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Cholelithiasis is a common disease of the digestive system. The risk factors for cholelithiasis have been reported and summarized many times in the published literature, which primarily focused on cross-sectional studies. Due to the inherent limitations of the study design, the reported findings still need to be validated in additional longitudinal studies. Moreover, a number of new risk factors for cholelithiasis have been identified in recent years, such as bariatric surgery, hepatitis B virus infection, hepatitis C virus infection, kidney stones, colectomy, osteoporosis, etc. These new findings have not yet been included in published reviews. Herein, we reviewed the 101 cholelithiasis-associated risk factors identified through research based on longitudinal investigations, including cohort studies, randomized controlled trials, and nested case control studies. The risk factors associated with the pathogenesis of cholelithiasis were categorized as unmodifiable and modifiable factors. The unmodifiable factors consist of age, sex, race, and family history, while the modifiable factors include 37 biological environmental factors, 25 socioenvironmental factors, and 35 physiochemical environmental factors. This study provides thorough and comprehensive ideas for research concerning the pathogenesis of cholelithiasis, supplying the basis for identifying high-risk groups and formulating relevant prevention strategies.

The effects of pks+ Escherichia coli and bile acid in colorectal tumorigenesis among people with cholelithiasis or cholecystectomy.

BACKGROUND AND AIM: Patients with cholelithiasis (CL) or cholecystectomy (CE) would have more chances of getting colorectal adenoma (CRA) or cancer (CRC). We aimed to figure out the effects of gut microbiota and bile acid on colorectal neoplasm in CL and CE patients. METHODS: This was a retrospective observational study that recruited 514 volunteers, including 199 people with normal gallbladders (normal), 152 CL, and 163 CE patients. Discovery cohort was established to explore the difference in gut microbiota through 16S rRNA and metagenomics sequencing. Validation cohort aimed to verify the results through quantitative polymerase chain reaction (qPCR). RESULTS: Significant enrichment of Escherichia coli was found in patients with cholelithiasis or cholecystectomy both in the discovery cohort (16S rRNA sequencing, PNormal-CL = 0.013, PNormal-CE = 0.042; metagenomics sequencing, PNormal-CE = 0.026) and validation cohort (PNormal-CL < 0.0001, PNormal-CE < 0.0001). Pks+ E. coli was found enriched in CL and CE patients through qPCR (in discovery cohort: PNormal-CE = 0.018; in validation cohort: PNormal-CL < 0.0001, PNormal-CE < 0.0001). The differences in bile acid metabolism were found both through Tax4Fun analysis of 16S rRNA sequencing (Ko00120, primary bile acid biosynthesis, PNormal-CE = 0.014; Ko00121, secondary bile acid biosynthesis, PNormal-CE = 0.010) and through metagenomics sequencing (map 00121, PNormal-CE = 0.026). The elevation of serum total bile acid of CE patients was also found in validation cohort (PNormal-CE < 0.0001). The level of serum total bile acid was associated with the relative abundance of pks+ E. coli (r = 0.1895, P = 0.0012). CONCLUSIONS: E. coli, especially pks+ species, was enriched in CL and CE patients. Pks+ E. coli and bile acid metabolism were found associated with CRA and CRC in people after cholecystectomy.

Incidence and risk factors for cholelithiasis after bariatric surgery: a systematic review and meta-analysis.

BACKGROUND: Obesity has been identified as an independent risk factor for cholelithiasis. As a treatment for obesity, bariatric surgery may increase the incidence of cholelithiasis. The risk factors for cholelithiasis after bariatric surgery remain uncertain. The purpose of this study was to explore the risk factors for postoperative cholelithiasis after weight-loss surgery and propose suggestions for clinical decision making. METHODS: Four databases, PubMed, EMBASE, Web of Science and Cochrane, were systematically searched for all reports about cholelithiasis after bariatric surgery, and literature screening was performed following prespecified inclusion criteria. The included studies were all evaluated for quality according to the NOS scale. Data extraction was followed by analysis using Reviewer Manager 5.4 and StataSE 15. RESULTS: A total of 19 articles were included in this meta-analysis, and all studies were of high quality. A total of 20,553 patients were included in this study. Sex [OR = 0.62, 95% CI (0.55, 0.71), P < 0.00001] and race [OR = 1.62, 95% CI (1.19, 2.19), P = 0.002] were risk factors for cholelithiasis after bariatric surgery. Surgical procedure, preoperative BMI, weight-loss ratio, smoking, hypertension, diabetes mellitus, and dyslipidemia were neither protective nor risk factors for cholelithiasis after bariatric surgery. CONCLUSION: Caucasian race and female sex are risk factors for developing cholelithiasis after bariatric surgery; surgical procedure, BMI, weight loss ratio, hypertension, diabetes mellitus, dyslipidemia, and smoking are not risk factors for cholelithiasis after bariatric surgery.

