Andrzej Matyja

Telocytes: new insight into the pathogenesis of gallstone disease

The major mechanisms of gallstone formation include biliary cholesterol hypersecretion, supersaturation and crystallization, mucus hypersecretion, gel formation and bile stasis. Gallbladder hypomotility seems to be a key event that triggers the precipitation of cholesterol microcrystals from supersaturated lithogenic bile. Telocytes, a new type of interstitial cells, have been recently identified in many organs, including gallbladder. Considering telocyte functions, it is presumed that these cells might be involved in the signalling processes. The purpose of this study was to correlate the quantity of telocytes in the gallbladder with the lithogenicity of bile. Gallbladder specimens were collected from 24 patients who underwent elective laparoscopic cholecystectomy for symptomatic gallstone disease. The control group consisted of 25 consecutive patients who received elective treatment for pancreatic head tumours. Telocytes were visualized in paraffin sections of gallbladders with double immunofluorescence using primary antibodies against c‐Kit (anti‐CD117) and anti‐mast cell tryptase. Cholesterol, phospholipid and bile acid levels were measured in gallbladder bile. The number of telocytes in the gallbladder wall was significantly lower in the study group than that in the control group (3.03 ± 1.43 versus 6.34 ± 1.66 cell/field of view in the muscularis propria, P < 0.001) and correlated with a significant increase in the cholesterol saturation index. The glycocholic and taurocholic acid levels were significantly elevated in the control subjects compared with the study group. The results suggest that bile composition may play an important role in the reduction in telocytes density in the gallbladder.

Lymph node involvement in ampullary cancer: the importance of the number, ratio, and location of metastatic nodes.

Lymph node involvement significantly affects survival of cancer patients. The aim of this study was to evaluate the importance of the number, ratio, and location of metastatic lymph nodes in ampullary cancers.

Loss of gallbladder interstitial Cajal-like cells in patients with cholelithiasis

Background  Interstitial cells of Cajal (ICCs) play an important role in the regulation of gut motility. There is growing evidence that interstitial Cajal‐like cells (ICLCs) are present in the gallbladder wall. We hypothesize that changes in the density of ICLCs in the gallbladder wall may lead to the development of cholelithiasis due to the impairment of the gallbladder motility. The purpose of this study was to identify ICLCs in the gallbladders of patients with gallstones and to assess their densities.

Evidence of interstitial Cajal-like cells in human gallbladder.

The aim of this study was to assess the presence of interstitial Cajal-like cells (ICLCs) in the human gallbladder and to determine their distinctive characteristics on the basis of double immunohistochemical stain- ing. Gallbladder specimens were obtained from 30 patients subjected to elective laparoscopic cholecystectomy for symptomatic gallstone disease. Tissue samples were fixed in 4% phosphate-buffered paraformaldehyde, processed, embedded in paraffin, and, after sectioning, routinely stained with HE. Tissue antigens were re- trieved using the heat-induced epitope retrieval (HIER) method. For simultaneous visualisation of two anti- gens, an indirect double immunofluorescence procedure was applied. ICLCs were defined as CD117-immunop- ositive and tryptase-immunonegative objects. They were predominantly fusiform in shape with sparse branches that were visible in some sections. ICLCs were observed throughout the organ including the gallbladders fun- dus, body (corpus) and neck, being most numerous in the corpus. The ICLCs were detected almost exclusively within the muscularis propria and they were arranged parallel to smooth muscle cells. The following subpopula- tions of ICLCs were observed: ICLC-IM (intramuscular ICLCs) localised between smooth muscle fibres form- ing one muscle bundle; and ICLC-IB (interbundle ICLCs) localised within the connective tissue separating smooth muscle bundles. Thus, the presence of ICLCs in the human gallbladder was clearly identified, demon- strated by double immunohistochemistry which was found to be a reliable method for differentiating ICLCs from mast cells. (Folia Histochemica et Cytobiologica 2012, Vol. 50, No. 4, 581-585)

Interstitial Cajal-Like Cells and Bile Lithogenicity in the Pathogenesis of Gall-Stone Disease

