Robotic management of primary cholecystoduodenal fistula: A case report and brief literature review.

BACKGROUND: Cholecystoduodenal fistula (CDF) arises from persistent biliary tree disorders, causing fusion between the gallbladder and duodenum. Initially, open resection was common until laparoscopic fistula closure gained popularity. However, complexities within the gallbladder fossa yielded inconsistent outcomes. Advanced imaging and robotic surgery now enhance precision and detection. METHOD: A 62-year-old woman with chronic cholangitis attributed to cholecystoduodenal fistula underwent successful robotic cholecystectomy and fistula closure. RESULTS: Postoperatively, the symptoms subsided with no complications during the robotic procedure. Existing studies report favourable outcomes for robotic cholecystectomy and fistula closure. CONCLUSIONS: Our case report showcases a rare instance of successful robotic cholecystectomy with CDF closure. This case, along with a review of previous cases, suggests the potential of robotic surgery as the preferred approach, especially for patients anticipated to face significant laparoscopic morbidity.

Gallstone-Associated Histopathological Changes in Liver: A Prospective Observational Study.

AIM AND OBJECTIVES: To assess the effect of gallstone disease on liver parenchyma and the prevalence and extent of liver pathology in cholelithiasis in our population at the Department of General Surgery, Indira Gandhi Institute of Medical Science (IGIMS), Patna. MATERIAL AND METHODS: The present prospective observational study was conducted on 100 either-sex patients scheduled for open or laparoscopic cholecystectomy. In all the patients, laboratory and radiological investigations were performed. An undamaged portion of the liver edge around the gallbladder fossa was selected and held by atraumatic forceps. Using sharp scissors, around 1 cm of the liver edge was taken out and sent for histopathological examination. RESULTS: The mean age of the patients was 39.28 ± 13.73 years. The majority of patients were females (69%). Pain was the predominant clinical feature in 51% of the patients, followed by vomiting (21%), nausea (18%), and indigestion (10%). In 36% of cases, the liver histology was abnormal, including steatosis, fibrosis, cholestasis, portal tract infiltration, and lobular parenchymal infiltration. A significant association was found between the duration of symptoms and abnormal histology findings (P<0.0001). CONCLUSION: Gallstone disease is associated with notable alterations in liver histology, and these changes tend to be more prevalent in individuals with a prolonged duration of symptoms.

Investigating the influence of the gut microbiome on cholelithiasis: unveiling insights through sequencing and predictive modeling.

BACKGROUND: Cholelithiasis is one of the most common disorders of hepatobiliary system. Gut bacteria may be involved in the process of gallstone formation and are therefore considered as potential targets for cholelithiasis prediction. OBJECTIVE: To reveal the correlation between cholelithiasis and gut bacteria. METHODS: Stool samples were collected from 100 cholelithiasis and 250 healthy individuals from Huzhou Central Hospital; The 16S rRNA of gut bacteria in the stool samples was sequenced using the third-generation Pacbio sequencing platform; Mothur v.1.21.1 was used to analyze the diversity of gut bacteria; Wilcoxon rank-sum test and linear discriminant analysis of effect sizes (LEfSe) were used to analyze differences in gut bacteria between patients suffering from cholelithiasis and healthy individuals; Chord diagram and Plot related heat maps were used to analyze the correlation between cholelithiasis and gut bacteria; Six machine algorithms were used to construct models to predict cholelithiasis. RESULTS: There were differences in the abundance of gut bacteria between cholelithiasis and healthy individuals, but there were no differences in their community diversity. Increased abundance of Costridia, Escherichia flexneri, and Klebsiella pneumonae were found in cholelithiasis, while Bacteroidia, Phocaeicola, and Phocaeicola vulgatus were more abundant in healthy individuals. The top 4 bacteria that were most closely associated with cholelithiasis were Escherichia flexneri, Escherichia dysenteriae, Streptococcus salivarius and Escherichiadysenteriae. The cholelithiasis model based on CatBoost algorithm had the best prediction effect (sensitivity: 90.48%, specificity: 88.32%, AUC: 0.962). CONCLUSION: The identification of characteristic gut bacteria may provide new predictive targets for gallstone screening. As being screened by the predictive model, people at high risk of cholelithiasis can determine the need for further testing, thus enabling early warning of cholelithiasis.

Correlation Between Hypothyroidism and Gallstone Disease in Central India.

