Age and incidence of occult pancreaticobiliary reflux in patients with benign gallbladder diseases.

BACKGROUND: Occult pancreaticobiliary reflux (OPBR) has a significant correlation with diseases of the gallbladder and biliary system. This study examined the incidence of OPBR by age in patients with benign gallbladder diseases. METHODS: We assessed 475 patients with benign gallbladder diseases who underwent surgery at Shanghai East Hospital from December 2020 to December 2021. Bile samples collected during surgery were tested for amylase. Patients with bile amylase >110 U/L (n = 64) were classified as the OPBR group; the rest (n = 411) as controls. RESULTS: Of the participants, 375 had gallbladder stone (GS), 170 had gallbladder polyp (GP), and 49 had gallbladder adenomyomatosis (GA). The OPBR group was generally older, with OPBR incidence increasing with age, peaking post-45. Rates by age were: 4.9% (<35), 5.2% (35-44), 20.7% (45-54), 22.5% (55-64) and 17.6% (≥65), mainly in GS patients. ROC analysis for predicting OPBR by age yielded an area under the curve of 0.656, optimal cut-off at 45 years. Logistic regression indicated age > 45, GP, male gender, and BMI ≥ 24 kg*m-2 as independent OPBR predictors in GS patients. Based on these variables, a predictive nomogram was constructed, and its effectiveness was validated using the ROC curve, calibration curve and decision curve analysis (DCA). Further stratification revealed that among GS patients ≤ 45, concurrent GA was an OPBR risk; for > 45, it was GP and male gender. CONCLUSIONS: The incidence of OPBR in GS patients is notably influenced by age, with those over 45, especially males without GP, being at heightened risk.

Short- and long-term outcomes of Roux-en-Y and Billroth II with Braun reconstruction in total laparoscopic distal gastrectomy: a retrospective analysis.

BACKGROUND: The controversy surrounding Roux-en-Y (R-Y) and Billroth II with Braun (BII + B) reconstruction as an anti-bile reflux procedure after distal gastrectomy has persisted. Recent studies have demonstrated their efficacy, but the long-term outcomes and postoperative quality of life (QoL) among patients have yet to be evaluated. Therefore, we compared the short-term and long-term outcomes of the two procedures as well as QoL. METHODS: The clinical data of 151 patients who underwent total laparoscopic distal gastrectomy (TLDG) at the Gastrointestinal Surgery Department of the Second Hospital of Fujian Medical University from January 2016 to December 2019 were retrospectively analyzed. Of these, 57 cases with Roux-en-Y procedure (R-Y group) and 94 cases with Billroth II with Braun procedure were included (BII + B group). Operative and postoperative conditions, early and late complications, endoscopic outcomes at year 1 and year 3 after surgery, nutritional indicators, and quality of life scores at year 3 postoperatively were compared between the two groups. RESULTS: The R-Y group recorded a significantly longer operative time (194.65 ± 21.52 vs. 183.88 ± 18.02 min) and anastomotic time (36.96 ± 2.43 vs. 27.97 ± 3.74 min) compared to the BII + B group (p < 0.05). However, no other significant differences were observed in terms of perioperative variables, including blood loss (p > 0.05). Both groups showed comparable rates of early and late complications. Endoscopic findings indicated similar food residuals at years 1 and 3 post-surgery for both groups. The R-Y group had a lower occurrence of residual gastritis and bile reflux at year 1 and year 3 after surgery, with a statistically significant difference (p < 0.001). Reflux esophagitis was not significantly different between the R-Y and BII + B groups in year 1 after surgery (p = 0.820), but the R-Y group had a lower incidence than the BII + B group in year 3 after surgery (p = 0.023). Nutritional outcomes at 3 years after surgery did not differ significantly between the two groups (p > 0.05). Quality of life scores measured by the QLQ-C30 scale were not significantly different between the two groups. However, on the QLQ-STO22 scale, the reflux score was significantly lower in the R-Y group than in the BII + B group (0 [0, 0] vs. 5.56 [0, 11.11]) (p = 0.003). The rest of the scores were not significantly different (p > 0.05). CONCLUSION: Both R-Y and B II + B reconstructions are equally safe and efficient for TLDG. Nevertheless, the R-Y reconstruction reduces the incidence of residual gastritis, bile reflux, and reflux esophagitis, as well as postoperative reflux symptoms, and provides a better quality of life for patients. R-Y reconstruction is superior to BII + B reconstruction for TLDG.

