Gallstones Research Articles

Injection of carbon dioxide instead of iodinated contrast to display the common bile duct during endoscopic retrograde cholangiopancreatography.

Common bile duct (CBD) stones are usually caused by biliary tract infection, biliary stricture, duodenal peripapillary diverticulum, Oddis sphincter dysfunction, and so on. Treatment is preferably with endoscopic retrograde cholangiopancreatography (ERCP), where an iodine-containing contrast agent is injected into the CBD to display the stone under fluoroscopy and then to confirm complete removal of the stone(s). We described a 65-year-old woman with CBD stones who had undergone cardiac pacemaker implantation and was allergic to iodinated contrast media. We performed ERCP + lithotomy + stent implantation under local anesthesia, with injection of carbon dioxide instead of iodinated contrast into the CBD, and successfully visualized the stones under fluoroscopy and then confirmed complete removal of them. The patient was generally in good condition without complications. Thus, we have demonstrated in this case report that carbon dioxide can be used as a safe, economical, and effective alternative to iodinated contrast agent during ERCP.

The Association between Gallstone Disease and Incidence of Cardiovascular Disease: A Systematic Review and Meta-Analysis.

Gallstone Disease (GSD) is a multifactorial risk factor for various complications. This study aimed to examine the relationship between GSD and Cardiovascular Disease (CVD) incidence through a systematic review and meta-analysis approach. A thorough search was conducted across Web of Science, Scopus, MEDLINE/PubMed, Cochrane Library, and Embase databases. Only studies published between 1980 and December 2023 were included. Chi-square, I2, and forest plots were used to assess heterogeneity. Begg's and Egger's tests were used to evaluate publication bias. Statistical significance was considered at p <0.05, and all analyses were performed using Stata 17. This meta-analysis involved 21 studies and comprised 2,138,282 participants; there has been a significant association found between GSD and an increased risk of CVD (with a relative risk of 1.46, 95% confidence interval: 1.32-1.63, p <0.001). The analysis found no evidence of publication bias based on Begg's test (p =0.085) and Egger's test (p =0.231). Subgroup analysis of the studies showed a higher risk of CVD in studies with a sample size of less than 10,000 participants, conducted in 2016 or later, utilizing a cross-sectional design, in Asian countries; the analysis had a moderate quality score, with a follow-up period of equal to or less than ten years. There has been a significant association found between GSD and an increased risk of incidence of CVD. Taking proactive steps to implement targeted interventions for individuals with gallstone disease could potentially reduce the risk of cardiovascular disease within this population.

Biochemical Study of Gallstones Compositions in Iraqipatients

The aim of this study is to determine the organic and inorganic components of bile and gallstones in Iraqi patients. Forty seven patients were included in this study with mean age (53+7) years and BMI (30.82+4.18) Kg/m2. Bile was classified according to its corresponding stones into: Bile of Mixed stones and Bile of pigment stones. IR spectra were studied for both types of stones and their bile in addition to biochemical analysis for organic and inorganic components. The organic components include: (cholesterol, bilirubin, bile salts, and phospholipids), while inorganic components include salts of: (calcium, phosphorus, iron, cupper and magnesium). The results reveal to there was significant low levels (p

Gallstone Disease Is Associated With an Increased Risk of Inflammatory Bowel Disease: Results From 3 Prospective Cohort Studies.

