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A male patient, aged over 75 years, was referred to the emergency room for pain in his right hypochondrium. This pain, which persisted for approximately 3 days, radiated to his right flank and right iliac quadrant and worsened after meals. The patient reported no nausea, vomiting, diarrhoea, fever or recent traumatic events. Blood laboratory tests, ultrasonography, an MRI and a CT scan were performed, leading to the diagnosis of a mass in the Morrison’s pouch with ultrasound features of adipose tissue compatible with a liposarcoma, infiltrating the liver and the right kidney. Subsequent CT-guided needle aspiration and a histological examination led to the diagnosis of actinomycosis. The patient was initially treated with a daily dose of 18 million IU of benzylpenicillin for 4 weeks and subsequently prescribed the oral administration of 3 g/day of amoxicillin for 11 months. A monitoring CT scan was performed after 1, 5, 8 and 12 months, and a CT scan re-evaluation confirmed that the mass had completely healed.

The risk of neoplasia in gallbladder polyps seems to be low, but the evidence from populations at high-risk of gallbladder cancer is limited. We aimed to estimate the risk and to identify the factors associated with neoplastic polyps in a high-risk Hispanic population.A retrospective cohort was recruited between January 2010 and December 2019 at a Chilean university center. Multivariate survival analyses were conducted. Fine-Gray models were fitted to account for competing risks. Covariate adjustment was conducted using propensity scores. The main outcome was the development of gallbladder adenomas or adenocarcinoma.Overall, 748 patients were included, 59.6% underwent cholecystectomy. The median follow-up of patients not subjected to cholecystectomy was 54.7 months (12-128.6 months). Seventeen patients (2.27%) developed the outcome. After adjustment by age, sex, intralesional blood flow, lithiasis and gallbladder wall thickening, only polyp size (≥10 mm, adjusted-HR: 15.01, 95%CI: 5.4-48.2) and number of polyps (≥3 polyps, adjusted-HR: 0.11, 95%CI: 0.01-0.55) were associated with neoplasia.In a Hispanic population at high-risk for gallbladder cancer, gallbladder polyps seem to have a low risk of neoplasia. Polyp size was the main risk factor, while having multiple polyps was associated with an underlying benign condition.

Background There are no reports on nationwide trends in subtotal cholecystectomy (STC) and cholecystostomy in England. We hypothesized that, as in the United States, a substantial increase in the utilization of these surgical procedures, over time, may be observed. We aimed to generate a reliable report on 4 of the most common gallbladder surgical procedures in England to allow cross-procedure comparisons and highlight significant changes in the management of benign gallbladder disease over time. Methods We obtained data from NHS Digital and extracted population estimates from the Office of National Statistics. We examined the trends in the use of STC, cholecystostomy, cholecystolithotomy and total cholecystectomy (TC) between 2000 and 2019. Results Of the 1,234,319 gallbladder surgeries performed, TC accounted for 96.8% (n = 1,194,786) and the other 3 surgeries for 3.2% (n = 39,533). The total number of gallbladder surgeries performed annually increased by 80.4% from 2000 to 2019. We detected increases in the counts of cholecystostomies by 723.1% (n = 290 in 2000 vs n = 2,387 in 2019) and STCs by 716.6% (n = 217 in 2000 vs n = 1,772 in 2019). Consequently, there was a decrease in the ratio of TC to STC (180:1 in 2000 vs 38:1 in 2019). A similar decrease was observed in the ratio of cholecystectomy to cholecystostomy (135:1 in 2000 vs 29:1 in 2019). Conclusion Increased utilization of STC and cholecystostomy was detected in England. These findings highlight the importance of regular monitoring of nationwide trends in gallbladder surgery and the associated clinical outcomes.

Background: Current management guidelines for gallbladder polyps (GBPs) focus on a diameter more than 1 cm as an indication for cholecystectomy. Since most GBPs are not malignant, unnecessary cholecystectomies can lead to unnecessary complications and costs. We developed a score to identify true polyps focusing on their cross-sectional area (CSA). Methods: We retrospectively analyzed the demographic, clinical, laboratory, and sonographic characteristics of 522 patients with GBPs who had undergone cholecystectomy at our hospital between January 2010 and July 2020 (reference group). We used univariate analysis to compare these parameters between 88 true polyps and 434 pseudopolyps and multivariate logistic regression analysis to identify parameters to include in our scoring model. Receiver operating characteristics and area under the curve were used to identify cut-off values. The model was tested on a validation group of 98 patients. Results: In the multivariate analysis, a CSA >123 mm2, positive blood flow signal, age >55.5 years, alanine aminotransferase (ALT) levels > 50 U/L, and an ALT/aspartate aminotransferase ratio > 0.77 were significantly associated with true polyps (odds ratio 6.528, 2.377, 2.617, 2.445, and −0.372, respectively). A prediction model based on cut-off values was used to distinguish a low-risk and high-risk GBP group; true polyps accounted for 6.54% and 58.72%, respectively (p

BACKGROUND The clinical utility of fatty meal stimulated cholescintigraphy particularly using a standardized formulation in patients with suspected functional gallbladder disorder has not been extensively studied. We present our seven-year clinical experience using an Ensure plus protocol. METHODS A retrospective study was performed on patients undergoing stimulated cholescintigraphy using Ensure Plus for evaluation of suspected functional gallbladder disorder. A gallbladder ejection fraction (GBEF) of

Background: Gallstone disease (GSD) is one of the most common gastroenterological disorders. It is known that drospirenone causes small increased risk of gallbladder diseases. However, the risk may vary between different adverse drug reaction databases. Objective: The purpose of this studty is to examine the safety and risk association between hormonal contraceptive drospirenone and gallbladder diseases using adverse drug reaction database of USFDA’s Federal Adverse Events Reporting System (FAERS), Europe’s Eudravigilance (EV) and Canada’s Canada Vigilance Adverse Reaction Online Database (CVARD). Methods: Individual Case Safety Reports of patients till October 2019 were downloaded from the Federal Adverse Event Reporting System, Eudravigilance, and Canadian database. These reports contained information on adverse events associated with all other drugs inclusive of drospirenone. The disproportionality method of data mining was used to calculate the risk association. Results: The lower limit of 95% CI of PRR was 3.27, 3.47 and 3.76, PRR was 33.08, 41.35 and 115.42, ROR was 37.20, 44.61 and 127.19, Chi-square value was 126572.89, 110392.95 and 362.46, and IC-2SD value was 0.16, 0.17, and 1.21 for FAERS, EU, and CVARD respectively indicating a week signal. Also, all the calculated parameters were above the threshold value. Conclusion: From our study, it was clear that the risk between drospirenone and gallbladder diseases was very low among three databases. There was no harm in prescribing this drug for a contraceptive action.