Post-cholecystectomy bile reflux gastritis: Prevalence, risk factors, and clinical characteristics.

OBJECTIVE: Bile reflux gastritis is caused by the backward flow of duodenal fluid into the stomach. A retrospective cohort study was performed to estimate the prevalence and risk factors of bile reflux gastritis postcholecystectomy, and to evaluate the endoscopic and histopathologic changes in gastric mucosa. METHODS: Patients with refractory upper abdominal pain right below the ribs with symptoms of bloating, burping, nausea, vomiting, and bile regurgitation during the period from January 2018 to December 2020, submitted to Zagazig University Hospitals were enrolled in this study. The studied 64 patients were divided into two groups; the control group (CG): 30 subjects who had never undergone any biliary interventions, and the post-cholecystectomy group (PCG): 34 patients who had undergone cholecystectomy. RESULTS: The prevalence of bile reflux gastritis was (16.7%) and (61.8%) in CG and PCG, respectively. Diabetes, obesity, elevated gastric bilirubin, and elevated stomach pH were all risk factors for bile reflux gastritis in both groups (r = .28,.48,.78,.57 respectively). Age, sex, epigastric pain, heartburn, vomiting, and the existence of bile reflux gastritis, on the other hand, had no correlation. DISCUSSION: After a cholecystectomy, bile reflux gastritis is prevalent, especially among obese and diabetic patients.

Does bile reflux reduce Helicobacter pylori gastritis?

BACKGROUND: Chronic abdominal pain is a frequent childhood complaint. This study aims to determine the relationship between bile reflux, which is increasing with the growth in packaged food consumption resulting from the changing food industry, and Helicobacter pylori gastritis. METHODS: In this retrospective study, 804 cases where there was an endoscopic examination for abdominal pain were included. We recorded the patients` age, sex, and macroscopic and microscopic endoscopic findings. Patients with chronic diseases were excluded. RESULTS: Our study included 804 cases. Of patients, 61.8% were female and 38.2% were male. The mean age was 11.56±4.14 years. The Helicobacter pylori gastritis rate was found to be 22.3% among all patients. Bile reflux was seen in 192 (23.9%) patients. Only 27 (14.1%) of the 192 patients had Helicobacter pylori positivity (p=0.002). CONCLUSIONS: Helicobacter pylori gastritis is less common among patients with bile reflux. In another study conducted in our outpatient clinic before the 2000s, the frequency of Helicobacter pylori gastritis was found to be 40%, but after 2000 this rate decreased to 22.3% due to bile reflux caused by the changing food industry. This result may be explained by the bactericidal effects of bile acids.

Bile Reflux After Single Anastomosis Duodenal-Ileal Bypass with Sleeve (SADI-S): a Meta-analysis of 2,029 Patients.

BACKGROUND: Single anastomosis duodenal-ileal bypass with sleeve (SADI-S) is a novel bariatric surgery modified from the classic biliopancreatic diversion with duodenal switch (BPD-DS). These surgical modifications address most BPD-DS hurdles, but the risk of bile reflux may hinder SADI-S acceptance. We aimed to evaluate the event rate of bile reflux after SADI-S. METHODS: PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were used to search English articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale and the JBI tool. Event rates were meta-analyzed using Comprehensive Meta-Analysis (CME) V3. RESULTS: Out of 3,027 studies analyzed, seven were included. Studies were published between 2010 and 2020. Six out of 7 studies were retrospective. Three studies had a low risk of bias, three studies had a moderate risk of bias, and one had a high risk of bias. The mean follow-up was 10.3 months. The total number of patients was 2,029, with 25 reports of bile reflux, resulting in an incidence of 1.23%, with an event rate of 0.016 (95% CI 0.004 to 0.055). CONCLUSIONS: Bile reflux has not been demonstrated to be problematic after SADI-S in this meta-analysis. Further long-term studies are needed.

Bile Reflux is a Common Finding in the Gastric Pouch After One Anastomosis Gastric Bypass.