The Etiology of Cholelithiasis in Children and Adolescents-A Literature Review.

The incidence of gallstone disease has increased in recent years. The pathogenesis of cholelithiasis is not fully understood. The occurrence of the disease is influenced by both genetic and environmental factors. This article reviews the literature on cholelithiasis in children, with the exception of articles on hematological causes of cholelithiasis and cholelithiasis surgery. The aim of this review is to present the latest research on the pathogenesis of gallstone disease in children. The paper discusses the influence of all factors known so far, such as genetic predisposition, age, infections, medications used, parenteral nutrition, and comorbidities, on the development of gallstone disease. The course of cholelithiasis in the pediatric population is complex, ranging from asymptomatic to life-threatening. Understanding the course of the disease and predisposing factors can result in a faster diagnosis of the disease and administration of appropriate treatment.

Bile leakage and the number of metal clips on the cystic duct during laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVE: The most common way of closing the cystic duct in laparoscopic cholecystectomy is by using metal clips (>80%). Nevertheless, bile leakage occurs in 0.4%-2.0% of cases, and thus causes significant morbidity. However, the optimal number of clips needed to avoid bile leakage has not been determined. The primary aim of this study was to evaluate bile leakage and post-procedural adverse events after laparoscopic cholecystectomy concerning whether two or three clips were used to seal the cystic duct. METHODS: Using a retrospective observational design, we gathered data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP) (GallRiks). From 2006 until 2019, 124,818 patients were eligible for inclusion. These were nested to cohorts of 75,322 (60.3%) for uncomplicated gallstone disease and 49,496 (39.7%) with complicated gallstone disease. The cohorts were grouped by the number (i.e. two or three) of metal clips applied to the proximal cystic duct. The main outcome was 30-day bile leakage and post-procedural adverse events. RESULTS: No significant differences surfaced in the rate of bile leakage (0.8% vs 0.8%; P = .87) or post-procedural adverse events (three clips, 5.7% vs two clips, 5.4%; P = .16) for uncomplicated gallstone disease. However, for complicated disease, bile leakage (1.4% vs 1.0%; P < .001) and post-procedural adverse events (10.2% vs 8.6%; P < .001) significantly increased when the cystic duct was sealed with three clips compared with two. CONCLUSIONS: Because no differences in the rates of bile leakage or adverse events emerged in uncomplicated gallstone disease when a third clip was applied, a third clip for additional safety is not recommended in such cases. On the contrary, bile leakage and adverse events increased when a third clip was used in patients with complicated gallstone disease. This finding probably indicates a more difficult cholecystectomy rather than being caused by the third clip itself.

Acute Cholecystitis: An Emerging Complication in Spinal Cord Injury Patients in the United States.