Introduction The decreased thyroid-stimulating hormone (TSH) levels affect almost every nucleated cell in our body, which directly affects the basal metabolic rate (BMR). It tends to affect multiple organ systems in the human body. In recent times, there have been changes in lifestyle and the consumption of processed foods has increased. Thus, cholelithiasis and hypothyroidism are being encountered frequently, even in rural populations. In recent times, the overt clinical presentation of hypothyroidism is rare due to early diagnosis and treatment of the subclinical hypothyroidism state itself. Aim The aim is to determine the correlation between cholelithiasis and hypothyroidism. Methods This was a cross-sectional study done on the patients presenting to the surgical department at Acharya Vinoba Bhave Rural Hospital affiliated to Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India between the duration from December 2020 to December 2022, having gallstone disease or with symptoms suggestive of gall bladder stones. The admitted patients were then evaluated for hypothyroidism by thyroid profile tests, and the results were documented. Using the collected data, factors such as clinical spectrum, correlation between cholelithiasis and hypothyroidism, relation with the demographic data, and body mass index (BMI) were studied. Results A total of 52 gallstone patients were included in the study. A greater number of patients were found to be above the age of 40 years (82.7%), with female preponderance (61.5%). More patients with cholelithiasis were from the group with having BMI more than normal (57.6%). More patients having both cholelithiasis and hypothyroidism were also from the group with having BMI more than normal. Most symptomatic patients complained of pain in the right hypochondriac region (88.5%). Of these 52 patients, nine (17.3%) were found to have hypothyroidism (seven were subclinical, two patients had overt clinical symptoms and signs) and the remaining 43 patients were euthyroid. Conclusions Our study supports that there is a correlation between cholelithiasis and hypothyroidism. Out of all the 52 patients, nine had hypothyroidism, seven were subclinical, and two had overt symptoms. Thus, we conclude that there is a correlation between cholelithiasis and hypothyroidism.

Socially Vulnerable Patients are More Likely to Fail Outpatient Management of Symptomatic Cholelithiasis.

INTRODUCTION: Symptomatic cholelithiasis is a common surgical problem with many patients requiring multiple gallstone-related emergency department (ED) visits before undergoing cholecystectomy. Social Vulnerability Index (SVI) identifies vulnerable patient populations. We assessed the association between social vulnerability and outpatient management of symptomatic cholelithiasis. METHODS: Patients with symptomatic cholelithiasis related ED-visits were identified within our health system from 2016 to 2022. Clinical outcomes data was merged with SVI census-track data, which comprises of 4 SVI subthemes (socioeconomic status, household characteristics, racial & ethnic minority status, and housing type & transportation). Multivariate analysis was used for statistical analysis. RESULTS: 47,292 patients presented to the ED with symptomatic cholelithiasis, of which 6103 (13.3%) resided in vulnerable census-tract regions. Of these patients, 13,795 (29.2%) underwent immediate cholecystectomy with a mean time to surgery of 35.1hours, 8250 (17.4%) underwent elective cholecystectomy at a mean 40.6 days from the initial ED visit, and 2924 (6.2%) failed outpatient management and returned 1.26 times (range 1 to 11) to the ED with recurrent biliary-related pain. Multivariate analysis found social vulnerability subthemes of socioeconomic status (OR 1.29, 95% CI 1.09-1.52) and Racial & Ethnic minority status (OR 2.41, 95% CI 2.05-2.83) to be associated with failure of outpatient management of symptomatic cholelithiasis. CONCLUSION: Socially vulnerable patients are more likely to return to the ED with symptomatic cholelithiasis. Policies to support this vulnerable population in the outpatient setting with timely follow-up and elective cholecystectomy can help reduce delays in care and overutilization of ED resources.

Hepatolithiasis: Epidemiology, presentation, classification and management of a complex disease.

The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts, above the hilar confluence of the hepatic ducts. The disease is more prevalent in Asia, mainly owing to socioeconomic and dietary factors, as well as the prevalence of biliary parasites. In the last century, owing to migration, its global incidence has increased. The main pathophysiological mechanisms involve cholangitis, bile infection and biliary strictures, creating a self-sustaining cycle that perpetuates the disease, frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of "recurrent pyogenic cholangitis". Furthermore, long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma. Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment. The management of symptomatic patients and those with complications can be complex, and relies upon a multidisciplinary team of hepatologists, endoscopists, interventional radiologists and hepatobiliary surgeons, with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications. This comprehensive review provides insight on various aspects of hepatolithiasis, with a focus on epidemiology, new evidence on pathophysiology, most important clinical aspects, different classification systems and contemporary management.

How traditional Chinese medicine can prevent recurrence of common bile duct stones after endoscopic retrograde cholangiopancreatography?