INTRODUCTION: Data on postoperative bile reflux after one anastomosis gastric bypass (OAGB) is lacking. Bile reflux scintigraphy (BRS) has been shown to be a reliable non-invasive tool to assess bile reflux after OAGB. We set out to study bile reflux after OAGB with BRS and endoscopy in a prospective series (RYSA Trial). METHODS: Forty patients (29 women) underwent OAGB between November 2016 and December 2018. Symptoms were reported and upper gastrointestinal endoscopy (UGE) was done preoperatively. Six months after OAGB, bile reflux was assessed in UGE findings and as tracer activity found in gastric tube and esophagus in BRS (follow-up rate 95%). RESULTS: Twenty-six patients (68.4%) had no bile reflux in BRS. Twelve patients (31.6%) had bile reflux in the gastric pouch in BRS and one of them (2.6%) had bile reflux also in the esophagus 6 months postoperatively. Mean bile reflux activity in the gastric pouch was 5.2% (1-21%) of total activity. De novo findings suggestive of bile reflux (esophagitis, stomal ulcer, foveolar inflammation of gastric pouch) were found for 15 patients (39.5%) in postoperative UGE. BRS and UGE findings were significantly associated (P = 0.022). Eight patients experienced de novo reflux symptoms at 6 months, that were significantly associated with BRS and de novo UGE findings postoperatively (P = 0.033 and 0.0005, respectively). CONCLUSION: Postoperative bile reflux in the gastric pouch after OAGB is a common finding in scintigraphy and endoscopy. The long-term effects of bile exposure will be analyzed in future reports after a longer follow-up. TRIAL REGISTRATION: Clinical Trials Identifier NCT02882685.

The Effect of Primary Duodenogastric Bile Reflux on the Presence and Density of Helicobacter pylori and on Gastritis in Childhood.

Background and Objectives: Although there are many studies that investigate the relationship between duodenogastric reflux (DGR) and Helicobacter pylori in adult patients, the reported data are contradictory. In addition, there are very few studies in the literature investigating the relationship between DGR and H.pylori in the pediatric age group. In the present study, we investigated the effect of primary DGR on H.pylori and gastritis. Materials and Methods: A total of 361 patients who were referred to the clinic of our hospital with dyspeptic complaints who had an upper gastrointestinal system endoscopy and a gastric biopsy were included in the study. Results: DGR was detected in 45 cases, and 316 cases that did not have DGR were considered as the control group. Comparisons were made between the DGR cases and the control group in terms of risk factors (age, gender), the presence and density of H.pylori, and the presence and severity of gastritis. The average age of the patients who were included in the study was 11.6 ± 4.6 years. A total of 128 (36%) of the cases were male and 233 (64%) were female. DGR was present in 45 (13%) of the cases. The average age of the patients with DGR was 13.9 ± 3.1 years, the average age of the control group was 11.3 ± 4.7, and there were statistically significant differences (p < 0.001). No significant differences were detected in terms of gender between DGR and the control group (p > 0.05). H.pylori (+) was detected in 29 (64%) of patients with DGR, and in 202 (64%) of the control group. No significant differences were detected between H.pylori prevalence (p = 0.947). Gastritis was detected in 37 (82%) of the patients with DGR, and in 245 (77%) of the control group (p = 0.476). No significant differences were detected between the presence and density of H.pylori, gastritis presence, severity and DGR (p > 0.05). Conclusions: The ages of patients with DGR were significantly higher than in the control group, and advanced age was shown to be a risk factor for primary DGR. It was found that the presence of DGR has no effect on the presence and severity of H.pylori. Given this situation, we consider it is important to eradicate H.pylori infection, especially in the case where H.pylori is present together with DGR.

Randomized Controlled Trial of One Anastomosis Gastric Bypass Versus Roux-En-Y Gastric Bypass for Obesity: Comparison of the YOMEGA and Taiwan Studies.

