KjG The Korean Journal of Gastroenterology Korean J Gastroenterol 1598-9992 2233-6869 Korean Society of Gastroenterology 10.4166/kjg.2015.66.1.33 kjg-66-33 Original Article Clinical Significance of Biliary Dilatation and Cholelithiasis after Subtotal Gastrectomy YoonHarry KwonChang-Il JeongSeok 1 LeeTae Hoon 2 HanJoung-Ho 3 SongTae Jun 4 HwangJae Chul 5 KimDae Jung 6 Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea Division of Gastroenterology, Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea Division of Gastroenterology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Ilsan, Korea Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea Correspondence to: Chang-Il Kwon, Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam 463-712, Korea. Tel: +82-31-780-5641, Fax: +82-31-780-5219, E-mail: endoscopy@cha.ac.kr 10 2015 04 10 2015 661 33 40 16032015 26042015 24052015 Copyright © 2015 Korean Ophthalmological Society 2015 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background/Aims

The well-organized study to support that increased cholelithiasis and bile duct dilatation can occur after gastrectomy has not been reported. The aim of this study was to determine the incidence of cholelithiasis and the degree of common bile duct (CBD) dilatation in patients undergoing subtotal gastrectomy, compared to those undergoing endoscopic treatment for gastric cancer.

 Methods

Patients who diagnosed with gastric cancer and received treatment at six academic referral centers were investigated for the incidence and time of cholelithiasis and the degree of CBD dilatation after treatment by analysis of 5-year follow-up CTs. The operation group underwent subtotal gastrectomy without vagotomy, while in the control group endoscopic treatment was administered for gastric cancer.

 Results

A total of 802 patients were enrolled in 5-year analysis (735 patients in the operation group and 67 patients in the control group). Cholelithiasis occurred in 47 patients (6.39%) in the operation group and 3 patients (4.48%) in the control group (p=0.7909). The incidences of cholelithiasis were 4.28% in Billoth-I and 7.89% in Billoth-II (p=0.0487). The diameter of proximal CBD and distal CBD increased by 1.11 mm and 1.41 mm, respectively, in the operation group, compared to 0.4 mm and 0.38 mm, respectively, in the control group (p<0.05). Patients with increased CBD dilatation more than 5 mm showed statistically significant increases in alkaline phosphatase and gamma-glutamyltransferase.

 Conclusions

The incidence of cholelithiasis was not increased due to subtotal gastrectomy without vagotomy, but the incidence was higher after Billoth-II compared to Billoth-I. In addition, significant change in the CBD diameter was observed after subtotal gastrectomy.

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Measurement of the common bile duct on abdominal computed tomography. (A) Proximal common bile duct in the porta hepatis. (B) Distal common bile duct in the pancreas head.

Baseline Characteristics and Liver Function Tests

Characteristic Operation group Control group p-value
Age (yr) 58.59±12.92 64.39±12.04 0.0038
Sex (male) 475 (64.63) 48 (71.64) 0.2484
Body weight (kg) 62.92±10.16 65.33±9.97 0.5919
AST (IU/L) 26.30±18.56 25.44±8.77 0.6032
ALT (IU/L) Total bilirubin (mg/dL) 23.83±39.58) 0.86±1.10 24.75±16.13 0.84±0.37 0.7713 0.7380
ALP (IU/L) 171.98±148.94 199.75±56.93 0.0605
GGT (IU/L) 65.41±171.48 61.00±66.62 0.8764

Values are presented as mean±SD or n (%).

Incidence of Cholelithiasis between Two Groups

Group Cholelithiasis No cholelithiasis p-value
Operation group 47 (6.39) 688 (93.61) 0.7909
Control group 3 (4.48) 64 (95.52)  

Values are presented as n (%).

Relationship between Incidence of Cholelithiasis and Post-operative Duration

Duration (mo) Operation group Control group p-value
0–6 13 (27.66) 0 0.7438
7–12 2 (4.26) 0  
13–24 4 (8.51) 0  
25- 28 (59.57) 3 (100)  
Total 47 (100) 3 (100)  

Values are presented as n (%).

Incidence of Cholelithiasis according to the Operation Method

Operation method Cholelithiasis No cholelithiasis p-value
Operation group (n=735)     0.0487
 Billoth-I (n=304) 13 (4.28) 291 (95.72)  
 Billoth-II (n=431) 34 (7.89) 397 (92.11)  
Control group (n=67)     0.8422
 ESD (n=41) 2 (4.88) 39 (95.12)  
 EMR (n=26) 1 (3.85) 25 (96.15)  

Values are presented as n (%).

EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection.

Degree Categorization for Change of Common Bile Duct Diameter

Group P-CBD Diameter change (mm)
 D-CBD Diameter change (mm)
0–5 6–8 9–12 >13 0–5 6–8 9–12 >13
Operation group (n=735) 707 (96.19) 20 (2.72) 6 (0.82) 2 (0.27) 708 (96.33) 19 (2.59) 6 (0.82) 1 (0.14)
Control group (n=67) 66 (98.51) 1 (1.49) 0 (0) 0 (0) 67 (100) 0 (0) 0 (0) 0 (0)

Values are presented as n (%).

D-CBD, distal common bile duct; P-CBD, proximal common bile duct.

Analysis for Change of Common Bile Duct Diameter

Variable Operation group (n=735) Control group (n=67) p-value
Initial diameter (mm)      
 P-CBD 4.89±1.88 4.84±1.58 0.8235
 D-CBD 4.61±1.47 5.13±1.50 0.0064
Number of diameter change>5 mm      
 P-CBD 34 (4.63) 1 (1.49) 0.3511
 D-CBD 30 (4.09) 0 (0) 0.1663
Diameter after 5 years follow up (mm)      
 P-CBD 6.01±2.68 5.31±1.88 0.0063
 D-CBD 6.03±2.38 5.51±1.80 0.0335
Delta diameter change (mm)      
 P-CBD 1.11±1.99 0.47±1.29 0.0004
 D-CBD 1.41±1.99 0.38±1.38 0.0335

Values are presented as mean±SD or n (%).

D-CBD, distal common bile duct; P-CBD, proximal common bile duct.

Delta diameter change was defined as average diameter at initial diagnosis minus average diameter after 5 years follow up.

Risk of Common Bile Duct Dilatation according to the Laboratory Finding

  P-CBD dilatation >5 mm D-CBD dilatation >5 mm
OR p-value OR p-value
AST 0.922 0.2546 1.052 0.2785
ALT 0.979 0.6667 0.977 0.4959
Total bilirubin 3.147 0.3353 0.145 0.2079
ALP 1.000 0.8324 0.996 0.3077
GGT 1.012 0.0450 1.006 0.0450

P-CBD, proximal common bile duct; D-CBD, distal common bile duct.