Gallstone diseases affect intestinal inflammation, bile flow, and gut microbiota, which in turn may increase the risk of inflammatory bowel disease (IBD). However, epidemiological studies exploring the associations between gallstone diseases and subsequent IBD risk have been limited. This is a combined analysis of 3 prospective cohort studies (Nurses' Health Study, Nurses' Health Study II, and UK Biobank) and replicated in a case-control study (Chinese IBD Etiology Study). We evaluated the hazard ratios (HRs)/odds ratios (ORs) between gallstone diseases with IBD risk by Cox logistic regression or conditional logistic regression, adjusting for demographic characteristics, lifestyles, comorbidities, and medication usage. We identified 3,480 cases of IBD over 2,127,471 person-years of follow-up in the 3 cohort studies. The participants with gallstone disease had a 38% increase in the risk of IBD (HR 1.38, 95% confidence intervals [CI] 1.21-1.59), 68% increase in Crohn's disease (HR 1.68, 95% CI 1.38-2.06), and 24% increase in ulcerative colitis (HR 1.24, 95% CI 1.03-1.49). In Chinese IBD Etiology Study, we found even larger magnitude of effects between gallstone diseases and IBD risk (IBD: OR 3.03, 95% CI 2.32-3.97; Crohn's disease: OR 5.31; 95% CI 3.71-7.60; ulcerative colitis: OR 1.49; 95% CI 1.07-2.06). There were no major differences in the estimated associations between the presence of unremoved gallstones and prior cholecystectomy with IBD risk. Gallstone disease was linked to an increased risk of IBD and its subtypes, independent of traditional risk factors. Further research is needed to confirm these associations and clarify the underlying biological mechanisms.

Accurate measurement of key structures in CBD patients using deep learning

The prevalence of common bile duct (CBD) stones presents a widespread and intricate clinical challenge that necessitates precise measurements for effective clinical management. In response, we developed a practical deep learning system designed to precisely measure key structures within endoscopic retrograde cholangiopancreatography (ERCP) images in CBD patients. This system excels in detecting key structures in CBD patients and provides comprehensive information about the quantity, size, location, and dimensions of the common bile duct. While the size, location, and dimensions of the CBD are derived from the scaling ratio of the estimated duodenoscope diameter, the quantity of stones is determined independently of this conversion between pixels and millimeters. A rigorous evaluation of the system’s performance was conducted utilizing diverse metrics such as the Dice coefficient, accuracy, area under the receiver operating characteristic (AUROC) curve, and a comprehensive confusion matrix. A dataset of 418 images from 403 patients was divided into three sets: 314 images (75%) from 299 patients (74%) for training, 52 images (12.5%) from 52 patients (13%) for validation, and 52 images (12.5%) from 52 patients (13%) for testing. The proposed system demonstrated remarkable results in key structure detection and measurement, with Dice coefficients and overall AUROCs of 95.6% and 95.0% for the duodenoscope, 94.6% and 94.0% for the bile duct, and 94.1% and 92.0% for stone identification, respectively. The system’s timely, precise measurements of CBD structures can significantly enhance clinical decision-making, improve patient outcomes, and streamline diagnostic and management processes.

Structured learning and mentoring: shortening the learning curve in laparoscopic common bile duct exploration.

Technological advances have made the laparoscopy procedure popular for simultaneous cholecystectomy and bile duct exploration. We aimed to assess the implementation of a structured mentorship program for training in laparoscopic common bile duct exploration (LCBDE). We explored the effectiveness thereof in facilitating the learning of LCBDE as a single-stage treatment of common bile duct stones (CBD) with gallbladder in situ. The surgical databases of a mentor (experienced in LCBDE) and a mentee (new to LCBDE) were analyzed. The analysis retrospectively compared the mentor's first 100 cases (MF) with the mentee's first 100 (MEF) cases, and the mentor's last 100 cases (ML) with the mentee's initial cases. Data included demographics, technical details, and postoperative outcomes. A total of 300 patients underwent LCBDE. For MF vs. MEF (both n = 100), MF had a lower transcystic approach rate (5% vs. 70%; p < 0.001) than MEF. Postoperative median hospital stay was significantly shorter in the MEF group compared to the MF group (2 vs 5, p < 0.001). No mortality or significant complications were observed in either group. For ML (n = 100) vs. MEF, the ML group had a higher transcystic rate (87% vs. 70%; p = 0.005). No differences in mortality or conversion were observed between the groups. Bile leak was lower in the ML (3% vs. 6%, p = 0.498) group than the MEF group. Postoperative median hospital stay did not significantly differ between the ML and MEF group (1 vs 2days, p = 0.952). Structured mentorship significantly influenced the successful adoption of LCBDE by the mentee, shortening the learning curve to provide outcomes in the first 100 cases, comparable to highly experienced centers. These results support the implementation of structured training and continuous mentoring to facilitate the learning curve of laparoscopic bile duct exploration.