BACKGROUND: Spinal cord injury (SCI) is a significant medical condition associated with various secondary complications, including cholelithiasis. Cholelithiasis can cause biliary duct obstruction and result in acute cholecystitis. The development of acute cholecystitis in SCI patients has been well studied in the Taiwanese population, showing an increased risk of acute cholecystitis in patients with SCI. The development of cholecystitis has not been well studied in the United States. MATERIALS AND METHODS: A retrospective review was performed on 3,939 propensity score-matched patients aged 18 to 85 years who had SCI/surgery from 2000 to 2019. Patients were divided based on the development of postoperative complications, specifically cholecystitis with cholecystectomy. RESULTS: SCI consisted of quadriplegia (42%), paraplegia (53%), unspecified lesion of cervical spinal cord (3%), and thoracic spinal cord (2%). All groups were comparable regarding age, gender, body mass index, smoking status, and Charlson comorbidity Index. The incidence of acute cholecystitis with subsequent cholecystectomy among patients with SCI was 43.0 per 10,000 person-years (95% confidence interval: 41.51-44.49). Median follow-up was 36 months. The development of cholecystitis was comparable among females (54.5%) and males (45.5%), and among African Americans (52.5%) and Caucasians (47.5%). CONCLUSION: There is an association between SCI and development of acute cholecystitis among U.S. PATIENTS: As SCI patients do not present with the classic signs of biliary colic, risk assessment for the development of acute cholecystitis will guide patient management and allow neurosurgeons to weigh the risks and benefits of prophylactic treatment for gallbladder complications.

Cholecystectomy in the elderly: clinical outcomes and risk factors.

AIM OF THE STUDY: Recent decades have seen a steady increase in the number of elderly patients undergoing cholecystectomy surgery. The objective of this study is to evaluate clinical outcomes in this cohort of patients and to identify any predictive factors correlative with adverse outcomes arising in the postoperative period. METHOD: A retrospective study was conducted regarding patients aged ≥65 years who underwent cholecystectomy surgery. The independent variables considered to be related to the patient were: age, gender, co-morbidities, and severity of cholelithiasis. The clinical variables were type of procedure, length of stay and hospitalization. The outcomes considered were mortality, re-intervention, transfer to intensive care and post-operative complications. RESULTS: 778 patients with an age between 65 and 74 and 508 patients with an age above 75 were reviewed. With the increase of age, patients who underwent cholecystectomy presented greater co-morbidity, more accesses in emergency, more cases of cholecystitis, which led to a higher number of interventions in open surgery. Considering postoperative outcomes: the need for intensive care, postoperative complications and mortality significantly increase in older patients. Negative predictive factors are the presence of co-morbidities, emergency access and cholecystectomy performed in open. CONCLUSIONS: Elderly patients undergoing cholecystectomy are an increased surgical risk group in particular because of the presence of co-morbidities and because of the frequent need to perform an emergency procedure often for complicated lithiasis pathology. This implies a special attention towards these patients, and towards those over 75 considering, when possible, alternative treatments such as percutaneous drainage. KEY WORDS: Cholecystectomy, Elderly, Outcomes, Risk factors.

Does "Sludge" Require Cholecystectomy?

Biliary sludge is a subjective, ill-defined term. Surgery is often consulted for laparoscopic cholecystectomy, regarded as a low risk procedure.After IRB approval, a word search was used to identify "sludge" in all ultrasounds performed in 2016. The number of patients undergoing cholecystectomy, complications, pathologic findings, and risk factors were identified. Non-operative patients were evaluated for subsequent symptoms and studies or procedures related to biliary pathology.2769 patients underwent RUQ US; 253 patients were found to have sludge. Of 48 (19%) cholecystectomy patients, 9 had cholelithiasis. No deaths occurred in the cholecystectomy group. Two surgical complications occurred. Fifty (24.4%) of the 205 non-operative patients underwent subsequent US imaging: 44% residual sludge, 28% normal, 18% stones, and 10% other.Sludge may resolve 28% of the time. Repeat ultrasound is prudent before proceeding with cholecystectomy. If an abnormality is seen on repeat imaging and risk factors persist, cholecystectomy may be reasonable.

Cholecystectomy Concomitant with Bariatric Surgery: Safety and Metabolic Effects.

