Perfidious gallbladders - a diagnostic dilemma with xanthogranulomatous cholecystitis

INTRODUCTION

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis characterised by marked thickening of the gallbladder wall and dense local adhesions. Pre-operative and intra-operative diagnosis is difficult and it often mimics a gallbladder carcinoma (GBC). Laparoscopic cholecystectomy (LC) is frequently unsuccessful with a high conversion rate. A series of patients with this condition led us to review our experience with XGC and to try to develop a care pathway for its management.

PATIENTS AND METHODS

A retrospective review of the medical records of 1296 consecutive patients who had undergone cholecystectomy between January 2000 and April 2005 at our hospital was performed. Twenty-nine cases of XGC were identified among these cholecystectomies. The clinical, radiological and operative details of these patients have been analysed.

RESULTS

The incidence of XGC was 2.2% in our study. The mean age at presentation was 60.3 years with a female:male ratio of 1.4:1. Twenty-three patients (79%) required an emergency surgical admission at first presentation. In three patients, a GBC was suspected both radiologically and at operation (10.3%), but was later disproved on histology. Seventeen patients (59%) had obstructive jaundice at first presentation and required an endoscopic retrograde cholangiopancreatography (ERCP) before LC. Of these, five had common bile duct stones. Abdominal ultrasound scan showed marked thickening of the gallbladder wall in 16 cases (55%). LC was attempted in 24 patients, but required conversion to an open procedure in 11 patients (46% conversion rate). A total cholecystectomy was possible in 18 patients and a partial cholecystectomy was the choice in 11 (38%). The average operative time was 96 min. Three patients developed a postoperative bile leak, one of whom required ERCP and placement of a biliary stent. The average length of stay in the hospital was 6.3 days.

CONCLUSIONS

Severe xanthogranulomatous cholecystitis often mimics a gallbladder carcinoma. Currently, a correct pre-operative diagnosis is rarely made. With increased awareness and a high index of suspicion, radiological diagnosis is possible. Preoperative counselling of these patients should include possible intra-operative difficulties and the differential diagnosis of gallbladder cancer. Laparoscopic cholecystectomy is frequently unsuccessful and a partial cholecystectomy is often the procedure of choice.

Secretin-stimulating MRCP in patients with pancreatobiliary maljunction and occult pancreatobiliary reflux: direct demonstration of pancreatobiliary reflux

We propose the hypothesis that the enlargement of the common bile duct (CBD) or gallbladder (GB) that is occasionally demonstrated on magnetic resonance cholangiopancreatography (MRCP) after secretin stimulation is caused by pancreatobiliary reflux. Recently, occult pancreatobiliary reflux (OPR) has been demonstrated in patients without morphological pancreatobiliary maljunction (MPBM). The aim of this study was to evaluate the efficacy of secretin-stimulating MRCP (SMRCP) in the diagnosis of pancreatobiliary reflux. The study included 14 patients with MPBM and 32 patients with a normal pancreatobiliary junction. OPR was evaluated by bile collection and diagnosed in seven of the 32 patients. All the patients underwent SMRCP; the related findings were considered positive when enlargement of the CBD or GB was observed. Positive findings on SMRCP were observed in all MPBM patients. In the patients with normal pancreatobiliary junction, there was significant difference between the mean amylase levels in the patients with positive and negative SMRCP findings (mean, 4,755.7 and 29.7 IU/l). The sensitivity and specificity of SMRCP for diagnosing OPR was 85.7% and 68.0%, respectively. SMRCP provides a non invasive method for excluding PBR and can identify patients who could benefit from bile duct sampling to diagnose OPR.

Subtraction Imaging: Applications for Nonvascular Abdominal MRI

OBJECTIVE

In this article we will illustrate the role of subtraction imaging for abdominal MRI applications.

CONCLUSION

Subtraction imaging has multiple applications for imaging the mediastinum, abdomen, and pelvis. Removing any preexisting signal of T1 unenhanced images causes contrast enhancement within a mass to become more conspicuous on subtracted sequences. This is helpful when evaluating a lesion with high signal on unenhanced T1-weighted sequences, where visual detection of enhancement can be difficult on conventional MRI.