UNLABELLED Gall-stone disease constitutes a serious clinical problem and is the most frequent cause of elective cholecystectomies. There are many etiopatogenic factors however; lithogenic bile and its stasis due to gall-bladder hypomotility seem to be the most important. In recent years discovery of pacemaker function of Interstitial Cells of Cajal changed our understanding of smooth muscle physiology and helped to disclose many gastrointestinal motility disorders. THE AIM OF THE STUDY was identification and quantification of interstitial Cajal-like cells (ICLCs) in gall-bladder muscle wall from patients with cholelithiasis and in gall-stone-free controls, as well as determination of the relationship between the number of ICLCs and Cholesterol Saturation Index (CSI) of bile in both analyzed groups. MATERIAL AND METHODS 20 patients operated for symptomatic cholelithiasis were enrolled into the study group. The control group consisted of 20 patients operated for pancreatic head tumors, with no pre- and intraoperative signs of gall-stones. Identification of ICLCs in the gall-bladder was performed by means of double immunofluorescence technique with anti c-Kit and anti-mast cell tryptase antibodies. Quantitative analysis was carried out under fluorescence microscopy conjoined with image analysis software. Bile samples were used for calculation of CSI. RESULTS ICLCs were detected within gall-bladder muscle wall. Number of ICLCs was statistically significantly lower in patients from the study group as compared to control. The study also revealed statistically significantly higher CSI in the study group. CONCLUSIONS The quantity of ICLCs is diminished in the gall-bladder from patients with cholelithiasis and there is negative correlation between the number of ICLCs and CSI of bile. Regarding the role of ICCs in regulation of GI tract motility, it appears that reduction in their number may be important etiopatogenic factor of cholelithiasis.

Carbon dioxide insufflation during screening unsedated colonoscopy: a randomised clinical trial.

One of the methods used to reduce pain and discomfort during colonoscopy is insufflation of carbon dioxide instead of air. However, the actual benefit of carbon dioxide insufflation is not unequivocally proven. The aim of the study was to evaluate the advantages of carbon dioxide insufflation during screening colonoscopy. A total of 200 patients undergoing screening colonoscopy between 2010 and 2011 were included in the prospective, randomized study carried out in a surgical referral center. Screening unsedated colonoscopy with either air or carbon dioxide insufflation was performed; patients were randomly assigned to air or carbon dioxide group by means of computer-generated randomization lists. All examinations were performed in an ambulatory setting with standard videocolonoscopes. The main outcomes analyzed were (a) duration of the entire procedure, (b) cecal intubation time, and (c) pain severity immediately, 15, and 60 min after the procedure. Group I included 59 women and 41 men and group II included 51 women and 49 men. The duration of the procedure was circa 10 min in both groups. Pain score values immediately and 15 min after the procedure were similar in both groups (P=0.624 and 0.305, respectively). A lower pain score was observed only after 60 min in patients insufflated with carbon dioxide (1.28 vs. 1.54, P=0.008). No pain reduction was observed in women and in obese patients (BMI>30). Carbon dioxide insufflation during unsedated screening colonoscopy does not decrease the duration of the procedure and appears to reduce pain intensity at 60 min after examination to an extent without clinical significance. The study was registered at ClinicalTrials.gov, number NCT01461564.

The experience and awareness of laparoendoscopic procedures among Polish surgeons in everyday clinical practice

Introduction In 2012, a total of 56 647 inguinal hernia repairs were performed in Poland. However, the absence of a uniform hernia repair register obscures the current herniology status in Poland, especially regarding laparoendoscopic procedures. Aim To determine the awareness of laparoendoscopic procedures among Polish surgeons and to ascertain their everyday clinical practice. Material and methods The data were collected at the national hernia conference in 2016, during an interactive session for surgeons with a special interest in herniology. They could respond to the survey items using the VoxVote application. All items and response options were displayed on participants’ smartphones. The questions were related to transabdominal preperitoneal/totally extraperitoneal (TAPP/TEP) hernia repair. The surgeons responded to 27 questions regarding routine inguinal hernia repair. One hundred and six surgeons from all regions of Poland participated in the survey. Results 19.2% of respondents never inform patients about the possibility of performing laparoendoscopic repair. 45.2% admitted that they had referred a patient with a difficult inguinal hernia to another hospital or surgeon. Seventy-five percent stated they would be willing to perform TAPP/TEP if the reimbursement rates were more favourable. In bilateral hernias, 61.6% of the respondents perform a two-step open repair, while only 25% perform a single-stage laparoendoscopic repair of bilateral hernia. In women, only 13.3% perform laparoendoscopic hernia repairs, and 19.0% do not use mesh. Conclusions The skill level to perform TAPP/TEP repair is still inadequate among Polish surgeons. The absence of accurate data makes it impossible to verify whether the treatment methods used are compliant with the guidelines.

Biliary Polyunsaturated Fatty Acids and Telocytes in Gallstone Disease.