BACKGROUND: The YOMEGA study (Y-study) was a randomized trial comparing one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB). Here, we aim to compare the Y-study and our pioneer trial from Taiwan (T-study). METHODS: Data from the Y-study and the T-study were collected and compared. RESULTS: The Y-study recruited 234 patients with a mean body mass index (BMI) of 43.9 and age of 43.5 years. The T-study recruited 80 patients with a similar mean BMI of 44.3 and mean age of 31.4 years. The studies had similar findings including (1) OAGB is easier and possibly safer procedure than RYGB. Both studies showed that OAGB had a shorter operation time than RYGB, but a lower surgical complication rate was only demonstrated in T-study. (2) Both procedures have similar weight loss but OAGB features better glycemic control than RYGB. Weight loss at 2 years after surgery was similar between two procedures, but OAGB reduced HbA1c to a greater degree than RYGB at 2 years in Y-study (- 2.3% vs. - 1.3%; p = 0.025). The resolution of the metabolic syndrome was 100% for both groups in the T-study. (3) OAGB carried a higher risk of malnutrition. OAGB had more malabsorptive problems with a lower hemoglobin level than RYGB at 2 years after surgery. Adverse malnutrition events occurred in nine (7.8%) OAGB patients in the Y-study. Four (3.4%) patients of OAGB received revision surgery in Y-study but none in T-study. (4) Bile reflux was noted in OAGB patients but did not influence quality of life or revision rate. Y-study found that bile in the gastric pouch was present in 16% of patients in the OAGB group versus none in the RYGB, but no inter-group difference in quality of life was detected. There was a trend for RYGB patients to experience more abdominal pain than OAGB. CONCLUSIONS: Both studies showed that OAGB is a technically easier procedure and features better glycemic control than RYGB, but has a mal-absorptive effect. However, the bile reflux and abdominal pain controversies persisted.

Esophagogastric junction function and gastric pressure profile after minigastric bypass compared with Billroth II.

BACKGROUND: Minigastric bypass (MGB) is being performed widely with effective weight loss and improvement in co-morbidities. Because of similarity to Billroth II (BII), there are concerns about bile reflux. OBJECTIVES: To assess the esophagogastric junction (EGJ) function, esophageal peristalsis, and reflux exposure after MGB and BII. SETTING: University Hospital, Italy; Public Hospital, Italy. METHODS: Obese patients underwent symptom questioning, endoscopy, high-resolution impedance manometry, and impedance-pH monitoring, before and 1 year after MGB. Esophageal motor function, EGJ, EGJ-contractile integral, intragastric pressure (IGP), and gastroesophageal pressure gradient were determined. Acid exposure time, number of refluxes, and symptom-association probability were assessed. A group of patients who underwent BII were studied with the same protocol and served as controls. RESULTS: Twenty-two MGB and 20 BII patients were studied. After surgery, none of the patients reported de novo heartburn or regurgitation. At endoscopic follow-up, esophagitis and bile findings were absent in all. High-resolution impedance manometry features did not vary significantly after MGB, whereas IGP and gastroesophageal pressure gradient statistically diminished (P < .01). BII patients had significantly lower values in IGP, sphincter pressure, and EGJ-contractile integral. In MGB patients, a marked decrease in number of refluxes (from median 41 to 7, P < .01) was observed, whereas BII patients had statistically significant higher acid exposure and number of refluxes (57, P < .001). CONCLUSIONS: In contrast to BII, MGB does not increase any kind of reflux. Also, the differences in IGP and gastroesophageal pressure gradient suggest that bile reflux occurs more readily after BII than after MGB, and that these 2 operations share more differences than similarities.

Comparison of the Bile Reflux Frequency in One Anastomosis Gastric Bypass and Roux-en-Y Gastric Bypass: a Cohort Study.

INTRODUCTION: One of the most acceptable procedures in bariatric surgery is laparoscopic gastric bypass. Laparoscopic Roux-en-Y gastric bypass (RYGB) is a common technique used in bariatric surgery. Recently, one anastomosis gastric bypass (OAGB) has been suggested as a simple, fast, and effective technique for obesity treatment. This study aims to compare the frequency of histologically proven bile reflux in OAGB and RYGB among patients with morbid obesity. METHODS: This prospective cohort study was performed from 2015 to 2017 in the Department of Bariatric Surgery of Isfahan University of Medical Sciences, Isfahan, Iran. Patients who had undergone RYGB or OAGB surgery were enrolled. Patients who had undergone revisional surgery were excluded. Data on demographics, symptoms, fasting blood sugar, lipid profile, endoscopic, and histologic findings (based on the Sydney bile reflux index) of bile reflux and postoperative complications were collected and compared for the two techniques. RESULTS: A total of 122 obese patients (22 males) who had undergone RYGB or OAGB surgery were included. The Sydney bile reflux index showed no statistically significant difference between RYGB and OAGB groups. Similarly, no statistically significant difference was found in the self-reported history of bile reflux-related symptoms, bile reflux markers in esophagogastroduodenoscopy, and postoperative complications between groups. CONCLUSIONS: OAGB and RYGB appear to be equal with respect to postoperative complications, bile reflux frequency, bile reflux index, and the Sydney system score.