Common bile duct stones, as a type of cholelithiasis, are a benign biliary obstruction that easily acute abdominalgia, and Endoscopic Retrograde Cholangiopancreatography (ERCP) is usually the first choice for clinical treatment. However, the increasing recurrence rate of patients after treatment is troubling clinicians and patients. For the prevention of recurrence after ERCP, there is no guideline to provide a clear drug regimen, traditional Chinese medicine however has achieved some result in the treatment of liver-related diseases based on the "gut-liver-bile acid axis". On the basis of this, this article discusses the possibility of traditional Chinese medicine to prevent common bile duct stones (CBDS) after ERCP, and we expect that this article will provide new ideas for the prevention of recurrence of CBDS and for the treatment of cholelithiasis-related diseases with traditional Chinese medicine in future clinical and scientific research.

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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.

Aetiology, presentation and outcomes of patients presenting with acute pancreatitis in a tertiary care hospital.

Acute pancreatitis (AP) is a multi-causal disease with a high rate of hospita lisation. Only a few cl inical stud ies have i nvestig ated the aetiologic al backgroun d, sever it y, and outcome of AP in Pakistan. Hence, this study was carried out to determine the aforementioned factors and correlate them w ith outcomes in a tert iary care set ting. This was a cros s -sec tional, retrospective study conducted at the Department of Gast roe nterolo gy, Aga Khan University Hospita l, Karachi, from Januar y 1, 2022, to December 31, 2022. Data was analysed using statis tical s oftware SPSS version 25. Vomiting was th e predominant presenting complaint and was seen in 139 (78.5%) patients. Gallstones were the predominant cause in 68 (37%) patients, followed by idiop athic panc reatitis in 22 (12%) p atients. Thirteen (7.1 % ) pat ients expire d. Patients with syst emi c complications were lik ely to suffer fro m severe disease (p=0.0 2), whereas those with lo cal complications were at an increa sed ris k of mor tal it y (p=0.04). Due to lac k of diagnostic facilities, the aetiology of a large number of AP cases remains unknown.

A rare case of a cholecysto-duodenocolonic fistula secondary to cholelithiasis.

Internal biliary fistula is a rare but well-known complication of cholelithiasis. It is a notoriously challenging entity to diagnose and manage. Gallstones are often the causative factor in the formation of a cholecystoenteric fistula, with the most common internal biliary fistula being a cholecystoduodenal fistula followed by a cholecystocolonic fistula. Rarely, do these fistulae exist simultaneously. Here, we present an uncommon case of cholecysto-duodenocolonic fistula.

Mendelian randomization study on the causal relationship between food and cholelithiasis.

Background: Cholelithiasis, commonly referred to as gallstones, is a prevalent medical condition influenced by a combination of genetic factors, lifestyle choices, and dietary habits. Specific food items have been associated with an increased susceptibility to cholelithiasis, whereas others seem to offer a protective effect against its development. Methods: In this study, we conducted a Mendelian randomization (MR) analysis using a large-scale genetic dataset comprising individuals with European ancestry to explore the potential causal relationship between diet and cholelithiasis. The analysis incorporated 17 food-related variables, which were considered as potential factors influencing the occurrence of this condition. Results: Our findings indicate that a higher consumption of cooked vegetables, dried fruit, and oily fish is associated with a reduced risk of cholelithiasis. Conversely, a higher consumption of lamb is associated with an increased risk of developing the condition. Importantly, these associations proved robust to sensitivity and heterogeneity tests, and the pleiotropic test results further supported the hypothesis of a causal relationship between diet and cholelithiasis. Conclusion: Through our study, we provide compelling evidence for the existence of a causal relationship between diet and cholelithiasis. Adopting a dietary pattern enriched with cooked vegetables, dried fruit, and oily fish, while minimizing lamb intake, may contribute to the prevention of cholelithiasis. Recognizing diet as a modifiable risk factor in the prevention and management of this condition is of paramount importance, and our study offers valuable insights in this regard.

Double Cystic Ducts Encountered During Laparoscopic Cholecystectomy in a Male Patient With Cholelithiasis: A Case Report.

One of the most uncommon cystic duct abnormalities is double cystic ducts exiting a single gallbladder. Adequate knowledge of this anomaly should be kept in mind to avoid any surgical complications. We present a case of a 49-year-old Asian Pakistani male patient who had an elective laparoscopic cholecystectomy and was discovered to have two distinct cystic ducts leaving the gallbladder. On examination, there were no other clinically relevant signs except for mild tenderness in the right hypochondrium. Ultrasound of the abdomen and pelvis confirmed the diagnosis of cholelithiasis. Standard four-port laparoscopic cholecystectomy was done via the open Hasson technique under general anesthesia. After meticulous dissection of the Calot's triangle, double cystic ducts were discovered draining a single gallbladder. The gallbladder was retrieved after clipping and cutting the cystic ducts and cystic artery. To minimize the risk of complications, surgeons must be aware of the numerous anatomical variations that may exist.