Introduction: Gallbladder carcinoma is often difficult to distinguish from benign gallbladder diseases. While the diagnostic accuracy of endoscopic transpapillary gallbladder drainage (ETGD) has been reported, these results were obtained retrospectively. This prospective study aimed to evaluate the cytological diagnostic accuracy of ETGD in patients with gallbladder disease. Methods: This single-arm prospective clinical trial included a total of 35 patients scheduled to undergo ETGD between March 2017 and September 2019. A 5F pigtail nasobiliary drainage tube was inserted into the gallbladder, and bile was collected over 5 times; if ETGD failed, a drainage tube was placed into the bile duct. The endpoints were, first, the cytological diagnostic accuracy of ETGD and, second, technical success rates and adverse events. Results: Of the 35 patients, 19 were finally diagnosed with gallbladder cancer. The success rate of ETGD tube insertion was 85.7%, and the morphological pattern of the cystic duct with the angle down and located on the right side had a significantly lower success rate for ETGD than that of other cystic duct patterns (odds ratio, 13.5; 95% confidence interval, 1.7–143.7; p = 0.02). Cytological samples were collected 5 times on median. The sensitivity, specificity, and accuracy in all patients were 78.9%, 100%, and 88.6%, respectively, while those in 30 patients with successful ETGD were 87.5%, 100%, and 93.3%, respectively. Adverse events occurred in 3 patients: mild pancreatitis in 1 patient and obstructive jaundice in 2 patients; all complications were resolved with conservative therapy. Discussion/Conclusions: Cytology using an ETGD tube is useful in differentiating benign and malignant gallbladder diseases (Clinical Trial Registry No. UMIN000026929).

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Gallbladder perforation still continues to perplex surgeons; 25 such patients diagnosed either pre- or intra-operatively and managed at our institute over the last 10 years period were analysed. Only eight were diagnosed pre-operatively, while a large majority (17) had a wrong initial working diagnosis. Symptoms and signs were variable. No blood investigation was specific. A computed tomography scan was generally better than ultrasound in detecting the perforation. All our cases were managed operatively with no mortality and a mean duration of hospital stay of 6.8 days. Most perforations were extra-hepatic (84%) and those of Niemeier’s type I (52.2%). Because of its varied clinical presentation, gallbladder perforation is often an intra-operative diagnosis, but early intervention carries a good outcome.

The spectrum of pathologies affecting the biliary tree in the pediatric population varies depending on the age of presentation. While in utero insults can result in an array of anatomic variants and congenital anomalies in newborns, diverse acquired biliary pathologies are observed in older children. These acquired pathologies display different presentations and consequences than adults. Multimodality imaging assessment of the pediatric biliary system is requisite to establishing an appropriate management plan. Awareness of the imaging features of the various biliary pathologies and conveying clinically actionable information is essential to facilitate appropriate patient management. In this paper, we will illustrate the anatomy and embryology of the pediatric biliary system. Then, we will provide an overview of the imaging modalities used to assess the biliary system. Finally, we will review the unique features of the pediatric biliary pathologies, complemented by histopathologic correlation and discussions of clinical management.

Biliary hyperkinesia is typically diagnosed in patients with biliary-like pain and no evidence of gall stones on imaging modalities but who have had biliary scintigraphy scan (HIDA) that shows ejection fraction ≥ 80%. This study aims to identify whether the removal of the gall bladder can alleviate the symptoms associated with biliary hyperkinesia. Systematic search following PRISMA guidelines was done from inception to January 2020 using PubMed/Medline, OVID, Embase, Cochrane database of systemic reviews, Cochrane central register of controlled trials, The Database of Abstracts of Reviews of Effects (DARE) and Cochrane library databases. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardized MD (SMD) for continuous outcomes. A meta-analysis was done using random-effect model in RevMan 5.4® software. Thirteen studies met the inclusion criteria and were included in the review. A total of 332 patients diagnosed with biliary hyperkinesia underwent cholecystectomy, of whom 303 (91.3%) reported symptomatic improvement RR 8.67 (95% CI 4.95, 15.16) P = 0.01. Six studies described abnormal histological features in 163/181 (90.05%) with high GB EF. RR 7.88 (95% CI 3.94, 15.75) P = 0.08. Chronic cholecystitis n = 155 (95%), cholesterolosis n = 7 (4.3%), and one showed features of acute cholecystitis. Patients with typical biliary colic symptoms without gallstones and markedly high ejection fraction might benefit from having cholecystectomy to alleviate their symptoms.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

Choledocholithiasis is a commonly encountered disease that is associated with various clinical presentations ranging from mild form of biliary colic to severe life-threatening acute cholangitis. Recently, peri-ampullary diverticulum (PAD) has been linked to the development of biliary diseases; however, data regarding its association with the development of acute cholangitis in the setting of choledocholithiasis are scarce. We aimed to identify predictors, specifically PAD, for the development of acute cholangitis in patients with choledocholithiasis. We performed a retrospective cross-sectional study of all patients admitted to Galilee Medical Center from 1 January 2010 to 31 December 2019 with different clinical presentations of documented choledocholithiasis including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes. Overall, 651 patients were included in the final analysis. Among them, 88 patients (13.5%) had choledocholithiasis associated with acute cholangitis (group A), as compared to 563 patients (86.5%) without acute cholangitis (group B). The average ages in groups A and B were 77.8 ± 13.6 and 62.4 ± 20.4 years, respectively (P

Background Various surgical approaches are available for cholecystectomy, but their long-term outcomes, such as incidence of incisional hernia, are largely unknown. Our aim was to investigate the long-term incidence of incisional hernia after cholecystectomy for different surgical approaches. Methods This systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42020178906). Three databases were searched for original studies on long-term complications of cholecystectomy with n > 40 and follow-up ≥6 months for incisional hernia. Risk of bias within the studies was assessed using the Newcastle-Ottawa Scale and the Cochrane “risk of bias” tool. Meta-analysis of the incidence of incisional hernia after 6 and 12 months was conducted when possible. Results We included 89 studies. Of these, 77 reported on multiport or single-incision laparoscopic cholecystectomy. Twelve studies reported on open cholecystectomy and 4 studies on robotic cholecystectomy. Weighted mean incidence proportion of incisional hernia after multi-port laparoscopic cholecystectomy was 0.3% (95% confidence interval 0–0.6) after 6 months and 0.2% after 12 months (95% confidence interval 0.1–0.3). Weighted mean incidence of incisional hernia 12 months postoperatively was 1.5% (95% confidence interval 0.4–2.6) after open cholecystectomy and 4.5% (95% confidence interval 0.4–8.6) after single-incision laparoscopic cholecystectomy. No meta-analysis could be conducted for robotic cholecystectomy, but incidences ranged from 0% to 16.7%. Conclusion We found low 1-year incidences of incisional hernia after multiport laparoscopic and open cholecystectomy, whereas risks of incisional hernia were considerably higher after single-incision laparoscopic and robotic cholecystectomy.