Outcomes of Laparoscopic Cholecystectomy in Elderly Patients

Background: Laparoscopic cholecystectomy (LC) is the standard treatment for both symptomatic gallstones and acute cholecystitis. Laparoscopic cholecystectomy is the surgical procedure to remove the gallbladder. While historically challenging in cases of acute cholecystitis, advancements in laparoscopic techniques have made it a viable and preferred treatment option for this condition. Objective: Our study’s objective was to evaluate the efficacy of LC in elderly individuals. Methods: This prospective observational study was conducted at the general surgical department of Mymensingh Medical College Hospital from January 2023 to December 2023. A total number of 70 elderly patients who had acute cholecystitis (symptomatic gallstone disease) were included in this study. Based on physical examination, general conditions, laboratory investigation, and radiographic results, gallstone disease was diagnosed. All cases provided a signed, informed consent form. The research was done after approval of the ethical committee. Results: Among the 70 patients the majority of patients (87.14%) fall within the 60-69 years age range. A smaller proportion of older patients: A smaller percentage (12.86%) of patients are aged 70 years or older. The majority of the patients (68.30%) were male and (32.70%) were female. Hypertension is the most prevalent comorbidity among the patients, approximately 15.6% of the patients. Diabetes mellitus follows as the second most common comorbidity, with 11.1% of patients Cardiac disease is the third most frequent comorbidity, present in 6.7% of the patients. Peripheral vascular disease is the least common comorbidity among those presented, affecting 4.4% of the patients. Regarding the symptoms and clinical presentation, patients exhibited a variety of the usual gallbladder disease symptoms, including epigastric pain (51.30%), fatty food intolerance (37.14%), nausea and vomiting (24.29%), Murphy’s sign (14.29%), biliary colic (32.86%), right upper ......

One-Stage Intraoperative ERCP combined with Laparoscopic Cholecystectomy Versus Two-Stage Preoperative ERCP Followed by Laparoscopic Cholecystectomy in the Management of Gallbladder with Common Bile Duct Stones: A Meta-analysis.

Concomitant gallbladder and common bile duct (CBD) stones, known as cholecystocholedocholithiasis, are clinically prevalent. There is currently no consensus on sequential versus simultaneous management approaches, and, if simultaneous, which approach to adopt. This meta-analysis evaluates the safety and efficacy of one-stage laparoscopic cholecystectomy (LC) with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) versus two-stage ERCP followed by LC for treating concomitant gallbladder and CBD stones. A comprehensive literature search was conducted in five databases, PubMed, Embase, Web of Science, VIP, and Wanfang, for all randomized controlled trials (RCTs), cohort and retrospective studies published up to February 2024. Data extraction was performed independently by two reviewers. The primary outcomes were CBD stone clearance rate and postoperative complications morbidity. Secondary outcomes included conversion to other procedures and length of hospital stay. Statistical analyses were performed using R (v.4.3.2) with weighted mean differences and odds ratios (ORs) calculated for continuous and dichotomous variables, respectively, with 95% confidence intervals (CIs). A total of 17 studies involving 2120 patients have been included, with 898 patients receiving single-stage and 1222 patients undergoing two-stage treatment. Of these studies, 9 were RCTs and 8 were retrospective cohort study. The one-stage group demonstrated superior outcomes in terms of CBD stone clearance (OR=2.07, p=0.0004), overall morbidity (OR=0.35, p<0.0001), post-operative pancreatitis (OR=0.49, p=0.006), conversion to other procedures (OR=0.38, p=0.0006), and length of hospital stay (MD=- 2.6456, 95% CI -3.5776; -1.7136, p<0.0001). No significant differences were observed in post-operative cholangitis (OR=0.44, p=0.12), post-operative bleeding (OR=0.76, p=0.47), or bile leakage (OR=1.28, p=0.54). For patients with concomitant gallbladder and CBD stones, the one-stage approach combining ERCP and LC appears safer and more effective, with advantages including higher stone clearance rates, reduced postoperative complications (particularly pancreatitis), shorter hospital stays, fewer residual stones, and decreased need for additional procedures. However, additional high-quality clinical trials are needed to establish the optimal treatment approach for various patient scenarios.