Biliary abnormalities associated with portal biliopathy: evaluation on MR cholangiography

OBJECTIVE

The purpose of our study was to evaluate the MRI features of portal biliopathy.

CONCLUSION

MR cholangiography coupled with dynamic 3D gradient-echo imaging could not only detect portal vein occlusion, cavernous transformation, and gallbladder varices but is also suitable for delineating associated bile duct abnormalities.

Endoscopic transcystic stent placement for an intrahepatic abscess due to gallbladder perforation

Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.

Amyloidosis of the gallbladder mimicking gallbladder cancer

We report a rare case of amyloidosis of the gallbladder in a 63-year-old woman with a history of primary amyloidosis. The patient was asymptomatic. Blood chemistry and hematologic laboratory levels, as well as values for tumor markers, were unremarkable. Ultrasonography (US) of the abdomen showed a focal echogenic lesion (22 x 15 mm) in the body of the gallbladder, and moderate enhancement was noted on contrast-enhanced US. Abdominal computed tomography revealed nodular wall thickening in the body of the gallbladder that was enhanced by contrast material. Although this patient was asymptomatic, the existence of gallbladder cancer could not be totally denied. Therefore, laparoscopic cholecystectomy was performed for total biopsy of the gallbladder. An intraoperative frozen-section examination revealed evidence of mild chronic cholecystitis with the appearance of hyalinal stroma. There was no malignant lesion. The final diagnosis, amyloidosis of the gallbladder, was obtained by alkaline alcoholic Congo red staining. Amyloid depositions were found in the walls of the vessels in the submucosa and the lamina propria mucosae, consistent with an elevated nodular lesion in the body of the gallbladder. To our knowledge, this is the first case of amyloidosis of the gallbladder mimicking gallbladder cancer that was diagnosed after laparoscopic cholecystectomy.

Diffuse gallbladder wall thickening: differential diagnosis

OBJECTIVE

The objective of our study was to review and illustrate the various clinical entities that may cause diffuse thickening of the gallbladder wall on diagnostic imaging studies.

CONCLUSION

Diffuse gallbladder wall thickening may be caused by a wide range of gallbladder diseases and extracholecystic pathologic conditions. In most cases its cause can be determined by correlation of the clinical presentation and associated imaging findings.

Early but prolonged gallbladder hydrops in a 7-month-old girl with Kawasaki syndrome: Report of a case

Kawasaki syndrome (KS) is a self-limiting childhood disease. Gallbladder hydrops is an uncommon manifestation of this syndrome, found rarely in infants. We report the case of a 7-month-old girl with KS manifesting as gallbladder hydrops, which resolved spontaneously during follow-up. To our knowledge, this represents the youngest such case ever reported. We discuss the clinical characteristics, radiological features, and outcome of gallbladder hydrops in KS during infancy to help understand this rare complication.

Diagnosis and treatment of gallbladder perforation

AIM: To present our clinical experience with gallbladder perforation cases.

METHODS: Records of 332 patients who received medical and/or surgical treatment with the diagnosis of acute cholecystitis in our clinic between 1997 and 2006 were reviewed retrospectively. Sixteen (4.8%) of those patients had gallbladder perforation. The parameters including age, gender, time from the onset of symptoms to the time of surgery, diagnostic procedures, surgical treatment, morbidity, and mortality were evaluated.

RESULTS: Seven patients had typeIgallbladder perforation, 7 type II gallbladder perforation, and 2 type III gallbladder perforation according to Niemeier’s classification. The patients underwent surgery after administration of intravenous electrolyte solutions, and were treated with analgesics and antibiotics within the first 36 h (mean 9 h) after admission. Two patients died of sepsis and multiple organ failure in the early postoperative period. Subhepatic abscess, pelvic abscess, pneumonia, pancreatitis, and acute renal failure were found in 6 patients.

CONCLUSION: Early diagnosis and emergency surgical treatment of gallbladder perforation are of crucial importance. Upper abdominal computerized tomography for acute cholecystitis patients may contribute to the preoperative diagnosis of gallbladder perforation.