In Japan, the number of bariatric surgeries performed has remained low. Thus, concomitant laparoscopic cholecystectomy (LC) with laparoscopic sleeve gastrectomy (LSG) is still relatively uncommon, but is increasing. We developed new port-sharing techniques for LC and LSG, which we performed on 26 obese Japanese patients with gall bladder (GB) diseases, using the LSG trocar arrangement and one additional trocar. We performed LC first, and after exchanging a port for a liver retractor in the epigastrium, we then completed LSG. One patient with an anomalous extrahepatic bile duct required one additional port. The mean LC time was 55 min, and the transition to LSG just after LC was smooth in all the patients. One patient suffered postoperative intraperitoneal hemorrhage, which was managed conservatively. Concomitant LC with LSG using port-sharing techniques is feasible and safe for obese Japanese patients with GB diseases.

Hemobilia, or hemorrhage within the biliary system, is an uncommon form of upper gastrointestinal (GI) bleeding that presents unique diagnostic and therapeutic challenges. Most cases are the result of iatrogenic trauma, although accidental trauma and a variety of inflammatory, infectious, and neoplastic processes have also been implicated. Timely diagnosis can often be difficult, as the classic triad of upper GI hemorrhage, biliary colic, and jaundice is present in a minority of cases, and there may be considerable delay in the onset of bleeding after the initial injury. Therefore, the radiologist must maintain a high index of suspicion for this condition and be attuned to its imaging characteristics across a variety of modalities. CT is the first-line diagnostic modality in evaluation of hemobilia, while catheter angiography and endoscopy play vital and complementary roles in both diagnosis and treatment. The authors review the clinical manifestations and multimodality imaging features of hemobilia, describe the wide variety of underlying causes, and highlight key management considerations.©RSNA, 2021.

Background Ultrasonographically detected gallbladder wall edema (GBWE) is a marker for anaphylaxis in dogs. Cardiac disease can cause GBWE with similar signs and should be included as a differential diagnosis to prevent interpretation errors. Hypothesis/objectives Document GBWE associated with cardiac disease. Animals Fourteen client-owned animals. Methods Prospective case series with abdominal focused assessment with abdominal sonography in trauma, triage and tracking (AFAST), and thoracic focused assessment with abdominal sonography in trauma, triage, and tracking (TFAST) performed at triage. Animals with GBWE and cardiac disease were enrolled. A board-certified radiologist reviewed images to confirm cardiac disease, GBWE, and characterize the caudal vena cava (CVC) and hepatic veins. Results Thirteen dogs and 1 cat had GBWE associated with cardiac disease. Gallbladder findings included mural thickness ranging from 3 to 5 mm, mild to moderate sludge (n = 3), and mild to moderate luminal distension (n = 6). CVC and hepatic venous distension were found in 5/6. Cardiac diagnoses in dogs included 11 with pericardial effusion (PCE) and 1 each with dilated cardiomyopathy and right-sided myocardial failure. Severity of PCE was rated as mild (n = 1), moderate (n = 6), or severe (n = 4). Seven of 11 had pericardiocentesis performed. Nine of 13 had ascites with 4 having abdominal fluid scores of 1 (n = 2), 2 (n = 2), 3 (n = 1), and 4 (n = 0). Lung ultrasound findings were as follows: dry lung (n = 6), B-lines (n = 4), and nodules (n = 1). The cat had moderate PCE, ascites scored as 1, and severe right-sided ventricular enlargement associated with a ventricular septal defect. Primary presenting complaints included acute weakness (n = 9), acute collapse (n = 5), gastrointestinal signs (n = 3), respiratory distress (n = 2), and need for cardiopulmonary resuscitation (n = 1). Conclusions and clinical importance Ultrasonographically detected GBWE was associated with PCE in this small cohort of cases.

Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP.FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (50-year old) with acute appendicitis (AA) and young males or females (50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost.During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs.In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Objective To determine the influence of normograde (NG) versus retrograde (RG) catheterization of the cystic duct and common bile duct (CBD) in dogs with gallbladder mucoceles (GBM) treated with open cholecystectomy. Study design Retrospective study. Animals Dogs (n = 117) with GBM. Methods Medical records were reviewed for signalment, history, clinical laboratory and diagnostic imaging findings, details of surgery including catheterization method, complications, and outcome. Long-term follow-up data were obtained by telephone or electronic communication. Relationships between catheterization method and clinical variables and outcome were evaluated. Results Dogs catheterized RG were more likely to experience any postoperative complication (p = .0004) including persistence of gastrointestinal signs (p = .0003). Survival to discharge and long-term survival did not differ by group (p = .23 and p = .49). Total bilirubin (TB) decreased by 70.3% after NG catheterization compared to 39.1% after RG catheterization (p = .03) and increased in 14.9% dogs catheterized NG and 38.0% dogs catheterized RG (p = .004). The presence of a diplomate surgeon at surgery resulted in decreased incidences of any perioperative or postoperative complication (p = .003 and p = .05). Conclusion Retrograde catheterization was associated with more postoperative concerns than NG catheterization, but similar survival times. Surgery should be performed by diplomates experienced in biliary surgery to minimize complications. Clinical significance Although both NG and RG techniques to catheterize the cystic duct and CBD are options for treatment of GBM with low mortality, results of this study provide some evidence to recommend NG over RG catheterization.

Management of high-risk surgical patients with cholecystitis poses a significant clinical problem. These patients are often left with the options of permanent cholecystostomy tube drainage or high-risk surgery. Numerous attempts have been made over the past 4 decades to fulfill the need for a minimally invasive, definitive treatment option for such gallbladder disease. These attempts have largely focused on endoluminal ablation with a variety of sclerosants and have been unable to reliably achieve permanent gallbladder devitalization. The advent of modern percutaneous devices and techniques have provided further opportunity to develop minimally invasive treatment options for high-risk patients. Cryoablation, a thermal ablation modality that induces cell death through tissue freezing, has recently emerged as a promising potential option to treat gallbladder disease. Early studies have demonstrated good technical and clinical success, and a prospective trial is ongoing. This manuscript explains the clinical need for gallbladder cryoablation, briefly revisits historical minimally invasive treatments, describes cryoablation technology and why it is well suited for the gallbladder, and reviews the preclinical and clinical studies evaluating the safety and efficacy of gallbladder cryoablation.