Causal effects from nonalcoholic fatty liver disease on cholelithiasis: A mendelian randomization study.

Background and Aims: Both nonalcoholic fatty liver disease (NAFLD) and cholelithiasis are highly prevalent hepatobiliary diseases with risk of progression into severe outcomes. Considering the close relationship between liver and gallbladder in anatomy and physiology, a potential causal relationship between NAFLD and cholelithiasis has been speculated. Methods: Mendelian randomization (MR) was employed using genome-wide association study (GWAS) summary statistics in Million Veteran Program (MVP) for NAFLD, and statistics in UK biobank for cholelithiasis. Results: Our results demonstrate that NAFLD has a causal effect on cholelithiasis risk (OR, 1.003; 95%CI, 1.000-1.006; p = 0.03). We also performed the sensitivity analysis and heterogeneity test to ensure the accuracy of outcome and avoid the reverse causality. Conclusion: NAFLD should be regarded as a potential pathogenic factor in pathogenesis study of cholelithiasis, and be considered in assessment and treatment of cholelithiasis.

TyG index is positively associated with HOMA-IR in cholelithiasis patients with insulin resistance: Based on a retrospective observational study.

BACKGROUND/OBJECTIVE: Cholelithiasis is a common disease but pose significant global health and financial burdens. Mechanisms of the disease are associated with insulin resistance (IR), obesity, metabolic syndrome, and type 2 diabetes. Insulin resistance is commonly observed in cholelithiasis patients. More recently, the triglyceride-glucose (TyG) index has been proposed as an alternative marker of insulin resistance. In our study we aimed to understand whether the TyG index is correlated with HOMA-IR in cholelithiasis patients. And also we aimed the predict a cutoff value for determining insulin resistance in cholelithiasis patients. METHODS: A total of 184 cholelithiasis patients were matched in terms of age, gender, and BMI. They were divided into two groups based on their Homa IR levels (IR and Non-IR group). This study was a retrospective, observational study and clinical data was obtained from electronic medical records. Cutoff value for Tyg index was established through ROC Analysis. Binary Logistic Regression was used to identify factors affecting insulin resistance. RESULTS: A significant cutoff value was found for the TyG index in determining the presence of insulin resistance. Having a TyG index of ≥8.71 indicates the presence of insulin resistance. The sensitivity was 68.48%, the specificity was 58.70%. Binary Logistic Regression analyses showed that an increase in Tyg Index, waist circumference and waist-to-height ratio values increases the risk of insulin resistance by 2.705 (p = 0.001), 1.032 (p = 0.029), and 334.057 (p = 0.012) times respectively. CONCLUSION: Our study indicated that TyG index is positively correlated with HOMA-IR. TyG index was found as a risk factor for insulin resistance.

A Comparative Investigation of the Bile Microbiome in Patients with Choledocholithiasis and Cholecystolithiasis through Metagenomic Analysis.

While the precise triggers of gallstone formation remain incompletely understood, it is believed to arise from a complex interplay of genetic and environmental factors. The bile microbiome is being increasingly recognized as a possible contributor to the onset of gallstone disease. The primary objective of this study was to investigate distinctions in the microbial communities within bile specimens from patients with choledocholithiasis (common bile duct stones) and cholecystolithiasis (gallbladder stones). We employed massively parallel sequencing of the 16S rRNA gene to examine the microbial communities within bile samples obtained from 28 patients with choledocholithiasis (group DS) and cholecystolithiasis (group GS). The taxonomic composition of the bile microbial communities displayed significant disparities between the group DS and the group GS. Within the 16 prevalent genera, only Streptococcus, Ralstonia, Lactobacillus, and Enterococcus were predominantly found in the group GS. In contrast, the group DS displayed a more diverse range of genera. The alpha diversity of bile specimens was also notably lower in the group GS compared to the group DS (p = 0.041). Principal coordinate analysis unveiled distinct clustering of bile microbial communities depending on the location of the gallstone. Linear discriminant analysis effect size analysis, with a score threshold of >3 and the Kruskall-Wallis test (α < 0.05), recognized Bacilli and Lactobacillales as potential taxonomic markers for distinguishing patients with cholecystolithiasis limited to the gallbladder. Significant variations were found in the distribution and diversity of bile microbial communities between patients with choledocholithiasis and cholecystolithiasis. This observation suggests that alterations in the bile microbiome may contribute to the development of gallstones in these patients.