Primary hydatid disease in a retroplaced gallbladder

A 60-year-old man with abdominal distension, fever, vomiting and pain on the right upper quadrant of the abdomen was admitted to our hospital. US revealed a well circumscribed lesion of mixed echogenicity. CT revealed hypoplasia of the right liver lobe, and a cystic mass with solid components replacing a retroplaced gallbladder. On T1-weighted MR images the lesion had low signal intensity and presented mild peripheral post-contrast enhancement, while on T2-weighted images the periphery was of moderately high signal intensity and the centre of fluid-like, high signal intensity. Adjacent liver parenchyma had relatively high signal intensity on T2-weighted images. The patient underwent exploratory laparotomy, and a hydatid cyst of the gallbladder that was inflamed was evidenced.

Porcelain gallbladder complicated with pancreas divisum

We report a rare case of porcelain gallbladder associated with pancreas divisum (PD). A 60-year-old woman suffered from discomfort in the back of the right side. An abdominal radiograph revealed a calcified spherical mass in the right upper quadrant. Ultrasonography revealed a scattered echo with a posterior acoustic shadow in the gallbladder wall. A plain computed tomography (CT) scan showed flecks of intramural calcification in the wall of the gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) showed separate openings for the Santorini and Wirsung ducts. The patient underwent cholecystectomy after porcelain gallbladder and pancreas divisum had been diagnosed. The porcelain gallbladder resulted from a stone impacted in the neck of the gallbladder. Patients with PD should be followed carefully, because gallstones often accompany PD, and porcelain gallbladder may result, as in this patient.

[Gallbladder volvulus: Two cases]

INTRODUCTION

Gallbladder volvulus remains a relatively rare disorder.

OBSERVATION

We report two cases, both in men older than 80 years and both diagnosed during surgery. Both patients presented signs of peritonitis (one generalized and the other localized) and severe sepsis.

DISCUSSION

We review the literature about gallbladder volvulus to analyze its incidence, etiology, and clinical, radiologic and therapeutic characteristics.

Torsion of the gallbladder: a rare cause of acute cholecystitis

We present a case of acute torsion of the gallbladder in a young woman. Approximately 400 cases have been reported since 1898, mostly in elderly women, and the incidence appears to be increasing. The anatomy and pathophysiology that predispose patients to this rare surgical emergency are discussed. Several clinical and imaging findings can be used to distinguish gallbladder torsion from typical acute cholecystitis. By recognizing and treating gallbladder torsion early in its course, a low surgical morbidity and mortality can be achieved. The case presented highlights for emergency physicians some of the considerations in identification of patients with acute cholecystitis who are at highest risk of gangrene and perforation, their emergency treatment, and the timing of surgery.

Preoperative diagnosis and management of thick-walled gallbladder based on bile cytology obtained by endoscopic transpapillary gallbladder drainage tube

BACKGROUND

It is often difficult to distinguish gallbladder cancers (GBC) from benign gallbladder diseases, which show thickened walls.

OBJECTIVES

To evaluate the efficacy of bile cytology using endoscopic transpapillary gallbladder drainage (ETGD) and CT.

DESIGN

Retrospective study.

SETTING

Division of Gastroenterology, Tokyo Medical University, Tokyo, Japan.

PATIENTS AND INTERVENTIONS

Eighty-five patients with gallbladder diseases, consisting of 27 GBC and 58 benign gallbladder diseases, were reviewed. A pigtail-type nasobilliary drainage tube was left indwelling in the gallbladder, and through this drainage tube washing cytology was performed with an ETGD tube.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy of CT and cytology. Complications and outcome were also evaluated.

RESULTS

CT and cytology with the ETGD tube had 81% and 81% sensitivity, 91% and 83% specificity, and 88% and 82% accuracy, respectively (P > .05). Looking only at the 71 successful ETGD cases, CT and ETGD cytology had 82% and 100% sensitivity, 92% and 98% specificity, and 89% and 99% accuracy, respectively (P = .036 and .025, respectively). Four patients with GBC in whom CT showed benign findings underwent open cholecystectomy because ETGD cytology revealed malignant findings. In contrast, 4 patients with benign diseases in whom CT suggested malignant finding underwent LC because the findings of ETGD cytology suggested benign disease.