Contains fulltext : 232906.pdf (Publisher’s version ) (Open Access) BACKGROUND: Preoperative differentiation between neoplastic and nonneoplastic gallbladder polyps, and the subsequent indication for cholecystectomy remains a clinical dilemma. The current 1 cm size threshold for neoplasia is unspecific. The aim of this study was to improve diagnostic work-up for gallbladder polyps using sonographic and MRI characteristics of neoplastic and nonneoplastic polyps. METHODS: A prospective, exploratory study including patients undergoing cholecystectomy for gallbladder polyp(s) was conducted. Patients underwent targeted transabdominal ultrasound (TAUS) and MRI. Outcomes were sensitivity and specificity for polyp diagnosis, and the radiological characteristics of neoplastic and nonneoplastic polyp types. Histopathology after cholecystectomy was used as reference standard. RESULTS: Histopathology demonstrated gallbladder polyps in 20/27 patients (74%): 14 cholesterol polyps, three adenomyomatosis, two adenomas and one gastric heterotopia. Sensitivity of polyp identification were 72% (routine TAUS) and 86% (targeted TAUS and MRI). Both adenomas were identified as neoplastic on targeted TAUS and MRI. Sonographic presentation as multiple, pedunculated polyps, either heterogeneous or with hyperechoic foci, or as single polyps containing cysts were limited to nonneoplastic polyps. On MRI hyperintense polyps on T1-weighted image were cholesterol polyps. An adenoma with high-grade dysplasia showed foci of decreased ADC values. We propose a checklist for polyp evaluation by targeted TAUS and a flowchart for radiological work-up of gallbladder polyps. CONCLUSIONS: The presented checklist and flowchart could aid diagnostic work-up for gallbladder polyps compared to current routine ultrasound, by elimination of nonneoplastic polyps and ultimately improve treatment decision for patients with gallbladder polyps.

Purpose Possible dulaglutide-induced cholecystitis, with successful resumption of dulaglutide after cholecystectomy, is discussed. Summary A 72-year-old White man was started on dulaglutide for outpatient management of type 2 diabetes, in addition to his existing antihyperglycemic regimen of metformin, glipizide, pioglitazone, and insulin glargine. His glycated hemoglobin (HbA1c) concentration improved from 8.2% to 7.2% with the addition of dulaglutide. Furthermore, the use of dulaglutide did not lead to weight loss. After 16 months of treatment with dulaglutide, he presented to the emergency room with nausea, loss of appetite, and progressive sharp, nonradiating right upper quadrant pain. Based on symptom presentation, laboratory workup, and computed tomography scan results, acute cholecystitis was diagnosed. He underwent a cholecystectomy to remove what was found to be a gangrenous gallbladder. Per documented surgical dictation from the cholecystectomy, the gallbladder was removed, but portions of the biliary tree were left intact. The patient was continued on dulaglutide postoperatively without recurrence of bile stones, biliary tree disease, or abdominal symptoms at 8 months after initial cholecystitis incident. Conclusion A male patient with possible dulaglutide-induced cholecystitis was successfully continued on dulaglutide therapy post cholecystectomy without recurrent complications within the biliary tract.

Introduction Although gallbladder disease is more common in women, there is a trend toward more complicated cases in male patients. Methods All cholecystectomies captured by the National Surgical Quality Improvement Program database for the year 2016 were reviewed. This encompassed 38 736 records. Records were reviewed for age, sex, procedure performed, operative time, postoperative diagnosis, functional status, American Society of Anesthesiologists (ASA) class, preoperative lab values (total bilirubin, alkaline phosphatase, white blood cell count, and aspartate aminotransferase. Descriptive and inferential statistical analyses were conducted. Results Male patients are more likely to undergo cholecystectomy for a diagnosis of cholecystitis, gallstone pancreatitis, or cholangitis than women who are more likely to carry a diagnosis of biliary dyskinesia. The average operative time increases for both sexes as the patients become older. The average operative time is higher for men than women in all age groups and the variance becomes greater as the patients become older. Age, sex, postoperative diagnosis, ASA class, and functional status were all independently significant in predicting operative time. There was no difference in need for cholangiogram between the sexes. Female patients were more likely to have their cholecystectomy completed laparoscopically and they were more likely to have their surgery performed as an outpatient. Conclusion These data show that women were more likely to present with uncomplicated gallbladder disease, while men were more likely to present with complicated gallbladder disease. This suggests that male patients present at a more advanced stage of disease.

Gallbladder polyps are an elevation of the mucous membrane that protrudes into the lumen of the gallbladder cavity. Their prevalence in the general population varies from 0.3 to 13.8%. According to the modern classification, polyps of the gallbladder are divided into benign non-tumor, benign tumor and malignant tumor polyps. A review of modern literature presents cohort and randomized controlled trials, including those summarized in meta-analyzes and systematic reviews, suggesting that the dominant form of polypoid formations of the gallbladder are cholesterol pseudo-polyps with no malignant potential associated with impaired cholesterol metabolism, often combined with gallbladder cholesterosis, metabolic syndrome and cardiovascular morbidity. Evidence is building up on the effectiveness of ursodeoxycholic acid for controlling components of the metabolic syndrome and cardiovascular risks. Ursodeoxycholic acid preparations may become promising for the management of cholesterol polyps.Полипы желчного пузыря являются возвышением слизистой оболочки, которое выступает в просвет полости желчного пузыря. Их распространенность в общей популяции варьирует от 0,3 до 13,8%. Согласно современной классификации полипы желчного пузыря подразделяют на доброкачественные неопухолевые, доброкачественные опухолевые и злокачественные опухолевые полипы. В обзоре современной литературы представлены когортные и рандомизированные контролируемые исследования, в том числе обобщенные в метаанализах и систематических обзорах, свидетельствующие о том, что доминирующей формой полиповидных образований желчного пузыря являются холестериновые псевдополипы, не имеющие злокачественного потенциала, ассоциированные с нарушением метаболизма холестерина, часто сочетающиеся с холестерозом желчного пузыря, метаболическим синдромом и сердечно-сосудистой заболеваемостью. Накапливаются доказательства эффективности урсодезоксихолевой кислоты для контроля компонентов метаболического синдрома и сердечно-сосудистых рисков. Препараты урсодезоксихолевой кислоты могут стать перспективными для ведения холестериновых полипов.

The robotic platform for cholecystectomy has been extensively studied in comparison to its laparoscopic counterpart with acceptable outcomes. However, wide acceptance of a robotic approach to cholecystectomy has been limited by increased operative room (OR) times and substantially higher cost. This is a single-institution retrospective review of Veteran patients presenting for elective laparoscopic (LC) and robotic (RC) cholecystectomies for benign biliary disease at the Dallas VA Medical Center. The primary goal was to interrogate 30-day morbidity as well as operative room times, estimated blood loss (EBL), hospital length of stay (LOS), and conversion rates. The entire cohort included 612 patients (age = 55.1 ± 12.9 years, men = 77.9%, BMI = 31.2 ± 6.3 kg/m2) undergoing elective cholecystectomy (LC = 441 and RC = 171) for benign biliary disease (biliary colic = 78.8%, history of biliary pancreatitis = 7.8%, history of cholecystitis = 5.7%). Univariate analysis comparing LC and RC showed the two groups to be of similar age (55.4 ± 12.4 vs. 54.4 ± 14.2 years; p = 0.4), male gender (79.4% vs. 74.3%, p = 0.2), and BMI (31.1 ± 6.4 vs. 31.5 ± 6.3 kg/m2; p = 0.5). Except for dyslipidemia (LC = 48.3% vs. RC = 36.8%; p = 0.01), both groups had the same rate of co-morbid conditions. ASA level III and IV (LC = 60.1 vs. RC = 69.0%, p = 0.04) was higher in the RC group. Both groups underwent surgical intervention for similar indications (biliary colic LC = 80.5% vs. RC = 74.3; p = 0.1). Hospital LOS (1.7 ± 3.2 vs. 0.3 ± 0.9 days, p

