Sex Disparities in the Presentation of Gallbladder Disease.

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.

Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF <15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

Changing management of gallstone-related disease in pregnancy - a retrospective cohort analysis.

OBJECTIVES: Gallstone-related disease is the second most common non-obstetric cause, following appendicitis, for acute abdomen in pregnancy. This study aimed to investigate treatment strategies, changes over time and outcome. MATERIALS AND METHODS: All consecutive patients with symptomatic gallstone-related disease during pregnancy admitted to Skane University hospital in Lund and Malmö 2001-2015 were analysed retrospectively. Information regarding the patient, pregnancy and fetus/child was recorded. The material was analysed by dividing it into two equal time periods and by comparing conservative management and surgical intervention. RESULTS: We included 96 patients with 97 pregnancies. The age was 30 (26-34) years and BMI 28 (24-31). Median length of pregnancy at first admission was 23 (13-31) weeks. The three most common diagnoses were biliary colic (n = 63), cholecystitis (n = 22) and acute pancreatitis (n = 16). Conservative treatment was practiced in 62 (64%) patients and intervention in 35 (36%). Conservatively treated patients were admitted later during pregnancy (week 26 (20-33) versus 17 (10-22), p < .001). Surgically treated patients had a longer total length of stay (all admissions) than conservatively treated patients (p = .001), less readmissions (p = .001) and equal birth outcome. Surgical intervention was more common in the later time period (48% versus 22%, p = .011). Of the conservatively treated patients, 56% were subjected to surgical intervention within 2 years after delivery. CONCLUSIONS: We found that intervention was more common in the later time period, with good results concerning safety, and less readmissions. A majority of the conservatively treated patients had surgical intervention within two years after delivery. Our results support surgical intervention in pregnancy.

Nineteen-year trends in incidence and indications for laparoscopic cholecystectomy: the NY State experience.

BACKGROUND: Since the introduction of laparoscopic cholecystectomy (LC), there has been continued evolution in technique, instrumentation and postoperative management. With increased experience, LC has migrated to the outpatient setting. We asked whether increased availability and experience has impacted incidence of and indications for LC. METHODS: The New York (NY) State Planning and Research Cooperative System longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 and 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and the associated primary diagnostic codes. Data were analyzed as relative change in incidence (normalized to 1000 LC patients) for respective diagnoses. RESULTS: From 1995 to 2013, 711,406 cholecystectomies were performed in NY State: 637,308 (89.58 %) laparoscopic. The overall frequency of cholecystectomy did not increase (1.23 % increase with a commensurate population increase of 6.32 %). Indications for LC during this time were: 72.81 % for calculous cholecystitis (n = 464,032), 4.88 % for biliary colic (n = 31,124), 8.98 % for acalculous cholecystitis (n = 57,205), 3.01 % for gallstone pancreatitis (n = 19,193), and 1.59 % for biliary dyskinesia (n = 10,110). The incidence of calculous cholecystitis declined (-20.09 %, p < 0.0001) between 1995 and 2013; meanwhile, other diagnoses increased in incidence: biliary colic (+54.96 %, p = 0.0013), acalculous cholecystitis (+94.24 %, p < 0.0001), gallstone pancreatitis (+107.48 %, p < 0.0001), and biliary dyskinesia (+331.74 %, p < 0.0001). Outpatient LC incidence catapulted to 48.59 % in 2013, from 0.15 % in 1995, increasing >320-fold. Analysis of LC through 2014 revealed increasing rates of digestive, infectious, respiratory, and renal complications, with overall cholecystectomy complication rates of 9.29 %. CONCLUSION: A shifting distribution of operative indications and increasing rates of complications should prompt careful consideration prior to surgery for benign biliary disease. For what is a common procedure, LC carries substantial risk of complications, thus requiring the patient to be an active participant and to share in the decision-making process.

Biliary dyskinesia: a surgical disease rarely found outside the United States.

BACKGROUND: Our objective was to determine if cholecystectomy for biliary dyskinesia (BD) was performed more commonly in the United States than in 4 comparator countries around the world. METHODS: Using the Nationwide Inpatient Sample, we extracted and analyzed data for cholecystectomy from 1991 to 2011 using ICD-9 (International Classification of Diseases 9th Revision) procedure codes. To derive the number of cholecystectomies performed for BD, we used the ICD-9 code 575.8, greater than 80% of which are patients with BD. The same or equivalent code was used for the international comparator group. Through a SURGINET query we obtained data from verifiable national databases in 4 developed countries including the Swedish quality registry for surgical treatments of gallstone-related conditions (GallRiks), the Norwegian Cholecystectomy Registry, the Australian Bureau of Statistics, and the Polish National Health Insurance Agency. RESULTS: In the years ranging from 2008 to 2011, the number of cholecystectomies for BD per 1,000,000 population per year was less than 25 in the 4 comparator countries and greater than 85 in the United States (P < .01). From 1991 to 2011, the number of cholecystectomies for BD in the United States significantly increased from 43.3 to 89.1 per 1,000,000 population (P < .01). CONCLUSIONS: These data strongly suggest that cholecystectomy for BD is over utilized in the United States. In addition, this trend continues to increase in frequency.