Percutaneous transhepatic papillary balloon dilation combined with dual-frequency double-pulse laser lithotripsy for large-diameter common bile duct stones

Objective: To evaluate the safety and efficacy of percutaneous transhepatic papillary balloon dilation (PTPBD) combined with flexible ureteroscopy-guided dual-frequency double-pulse ND:YAG (FREDDY) laser lithotripsy (PTPBD-FREDDY) for the treatment of giant (>1.5 cm diameter) common bile duct stones. Methods: A retrospective analysis was conducted on 26 patients with large-diameter difficult choledocholithiasis admitted to two medical centers from December 2017 to October 2021. Among these patients, four could not tolerate surgery or endoscopic treatment, six experienced failure of endoscopic treatment, and 16 refused to undergo endoscopic or surgical treatment. All patients underwent the PTPBD-FREDDY procedure. The FREDDY laser lithotripsy was performed under ureteroscopic guidance, followed by a balloon to push the stones into the duodenum. The primary endpoint was the technical success rate, and the secondary endpoints included the rate of stone recurrence and related complications. Results: All 26 patients successfully completed the operation, achieving a technical success rate of 100%. The average lithotripsy frequency and operation time for bilirubin stones were significantly higher than those of mixed stones and cholesterol stones (P<0.01). The main postoperative complications included mild fever (n=3), abdominal pain (n=3), nausea (n=2) and vomiting (n=1). One patient experienced biliary tract bleeding, which improved after conservative treatment. No serious complications such as pancreatitis, sepsis, or biliary perforation were observed. After 2 years of follow-up, no cases of stone recurrence were observed. Conclusions: PTPBD-FREDDY is a safe and effective treatment for patients with giant common bile duct stones. It provides a new therapeutic option for patients with giant choledocholithiasis who can not tolerate surgery or have failed endoscopic treatment, demonstrating promising prospects.

Polygoni Cuspidati Rhizoma et Radix extract activates TFEB and alleviates hepatic steatosis by promoting autophagy

Hepatic steatosis is a metabolic disorder characterized by excessive accumulation of lipid in the liver. The activation of autophagy shows a promising effect in the elimination of intracellular lipids, potentially improving steatosis. Polygoni Cuspidati Rhizoma et Radix (PCRR) has been used for thousands of years in treating atherosclerosis, hepatitis, and gallstone disease. We recently found that PCRR exerts a potent anti-hepatic steatosis effect, but the active compounds responsible for its effect and underlying mechanism remain unknown. This study aims to investigate whether PCRR water extract intervention improves steatosis by regulating hepatic autophagic flux. We demonstrated that PCRR water extract promoted autophagic flux, enhanced lysosomal biogenesis, and alleviated steatosis in hepatocytes and in the livers of rats with steatosis through autophagy induction. Mechanistic investigation revealed that PCRR water extract inhibited the activity of MTORC1, thereby dephosphorylating and hence inducing nuclear translocation of the lipophagy inducer TFEB. Notably, knockdown of TFEB attenuated the promoting effects of PCRR on lipophagy in hepatocytes. Furthermore, blockage of autophagy by chloroquine inhibited the therapeutic effect of PCRR against hepatic steatosis in HFD-fed rats. Our findings demonstrate the potential of PCRR water extract as a novel autophagy enhancer for treating hepatic steatosis.

