent post-LRYGBP CCE. Of these 39 patients, 9 (7.5%) had a positive ultrasound prior to LRYGBP. Multivariate analysis identified weight loss at 3 months post-LRYGB of more than 50% of excess weight [HR (95% CI), 2.04 (1.04-4.28); p = 0.037) as the sole significant independent predictor of delayed symptomatic cholecystolithiasis. CONCLUSIONS: Symptomatic gallstone disease occurred only in 6.9% of patients post-LRYGBP. Multivariate analysis identified weight loss at 3 months post-LRYGBP of more than 50% of excess weight as the sole significant independent predictor of delayed symptomatic cholecystolithiasis. Prophylactic CCE should not be recommended at the time of LRYGBP.

[Disorders of lipid metabolism in patients with cholelithiasis and gallbladder cholesterosis depending on apolipoprotein E genotype].

The work was aimed to study blood lipid spectrum in 133 patients with cholelithiasis (CL) and 159 with gallbladder cholesterosis (GC) as well as apoE genotypes (based on restriction fragment polymorphism) in 49 and 36 respectively. Lipid composition was shown to significantly differ in the two conditions. LDL cholesterol was increased in GC and TG in CL. A rise in LDL cholesterol in both groups was apparent before the age of 30 yr (34.6 +/- 8.4 and 52.6 +/- 12.9% respectively), that in TG and VLDL after 40 yr. E3/3 genotype (norm) was identified in 75.5 +/- 6.2% of the patients with CL and in 83.4 +/- 6.2% in those with GC (p < 0.05). e4 allele (mutation) equally frequently occurred in 10.2 +/- 4.3 and 8.1 +/- 4.5% of patients with CL and GC (p > 0.5), e2 allele in 14.5 +/- 5.0 and 8.1 +/- 4.5% (p < 0.05). These data suggest that patients of both groups equally frequently suffered disturbances in metabolism of saturated (e2 allele) and polyunsaturated (e4 allele) fatty acids predisposing for hypercholesterolemia and hyperlipidemia. They explain why CL is frequently associated with cholesterosis and GC with the formation of caliculi. However, the absence of significant correlation between CL, GC and alleles e2, e4 suggests participation of other factors in pathogenesis of these diseases (LP(a), LDL heterogeneity).

[Biochemical characteristics of operating bile composition in different types of cholecystolithiasis].

With a view to predicting the outcomes of surgical treatment of cholelithiasis, depending on the composition of concretions by high performance liquid chromatography was studied lipid composition and the spectrum of the operating bile acids in 10 patients with bile pigment cholelithiasis, 15--with cholesterol cholelithiasis, 15--with a combination of cholesterol cholelithiasis, and scab forms cholesterosis gallbladder, 6--to polypous-mesh form cholesterosis gallbladder. As a control, use the operating bile 6 patients with adenomatous and fibro-adenomatous polyps of the gallbladder. Based on the results of the study was proved the need for correction of biliary insufficiency in patients operated on for cholesterin associated pathology of the gallbladder. Spectrum of bile acids of operating bile helped justify holding litholytic therapy to prevent aggregation of bile.

Peroral cholecystoscopy with electrohydraulic lithotripsy for treatment of symptomatic cholelithiasis in end-stage liver disease (with videos).

BACKGROUND: Patients with end-stage liver disease have an increased risk of symptomatic gallstone disease, as well as complications associated with cholecystectomy. We hypothesized that peroral transpapillary cholecystoscopy with electrohydraulic lithotripsy of gallbladder stones is technically feasible and beneficial in patients who are high operative risks. DESIGN: Observational, descriptive. PATIENTS: Patients with Child's class C cirrhosis and with gallstone symptoms who were awaiting liver transplantation. INTERVENTIONS: Gallbladder stenting, dilation of the cystic duct, cholecystoscopy, electrohydraulic lithotripsy, ursodiol therapy. MAIN OUTCOME MEASUREMENTS: Gallbladder access and visualization, stone clearance, symptom relief, and complications. RESULTS: The gallbladder wall and stones were adequately visualized. Electrohydraulic lithotripsy achieved stone clearance after two sessions. Mild postprocedure pancreatitis occurred after the first treatment. The patient remained symptom free, stent free, and stone free until a liver transplantation, which was performed 25 months later. LIMITATIONS: Proof of concept performed in a single patient. CONCLUSIONS: Peroral transpapillary cholecystoscopy is technically feasible. Electrohydraulic lithotripsy of gallbladder stones under direct vision can achieve stone clearance. Patients with cirrhosis who are awaiting transplantation and other high-risk surgical candidates with symptomatic gallstone disease may benefit from this treatment option. Studies to assess the efficacy and safety of this novel technique are needed before routine clinical use can be recommended.

[Gallbladder complications after bariatric surgery]. / Complications vésiculaires après chirurgie bariatrique.

With the increased incidence of obesity in the developed countries, and the failure of medical treatments, bariatric surgery has increased rapidly. Although laparoscopic gastroplasty is the most popular bariatric intervention in France, the gold standard tends to be the laparoscopic gastric bypass. The severe weight loss caused by this type of procedure induces specific middle or long term complications such as biliary lithiasis. In this literature we describe different physiopathological mechanisms of lithiasis after gastric bypass by coeliosurgery or gastroplasty, their diagnosis, and preventive treatment to avoid these complications.