BACKGROUND: Obesity and fast weight loss in the postoperative period of bariatric surgery increase significantly the risk of cholelithiasis. Moreover, emerging evidence has pointed out the role of bile acids as possible metabolism and weight loss enhancers. This study aims to analyze the influence of cholecystectomy (CL) concomitant with bariatric surgery on weight loss, metabolic repercussions, and postoperative morbidity. STUDY DESIGN: Retrospective cohort study. A total of 363 medical records were analyzed between 2002 and 2017, with 255 patients divided into four groups: with concomitant CL: sleeve gastrectomy (SG + CL group) and Roux-en-Y gastric bypass (GB + CL group); without concomitant CL: sleeve gastrectomy (SG group) and RYGB (GB group). RESULTS: CL concomitant with bariatric surgery is not related to worse long-term metabolic outcomes when compared to isolated bariatric surgery. In the postoperative follow-up of the isolated bariatric surgeries, 18 (16.5%) patients underwent cholecystectomy. There was no statistical difference between the groups regarding post-surgical complications. CONCLUSION: CL did not lead to worse metabolic outcomes and was also not related to a higher incidence of postoperative complications. Cholelithiasis and cholecystitis are important concerns in the postoperative period of bariatric surgery and a careful evaluation of the concomitant procedure should be performed.

Analysis of the Management of Cholelithiasis in Bariatric Surgery Patients: a Single-Center Experience.

PURPOSE: Cholelithiasis is an issue in bariatric surgery patients. The incidence of cholelithiasis is increased in morbidly obese patients. After bariatric surgery, the management maybe sometimes challenging. There is no consensus about how to deal with cholelithiasis prior to bariatric surgery. MATERIALS AND METHODS: A retrospective review from our prospectively collected bariatric surgery database. Primary bariatric procedures from 2009 to 2020 were included. Prevalence of cholelithiasis and its management prior to bariatric surgery and the incidence and management of postoperative biliary events were analyzed. RESULTS: Over 1445 patients analyzed, preoperatively cholelithiasis was found in 153 (10.58%), and 68 out of them (44.44%) were symptomatic. Seventy-six patients had a concomitant cholecystectomy. In those cases, the bariatric procedure did not show increased operative time, length of stay, morbidity, or mortality compared to the rest of primary bariatric procedures. Twelve patients (15.58%) with previous cholelithiasis and no concomitant cholecystectomy presented any kind of biliary event and required cholecystectomy. De novo cholelithiasis rate requiring cholecystectomy was 3.86%. Postoperative biliary events both in de novo and persistent cholelithiasis population did not show any difference between the type of surgery, weight loss, and other characteristics. CONCLUSIONS: Cholelithiasis was present in 10.58% of our primary bariatric surgery population. Concomitant cholecystectomy was safe in our series. Non-surgical management of asymptomatic cholelithiasis did not lead to a higher risk of postoperative biliary events. The global postoperative cholecystectomy rate was equivalent to the general population.

THE USE OF MICROBIOLOGICAL AND LABORATORY DATA IN THE CHOICE OF EMPIRICAL ANTIBIOTIC THERAPY IN PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY - THE ROLE OF LOCAL ANTIBIOGRAMS.

Antibiotic therapy is indicated during acute cholecystitis. However, in the treatment of uncomplicated cholelithiasis, prophylactic use of antibiotics is controversial. Microbiological and laboratory data are the basis for the choice of antibiotic treatment. However, monitoring and updating local antibiograms is important because they ensure effective therapy in the given clinical environment. The study included 110 consecutive patients who underwent laparoscopic cholecystectomy, divided into the group of uncomplicated cholelithiasis (n=60) and the group of acute cholecystitis (n=50). Preoperative data included age, sex, body mass index, leukocytes, C-reactive protein, and ultrasound examination. Bile samples for bacteriological testing were obtained under aseptic conditions during the surgery. Cultures were evaluated for aerobic, anaerobic and fungal organisms using routine tests. After the surgery, gallbladder specimens were sent for histopathological examination. In the group of uncomplicated cholelithiasis, 6/60 positive samples were found, and in the group of acute cholecystitis, there were 25/50 positive microbiological findings. Citrobacter sp. and Enterococcus faecalis predominated in the group of uncomplicated cholelithiasis, and Escherichia coli, Enterococcus faecalis, Proteus mirabilis and Citrobacter sp. in the group of acute cholecystitis. Antibiotics were administered to 49/50 patients with acute cholecystitis and to 32/60 patients with uncomplicated cholelithiasis. Cefazolin was the most frequently used antibiotic and also the most resistant antibiotic. To conclude, the administration of antibiotics in elective patients is not justified. The results of this study indicate that third-generation cephalosporin or ciprofloxacin + metronidazole should be administered in mild and moderate acute cholecystitis, and fourth-generation cephalosporin + metronidazole in severe acute cholecystitis in this local setting. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Ursodeoxycholic acid for the prevention of symptomatic gallstone disease after bariatric surgery (UPGRADE): a multicentre, double-blind, randomised, placebo-controlled superiority trial.