Bridging Three Years of Insights: Examining the Association Between Depression and Gallstone Disease

Bridging Three Years of Insights: Examining the Association Between Depression and Gallstone Disease

Comparison of radiation exposure and fluoroscopy time between minimally invasive common bile duct exploration and endoscopic retrograde cholangiopancreatography for choledocholithiasis

ImportanceRadiation exposure causes dose-dependent deleterious effects and efforts should be made to decrease patient exposure to ionizing radiation. Patients with choledocholithiasis are commonly exposed to ionizing radiation as fluoroscopy-guided interventions including minimally invasive common bile duct exploration (MICBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred treatment modalities for common bile duct (CBD) stone clearance. However, radiation exposure and fluoroscopy times have not been compared between these two treatment modalities. ObjectiveTo compare fluoroscopy time (FT) and radiation exposure (RE) between MICBDE and ERCP in patients with choledocholithiasis. DesignThis is a retrospective analysis of a prospectively maintained database of a single surgeon performing MICBDE at an academic referral center between May 2021 and June 2023 compared to a retrospective analysis of all ERCPs performed between January 2020 and February 2021. Patient demographics, procedural details, fluoroscopic details, and post operative outcomes were compared between the MICBDE and ERCP. SettingSingle institution academic referral center located in the American Southwest. Participants109 patients with choledocholithiasis were divided into 2 groups. 53 patients (48.62%) underwent ERCP, and 56 patients (51.38%) underwent MICBDE. Inclusion criteria were; all patients presenting with choledocholithiasis and subsequently underwent ERCP or MICBDE. Patients who underwent ERCP for non-choledocholithiasis related reasons were excluded. Main outcomes and measuresPrimary outcomes include FT measured in minutes and RE measured in milligray (mGy). Secondary outcomes were successful clearance of the common bile duct, complications, procedural time, and reinterventions. ResultsA significant difference (P<.001) between fluoroscopy times was identified between ERCP (3.1mins) and MICBDE (1.54mins). Median RE doses between the ERCP group (38 mGy) and the MICBDE group (38.41 mGy) were not statistically different (p=0.88). Technical success of CBD clearance was similar in both groups (91% in MICBDE group vs 93% in ERCP group; p=0.711). Conclusion and RelevanceAdvantages of MICBDE over ERCP include; treatment of choledocholithiasis at the time of cholecystectomy, which reduces the risk of additional anesthesia episodes and the introduces the potential for shorter hospital length of stay. This study shows that MICDBE has lower FT compared to ERCP and comparable RE. Given the advantages of MICBDE, it should be strongly considered at the time of laparoscopic cholecystectomy.

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Background: Gallstones are a common gastrointestinal disorder often requiring cholecystectomy. Laparoscopic cholecystectomy, the gold standard for gallbladder removal, involves pneumoperitoneum (PNP) using carbon dioxide (CO2) for better visibility and access. However, postoperative shoulder pain remains a frequent complication, largely attributed to CO2 insufflation. This study compares the incidence and severity of postoperative shoulder pain between low-pressure pneumoperitoneum (LPP) and standard-pressure pneumoperitoneum (SPP) during laparoscopic cholecystectomy. Materials and Methods: A prospective interventional study was conducted at SMS Hospital, Jaipur, including 80 patients with gallstone disease undergoing elective laparoscopic cholecystectomy. Patients were divided into two groups: LPP (8–10 mm Hg) and SPP (12–14 mm Hg), each comprising 40 patients. Pain was assessed using the Verbal Rating Scale (VRS) at 2, 6, 12, 24, and 48 hours postoperatively. Data were analyzed using the unpaired two-tailed t-test, with a P value &lt; 0.05 considered statistically significant. Results: The incidence of shoulder pain was significantly lower in the LPP group (10%) compared to the SPP group (40%) (P = 0.00). Mean VAS scores at 2, 6,12,24, and 48 hours post-surgery were consistently lower in the LPP group, with significant differences noted at each time point. At 12 hours, the LPP group had a mean VAS score of 0.62 ± 0.34 compared to 2.92 ± 1.4 in the SPP group (P = 0.00). By 48 hours, no LPP patients reported shoulder pain, whereas the SPP group still reported a mean VAS score of 0.62 ± 0.21 (P = 0.00). Conclusion: LPP is associated with significantly lower incidence and severity of postoperative shoulder pain compared to SPP in laparoscopic cholecystectomy. These findings suggest that LPP could be a better option for reducing patient discomfort and improving postoperative outcomes