It has been reported that intake of ω-3 polyunsaturated fatty acids (PUFAs) reduces the risk of coronary heart disease. It also influences bile composition, decreasing biliary cholesterol saturation in the bile of patients with gallstones. In addition to bile composition disturbances, gallbladder hypomotility must be a cofactor in the pathogenesis of cholelithiasis, as it leads to the prolonged nucleation phase. Our current knowledge about gallbladder motility has been enhanced by the study of a population of newly described interstitial (stromal) cells—telocytes (TCs). The purpose of this study was to determine whether TC loss, reported by our team recently, might be related to bile lithogenicity, expressed as cholesterol saturation index or the difference in biliary PUFA profiles in patients who suffer from cholecystolithiasis and those not affected by this disease. We determined biliary lipid composition including the fatty acid composition of the phospholipid species in bile. Thus, we investigated whether differences in biliary fatty acid profiles (ω-3 PUFA and ω-6 PUFA) in gallbladder bile may influence its lithogenicity and the quantity of TCs within the gallbladder wall. We conclude that the altered PUFA concentrations in the gallbladder bile, with elevation of ω-6 PUFA, constitute important factors influencing TC density in the gallbladder wall, being one of the possible pathophysiological components for the gallstone disease development. This study established that altered bile composition in patients with cholelithiasis may influence TC quantity within the gallbladder muscle, and we concluded that reduction in TC number may be a consequence of the supersaturated bile toxicity, while some other bile components (ω-3 PUFA, glycocholic, and taurocholic acids) may exert protective effects on TC and thus possibly influence the mechanisms regulating gallbladder and extrahepatic bile duct motility. Thus, ω-3 PUFA may represent a possible option to prevent formation of cholesterol gallstones.

Interstitial cajal-like cell: a new player in cholelithiasis?

To the Editor: Th e incidence of gallstones is relatively high in the developed countries, with ~ 10 % of the whole population being aff ected. Even though there is a lack of clear hypothesis on gallstone formation, a few factors are proved to be responsible for this process: cholesterol supersaturation, hydrophobic bile salts, pronucleating proteins, mucus hypersecretion with gel formation in the gallbladder and disrupted gallbladder motility. Th e gallbladder dysmotility seems to be a “ trigger ” event in the pathogenesis of cholesterol gallstones, providing the time necessary for the precipitation of cholesterol microcrystals from bile supersaturated with cholesterol. Considering increasing knowledge of the role of interstitial cells of Cajal in the regulation of gastrointestinal tract (GI) motility as well as in the pathogenesis of multiple GI disorders, and the fact that these cells were recently described in human gallbladder and biliary tract, we wondered whether interstitial cells of Cajal (or interstitial Cajal-like cells — ICLCs — as they are called when localized in extraintestinal organs) are present in gallbladder wall in patients with cholelithiasis and whether their density decreases or perhaps remains intact. We used indirect double immunofl uorescence method to visualize ICLCs. A characteristic feature of ICLCs is the expression of transmembrane tyrosine kinase receptor proteins, including the c-Kit receptor (CD117), which enables the identifi cation of ICLCs. Unfortunately, the CD117 is present in the mast cells as well, and for that reason we stained slides with anti-mast cell tryptase. ICLCs were defi ned as c-Kitpositive nucleated cells that lacked mast cell tryptase expression ( Figure 1 ). ICLCs were observed throughout the gallbladder, including the fundus, body (corpus), and neck, although they were predominantly located in the corpus, almost exclusively within the muscularis propria. ICLCs had a centrally located nucleus and were mostly fusiform in shape; however, sparse, round tryptase / c-Kit-positive cells were also present ( 1 ). In our study (2), we reported for the fi rst time that interstitial Cajal-like cells are lost or damaged in patients suff ering from cholelithiasis. We observed the cells positive for the c-Kit receptor (CD117) in the gallbladder wall in all cases examined. ICLCs were most frequently located in the muscularis propria. Th e density of ICLCs in the muscularis propria was signifi cantly lower in the patients with gallstones than the density observed in the controls (26.24 ± 10.89 vs. 56.29 ± 13.35 cell mm − 2 in the muscularis propria, P < 0.001). Th e published data on ICLCs in the human gallbladder are still very limited. ICLCs were described in the wall of the human gallbladder by Hinescu et al. ( 3 ) and in the bile ducts by Ahmadi et al. ( 4 ). Both teams reported that ICLCs in the gallbladder formed a cellular network that is likely involved in biliary tract motility. Consequently, animal studies suggested the potential role of ICLCs in functional disturbances of the gallbladder. So far, we have not found any works published on ICLCs in the context of pathogenesis of gallstone in humans. Our studies revealed that ICLCs play a role in the pathogenesis of gallstone disease. Furthermore, from the currently fi nished research ( 5 ) we conclude that bile content may infl uence these cells. It implies some possible future medical interventions .

Practical Approach to Inguinal Hernia Treatment -Guidelines of the Association of Polish Surgeons

Department of General, Oncological and Gastroenterological Surgery, University Hospital, Collegium Medicum Jagiellonian University in Cracow1 Kierownik: prof. dr hab. J. kulig Department of Anatomy, Collegium Medicum Jagiellonian University in Cracow2 Kierownik: prof. dr hab. J. Walocha 2nd Department of General Surgery, University Hospital, Collegium Medicum Jagiellonian University in Cracow3 Kierownik: prof. dr hab. A. budzyński Department of General and Vascular Surgery, Ceynowa Hospital in Wejherowo4 Kierownik: dr n. med m. Witzling 2nd Department of General, Gastroenterological and Digestive Tract Surgery, Medical University in Lublin5 Kierownik: prof. dr hab. g. Wallner