Bile Gastritis Following Laparoscopic Single Anastomosis Gastric Bypass: Pilot Study to Assess Significance of Bilirubin Level in Gastric Aspirate.

INTRODUCTION: Laparoscopic single anastomosis gastric bypass (SAGB) is increasingly performed for morbidly obese patients. AIM OF WORK: This pilot study aims primarily at evaluating the incidence of bile gastritis after SAGB. The occurrence of reflux oesophagitis and reflux symptoms were also assessed. PATIENTS AND METHODS: This study included 20 patients having no reflux symptoms. All patients underwent a SAGB as a primary bariatric procedure by a single surgeon. Patients included consented to have an upper GI endoscopy done at 6 months postoperatively. Gastric aspirate was sent for bilirubin level assessment. Gastric and esophageal biopsies were submitted for histopathology and campylobacter-like organism (CLO) test. RESULTS: In our study, the rate of bile gastritis was 30%. In 18 patients, the level of bilirubin in gastric aspirate seems to be related to the degree of mucosal inflammation. The remaining two patients had microscopic moderate to severe gastritis with normal aspirate bilirubin level. Two patients with bilirubin level in aspirate more than 20 mg/dl had severe oesophagitis, gastritis with erosions, and metaplasia. Relationship between bilirubin level and histopathological findings of gastric biopsy examination was statistically significant with a P value of 0.001. CONCLUSION: The incidence of bile gastritis in this cohort is higher than reported in the literature, and this may be worrying. The correlation between endoscopic findings and patients' symptoms is poor. Bilirubin level and pH in aspirate might be useful tools to confirm alkaline reflux. Its level might help to choose candidates for revision surgery after SAGB. This needs further validation with larger sample size.

Detecting Bile Reflux-the Enigma of Bariatric Surgery.

Duodeno-gastro-esophageal reflux, or bile reflux, is a condition for which there is no diagnostic gold standard, and it remains controversial in terms of carcinoma risk. This is pertinent in the context of an increasingly overweight population who are undergoing weight-loss operations that theoretically further increase the risk of bile reflux. This article reviews investigations for bile reflux based on efficacy, patient tolerability, cost, and infrastructure requirements. At this time, whilst no gold standard exists, hepatobiliary scintigraphy is the least invasive investigation with good-patient tolerability, sensitivity, and reproducibility to be considered first-line for diagnosis of bile reflux. This review will guide clinicians investigating bile reflux.

Randomized controlled trial of uncut Roux-en-Y vs Billroth II reconstruction after distal gastrectomy for gastric cancer: Which technique is better for avoiding biliary reflux and gastritis?

AIM: To identify which technique is better for avoiding biliary reflux and gastritis between uncut Roux-en-Y and Billroth II reconstruction. METHODS: A total of 158 patients who underwent laparoscopy-assisted distal gastrectomy for gastric cancer at the First Hospital of Jilin University (Changchun, China) between February 2015 and February 2016 were randomized into two groups: uncut Roux-en-Y (group U) and Billroth II group (group B). Postoperative complications and relevant clinical data were compared between the two groups. RESULTS: According to the randomization table, each group included 79 patients. There was no significant difference in postoperative complications between groups U and B (7.6% vs 10.1%, P = 0.576). During the postoperative period, group U stomach pH values were lower than 7 and group B pH values were higher than 7. After 1 year of follow-up, group B presented a higher incidence of biliary reflux and alkaline gastritis. However, histopathology did not show a significant difference in gastritis diagnosis (P = 0.278), and the amount of residual food and gain of weight between the groups were also not significantly different. At 3 mo there was no evidence of partial recanalization of uncut staple line, but at 1 year the incidence was 13%. CONCLUSION: Compared with Billroth II reconstruction, uncut Roux-en-Y reconstruction is secure and feasible, and can effectively reduce the incidence of alkaline reflux, residual gastritis, and heartburn. Despite the incidence of recanalization, uncut Roux-en-Y should be widely applied.