Integration of bile proteomics and metabolomics analyses reveals novel insights into different types of gallstones in a high-altitude area

BackgroundTo explore the pathogenesis of different subtypes of gallstones in high-altitude populations from a molecular perspective.MethodsWe collected bile samples from 20 cholesterol gallstone disease (CGD) patients and 20 pigment gallstone disease (PGD) patients. Proteomics analysis was performed by LC/MS DIA, while metabolomics analysis was performed by UPLC- Q-TOF/MS.ResultsWe identified 154 up-regulated and 196 down-regulated differentially expressed proteins, which were significantly enriched in neurodegenerative diseases, energy metabolism, amino acid metabolism etc. In metabolomics analysis, 20 up-regulated and 63 down-regulated differentially expressed metabolites were identified, and they were significantly enriched in vitamin B6 metabolism. Three pathways of integrated proteomics and metabolomics were significantly enriched: porphyrin and chlorophyll metabolism, riboflavin metabolism and aminoacyl-tRNA biosynthesis. Remarkably, 7 differentially expressed proteins and metabolites showed excellent predictive performance and were selected as potential biomarkers.ConclusionThe findings of our metabolomics and proteomics analyses help to elucidate the underlying mechanisms of gallstone formation in high-altitude populations.

Intragallbladder versus intravenous indocyanine green (ICG) injection for enhanced bile duct visualization by fluorescent cholangiography during laparoscopic cholecystectomy: a retrospective cohort study.

Iatrogenic bile duct injuries (BDIs) prevention during laparoscopic cholecystectomy (LC) relies on meticulous anatomical dissections through direct visualization. Near-infrared fluorescence (NIRF) with indocyanine green (ICG) improves the visualization of extrahepatic biliary structures. Although ICG can be administered either intravenously or intragallbladder, there remains uncertainty regarding the optimal method for different patient populations. This study sought to assess the suitability of each method for specific patient groups. Between October 2021 and May 2022, 59 consecutive patients underwent fluorescence-guided LC at West China Hospital of Sichuan University. Among them, 32 patients received an intravenous injection of ICG (10 mg) 10 to 12 hours prior to surgery (Group A: the intravenous group), while 27 patients received an intragallbladder injection of ICG (10 mg) (Group B: the intragallbladder group). Baseline clinical factors, inclusion criteria, and measurements of parameters and complications were assessed. Data were retrospectively collected and analyzed to evaluate the comparability of the two groups and the clinical outcomes. Groups A and B included 32 patients (18 males, 14 females), and 27 patients (13 men, 14 women), respectively. In our statistical analysis, significant differences were observed in preoperative diagnoses between the two groups (P=0.041), but the majority of other baseline clinical factors were comparable. Notably, no statistically significant differences were found in complication rates. However, Group A had a shorter operative time (60.38±9.35 vs. 66.78±9.88 min, P=0.01) and superior bile duct fluorescence (P=0.04) than Group B. Interestingly, fluorescence was not observed in impacted gallbladder stones in Group B. Additionally, patients with cirrhosis (P=0.008) and fatty liver (P=0.005) in Group B had higher common bile duct-to-liver ratios (BLRs) than those in Group A. ICG fluorescence cholangiography allows to visualize extrahepatic biliary anatomical structures with both administration methods. However, the efficacy of bile duct fluorescence varies with different administration routes in diverse patient populations. Hence, appropriate administration route selection for ICG should be tailored to individual patients.

CANVAS For A Diagnosis: Can You Hear The Hooves Of Zebras?