Outcomes after laparoscopic cholecystectomy in children with biliary dyskinesia.

Our objectives were to determine the prevalence of biliary dyskinesia (BD) as an indication for cholecystectomy in children and to identify presenting clinical findings and optimal ejection fraction (EF) associated with the resolution of symptoms after surgery. We conducted a retrospective review of medical records of 212 pediatric patients who underwent cholecystectomy from August, 1998 to November, 2006. Patients who met criteria for BD had their short-term outcomes examined by record review and their long-term postoperative outcomes recorded by questionnaire. To compare EF and clinical presentation to symptom resolution or outcome, χ tests were used. Logistic regression was used to evaluate possible predictors of symptom resolution. BD was the indication for cholecystectomy in 20% of patients (44 of 212). Short-term outcome was not predicted by any of the collected variables. An EF ≤11% predicted higher rate of symptom resolution (P=0.02). Although patients with specific right upper quadrant pain had higher rates of long-term improvement than those with nonspecific abdominal pain (57.9% vs. 18.2%), this did not reach significance (P=0.057). The only predictor emerging from the logistic regression was EF cutoff at 11% (odds ratio=17.5; 95% confidence interval, 1.756-174.418). In this series, symptoms of BD were more likely to be resolved by cholecystectomy in children with EF ≤11%.

Gallbladder dyskinesia: fact or fiction?

Gallbladder dyskinesia is a functional (motility) disorder of the gallbladder resulting in episodic abdominal pain that, in carefully selected cases, resolves with cholecystectomy. It is a diagnosis of exclusion: several functional and organic disorders have to be excluded, and confounding factors addressed, before a diagnosis of gallbladder dyskinesia can be entertained. The combination of high clinical suspicion and an abnormally low gallbladder ejection fraction on cholecystokinin stimulated-cholescintigraphy predict benefit from removing the gallbladder.

Biliary disease in children.

Biliary diseases in children are infrequent; however, they can be associated with high morbidity and mortality if an accurate diagnosis is not made and adequate treatment provided in a timely fashion. Biliary atresia, choledochal cysts, gallbladder disease, and Alagille syndrome can be associated with similar clinical symptoms, laboratory findings, and radiographic findings, which makes accurate diagnosis difficult. The correct treatment for each of these clinical entities is different and can significantly reduce morbidity and mortality from these diseases. In this article, we discuss the epidemiology, approach to diagnosis, prognosis, and treatment modalities for these four disease processes.

[Pathogenesis of chronic acalculous cholecystitis in inhabitants of the Republic of Chuvashia].

The study of Serum content of Selenium, Zinc, Manganese in inhabitants of the Republic of Chuvashia and also in chronic acalculous cholecystitis patients. Possibility of correction motor dysfunction of gallbladder with the use of natural mineral water "Syvlah-Zdorovie".

Biliary strictures after liver transplantation: risk factors and prevention by donor treatment with epoprostenol.

Biliary strictures (BS), a major complication after orthotopic liver transplantation (OLT), cause morbidity, mortality, graft loss, and increased costs. The virtually unchanged incidence of BS (approximately 10%-25%) suggests that they are not simply "technical" in origin, but probably represent a mucosa ischemic injury inherent in the transplantation procedure. To study risk factors for BS, we analyzed 403 OLTs performed between January 1, 1997 and December 31, 2006, at a single center, excluding cases of regraft or death within 1 month. The average time to the diagnosis of the BS was 253 days (range, 7-1002 days). Upon univariate analysis, the absence of flushing of donor bile ducts, an imported versus a locally procured liver, and rejection were risk factors for BS. In contrast, the following factors were protective: donor cardiac arrest followed by resuscitation (suggesting an ischemic preconditioning effect) as well as addition of epoprostenol to and pressurization of the preservation solution. Patients with higher postoperative peak values of transaminases, bilirubin, alkaline phosphatase, and gamma glutamyl transpeptidase were at greater risk for later development of BS. Donor hypotension, donor age, donor intensive care unit (ICU) stay, type of preservation, positive cross-match, cold and warm ischemia times, sequential versus simultaneous portal/arterial reperfusion, as well as cytomegalovirus (CMV) infection were not risk factors for BS. Upon multivariate analysis, only epoprostenol and pressurization offered protection from BS. In conclusion, this study 2 novel points: (1) patients with high(er) transaminase values and cholestasis early postoperatively are at greater risk to develop later BS and require close monitoring and (2) donor maneuvers for better flushing and preserving peribiliary vascular plexus and biliary mucosa (epoprostenol and pressurization of preservation solution) offer protection from BS.

Efficacy of laparoscopic cholecystectomy in the pediatric population.