BACKGROUND: Rapid weight loss is a major risk factor for the formation of cholesterol gallstones. Consequently, patients with morbid obesity undergoing bariatric surgery frequently develop symptomatic gallstone disease. This trial assessed the efficacy of ursodeoxycholic acid versus placebo for the prevention of symptomatic gallstone disease after bariatric surgery. METHODS: This multicentre, double-blind, randomised, placebo-controlled superiority trial enrolled patients with an intact gallbladder scheduled for laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy in three hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module to receive 900 mg ursodeoxycholic acid daily for 6 months or matched placebo. Randomisation was stratified by the presence of asymptomatic gallstones at baseline and type of surgery. Patients, clinicians, and study staff were masked to treatment allocation. The primary endpoint was symptomatic gallstone disease within 24 months, assessed in the modified intention-to-treat population (all randomly assigned eligible patients with any post-randomisation measurement). Prespecified subgroup analyses were done based on the stratification groups. Safety was assessed in all patients who took at least one dose of the study drug. This trial is registered with the Netherlands Trial Register, NL5954. FINDINGS: Between Jan 11, 2017, and Oct 22, 2018, 985 patients were randomly assigned to receive either ursodeoxycholic acid (n=492) or placebo (n=493). 967 patients were included in the modified intention-to-treat population, of whom 959 had data available for primary endpoint assessment. 189 (20%) patients had asymptomatic gallstones at baseline and 78 (8%) received a sleeve gastrectomy. Symptomatic gallstone disease occurred in 31 (6·5%) of 475 patients in the ursodeoxycholic acid group and in 47 (9·7%) of 484 patients in the placebo group (relative risk 0·67, 95% CI 0·43-1·04, p=0·071). Logistic regression showed a significant interaction between ursodeoxycholic acid and the presence of asymptomatic gallstones at baseline (p=0·046), with an effect of ursodeoxycholic acid in patients without (0·47, 0·27-0·84, p=0·0081), and no effect in patients with asymptomatic gallstones at baseline (1·22, 0·61-2·47, p=0·57). The effect was stronger in patients without gallstones at baseline undergoing RYGB (0·37, 0·20-0·71, p=0·0016), whereas the subgroup of patients undergoing sleeve gastrectomy was too small to draw clear conclusions. Adverse events were rare. In the ursodeoxycholic acid group, diarrhoea occurred in four (0·9%) of 444 patients and skin rash in two (0·5%) patients. In the placebo group, diarrhoea occurred in two (0·4%) of 453 patients and skin rash in two (0·4%) patients. The total number of serious adverse events did not significantly differ between the trial groups (75 [17%] in 444 patients in the ursodeoxycholic acid group and 102 [23%] in 453 patients in the placebo group). The most common serious adverse events were abdominal pain and internal hernia. No serious adverse event was attributed to the study drug. INTERPRETATION: Ursodeoxycholic acid prophylaxis did not significantly reduce the occurrence of symptomatic gallstone disease in all patients after bariatric surgery. In patients without gallstones before RYGB surgery, ursodeoxycholic acid treatment reduced the occurrence of symptomatic gallstone disease compared with placebo. Further research is needed to assess the efficacy of ursodeoxycholic acid after sleeve gastrectomy. FUNDING: The Netherlands Organization for Health Research and Development, Zambon Netherlands BV, Foundation for Clinical Research of the Slotervaart Hospital, the Spaarne Gasthuis Academy, and Amsterdam Gastroenterology Endocrinology Metabolism.

Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass: a meta-analysis.