CONCLUSIONS

Cytology using an ETGD tube is very useful in the diagnosis and management of gallbladder diseases.

Cholecystocolonic fistula diagnosed with CT-intravenous cholangiography

Cholecystoenteric fistulas are often not diagnosed preoperatively and delineation of fistula can have an influence on surgical planning. We report a case of cholecystocolonic fistula diagnosed preoperatively using CT-i.v. cholangiography and review the published reports.

Day-case laparoscopic cholecystectomy: treatment of choice for selected patients?

BACKGROUND

The authors report their 7-year experience with day-case laparoscopic cholecystectomy (LC) to determine its applicability, safety, and cost effectiveness.

METHODS

Of 920 consecutive patients who underwent elective LC over a 7-year period, 567 (62%) were scheduled for day-case surgery. The median age of the patients was 48 years (range, 16-74 years), and the male/female ratio was 148/419. The selection criteria required an American Society of Anesthesiologists (ASA) grade of 1 or 2, absence of morbid obesity, low risk of common bile duct stones, adult company at home, and residence within 100 km of the hospital. The LC procedure was performed using a standard four-cannula technique. Propofol-opiate-rocuron-sevoflurane anesthesia, prophylactic antiemetics, and preemptive analgesia were administered in all cases.

RESULTS

The mean length of the operation was 56 +/- 18 min. There was no hospital mortality, and 7 (1.2%) of 567 patients required conversion to open cholecystectomy. Approximately 356 (63%) of the 567 patients were discharged home on the same day as the operation, whereas 211 patients (37%) were admitted overnight after the operation because of social reasons (13.7%), surgeon preference (15.2%), nausea and/or pain (15.2%), operation late in the afternoon (14.2%), or patient preference (41.7%). There were no serious complications. A total of 22 patients visited the emergency unit, and 7 patients required readmission, giving a readmission rate of 2%. The overall postoperative morbidity rate was 6% (n = 22), with morbidities including retained stones (n = 2), bile leakage (n = 1), and pneumonia (n = 1). The mean procedural cost to the hospital was 1,836 euros for day-case LC, as compared with 2,712 euros for an inpatient operation.

CONCLUSIONS

For selected patients, day-case LC is feasible and safe, providing a substantial reduction in hospital costs.

Gallbladder volvulus: review of the literature and report of a case

Gallbladder volvulus is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. The presence of a redundant mesentery (floating gallbladder) is a prerequisite for volvulus. The disease, described for the first time by Wendel in 1898, is an extremely rare surgical disease. The disease mimics acute cholecystitis symptoms. Because of these two conditions, preoperative diagnosis of the disease is difficult. In any case, the definitive diagnosis is made during surgery. Volvulus of the gallbladder is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy. We report a case of gallbladder volvulus suspected pre-operatively using pre-operative imaging with ultrasound. The cases reported in the literature are reviewed and the treatment of gallbladder volvulus is also discussed.

Laparoscopic cholecystectomy in a patient with situs inversus totalis: feasibility and technical difficulties

Situs inversus is a rare anomaly characterized by transposition of organs to the opposite side of the body. In patients with this anomaly, cholelithiasis is observed with a frequency similar to that in the normal population. Herein, we report on a patient with situs inversus totalis who underwent laparoscopic cholecystectomy for mucocele of the gallbladder. Diagnostic pitfalls and technical difficulties of the operation with technical options are discussed in the context of the available literature. Difficulty is encountered particularly in skeletonizing the structures in Calot's triangle, which consumes extra time and is more demanding than in patients with a normally located gallbladder. A summary of an additional 32 similar cases reported in the medical literature is also presented.