Abstract Background A 75year old male presented to a Movement Disorder Service with complex multimorbidity including: chronic pain, type 2 diabetes mellitus, hypoventilatory obesity syndrome, biliary calculus, moderate aortic stenosis, marked orthostatic hypotension, pulmonary hypertension, coronary artery bypass grafting, permanent pacemaker for complete atrioventricular block, carpal tunnel release bilaterally, polypharmacy and bilateral cataracts. History elucidated a distal to proximal sensory loss over 20years and neuropathic pain without nerve conduction confirmation; and progressively ataxic gait over several years. He also complained of hypophonia, bruxism, excessive daytime somnolence, passages, transitions, visual agnosia, textural illusion, oscillopsia, irritability, inflexibility, hoarding, impulsivity, disorganisation, inattention, apathy, depression and aspontaneity. He was intolerant of nocturnal continuous positive airway pressure device. Epworth score was 21. Methods Examination demonstrated: marked orthostatic hypotension, preserved cognition, hypersomnolence, dyspraxic dysgraphia, palmar and antecubital agraphaesthesia, downbeat horizontal nystagmus at eccentric gaze positions, square wave jerks, bidirectionally impaired head impulse test, dysmetric saccades, asymmetric cerebellar signs in upper and lower limbs, rightward Pisa syndrome, kinesigenic dystonic axial posturing, rightward laterocollis and equivocal Babinski/Oppenheim reflexes. Gait assessment demonstrated sensory and cerebellar ataxic features with marked apraxia. No pes cavus. Results Computed tomography of brain had Fazekas 1 small vessel disease, Medial temporal atrophy score 1, Koedam 1 and age-commensurate cerebral and cerebellar atrophy. RFC1 gene testing confirmed biallelic intronic AAGGG repeat expansion disorder. Conclusion Cerebellar Ataxia Neuropathy and Vestibular Areflexia Syndrome (CANVAS) should be considered in patients with presentations from mid-life of progressive sensory ataxic neuropathy, altered vestibular ocular reflex, gaze evoked nystagmus and prominent dysautonomia. CANVAS is a rare autosomal recessive genetic disorder with a protean presentation. Referral to Genetics Services should be undertaken for family counselling. Keeping an open mind in complex, multimorbid patients to a potentially unifying diagnosis is important to guide prognostication. The rumble of hooves in the distance is not always that of horses.

Parameters for safe dissection at Calot's Triangle in Laparoscopic Cholecystectomy.

To explore the parameters critical to safe laparoscopic cholecystectomies. The prospective study was conducted at Al-Yarmook Teaching Hospital, Baghdad, from May 1, 2020, to December 31, 2021, and comprised patients with gall-stone disease who were admitted for laparoscopic cholecystectomy. Consecutive non-probability sampling technique was used for collecting the data which was analysed using SPSS (version 25). Of the 93 patients, 68(73.12%) were females, and 25(26.88) were males. The overall mean age was 40.7±8.1 years, and 52(55.91%) patients were aged >40 years. Calot triangle was seen in 72(77.4%) cases, while the sulcus of Rouviere, duodenum and right hepatic artery were spotted in 50(53.8%), 49(52.7%) and 19(20.4%) cases, respectively. There was a significant association of late presentation, lateral traction, 4-port option, good setting and difficult anatomy with anatomical landmark visualisation (p<0.05). There is a need for a national guideline to ensure safe laparoscopic cholecystectomy.

Investigating causal links between gallstones, cholecystectomy, and 33 site-specific cancers: a Mendelian randomization post-meta-analysis study

Background and aimThe association between gallstones/cholecystectomy and cancer remains inconclusive in the current literature. This study aimed to explore the causal connections between gallstones/cholecystectomy and cancer risk by utilizing a bidirectional two-sample multivariable Mendelian randomization approach with Genome-Wide Association Studies data.MethodsUtilizing Genome-Wide Association Studies data from the UK Biobank and FinnGen, this research employed multivariable Mendelian randomization analyses to explore the impact of gallstones and cholecystectomy on the risk of 33 distinct cancer types. Instrumental variables for gallstones and cholecystectomy were carefully selected to ensure robust analyses, and sensitivity and heterogeneity tests were conducted to verify the findings’ validity.ResultsMultivariable Mendelian randomization analysis, incorporating data from more than 450,000 individuals for gallstones and cholecystectomy, revealed nuanced associations with cancer risk. Cholecystectomy was associated with a significantly increased risk of nonmelanoma skin cancer (OR = 1.59, 95% CI: 1.21 to 2.10, P = 0.001), while gallstones were linked to a decreased risk of the same cancer type (OR = 0.63, 95% CI: 0.47 to 0.84, P = 0.002). Interestingly, the analysis also suggested that cholecystectomy may lower the risk of small intestine tumors (OR = 0.18, 95% CI: 0.043 to 0.71, P = 0.015), with gallstones showing an inverse relationship, indicating an increased risk (OR = 6.41, 95% CI: 1.48 to 27.80, P = 0.013).ConclusionsThe multivariable Mendelian randomization analysis highlights the differential impact of gallstones and cholecystectomy on cancer risk, specifically for nonmelanoma skin cancer and small intestine tumors. These results underscore the importance of nuanced clinical management strategies and further research to understand the underlying mechanisms and potential clinical implications of gallstone disease and cholecystectomy on cancer risk.