Bile Reflux Scintigraphy After Mini-Gastric Bypass.

BACKGROUND: Significant weight-loss and diabetes remission have been reported after mini-gastric bypass (MGB). Concern has been raised regarding postoperative bile reflux (BR), but it has not been demonstrated in previous studies. We set out to find out if BR is evident in hepatobiliary scintigraphy after MGB. METHODS: Nine consecutive patients, seven with type 2 diabetes, underwent MGB (15 cm gastric tube, 250-275 cm biliary limb) at our institution with a 12-month follow-up, with none lost to follow-up. Then, 10.7 months (8.6-13.0) after MGB, all patients underwent hepatobiliary scintigraphy and a reflux symptom questionnaire (GerdQ) was filled out. A gastroscopy with biopsies was done for all patients with a bile-reflux-positive scintigraphy. RESULTS: Mean age at operation was 56 years (41-65) and preoperative BMI 43.1 kg/m2 (34.2-54.6). Mean %EWL was 83.9 (49.5-128.3) at 12 months. Four patients reached diabetes remission and two became insulin-independent. Hepatobiliary scintigraphy showed a transient BR into the gastric tube for five patients. Bile tracer was found in the gastric tube at 23-58 min after the tracer injection and highest activity was 8% (1-8%) at 58 min. Bile tracer was not found in the esophagus of any of the patients. One patient with a positive scintigraphy in the gastric tube required re-operation. Two patients with reflux symptoms had a negative scintigraphy. CONCLUSION: Our results indicate that transient bile reflux is common after MGB in the gastric tube, but not in the esophagus. The clinical relevance of bile reflux needs further studies.

Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis.

BACKGROUND: Although delta-shaped gastroduodenostomy (DSGD) is used increasingly as an intracorporeal Billroth I anastomosis after distal gastrectomy, worries about anatomical distortion always exist in twisting stomach and making an oblique incision on duodenum. We developed a new method of intracorporeal gastroduodenostomy, the linear-shaped gastroduodenostomy (LSGD), in which anastomosis is done using endoscopic linear staplers only without any complicated rotation. In this report, we introduced LSGD and compared its short-term and long-term outcomes with DSGD. METHODS: We analyzed 261 consecutive gastric cancer patients who underwent the intracorporeal gastroduodenostomy between January 2009 and May 2014 (LSGD: 190, DSGD: 71), retrospectively. All of them underwent a laparoscopic or robotic distal gastrectomy with regional lymph node dissection. Early surgical outcomes such as operation time, postoperative complications, days until soft diet began, length of hospital stay, and endoscopic findings in postoperative 6 and 12 months were evaluated. RESULTS: Although the proportion of robotic approach and D2 lymphadenectomy were significantly higher in LSGD group, the rates for overall complications (13.2 % [LSGD] vs. 9.9 % [DSGD], p = 0.470) and major complications (5.8 vs. 5.6 %, p = 1.0) were similar between two groups. There were no differences in anastomotic bleeding (1.1 vs. 1.4 %, p = 1.0), stenosis (3.2 vs. 2.8 %, p = 1.0), and leakage (0.5 vs. 0.0 %, p = 1.0). Endoscopy performed 6 months postoperatively showed that residual food (p = 0.022), gastritis (p = 0.018), and bile reflux (42.0 vs. 63.2 %, p = 0.003) were significantly decreased in LSGD and there were no significant differences in postoperative 12 months. CONCLUSION: LSGD is an innovative reconstruction technique with comparable short-term outcomes to DSGD. In addition, reduced residual food, gastritis, and bile reflux were seen in LSGD.

Rate of duodenal-biliary reflux increases in patients with recurrent common bile duct stones: evidence from barium meal examination.