Gallbladder (GB) polyp is a mucosal projection into the GB lumen. With increasing health aware ness, GB polyps are frequently found using ultrasonography during health screening. The preva lence of GB polyps ranges between 1.3% and 9.5%. Most patients are asymptomatic and have benign characteristics. Of the nonneoplastic polyps, cholesterol polyps are most common, ac counting for 60%-70% of lesions. However, a few polyps have malignant potential. Currently, the guidelines recommend laparoscopic cholecystectomy for polyps larger than 1 cm in diameter due to their malignant potential. The treatment algorithm can be influenced by the size, shape, and numbers of polyps, old age (>50 years), the presence of primary sclerosing cholangitis, and gallstones. This review summarizes the commonly recognized concepts on GB polyps from diag nosis to an algorithm of treatment.

Context Mitchell–Riley syndrome due to RFX6 gene mutations is characterized by neonatal diabetes and protracted diarrhea. The RFX6 gene encodes a transcription factor involved in enteroendocrine cell differentiation required for beta-cell maturation. In contrast to the pathway by which RFX6 mutations leads to diabetes, the mechanisms underlying protracted diarrhea are unknown. Objective To assess whether glucagon-like peptide-1 (GLP-1) was involved in the pathogenesis of Mitchell–Riley syndrome protracted diarrhea. Methods Two case report descriptions. in a tertiary pediatric hospital. “Off-label” treatment with liraglutide. We describe 2 children diagnosed with Mitchell–Riley syndrome, presenting neonatal diabetes and protracted diarrhea. Both patients had nearly undetectable GLP-1 plasma levels and absence of GLP-1 immunostaining in distal intestine and rectum. The main outcome was to evaluate whether GLP-1 analogue therapy could improve Mitchell–Riley syndrome protracted diarrhea. Results “Off-label” liraglutide treatment, licensed for type 2 diabetes treatment in children, was started as rescue therapy for protracted intractable diarrhea resulting in rapid improvement during the course of 12 months. Conclusion Congenital GLP-1 deficiency was identified in patients with Mitchell–Riley syndrome. The favorable response to liraglutide further supports GLP-1 involvement in the pathogenesis of protracted diarrhea and its potential therapeutic use.

BACKGROUND Gallbladder polyps (GBPs) are known to be associated with obesity and metabolic diseases. However, to date, the relationship between GBPs and abnormal body fat distribution, such as fatty liver, visceral obesity, or sarcopenia, has not yet been established. AIM To evaluate whether GBPs are associated with fatty liver, visceral obesity, or sarcopenia. METHODS We retrospectively reviewed the medical records of subjects who underwent various laboratory tests, body composition measurement with a non-invasive body composition analyzer, and abdominal ultrasonography during health checkups. A total of 1405 subjects with GBPs were compared with 2810 age- and sex-matched controls. RESULTS The mean age of the subjects was 46.8 ± 11.7 years, and 63.8% were male. According to multiple logistic regression analysis, the presence of fatty liver [odds ratio (OR) 1.413; 95% confidence interval (CI) 1.218-1.638; P < 0.001] was an independent risk factor for GBP, together with low levels of alanine aminotransferase (OR 0.993; 95%CI 0.989-0.996; P < 0.001). Additionally, fatty liver showed both independent (OR 1.629; 95%CI, 1.335-1.988; P < 0.001) and dose-dependent (moderate to severe fatty liver; OR 2.137; 95%CI, 1.662-2.749; P < 0.001) relationship with large GBPs (≥ 5 mm). The presence of sarcopenia and high visceral fat area were not significantly associated with GBPs. CONCLUSION Fatty liver was found to be closely associated with GBPs irrespective of sarcopenia and visceral obesity.

Prenatal diethylstilbestrol (DES) exposure is associated with increased risk of hormonally mediated cancers and other medical conditions. We evaluated the association between DES and risk of pancreatic cancer and pancreatic disorders, type 2 diabetes, and gallbladder disease, which may be involved with this malignancy. Our analyses used follow-up data from the US National Cancer Institute DES Combined Cohort Study. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for age, sex, cohort, body mass index, smoking, and alcohol for the association between prenatal DES exposure and type 2 diabetes, gallbladder disease (mainly cholelithiasis), pancreatic disorders (mainly pancreatitis), and pancreatic cancer among 5667 exposed and 3315 unexposed individuals followed from 1990 to 2017. Standardized incidence rate (SIR) ratios for pancreatic cancer were based on age-, race-, and calendar year-specific general population cancer incidence rates. In women and men combined, the hazards for total pancreatic disorders and pancreatitis were greater in the prenatally DES exposed than the unexposed (HR = 11, 95% CI 2.6–51 and HR = 7.0, 95% CI 1.5–33, respectively). DES was not associated overall with gallbladder disease (HR = 1.2, 95% CI 0.88–1.5) or diabetes (HR = 1.1, 95% CI 0.9–1.2). In women, but not in men, DES exposure was associated with increased risk of pancreatic cancer compared with the unexposed (HR: 4.1, 95% CI 0.84–20) or general population (SIR: 1.9, 95% CI 1.0–3.2). Prenatal DES exposure may increase the risk of pancreatic disorders, including pancreatitis in women and men. The data suggested elevated pancreatic cancer risk in DES-exposed women, but not in exposed men.

Data related to the role of epigenetic modifications in gallbladder carcinoma (GBC) is limited. We intended to assess the role of crucial epigenetic modifiers pertaining to histone modification and DNA-methylation system in gallbladder carcinogenesis. The expression of EZH2, H3K27me3, and DNA methyltransferases (DNMTs) was analyzed by immunohistochemistry in cases of GBC (n = 39), gallbladder dysplasia (GBD, n = 12), and benign mucosa (BM, n = 16). A semi-quantitative scoring system was used for assessing the immunohistochemical expression. The expression of EZH2 was significantly higher in cases of GBC than GBD (p value 0.001). The cases of BM were negative. Its expression was also higher in poorly differentiated tumors and positively correlated with the proliferative activity (MIB-1 labeling index) (p value 0.03 and 0.01, respectively). There was no significant difference in the expression levels of H3K27me3, DNMT-1, and DNMT-3B among GBC, GBD, and BM cases. Although GBC cases with strong EZH2 expression showed a shorter overall survival, the difference was not statistically significant. This study highlights the crucial role of the key epigenetic regulators EZH2 in the pathobiology and evolution of gallbladder carcinogenesis. Given the reversibility of epigenetic alterations, EZH2 may be a novel therapeutic target for gallbladder carcinogenesis.