Nutritional and potential health benefits of chufa oil, olive oil, and anhydrous milk fat against gallstone disease in a C57BL/6N mouse model.

Dietary lipids play a major role in many diseases, particularly cardiovascular diseases. Recently, the health value of plant oils, particularly heart health, has been recognized. Despite these facts, limited information is available on the potential nutritional and anti-arteriolosclerosis effects of chufa oil, olive oil, and anhydrous milk fat in C57BL/6N mice. In the present study, the effects of olive oil (OO), chufa oil (CO), and anhydrous milk fat (AMF) on 4-week-old C57BL/6N male mice, a model for studies of diet-induced atherosclerosis, were investigated. The AIN-93G-based diet was supplemented with 15% of either OO, CO, or AMF. The final mixture of the diets contained 15% fat, approximately 1.25% cholesterol, and 0.5% sodium cholate. The data obtained showed that most mice had gallstone disease. The highest percentage of the gallstones formed were found in AMF groups (approximately 85.7% of the mice). However, the lowest one was found in the chufa oil group (42.9%), followed by the olive oil group (57.1%). Although the mice's food intake significantly differed, their body weights did not change during the feeding period. The diet supplemented with CO resulted in a significant reduction in serum cholesterol compared with the other groups. Livers from the CO-fed group showed higher triglyceride levels than those from the AMF group. No significant differences were found in atherosclerotic lesions in the aortic valve between the groups. Collectively, our results show no deleterious nutritional effects of the fats used on C57BL/6N mice fed cholesterol-rich diets. Chufa oil improved cholesterol metabolism and atherogenic index in mice. However, the major issue is the formation of gallstones in all mice, which is most prominent in AMF, followed by olive oil and chufa oil diets.

Efficacy of Upper Gastrointestinal Endoscopy In Cholelithiasis Before Laparoscopic Cholecystectomy

Background: The most prevalent condition affecting the gallbladder and biliary tree is cholelithiasis. Presence of gall stones is discovered commonly during imaging tests for other pathologies. Laparoscopic cholecystectomy is a preferred modality for the treatment of gallstone disease. Objective: The primary aim of the study is to determine the efficacy of upper gastrointestinal endoscopy as a routine investigative modality in symptomatic presentation of cholelithiasis prior to laparoscopic cholecystectomy. Methods: A total 50 participants having single or multiple stones in the gall bladder found on ultrasound were included in the study. Enrolled patients underwent routine investigations. The baseline demographic details like patient name, age, gender, clinical presentation, and upper endoscopy findings were documented. The intensity of the pain was measured by visual analogue scale. Results: A total of 36% patients were in the age-group of &lt; 30 years. The highest incidence of cholelithiasis was observed in female gender. Abdominal pain was the most common symptom. The most common upper gastrointestinal endoscopy findings were gastritis followed by gastritis erosion. A significant reduction of pain was noted in group I as compared to group II at first- and fourth-week time durations. Conclusion: Cholelithiasis has common clinical presentations in similarity to other upper gastrointestinal diseases. Upper gastrointestinal endoscopy can be recommended for patients with atypical presentation to prevent post-surgical adverse outcomes.