[Common occurrence of non-alcoholic fatty liver disease and cholecystolithiasis]. / A nem alkoholos zsírmáj és az epekövesség együttes elofordulásának megfigyelése.

INTRODUCTION: Non-Alcoholic Fatty Liver Disease is an acquired metabolic disease of the liver caused by accumulation of triglycerides in hepatocytes that is followed by necrobiotic inflammatory reaction, fibrosis and cirrhosis. Obesity, insulin resistance, diabetes mellitus and hyperlipidaemia are important pathogenetic factors of the process. It is known that among patients with cholecystolithiasis and diabetes mellitus in their anamnesis complications of cholecystolithiasis occur much more frequently like among patients without diabetes. AIM: The aim of the study is observation of the incidence of cholecystolithiasis and its complications in patients with Non-Alcoholic Fatty Liver Disease and comparison of cholecystolithiasis incidence between healthy population and population with Non-Alcoholic Fatty Liver Disease. METHODS: Abdominal ultrasonographical findings were analysed in patients hospitalised at our department and in outpatients, patients with severe accompanied diseases were excluded of the analysis. The analysed basic file of patients could be considered as a selected file. The independence of the two examined variables was measured by chi(2) test. RESULTS: Steatosis was described in 38% of the examined patients, cholecystolithiasis was described in 16% of patients. Cholecystolithiasis and its complications occur two times more frequently in patients with Non-Alcoholic Fatty Liver Disease (33%) like Non-Alcoholic Fatty Liver Disease in patients with cholecystolithiasis (16%). Complications of cholecystolithiasis occur more frequently among patients with Non-Alcoholic Fatty Liver Disease like in healthy individuals. The chi(2) test did not bring significant results concerning the independence of cholecystolithiasis and Non-Alcoholic Fatty Liver Disease. CONCLUSION: Pathogenetic factors of Non-Alcoholic Fatty Liver Disease participate in the pathogenesis of cholecystolithiasis. Their common pathogenetic factors bring about that the formation of cholecystolithiasis is probably faster than the progression of steatosis.

Menopausal hormone therapy and gallbladder disease: the Study of Health in Pomerania (SHIP).

OBJECTIVE: Several studies suggest that oral menopausal hormone therapy (MHT) is associated with an increased risk of gallbladder disease. It has been hypothesized that nonoral MHT may reduce the risk of cholelithiasis. The objective of the present study was to analyse the association between (1) use of life-time MHT (ever use) and gallbladder disease and (2) nonoral use of MHT and gallbladder disease. DESIGN: Cross-sectional study using population-based data from the Study of Health in Pomerania (SHIP). POPULATION: The study population included 994 postmenopausal women, aged 40-79 years. The subgroup of current oral and nonoral MHT users comprised 139 women. METHODS AND MEASUREMENTS: Sociodemographic, medical and reproductive characteristics were based on computer-assisted personal interviews, and selected laboratory parameters were analysed. Gallbladder disease was defined by either a prior history of cholecystectomy or the presence of current sonographically diagnosed gallstones. Data analyses consisted of descriptive, bivariable and multivariable procedures. We performed Poisson regression with Huber/White standard errors to investigate the association between ever use, current nonoral use of MHT and gallbladder disease. RESULTS: We found no significant association between ever use of MHT and gallbladder disease and sonographically diagnosed gallstones in fully adjusted analyses. Women who used MHT had a significantly higher risk for cholecystectomy compared to nonusers. There was no association between nonoral use of MHT and gallbladder disease. CONCLUSIONS: Our analyses do not lend support to the hypothesis that use of MHT is associated with gallbladder disease.

Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass.

BACKGROUND: Because of the claim that about one third of patients develop gallstones within 6 months of Roux-en-Y gastric bypass (RYGB), many have recommended preoperative ultrasonography for all patients and/or prophylactic cholecystectomy (CCY), or ursodiol to prevent stone formation. METHODS: Prospective data were collected from 1391 consecutive patients followed up for > or = 6 months after RYGB (2000-2005) to assess our practice of not routinely removing the gallbladder and not administering ursodiol. RESULTS: Of the 1391 patients, 334 (24%) had undergone CCY before RYGB. Of the remaining 1057 asymptomatic patients, 516 had undergone preoperative ultrasonography. Stones were identified in 99 (19%), sludge in 5 (0.97%), and polyps in 6 (1.1%). Of the 984 patients with gallbladders left in situ after RYGB, only 80 (8.1%) became symptomatic and required delayed CCY. The average excess weight loss at the delayed CCY was 65%. The risk of undergoing delayed CCY seemed to be restricted to the first 29 months after RYGB, because none of 165 patients followed up for 30-144 months required CCY. CONCLUSION: Although CCY should be performed whenever symptoms mandate, the value of routine preoperative ultrasonography and CCY was not apparent from the results of our study. Waiting until symptoms develop might simplify the operative procedure because of the significant weight loss that should have occurred after RYGB. Using an expectant approach, most patients undergoing RYGB will not require CCY.