BACKGROUND: Bariatric surgery could increase the risk of cholelithiasis, although it is unclear whether the incidence rates of cholelithiasis are similar after different bariatric procedures. OBJECTIVES: To compare the incidence rates of cholelithiasis after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in people with obesity. SETTING: Meta-analysis of cohort studies. METHODS: We searched the PubMed and Web of Science databases for relevant studies before December 2020, and estimated the summary odds ratios (OR) and 95% confidence intervals (CI) using a random-effects model or fixed-effects model, according to the heterogeneity. RESULTS: In total, 8 cohort studies were included in this meta-analysis, and 94,855 and 106,844 participants received SG and RYGB, respectively. Compared with those receiving RYGB, the summary results showed that participants receiving SG had a 35% lower rate of cholelithiasis (OR, .65; 95% CI, .49-.86). Also, the participants receiving SG had a significantly lower incidence of cholecystectomy than those receiving RYGB (OR, .54; 95% CI, .30-.99). In a subgroup analysis, SG was associated with a significantly lower incidence of subsequent cholelithiasis than RYGB in both Western and non-Western countries. SG led to a significantly lower incidence of cholelithiasis than RYGB only when the follow-up was <2 years instead of over 2 years. CONCLUSION: Participants receiving SG had a significantly lower incidence of cholelithiasis than those receiving RYGB, particularly within the first 2 years after the bariatric surgery.

Preoperative one-stop magnetic resonance imaging evaluation of the pancreaticobiliary junction and hepatic arteries in children with pancreaticobiliary maljunction: a prospective cohort study.

PURPOSE: Pancreaticobiliary maljunction (PBM) is routinely assessed by intraoperative cholangiography (IOC), whereas accompanying abnormalities in the hepatic artery are assessed by preoperative contrast multi-slice computed tomography (MSCT). We evaluated the efficiency of performing one-stop preoperative magnetic resonance imaging (MRI) for delineating the anatomy of the pancreaticobiliary junction and the hepatic artery. METHODS: The subjects of this prospective analysis were children who underwent Roux-en-Y surgery for PBM in our institution during a recent 3-year period. Preoperative one-stop MRI was conducted using 3.0-T MRI. The efficiency of one-stop MRI was compared with that of IOC for assessing the bile duct, and with contrast MSCT for assessing the blood vessels. RESULTS: Sixty-five children underwent one-stop preoperative MRI, which had a 100% concordance rate, versus IOC for assessing the bile duct type. Protein plugs or cholelithiasis were identified by IOC in 8 children and by one-stop MRI in 45 children (P = 0.0233). Cholangitis was not identified by IOC in any children but it was identified by one-stop MRI in 29 children. MSCT was also performed in 46 children and revealed a variant hepatic artery in 9 and cholangitis in 21. One-stop MRI had a 100% concordance rate versus MSCT. CONCLUSION: Preoperative one-stop MRI accurately delineates the bile duct anatomy as well as the hepatic artery, cholangitis, and protein plugs in children with PBM.

Risk factors for 30-day readmission and indication for ERCP following laparoscopic cholecystectomy: a retrospective NSQIP cohort study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the safest, most commonly performed surgical procedures, but postoperative complications including bile leak, retained stone, cholangitis, and gallstone pancreatitis following LC occur in up to 2.6% of cases and may require readmission with possible endoscopic retrograde cholangiopancreatography (ERCP) intervention. There is a paucity of literature on factors predictive of need for ERCP following LC. The goal of this study is to describe the prevalence and risk factors for readmission with indication for ERCP. METHODS: We queried the ACS/NSQIP 2012-2017 Participant User Files for patients who underwent LC. Patient demographics, comorbidities, operative characteristics, and postoperative outcomes were evaluated. Multivariate logistic regression was used to identify risk factors for readmission with indication for ERCP intervention. RESULTS: Of 275,570 patients, 11,010 (4.00%) were readmitted within the 30-day postoperative period. Among these, 930 (8.44%) were admitted with indication for ERCP intervention. On multivariate regression, readmissions were more likely in older patients, inpatients, and patients with baseline comorbidities, acute preoperative morbidity, and those discharged to care facilities. The use of intraoperative cholangiogram was associated with lower odds of readmission. Less than 10% of readmitted patients had an indication for ERCP. Those who were readmitted with an indication for ERCP were more likely to have undergone emergency surgery, experienced longer operative times, and had elevated preoperative LFTs or gallstone pancreatitis prior to surgery. The risk of 30-day mortality was significantly higher among patients who experienced any complications after their surgery (OR 13.03, 95% CI 10.57-16.07, p < 0.001). CONCLUSIONS: Older patients, patients with greater preoperative morbidity, and those discharged to care facilities were more likely to be readmitted for any reason following laparoscopic cholecystectomy, whereas patients with evidence of complicated gallstone disease were more likely to be readmitted with an indication for ERCP, even when controlling for the use of intraoperative cholangiogram. Initiatives aimed at reducing readmission with indication for ERCP should focus on these patient subgroups.