Genetic risk, adherence to healthy lifestyle behaviors, and risk of cholelithiasis: A population-based cohort study.

OBJECTIVE: Genetic and lifestyles contribute to cholelithiasis, but the impact of adhering to healthy lifestyle on cholelithiasis risk remains uncertain. We aimed to assess combined lifestyle factors and a polygenic risk score on incident cholelithiasis. METHODS: We utilized cholelithiasis genome-wide association study (GWAS) data from FinnGen study, constructing varied polygenic risk score (PRS), and applied them to 317,640 UK Biobank participants. The relative and absolute risk of incident cholelithiasis associated with six well-established lifestyle risk factors, was evaluated and stratified by PRS (low risk [quintile 1], intermediate risk [quintiles 2-4] and high risk [quintile 5]). Lifestyle score was also categorized into favorable, intermediate, and unfavorable groups. RESULTS: The PRS derived from 13 single nucleotide polymorphisms (p ≤ 5 × 10-6, r2 < 0.001) showed the best performance. A significant gradient of increase in risk of cholelithiasis was observed across the quintiles of the polygenic risk score (p < 0.001). Compared to participants with low genetic risk, those with intermediate or high genetic risk had a 10% (95% confidence interval [CI] = 1.05-1.17) and 24% (95% CI = 1.16-1.32) higher risk of cholelithiasis. An unfavorable lifestyle was associated with an approximately 50% higher risk of cholelithiasis than a favorable lifestyle. Participants with high genetic risk and an unfavorable lifestyle had 98% (Hazard ratio [HR]: 1.98; 95% CI: 1.67-2.35) higher risk of cholelithiasis than those with low genetic risk and a favorable lifestyle. CONCLUSIONS: Our study highlights the importance of lifestyle behaviors intervention on cholelithiasis risk regardless of the genetic risk in White European population.

An Indian surgeon's perspective on management of asymptomatic gallstones.

INTRODUCTION: Cholelithiasis is widely prevalent in India, with a majority of patients being asymptomatic while a small proportion experiencing mild complications. In the laparoscopic era, the rate of cholecystectomies has increased owing to early recovery and fewer complications. In asymptomatic patients, the risk of complications must be balanced against the treatment benefit. Recent guidelines suggest no prophylactic cholecystectomy in asymptomatic patients. We aimed to find out the Indian surgeons' perspective on asymptomatic gallstone management. METHODS: A cross-sectional e-survey was conducted of practicing surgeons, onco-surgeons and gastrointestinal-surgeons in India. The survey had questions regarding their perspective on laparoscopic cholecystectomy and treatment modalities in asymptomatic gallstones. RESULTS: A total of 196 surgeons responded to the survey. Their mean age was 42.3 years. Overall, 111 (57%) respondents worked in the private sector. Most surgeons (164) agreed that the rate of cholecystectomy has increased since the advent of laparoscopy; 137 (70%) respondents agreed that they would not operate on patients without risk factors. Common bile duct stones, chronic hemolytic diseases, transplant recipients, and diabetes mellitus were the risk factors. Majority of the participants agreed on not performing a cholecystectomy in patients with asymptomatic gallstones. CONCLUSION: There exists a lack of consensus among Indian surgeons on asymptomatic gallstone management in India. Where the majority of cases are asymptomatic and do not require surgery, certain comorbidities can influence the line of treatment in individual patients. Currently, the treatment guidelines for asymptomatic patients need to be established as cholecystectomies may be overperformed due to the fear of development of complications.

Successful Percutaneous Ultrasonic Lithotripsy of Gallstones.

Background: Acute calculous cholecystitis is the obstruction of the cystic duct by a gallstone that leads to inflammation of the gallbladder necessitating cholecystectomy. Case Series: We present the cases of 2 patients with acute calculous cholecystitis who were deemed ineligible candidates for cholecystectomy because of their complicating medical histories. Both patients initially underwent cholecystostomy and drain placement with interventional radiology for management of acute calculous cholecystitis. Their large gallstones remained refractory to attempts at removal by electrohydraulic lithotripsy via the cholecystostomy access. The patients' gallstones were successfully removed via percutaneous ultrasonic lithotripsy during a collaborative procedure with interventional radiology and urology. Conclusion: An interdisciplinary approach using percutaneous cholecystolithotomy with rigid ultrasonic lithotripsy is an effective method for removing challenging gallstones in patients for whom traditional approaches fail.