[Emergent cholecystectomy after acute cholecystitis with no improvement from i.v. antibiotics]

The complete rotation of the gall bladder followed by acute inflammation is a very rare and dangerous event. Volvulus of the gall bladder almost seems to be caused by an abnormal motility of this organ. Because of the rarity of this disease, the preoperative diagnosis frequently is correct. With this report of three cases who had laparoscopic or conventional surgery within a period of 7 years at our department, the peculiarity of this disease is demonstrated.

Gallbladder Perforation: Risk Factors and Outcome

BACKGROUND

Gallbladder perforation is difficult to diagnose and is associated with significant morbidity. This study investigates factors affecting outcome in patients with gallbladder perforation over two decades.

MATERIALS AND METHODS

From 1982 to 2002 data from patients undergoing cholecystectomy at one institution were prospectively collected. Patients treated for gallbladder perforation and gangrenous cholecystitis were identified and outcomes were compared. The chi(2) test, Student's t-test, and Mann-Whitney rank sum test were used for statistical analysis.

RESULTS

Two hundred eight of 11,360 patients who underwent cholecystectomy were diagnosed with gangrenous cholecystitis and 30 were diagnosed with gallbladder perforation. The perforation was contained in 9 and free in 21 patients. The diagnosis of gallbladder perforation was made preoperatively in 3% of patients. Men outnumbered women and Hispanics outnumbered Caucasians. Compared to patients with gangrenous cholecystitis, patients with gallbladder perforation presented at an older age (53 versus 60 years; P < 0.05), had more cardiovascular comorbidity (29% versus 50%; P < 0.05) and postoperative complications (19% versus 37%; P < 0.05), and required more ICU admissions (9% versus 33%; P < 0.001) and longer hospital stays (8 versus 13 days; P < 0.001). Early cholecystectomy within 24 h improved outcome (P < 0.05).

CONCLUSIONS

Gallbladder perforation is a rare complication of cholelithiasis that occurs more often in men, Hispanics, and older patients. It is rarely diagnosed preoperatively. Late operative intervention is associated with increased morbidity, mortality, number of ICU admissions, and long postoperative hospital stays. An early cholecystectomy strategy may lead to improved outcomes but may be difficult to implement and may not be cost-effective.

Functional gallbladder and sphincter of oddi disorders

The functional disorder of the gallbladder (GB) is a motility disorder caused initially either by metabolic abnormalities or by a primary motility alteration. The functional disorders of the sphincter of Oddi (SO) encompass motor abnormalities of either the biliary or the pancreatic SO. Dysfunction of the GB and/or biliary SO produce similar patterns of pain. The pain caused by a dysfunction of the pancreatic SO can be similar to that of acute pancreatitis. The symptom-based diagnostic criteria of motility dysfunction of the GB and biliary SO are episodes of moderate to severe steady pain located in the epigastrium and right upper abdominal quadrant that last at least 30 minutes. GB motility disorder is suspected after gallstones and other structural abnormalities have been excluded. This diagnosis should then be confirmed by a decreased GB ejection fraction induced by cholecystokinin at cholescintigraphy and after disappearance of the recurrent biliary pain after cholecystectomy. Symptoms of biliary SO dysfunction may be accompanied by features of transient biliary obstruction, and those of pancreatic SO dysfunction are associated with elevation of pancreatic enzymes and even pancreatitis. Biliary-type SO dysfunction is more frequently recognized in postcholecystectomy patients. SO manometry is valuable to select patients with sphincter dysfunction; however, because of the high incidence of complications, these patients should be referred to an expert unit for such assessment. Thus invasive tests should be performed only in the presence of compelling clinical evidence and after noninvasive testing has yielded negative findings. The committee recommends that division of the biliary or pancreatic sphincters only be considered when the patient has severe symptoms, meets the required criteria, and other diagnoses are excluded.

Imagerie des épaississements de la paroi vésiculaire

Thickening of the gallbladder wall may result from a large spectrum of pathological conditions, intrinsic as well as extrinsic to the biliary tract, and may have different appearances. Accurate diagnosis is usually established after a correlation of imaging findings, laboratory data and clinical history. US remains the initial imaging modality for the evaluation of acute right upper quadrant pain. CT and MRI are complementary to US and have an increasing role in assessing a thickened-wall gallbladder.