PURPOSE: Gallbladder disease is increasingly affecting the pediatric population. The advent of new technology in the 1980s, specifically, hepatobiliary scintigraphy and laparoscopic cholecystectomy, gave a dramatic rise in both the diagnosis and treatment of biliary disease in the pediatric population. The purpose of this study was to determine (a) whether laparoscopic cholecystectomy for biliary dyskinesia is efficacious in the treatment of children with biliary colic and (b) the ability of cholescintigraphy to predict which patients may benefit from an operative intervention. METHODS: We performed a retrospective review of the records of all patients (N = 184) who underwent laparoscopic cholecystectomy, correlating postoperative results with degree of dyskinesia (percentage of ejection fraction), histopathology, associated gastrointestinal diagnoses, age, and sex. Biliary dyskinesia was defined by ultrasonography without evidence of cholelithiasis with clinical diagnosis of biliary colic. RESULTS: Of the 184 patients who underwent laparoscopic cholecystectomy, 117 had a diagnosis of biliary dyskinesia and 108 were available for follow-up. Mean follow-up was 8.3 months. One hundred patients (92.6%) reported resolution or improvement of preoperative symptoms (64.8% reported complete resolution and 27.8% reported improvement in symptoms). The mean age of the patients was 14.1 years. No correlation was seen for degree of dyskinesia, histopathology, age, and sex. Patients with a preoperative diagnosis of gastroesophageal reflux were more likely to report resolution of symptoms, although this finding was not statistically significant. There was no major complication; 1 patient suffered a prolonged ileus, 1 patient suffered a wound infection, and 1 patient required incisional hernia repair. CONCLUSION: Laparoscopic cholecystectomy is safe, efficacious, and durable in children suffering from biliary dyskinesia.

[Functional condition of the hepatobiliary system in patients with biliary dyskinesia].

AIM: To study function of the liver, sphincter system and the gall bladder (GB) in patients with biliary dyskinesia (BD). MATERIAL AND METHODS: Thirty-four patients with BD have undergone clinical, fibrogastroduodenoscopic examinations, fractional duodenal intubation with examination of the bile, ultrasonography, dynamic scintigraphy of the hepatobiliary system. RESULTS: The examination of the patients has detected GB hypotonia (65%), GB hypertension (35%), Oddi's sphincter hypertention (28%), Oddi's sphincter hypotonia (44%), Lutkens' sphincter hypertonicity (19%), Lutkens' sphincter hypotonia (13%), impairment of intrahepatic biliary tracts (65%), lithogenic bile (100%), duodenogastric reflux (41%). CONCLUSION: Consecutive use of duodenal tubing, ultrasonography and hepatobiliscintigraphy provide assessment of defects in the function of the liver, biliary tract and sphincter system in patients with BD.

[Some features of functional gastroenterological diseases in young people].

Gastroenterological diseases are the most widespread ones in the structure of the diseases among adults and young patients. Functional gastroenterological diseases present a particular issue as with them chronical gastroenterological and bile-excreting diseases may start. The author analyzed current state of this issue, epidemiology of gastroesophageal reflux disease, gastric dyspepsia and biliary dyskinesia in young patients (15-30 years). Peculiarities of this pathology have been underlined. It attracts attention of clinicians to this problem; let diagnostics of functional gastroenterological diseases be improved.

[Frequency of the detection of billiary sludge in ulcerative disease].

Patients with gastric and duodenal ulcer, in who never had the typical complaints, and anamnestic data about pathology of biliary system were examined. More than one third of the biliary sludge was found. Finding dates demonatrate an appearence of hypokinetic biliary dysfunction in patients with gastric and duodenal ulcer. The received results indicate the for necessity of obligatory ultrasonic research for the purpose of revealing biliary dysfunctions in patients with gastric ulcer; subsequent dynamic supervision and preservation of pathological changes to prevente cholelithiasis.

Long-term outcome after endoscopic sphincterotomy in patients with biliary colic and suspected sphincter of Oddi dysfunction.

Seventy-three highly selected patients (35 type II, 38 type III) with intractable biliary-type pain were studied with biliary manometry after a baseline endoscopic retrograde cholangiopancreatography was normal or showed only duct dilatation. No differences between the two groups were noted in regard to baseline sphincter hypertension (60% versus 55%), improvement after endoscopic sphincterotomy at mean follow-up of 3 years, or post-procedure pancreatitis rates (15% versus 16%). Although not statistically significant, a tendency for patients with bile ducts > or = 12 mm to have sustained clinical improvement after sphincterotomy was noted in comparison with patients having ducts < 12 mm; an inverse correlation between improvement in symptoms and presence of an intact gallbladder at baseline was also seen. The authors suggest that the current classification, which divides patients with recurrent right upper quadrant pain into types I, II, and III, is inadequate to define either incidence of sphincter of Oddi dysfunction or subsequent response to endoscopic sphincterotomy.