A gallbladder (GB) polyp is an elevation of the GB mucosa that protrudes into the GB lumen. GB polyps have an estimated prevalence of 0.3-9.5% and can be divided into neoplastic (true) polyps and nonneoplastic polyps (pseudopolyps). Pseudopolyps are most commonly cholesterol polyps but also include focal adenomyomatosis and inflammatory polyps with no malignant potential. Neoplastic polyps, however, can be benign or malignant. Benign polyps are most commonly adenomas, while malignant polyps are usually adenocarcinoma. Transabdominal ultrasonography is the main radiological modality used for diagnosing and surveilling GB polyps. On the other hand, because it is difficult to diagnose GB polyps before surgery, alternative imaging modalities, such as endoscopic ultrasound, are being further evaluated. The current guidelines recommend cholecystectomy for GB polyps ≥ 10 mm in size as well as suboptimal sized GB polyps (6-9 mm) with other risk factors, including age >50, sessile, and symptoms. The quality of the evidence behind this practice is relatively low. Therefore, this review identifies the current gaps in the available evidence and guidelines and introduces methods that can help make decisions regarding patients who require a cholecystectomy or follow-up.

Background Choledochal cysts are divided into 5 types. Physicians believe that Caroli disease (which refers to type V biliary cysts) is a special type of biliary cyst caused by a mutation in the PKHD1 gene and is associated with autosomal recessive polycystic kidney disease (ARPKD). There is currently no clear association between other types of choledochal cysts and polycystic kidney disease. Case presentation We report a 65-year-old male patient with jaundice, decreased appetite, and itchy skin. His biochemistry test results indicated obstructive jaundice disease. Cross-sectional imaging showed a type IVA choledochal cyst accompanied by autosomal dominant polycystic kidney disease (ADPKD). Due to economic difficulties, the patient achieved percutaneous transhepatic cholangial drainage (PTCD) instead of surgery. Conclusion To our knowledge, this is the second case report of the coexistence of type IVA choledochal cysts and ADPKD. We conclude that it is vital to be aware that the above condition is a possibility. This case report will aid earlier diagnosis and management and possibly prevent further damage to liver and kidney function.

CASE DESCRIPTION An 8-year-old 36.3-kg (79.9-lb) spayed female Rottweiler was evaluated because of anorexia and vomiting. CLINICAL FINDINGS Extrahepatic biliary obstruction (EHBO) secondary to pancreatitis was suspected on the basis of results from serum biochemical analyses, CT, and cytologic examination. TREATMENT AND OUTCOME Only marginal improvement was observed after 24 hours of traditional medical management; therefore, novel continual biliary drainage was achieved with ultrasonographically and fluoroscopically guided placement of a percutaneous transhepatic cholecystostomy drainage (PCD) catheter. Within 24 hours after PCD catheter placement, the dog was eating regularly, had increased intestinal peristaltic sounds on abdominal auscultation, no longer required nasogastric tube feeding, and had decreased serum total bilirubin concentration (7.7 mg/dL, compared with 23.1 mg/dL preoperatively). Bile recycling was performed by administering the drained bile back to the patient through a nasogastric tube. The PCD remained in place for 5 weeks and was successfully removed after follow-up cholangiography confirmed bile duct patency. CLINICAL RELEVANCE Transhepatic PCD catheter placement provided fast resolution of EHBO secondary to pancreatitis in the dog of the present report. We believe that this minimally invasive, interventional procedure has the potential to decrease morbidity and death in select patients, compared with traditional surgical options, and that additional research is warranted regarding clinical use, safety, and long-term results of this procedure in veterinary patients, particularly those that have transient causes of EHBO, are too unstable to undergo more invasive biliary diversion techniques, or have biliary diseases that could benefit from palliation alone.

Current guidelines support laparoscopic cholecystectomy as the treatment of choice for pregnant women with symptomatic gallbladder disease, regardless of the trimester. Early intervention has remained the standard of care, but recent evidence has challenged this practice in pregnant women. We sought to compare surgical and maternal–fetal outcomes of antepartum versus postpartum cholecystectomy in New York State. Between 2005 and 2014, the New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for patients who underwent cholecystectomy within 3 months before (antepartum cholecystectomy, APCCY: n = 82) and after (postpartum cholecystectomy, PPCCY: n = 5040) childbirth to approximate third-trimester operations. All patients who underwent cholecystectomy during pregnancy (n = 971) were extracted to evaluate inter-trimester differences. Subgroup analysis compared APCCY patients who were not hospitalized within 1 year before APCCY (n = 80) and PPCCY patients who were hospitalized within 1 year before childbirth (n = 29) for symptomatic biliary disease. Multivariable generalized linear regression models were used to characterize the association between timing of cholecystectomy and several primary outcomes: length of stay (LOS), 30-day non-pregnancy, non-delivery readmission (NPND), bile duct injury (BDI), composite maternal outcome (antepartum hemorrhage, preterm delivery, cesarean section), any complications, and fetal demise. Third-trimester APCCY women had longer LOS (Ratio: 1.44, 95% CI [1.26–1.66], p

Endoscopic ultrasonography (EUS) has excellent spatial resolution and allows more detailed examination than abdominal ultrasonography (US) in terms of qualitative diagnosis of tumors and evaluation of tumor invasion depth. To understand the role of EUS in gallbladder disease, we need to understand the normal gallbladder wall structure and how to visualize it on EUS. In addition, gallbladder lesions can be classified into two broad categories: protuberant and wall-thickening lesions. Here, the features on EUS were outlined. We also outlined the current status of EUS-FNA for gallbladder lesions as there have been scattered reports of EUS-FNA in recent years.

Background: Some reports assert that there is a risk that laparoscopy might worsen the prognosis of incidental gallbladder carcinoma (IGBC) after laparoscopic cholecystectomy (LC) compared with ope...

Background Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients. Method A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay. Results This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00–2.78), major complication (OR 1.79, CI95% 1.45–2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84–2.55), risk of bile leaks (OR 1.50, CI95% 1.07–2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41–11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24–3.18). Conclusion Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent.