Complete pancreatic heterotopia of gallbladder with hypertrophic duct simulating an adenomyoma

The gallbladder is an unusual location of pancreatic heterotopia, defined as the presence of pancreatic tissue lacking anatomical and vascular continuity with the main body of the gland. A 28-year-old man presented with anorexia, nausea and pain in the right upper abdomen. On physical examination, the abdomen was tender to palpation and Murphy sign was positive. The patient underwent a cholecystecomy. This case, in our opinion, is very interesting since it permits to consider a controversial issue in the pathology of the gallbladder. The histological appearance of ductal structure in pancreatic heterotopia resembles the histological picture of both Aschoff-Rokitansky (AR) sinuses and adenomyomas. This finding suggests that these lesions are linked by a common histogenetic origin. We suggest that the finding of an adenomyoma in the gallbladder should prompt an extensive sampling of the organ in order to verify the coexistence of pancreatic rests.

Ampullary xanthogranulomatous inflammation mimicking periampullary cancer: report of a case

CONTEXT

Xanthogranulomatous inflammation commonly affects the gallbladder. To date, there have been no reports of xanthogranulomatous inflammation of the ampulla.

CASE REPORT

A 48-year-old female presented to us with fever, jaundice and a palpable gallbladder. Evaluation revealed features of periampullary malignancy. The patient underwent a Whipple's pancreaticoduodenectomy. Histopathology revealed a xanthogranulomatous inflammation affecting the ampulla and the gallbladder.

CONCLUSION

Xanthogranulomatous inflammation should be added to the differential diagnosis of patients presenting with a suspected periampullary lesion accompanied by a thick-walled gallbladder.

Congenital duplication of the gallbladder

Duplication of the gallbladder is a rare congenital anomaly of the biliary system. In this article, two cases of gallbladder duplication are presented. The first case is a patient with double gallbladder and concomitant choledocholithiasis. The probable diagnosis of double gallbladder was made preoperatively by computed tomography. The patient underwent a successful open cholecystectomy and common bile duct exploration. In the second case, two cystic formations in the place of gallbladder are demonstrated with ultrasound scan in a woman with acute cholecystitis. At surgery, two gallbladders were found. A brief review of epidemiology and anatomy of double gallbladder is included, along with a discussion of the difficulties in diagnosis and treatment of this condition.

Porcelain gallbladder with extrahepatic bile duct obstruction in a child

An extrahepatic bile duct obstruction was diagnosed in a 13-year-old boy presenting with pruritus, abdominal pain and jaundice. Several weeks after sphincterotomy and biliary stenting via endoscopic retrograde cholangiopancreaticography which relieved the obstruction, the patient was operated on. Severe fibrosis encased the extrahepatic biliary tract, so only cholecystectomy was performed because planned hepaticojejunoanastomosis could jeopardize the vascular supply to the liver. Histopathology showed calcification of the gallbladder wall and chronic fibroproliferative changes in the surrounding tissue. The stricture of extrahepatic biliary duct resolved after 3 years of repeated replacement of stents. The stenting was thereafter terminated. In the following 3 years no dilation of intrahepatic bile ducts and no laboratory signs of cholestasis recurred and the now 19-year-old boy is doing well. Neither a case of porcelain gallbladder with extrahepatic bile duct obstruction in a child nor a successful treatment of the obstruction by long-term stenting has been described in the literature yet.

Successful laparoscopic management for cholecystoenteric fistula

AIM: Since 1987, laparoscopic cholecystectomy (LC) has been widely used as the favored treatment for gallbladder lesions. Cholecystoenteric fistula (CF) is an uncommon complication of the gallbladder disease, which has been one of the reasons for the conversion from LC to open cholecystectomy. Here, we have reported four cases of CF managed successfully by laparoscopic approach without conversion to open cholecystectomy.

METHODS: During the 4-year period from 2000 to 2004, the medical records of the four patients with CF treated successfully with laparoscopic management at the Chang Gung Memorial Hospital-Taipei were retrospectively reviewed.