BACKGROUND: Stone recurrence is a common late adverse event after ERCP in patients with common bile duct stones (CBDS). Duodenal-biliary reflux (DBR) is considered a major cause of CBDS recurrence. However, specific evidence is still lacking. OBJECTIVE: To investigate the DBR rate in patients with recurrent CBDS after ERCP. DESIGN: A prospective case-control study. SETTING: A tertiary center. PATIENTS: During follow-up, patients with a history of either recurrent CBDS (recurrence group) or nonrecurrent CBDS (control group) were invited to participate in the study. All patients had previously undergone successful CBDS removal by ERCP. Patients in the control group were matched with the recurrence group by age and gender in a 1:1 ratio. Patients with gallbladder stones, hepatolithiasis, remnant CBDS, CBD strictures, or stents were excluded. INTERVENTIONS: Standard barium meal examination, MRCP, and enhanced abdominal CT. MAIN OUTCOME MEASUREMENTS: DBR. RESULTS: Thirty-two patients with a history of recurrent CBDS and 32 matched control subjects were enrolled. Baseline characteristics and parameters regarding the first ERCP were comparable between the 2 groups. The DBR rate was significantly higher in the recurrent than in the control group (68.8% vs 15.6%, P < .001). Multivariate analysis indicated that DBR (OR, 9.59; 95% CI, 2.65-34.76) and acute distal CBD angulation (OR, 5.48; 95% CI, 1.52-19.78) were independent factors associated with CBDS recurrence. DBR rates in patients with no, single, or multiple recurrences were 15.6%, 60.9%, and 88.9%, respectively (P < .001). Intrahepatic bile duct reflux was more common in patients with multiple recurrences. LIMITATIONS: Small sample size. CONCLUSIONS: DBR is correlated with CBDS recurrence in patients who had previously undergone ERCP. DBR and acute distal CBD angulation are 2 independent risk factors related to stone recurrence. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT02329977.)

Clinical significance of bile reflux into the pancreatic duct without pancreaticobiliary maljunction assessed by intraoperative cholangiography.

INTRODUCTION: Bile reflux into the pancreatic duct (BRPD) is sometimes demonstrated during intraoperative cholangiography (IOC) even in patients without pancreaticobiliary maljunction. However, the clinical significance of this finding in laparoscopic and open cholecystectomy is unclear. METHODS: Among 484 patients who underwent cholecystectomy (372 laparoscopic, 112 open), patients whose pancreatic duct was depicted in IOC were selected. The value of pancreatic amylase (p-amylase) of the gallbladder bile, histological changes, and the immunohistochemical expression of proliferating cell nuclear antigen (PCNA) in the gallbladder mucosa were analyzed in patients with BRPD. The data were then compared to those in patients without BRPD whose gallbladder bile p-amylase was measured (control group, n = 20). RESULTS: The success rate of IOC was 93.6%. The rate of BRPD in laparoscopic and open cholecystectomy was 5.2% and 5.7%, respectively. The value of gallbladder bile p-amylase in patients with BRPD was significantly higher than in the control group (790.5 vs 14.0 IU/L, P = 0.034). The value of the PCNA labeling index in patients with BRPD was significantly higher than that of the control group (15.4% vs 4.1%, P = 0.0026). Among the 24 patients with BRPD, pathological changes in the gallbladder mucosa were detected in five (two hyperplasia, three metaplasia), but there was no correlation between the presence of pathological change and PCNA labeling index or gallbladder bile p-amylase. CONCLUSIONS: IOC could detect BRPD both in laparoscopic and open cholecystectomy at a similar rate. Patients with BRPD had high levels of gallbladder bile p-amylase and PCNA labeling index, findings similar to those in patients with pancreaticobiliary maljunction.

The impact of pyloric drainage on clinical outcome following esophagectomy: a systematic review.