To evaluate the comparative outcomes of three-dimensional (3D) versus two-dimensional (2D) imaging during laparoscopic cholecystectomy. We conducted a systematic search of electronic information sources and bibliographic reference lists and applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Procedure time, Calot’s triangle dissection time, gallbladder removal time, gallbladder perforation, intraoperative bleeding, postoperative complications, conversion to open and intraoperative errors were the evaluated outcome parameters. We identified 6 randomised controlled trials (RCT) reporting a total of 577 patients who underwent laparoscopic cholecystectomy using 3D (n = 282) or 2D (n = 295) imaging. The 3D imaging was associated with significantly shorter procedure time (MD − 4.23, 95% CI − 8.14 to − 0.32, p = 0.03), Calot’s triangle dissection time (MD − 4.19, 95% CI − 6.52 to − 1.86, p = 0.0004) and significantly lower risk of gallbladder perforation (RR 0.50, 95% CI 0.28–0.88, p = 0.02) compared to the 2D approach. No significant difference was found in gallbladder removal time (MD − 0.79, 95% CI − 2.24 to 0.66, p = 0.28), intraoperative bleeding (RR 1.14, 95% CI 0.68–1.90, p = 0.61), postoperative complications (RD − 0.01, 95% CI − 0.06 to 0.05, p = 0.85), conversion to open (RD 0.00, 95% CI − 0.02 to 0.03, p = 0.70) or intraoperative errors (RR 0.96, 95% CI 0.79–1.17, p = 0.70) between the two groups. Although our findings suggest that the use of 3D imaging during laparoscopic cholecystectomy may be associated with significantly shorter procedure time, Calot’s triangle dissection time and gallbladder injury compared to the 2D imaging, the differences seem to be clinically insignificant. Moreover, both approaches carry s similar risk of postoperative morbidities. The impact of the surgeon’s level of experience and difficulty of the procedure on the outcomes of each imaging modality remains unknown.

Benign gallbladder diseases usually present with intraluminal lesions and localized or diffuse wall thickening. Intraluminal lesions of the gallbladder include gallstones, cholesterol polyps, adenomas, or sludge and polypoid type of gallbladder cancer must subsequently be excluded. Polyp size, stalk width, and enhancement intensity on contrast-enhanced ultrasound and degree of diffusion restriction may help differentiate cholesterol polyps and adenomas from gallbladder cancer. Localized gallbladder wall thickening is largely due to segmental or focal gallbladder adenomyomatosis, although infiltrative cancer may present similarly. Identification of Rokitansky-Aschoff sinuses is pivotal in diagnosing adenomyomatosis. The layered pattern, degree of enhancement, and integrity of the wall are imaging clues that help discriminate innocuous thickening from gallbladder cancer. High-resolution ultrasound is especially useful for analyzing the layering of gallbladder wall. A diffusely thickened wall is frequently seen in inflammatory processes of the gallbladder. Nevertheless, it is important to check for coexistent cancer in instances of acute cholecystitis. Ultrasound used alone is limited in evaluating complicated cholecystitis and often requires complementary computed tomography. In chronic cholecystitis, preservation of a two-layered wall and weak wall enhancement are diagnostic clues for excluding malignancy. Magnetic resonance imaging in conjunction with diffusion-weighted imaging helps to differentiate xathogranulomatous cholecystitis from gallbladder cancer by identifying the presence of fat and degree of diffusion restriction. Such distinctions require a familiarity with typical imaging features of various gallbladder diseases and an understanding of the roles that assorted imaging modalities play in gallbladder evaluations.

Background Dyslipidaemia and male sex are associated with gallbladder polyp (GBP) formation. However, the potential relation between the non-high-density lipoprotein-cholesterol-to-high-density lipoprotein-cholesterol (non-HDL-c/HDL-c) ratio and GBPs in men is unclear. Methods A total of 1866 eligible subjects were selected for this retrospective cohort study from Wuhan Union Hospital between April 1, 2013, and November 30, 2014. Clinical and laboratory data of subjects were collected. Patients with GBPs or cholecystectomy at baseline, with missing data for baseline lipid profiles, following abdominal ultrasonography or taking lipid-lowering drugs were excluded. The patients were divided into five groups based on their non-HDL-c/HDL-c ratios, and descriptive analyses of the baseline data were performed. A Cox proportional hazards model was applied to estimate the relationship between the non-HDL-c/HDL-c ratio and GBPs. Results After a median follow-up of 1 year, 7.34% (n = 137) of the subjects developed GBPs. Compared with subjects without GBPs, those who developed GBPs after follow-up had significantly higher triglyceride (TG) levels and non-HDL-c/HDL-c ratios. The prevalence of GBPs showed a linearity increment with age, peaked in the 30–39 years group, 40–49 years group and 50–59 years group, and then declined slightly. The results of univariate analysis showed that the non-HDL-c/HDL-c ratio (hazard ratio (HR) = 1.29, 95% confidence interval (CI), 1.05–1.60, P = 0.0159) was positively correlated with GBPs. In the fully adjusted Cox regression model, the HRs were 2.24 for quintile 2 (95% CI: 1.13–4.44, P = 0.0203), 1.50 for quintile 3 (95% CI: 0.73–3.10, P = 0.269), 2.52 for quintile 4 (95% CI: 1.26–5.01, P = 0.0087) and 2.13 for quintile 5 (95% CI: 1.04–4.37, P = 0.0397). No interaction was found among the subgroups. Conclusions A higher non-HDL-c/HDL-c ratio is independently related to a higher risk of GBP formation in Chinese men. Further research is needed to investigate whether this association exists in different regions and races.

Cholecystectomy is the most commonly performed procedure in sickle cell disease (SCD) patients, but outcomes after cholecystectomy have not been well studied. Our aim was to explore the characteristics and outcomes of cholecystectomy in patients with SCD compared with patients without SCD, and assess whether acuity of presentation played a role.Patients younger than age 35, with the primary diagnosis of gallbladder disease, who underwent cholecystectomy, were identified in the Nationwide Inpatient Sample (2005 to 2014). Patients were grouped into treatment groups by sickle cell status and acuity of surgery. Patient demographics, length of stay, hospital charges, and complications were evaluated. Descriptive and multivariate regression analyses were performed to compare these groups.There were 149,415 patients analyzed; 1,225 (0.82%) had SCD. SCD was associated with higher complication rates (2.69% vs 1.12%), longer lengths of stay (3 days vs 2 days), and higher median hospital charge ($29,170 vs $25,438) (all p0.01). Stratified by level of acuity, comparing the SCD group with the non-SCD group, higher complication rates were seen in the acute presentation group (3.92% vs 1.00%, p0.01), but were not demonstrated in the elective group (0.98% vs 1.95%, p = 0.114).SCD patients appear to have a longer length of stay, higher hospital spending, and increased complication rates compared with non-SCD patients undergoing cholecystectomy. This difference is pronounced among patients who underwent surgery in the acute setting. The data suggest that planned cholecystectomy may be beneficial in improving postoperative outcomes in SCD patients.

Background Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. Study design Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. Results One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. Conclusion Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.