RESULTS: The study comprised two male and two female patients with ages ranging from 36 to 74 years (median: 53.5 years). All the four patients had right upper quadrant pain. Two of the four patients were detected with pneumobilia by abdominal ultrasonography. One patient was diagnosed with cholecystocolic fistula preoperatively correctly by endoscopic retrograde cholangiopancreatography and the other one was diagnosed as cholecystoduodenal fistula by magnetic resonance cholangiopancreatography. Correct preoperative diagnosis of CF was made in two of the four patients with 50% preoperative diagnostic rate. All the four patients underwent LC and closure of the fistula was carried out by using Endo-GIA successfully with uneventful postoperative courses. The hospital stay of the four patients ranged from 7 to 10 d (median, 8 d).

CONCLUSION: CF is a known complication of chronic gallbladder disease that is traditionally considered as a contraindication to LC. Correct preoperative diagnosis of CF demands high index of suspicion and determines the success of laparoscopic management for the subset of patients. The difficult laparoscopic repair is safe and effective in the experienced hands of laparoscopic surgeons.

Ectopic hypoplastic and multiseptate gallbladder with coexisting choledochal cyst: evaluation with sonography and magnetic resonance cholangiopancreaticography

Multiseptate gallbladder, a rare congenital anomaly, may exist as an isolated anomaly or may coexist with other biliary system anomalies. We report a case of a multiseptate, ectopic, hypoplastic gallbladder associated with a choledochal cyst. The diagnosis was made using sonography and magnetic resonance cholangiopancreaticography.

Frozen section examination of liver, gallbladder, and pancreas

CONTEXT

Frozen section of the liver is a comparatively frequent request that most often applies to a relatively limited number of situations. The only indication for frozen tissue examination of a gallbladder with any frequency is the presence of a polypoid mucosal lesion or a suspicious thickening of the gallbladder wall. A variety of intraoperative consultations may be applicable during surgery of the pancreas.

OBJECTIVE

To examine the indications and pitfalls regarding the gross examination and frozen section performance for liver, gallbladder, and pancreas.

DATA SOURCES

Author experience and review of the pertinent literature.

CONCLUSIONS

Although indications are relatively straightforward for frozen section of liver and gallbladder, handling of the pancreas specimens for frozen tissue examination is often a cause for a certain degree of anxiety. This situation is the result of a relative rarity of such specimens outside large tertiary referral medical centers coupled with a variety of confounding factors, including the presence of chronic pancreatitis with distortion of the normal structures and the frequent presence of variable degrees of dysplasia. The suboptimal preservation of the frozen tissue adds further angst to the scenario. In this article, the main issues are critically examined in light of the experience of the author and others.

Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy

BACKGROUND

Resident participation in laparoscopic cholecystectomy (LC) is important for education but increases the time of operation. This time cost in training programs is not well-defined, and available data show no decrease in operative time as residents progress in training. We undertook this study to determine the effect of the resident and attending surgeon seniority on the operative performance of LC.

PATIENTS AND METHODS

We undertook a retrospective review of LCs performed for all indications over two academic years in our training program. Operations were performed by junior (PGY 1-3) or senior (PGY 4-5) residents, assisted by junior (trained after 1994) or senior attending surgeons, none of whom had fellowship training in advanced laparoscopy. Demographics, surgeon, assistant, operative time, and operative complications were recorded. Operative diagnoses were defined as noninflammatory (biliary colic, dyskinesia, or polyps) or inflammatory (cholecystitis, pancreatitis). The primary outcome was time in minutes from skin incision to closure; secondary outcomes were complications and conversions to laparotomy. ANOVA, Student's t-test, and chi2 tests were used as appropriate with statistical significance attributed to P < 0.05.