Symptomatic cholelithiasis may be the first sign of sarcoidosis.

Sarcoidosis is a multisystemic noncaseating granulomatous disease that rarely affects the gastrointestinal system. The initial diagnosis of sarcoidosis with gallbladder/gallbladder-associated lymph node involvement is a very rare condition in the literature. Herein, we aimed to report a case of newly diagnosed sarcoidosis with lymph node involvement associated with the gallbladder.

Symptomatic cholelithiasis may be the first sign of sarcoidosis

SUMMARY Sarcoidosis is a multisystemic noncaseating granulomatous disease that rarely affects the gastrointestinal system. The initial diagnosis of sarcoidosis with gallbladder/gallbladder-associated lymph node involvement is a very rare condition in the literature. Herein, we aimed to report a case of newly diagnosed sarcoidosis with lymph node involvement associated with the gallbladder.

RESUMO A sarcoidose é uma doença granulomatosa multissistêmica não-caseosa que raramente afeta o sistema gastrointestinal. O diagnóstico inicial de sarcoidose com envolvimento de linfonodo da vesícula biliar ou associado à vesícula biliar é muito raro na literatura. Aqui, o nosso objetivo foi relatar um caso de sarcoidose recém-diagnosticado com envolvimento de linfonodos associados à vesícula biliar.

Management of pyruvate kinase deficiency in children and adults.

Pyruvate kinase deficiency (PKD) is an autosomal-recessive enzyme defect of the glycolytic pathway that causes congenital nonspherocytic hemolytic anemia. The diagnosis and management of patients with PKD can be challenging due to difficulties in the diagnostic evaluation and the heterogeneity of clinical manifestations, ranging from fetal hydrops and symptomatic anemia requiring lifelong transfusions to fully compensated hemolysis. Current treatment approaches are supportive and include transfusions, splenectomy, and chelation. Complications, including iron overload, bilirubin gallstones, extramedullary hematopoiesis, pulmonary hypertension, and thrombosis, are related to the chronic hemolytic anemia and its current management and can occur at any age. Disease-modifying therapies in clinical development may decrease symptoms and findings associated with chronic hemolysis and avoid the complications associated with current treatment approaches. As these disease-directed therapies are approved for clinical use, clinicians will need to define the types of symptoms and findings that determine the optimal patients and timing for initiating these therapies. In this article, we highlight disease manifestations, monitoring approaches, strategies for managing complications, and novel therapies in development.

Laparoscopic Cholecystectomy in the Cirrhotic: Review of Literature on Indications and Technique.

Cholelithiasis is twice more common in patients suffering from liver cirrhosis compared to overall population and in those patients, acute cholecystitis occurs significantly more often. Our goal was to review the literature and to overview the indications, contra-indications, and alternatives in the cirrhotic with biliary stones. We conducted a systematic review of the literature using the key words "Cirrhosis", "cholecystectomy", "laparoscopy"and "indications". Selected articles were reviewed for information specific to indications, contra-indications, and alternatives to laparoscopic cholecystectomy in cirrhotics. Results showed that laparoscopic cholecystectomy might offer several advantages in cirrhotic population, however cholecystectomy can be challenging: specific indications and alternatives to surgery must be discussed case by case. Laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis; special precautions are warranted regarding pneumoperitoneum pressure, trocar placement and increased safety with Indocyanine-green (ICG) fluorescence cholangiography. Nevertheless, in high-risk cirrhotic patients (Child C) and/or in common bile duct lithiasis endoscopic and non-surgical conservative treatments are preferable.