Medizin - Open Access LMU - Teil 07/22 Archiv

Gallbladder biles and stones were obtained at 116 cholecystectomies for symptomatic gallstone disease. All 33 patients younger than 50 years had cholesterol stones, whereas 40% of the older patients had pigment stones. We compared the reliability of three different bile tests for the differentiation between cholesterol and pigment stone patients. Whereas both the presence of cholesterol monohydrate crystals in fresh gallbladder bile and a nucleation time 20 days in ultrafiltered gallbladder bile had a specificity of 100% for cholesterol gallstone disease, biliary supersaturation with cholesterol (cholesterol saturation index >1.0) had a low specificity. The sensitivity of nucleation time 20 days for cholesterol gallstone disease was 78% in concentrated gallbladder biles (biliary total lipid concentration 5 g/dl) but only 21% in dilute biles (biliary total lipid concentration

Rapid aggregation of cholesterol-phospholipid vesicles in gallbladder bile seems to be the first event in the production of cholesterol crystals, a prerequisite for cholesterol gallstone formation. We examined the amount of these vesicles in 33 human gallbladder biles in relation to biliary lipid composition and to the presence of cholesterol crystals. Biliary microscopy detected cholesterol crystals in all 19 biles from patients with cholesterol gallstones but in none of 14 biles from patients with pigment stones. Gel chromatography was used to separate vesicles and micelles in the native bile with an eluting buffer containing 10 mM sodium cholate to prevent disruption of micellar lipids. Cholesterol, phospholipid and bile salt concentrations were measured in every fraction collected. Bile acid, phospholipid, cholesterol and total lipid concentrations were not significantly different in samples with and without cholesterol crystals. The cholesterol saturation index (1.4 ± 0.11 vs. 1.0 ± 0.08) was significantly (p < 0.01) higher in biles with crystals than without crystals. Gel filtration revealed a vesicular peak in addition to micellar fraction in 18 (23.1 ± 3.2% of total cholesterol) of the 19 biles with crystals but only in three (15.7 ± 2.4% of total cholesterol) of 14 biles without crystals. There was no relation between biliary lipid concentration or the cholesterol saturation index and the percentage of vesicular cholesterol in biles with or without crystals. The close association of vesicles and crystals in human gallbladder bile supports the contention that vesicles are important in the initial nucleation of cholesterol monohydrate crystals.

The high rate of stone recurrence represents a drawback of non-surgical therapy of cholesterol gallstone disease. Although most studies report that long-term bile acid treatment does not have protective effects, preliminary results suggest that low-dose ursodeoxycholic acid decreases the rate of gallstone recurrence in a subgroup of younger patients. To clarify the underlying mechanism we investigated whether low-dose ursodeoxycholic acid treatment influences biliary cholesterol saturation and/or nucleation time of cholesterol. Ten patients with cholesterol gallstones and functioning gallbladder received 250 mg ursodeoxycholic acid/day at bedtime 6–10 days prior to cholecystectomy. Eleven patients with cholesterol gallstones without treatment served as controls. Cholesterol crystals were present in the gallbladder bile of 7 out of the 10 patients receiving ursodeoxycholic acid and in all control biles. Ursodeoxycholic acid treatment significantly (P < 0.02) decreased the cholesterol saturation index (mean ± S.E.: 0.94 ± 0.05 vs. 1.43 ± 0.18) and led to an approximately 5-fold prolongation (P < 0.005) of the cholesterol nucleation time (mean ± S.E.: 12.0 ± 2,4 vs. 2.3 ± 0.7 days). We conclude that lowdose ursodeoxycholic acid might be effective in the prevention of post-dissolution gallstone recurrence by both decreasing cholesterol saturation and prolonging cholesterol nucieation time

Aufgrund schlechter Erfahrungen mit der Resorption von Knochentransplantaten benutzte Jacques Joseph in geeigneten Fällen Elfenbeinspäne für die Sattelnasenkorrektur. Vor dem Hintergrund, dass sicher nicht mehr viele von Joseph so operierte Patienten am Leben sind, berichten die Autoren über Langzeitergebnisse von 3 Fällen, bei denen 42, 43 und 63 Jahre zuvor Elfenbeinspäne in den Nasenrücken implantiert worden waren. Die Langzeitprognose aus heutiger Sicht und Josephs eigene Beobachtungen zu diesem Material sowie einige auch heute noch nicht allseits geklärte Umstände des Wirkens dieses genialen Operateurs werden besprochen.