Delayed emptying of the gastric conduit following esophagectomy can be associated with an increased incidence of complications including aspiration pneumonia and anastomotic leak. The aim of this systematic review is to evaluate the current modalities of pyloric drainage following esophagectomy and their impact on anastomotic integrity and postoperative morbidity. Medline, Web of Science, Cochrane library, trial registries, and conference proceedings were searched. Five pyloric management strategies following esophagectomy were evaluated: no intervention, botulinum toxin (botox) injection, finger fracture, pyloroplasty, and pyloromyotomy. Outcomes evaluated were hospital mortality, anastomotic leak, pulmonary complications, delayed gastric emptying, and the late complication of bile reflux. Twenty-five publications comprising 3172 patients were analyzed. Pooled analysis of six comparative studies published after 2000 revealed pyloric drainage to be associated with a nonsignificant trend toward a reduced incidence of anastomotic leak, pulmonary complications, and delayed gastric emptying. Overall, the current level of evidence regarding the merits of individual pyloric drainage strategies remains very poor. There is significant heterogeneity in the definitions of clinical outcomes, in particular delayed gastric emptying, which has prevented meaningful assessment and formulation of consensus regarding the management of the pylorus during esophagectomy. Pyloric drainage procedures showed a non-significant trend toward fewer anastomotic leaks, pulmonary complications, and reduced gastric stasis when employed following esophagectomy. However, the ideal technique remains unproven suggesting that further collaborative investigations are needed to determine the intervention that will maximize the potential benefits, if any, of pyloric intervention.

Gallbladder cancers: associated conditions, histological types, prognosis, and prevention.

INTRODUCTION: Gallbladder cancer has a poor prognosis, with a reported 5-year survival of 5%. The prognosis improves when an R0 resection is feasible, but an early diagnosis is rare. The aim of the present study is to analyze the different conditions associated with gallbladder carcinomas and to report the main prognostic factors for these tumors to enable prevention. MATERIALS AND METHODS: From 1986 to 2012, 75 patients were found to have gallbladder cancer during the study of 2942 patients affected by biliary tract diseases; 34 of these patients had gallbladder and gallstones, and had been subjected to bile analysis. Pancreatobiliary reflux was studied by biliary trypsin and C-Ki-ras genes were analyzed in 11 cases. RESULTS: Gallstones were found in 72 of 75 gallbladder cancer patients; in particular, large gallstones were associated with 88.88% of squamous-cell carcinoma, 68.2% of adenocarcinoma, and never with papillary adenocarcinoma. Pancreatobiliary reflux was associated with papillary adenocarcinoma in 100% of cases, but seldom with squamous cell carcinoma. C-Ki-ras mutations were found in 100% of patients with papillary carcinoma. DISCUSSION AND CONCLUSION: R0 resection in in-situ cancer has the best prognosis. Preventive cholecystectomy should be performed in high-risk patients (gallstones larger 3 cm; adenomatous polyps>1 cm; pancreatobiliary reflux, porcelain gallbladder, segmental adenomyomatosis, xanthogranulomatous cholecystitis). The histological stratification of gallbladder cancer should be carried out before starting further studies because squamous-cell carcinoma, adenocarcinoma, and papillary carcinoma are associated with different risk factors and genetic mutations and have different responsiveness to chemotherapies.

Pancreatobiliary reflux in individuals with a normal pancreaticobiliary junction: a prospective multicenter study.

BACKGROUND: Pancreatobiliary reflux (PBR) can occur in individuals without pancreaticobiliary maljunction. The aim of this study was to elucidate the incidence of PBR in individuals with a normal pancreaticobiliary junction and its impact on the biliary tree. METHODS: Data were prospectively collected from 15 centers on 420 patients with a morphologically normal pancreaticobiliary junction who had undergone bile sampling and measurement of the biliary amylase level. We investigated the incidence and predictive factors for high biliary amylase levels (HBAL), as well as the relationship of HBAL with biliary malignancy. RESULTS: Twenty-three patients (5.5%) showed HBAL (≥10,000 IU/L). Univariate analysis showed that risk factors for the elevation of biliary amylase levels were the existence of a relatively long common channel (≥5 mm), acute pancreatitis, and papillitis. Multivariate analysis revealed that only the existence of a relatively long common channel was a significant factor for PBR. Biliary amylase levels in patients with a relatively long common channel were significantly higher than in patients without a long common channel (12,333 vs. 2,070 IU/L, P = 0.001). The incidence of HBAL (P < 0.001), as well as the overall biliary amylase levels (P = 0.007) were significantly higher in patients with gallbladder cancer than in those without gallbladder cancer. CONCLUSIONS: The PBR was frequently observed in individuals with a relatively long common channel. Patients showing HBAL with normal pancreaticobiliary junction are at high risk for gallbladder cancer.