Background/purpose The aim of the present study was to investigate the relationship between hepatobiliary scintigraphy findings and histopathological results in patients with recurrent biliary colic. Methods We retrospectively enrolled 107 patients who underwent hepatobiliary scintigraphy for recurrent biliary colic and subsequent cholecystectomy. According to the hepatobiliary scintigraphy findings, patients were categorized into a nonvisualization of gallbladder activity (nonvisualized GB) group, low gallbladder ejection fraction (GBEF) group, and normal GBEF group. Differences in histopathologic factors between the three groups were evaluated and multivariate logistic regression analyses were performed to identify histopathological predictors for hepatobiliary scintigraphy findings. Results The nonvisualized group had a higher frequency of patients with empyema and severe infiltration by neutrophils, lymphoplasma cells, and eosinophils. The low GBEF group had a higher muscle-to-total wall thickness ratio and muscle-to-fibrosis thickness ratio of the gallbladder wall than those in the normal GBEF group. On multivariate logistic regression analyses, severe degrees of lymphoplasma cell infiltration and eosinophil infiltration were independent predictors for nonvisualization of gallbladder activity, and a higher muscle-to-fibrosis thickness ratio was an independent predictor for low GBEF. Conclusions In patients with recurrent biliary colic, nonvisualization of gallbladder activity on hepatobiliary scintigraphy was related to the degree of inflammation in the gallbladder, while low GBEF was related to muscular hypertrophy of the gallbladder.

Based on the spatial relationship of an aberrant right hepatic duct (ARHD) with the cystic duct and gallbladder neck, we propose a practical classification to evaluate the specific form predisposing to injury in laparoscopic cholecystectomy (LC). We retrospectively investigated the preoperative images (mostly magnetic resonance cholangiopancreatography) and clinical outcomes of 721 consecutive patients who underwent LC at our institute from 2015 to 2018. We defined the high-risk ARHD as follows: Type A: communicating with the cystic duct and Type B: running along the gallbladder neck or adjacent to the infundibulum (the minimal distance from the ARHD

Gallbladder (GB) wall thickening is a relatively common finding on imaging. While there are clear recommendations for the management of gallstones, GB wall thickening presents a significant challenge. Despite advances in radiological as well as endoscopic techniques, the ability to characterize GB wall thickening is still limited.This review summarizes the currently available literature on various imaging investigations to characterize GB wall thickening. This review also summarizes the differences between benign and malignant GB wall thickening based on available imaging modalities. Transabdominal ultrasonography is the first-line investigation for evaluation of GB wall thickening. However, further characterization requires additional imaging tests. Magnetic resonance imaging (MRI) with the use of gadolinium and diffusion-weighted sequence is the preferred modality for GB wall characterization.The accurate characterization of GB wall thickening is a challenging task. The available imaging criteria allow differentiation of benign and malignant GB wall thickening with moderate accuracy. The advanced imaging techniques, including contrast enhanced ultrasound, contrast-enhanced endoscopic ultrasound, and shear wave elastography, continue to evolve. There is a need for a well-designed reporting system for GB wall thickening to ensure uniformity of reporting of imaging tests, especially in regions with a high prevalence of GB cancer.

Gallstone disease is the term commonly used to refer to gallstones that cause symptoms. There is a myriad of complications that can arise from gallstones: acute cholecystitis, xanthogranulomatous cholecystitis, emphysematous cholecystitis, gallbladder wall perforations, pericholecystic abscesses, Mirizzi syndrome, cholecystoenteric fistulas, choledocholithiasis, gallstone pancreatitis, porcelain gallbladder, gallbladder malignancies, and many more. The aim of this pictorial review is to revisit how multimodality imaging can help with the diagnosis of gallstone disease. We review the classic imaging findings on different imaging modalities for gallstone disease and its associated complications and how it is useful in early diagnosis for timely management of complications as well as surgical planning.

Background and aim To evaluate the benefits of contrast-enhanced ultrasound (CEUS) with high frequency transducers in characterization of focal gallbladder lesions (FGL). Material and methods From January 2017 to April 2019, 59 FGL detected by B mode ultrasound (BMUS) were examined, first with the low frequency convex transducer (1-5 MHz) and afterwards with high frequency transducer (7.5-12 MHz). High frequency dynamic CEUS were applied after bolus injection of 4.8 ml Sulphur hexafluoride microbubbles (SonoVue®, Milan). The BMUS and CEUS imaging features were recorded and compared. All lesions were confirmed by surgical resection and histopathologic results. Results The final diagnoses of 59 FGL included gallbladder adenocarcinoma (n = 15), gallbladder polyps (n = 11), gallbladder adenomas (n = 18), focal adenomyomatosis (n = 9), and gallbladder Ascariasis debris (n = 6). The mean diameter of FGL was 24.5±11.4 mm, and mean depth to the abdominal wall was 21.2±7.3 mm. While applying CEUS with high frequency transducer, specific diagnostic features, including arterial phase irregular intralesional vascularity (10/15, 66.7%), late phase hypoenhancement (12/15, 80%), destruction of gallbladder wall (8/15, 53.3%), infiltration to the adjacent liver (6/15, 40.0%) were significantly higher in malignant FGL. The overall sensitivity, specificity and diagnostic accuracy for the correct characterization of malignant FGL were significantly improved by CEUS with high frequency transducer (sensitivity 93.3%, specificity 88.5%, accuracy 100%). Conclusion With its superior contrast resolution, CEUS performed with high frequency transducers is helpful to achieve better visualization of gallbladder fundus and make differential diagnosis of gallbladder lesions, which might greatly improve diagnostic confidence between malignant and benign FGL.

ATP-binding cassette (ABC) subfamily B member 4 (ABCB4), also known as multidrug resistance protein 3 (MDR3), encoded by ABCB4, is involved in biliary phospholipid secretion, protecting hepatobiliary system from deleterious detergent and lithogenic properties of the bile. ABCB4 mutations altering canalicular ABCB4 protein function and expression may have variable clinical presentation and predispose to several human liver diseases. Well-established phenotypes of ABCB4 deficit are: progressive familial intrahepatic cholestasis type 3, gallbladder disease 1 (syn. low phospholipid associated cholelithiasis syndrome), high ɣ-glutamyl transferase intrahepatic cholestasis of pregnancy, chronic cholangiopathy, and adult biliary fibrosis/cirrhosis. Moreover, ABCB4 aberrations may be involved in some cases of drug induced cholestasis, transient neonatal cholestasis, and parenteral nutrition-associated liver disease. Recently, genome-wide association studies have documented occurrence of malignant tumours, predominantly hepatobiliary malignancies, in patients with ABCB4/MDR3 deficit. The patient's age at the time of the first presentation of cholestatic disease, as well as the severity of liver disorder and response to treatment are related to the ABCB4 allelic status. Mutational analysis of ABCB4 in patients and their families should be considered in all individuals with cholestasis of unknown aetiology, regardless of age and/or time of onset of the first symptoms.

Background: As minimally invasive pediatric surgery becomes standard approach to many surgical solutions, access has become an important point for improvement. Laparoscopic cholecystectomy (LC) is ...