RESULTS

Three hundred fifteen LCs were performed. Two hundred seventy were without conversion to laparotomy or intraoperative cholangiography and were included in time and complication analysis. Junior attendings averaged 4 and senior attendings averaged 21 postresidency years. No differences were found on univariate analysis between groups in demographics or diagnosis category. Operative times were longer for junior residents irrespective of attending seniority: Jr Res/Jr Staff (n = 65): 86 +/- 32 min; Jr/Sr (n = 78): 88 +/- 38 min; Sr/Jr (n = 52): 73 +/- 27 min; Sr/Sr (n = 75): 67 +/- 24 min (P < 0.05). The overall rate of operative complications was higher in junior than senior resident cases (5.6% versus 0.78%, P < 0.05). The most common complication was cystic duct leak, of which 4/5 occurred in junior resident cases. Senior attendings had a trend toward increased conversions (8.4% versus 3.7%, P = 0.09).

CONCLUSION

Resident, but not attending surgeon, seniority influences operative time and complication rate in LC. This information may help surgical educators maximize both resident learning and operative efficiency and safety.

Gallbladder sludge and acute pancreatitis induced by acute hepatitis A

In this case report, a young woman with gallbladder sludge and acute pancreatitis due to acute hepatitis A (HAV) is presented. She was admitted to our hospital with abnormal hepatic enzymes. Five days prior to her admission, an initial abdominal ultrasound was performed at another hospital and revealed no abnormality, while her serum aspartate aminotransferase (AST) level was at the upper limit of normal (ULN) x 8. A second ultrasound was performed at our hospital and revealed a gallbladder wall thickness (9.3 mm), gallbladder sludge in the gallbladder lumen, pancreatic edema, ascites, and hepatomegaly while AST was at the ULN x 50. Magnetic resonance imaging and magnetic resonance cholangiopancreatography revealed imaging features of an acute stage of pancreatitis and gallbladder wall thickness with coexisting sludge in the gallbladder lumen. HAV infection was diagnosed by the detection of immunoglobulin M against HAV in the serum. The patient underwent two repeated abdominal ultrasound examinations on the 5th (AST was at the ULN x 3) and the 20th days (AST was at the normal) after her discharge, and both revealed normal findings. In our case, we observed reversible changes in the hepatobiliary and pancreatic system which was related to the severity of hepatic necro-inflammation. HAV-associated pancreatitis may be due to the formation of biliary sludge during the acute phase of the viral illness, but this association needs further investigation.

Myeloid metaplasia in the gall bladder: a case report

Idiopathic myelofibrosis is often associated with myeloid metaplasia (extramedullary haemopoiesis) in the spleen and liver. However, the gall bladder is an extremely unusual site for it to occur. A 59 year old man with myelofibrosis, who underwent cholecystectomy for chronic cholecystitis, showed myeloid metaplasia in his gall bladder. Pathologically, this may lead to diagnostic difficulties.

[Diagnostics for diseases of the gallbladder and biliary tract from the viewpoint of the internist and surgeon. Demands made on radiological diagnostics]

Jaundice and colic pain of the right upper quadrant are the main symptoms of biliary diseases. Gallstone-related diseases often lead to hospital admission. The evaluation of a patient with biliary symptoms requires a combination of history taking, physical examination, laboratory analysis, and imaging modalities. A high-quality magnetic resonance imaging (MRI) or computed tomography (CT) scan is usually sufficient to evaluate a patient with painless jaundice. Ultrasonography is helpful as an initial screening test to guide the diagnostic work-up. Invasive methods (e.g., ERCP) are mainly used for palliation of patients with incurable disease.

Primary hydatid disease of the gallbladder: a rare clinical entity

Hydatid disease is endemic in Greece, and has been known from Hippocrates' time to cause cysts in the liver. We report here three very rare cases of primary gallbladder hydatid disease without prior history or evidence of concurrent disease activity in any other location. To our knowledge, only two previous reports exist, each of one patient suffering from primary gallbladder hydatid disease. Unlike the insidious hydatid cysts of the liver, gallbladder hydatidosis in our patients was associated with early diagnosis, due to gallbladder dysfunction symptoms presenting early in its course. Moreover, the size of gallbladder cysts compared to liver cysts at diagnosis was small (maximal diameter, <5 cm), making total cyst excision along with cholecystectomy feasible for all of our patients. During long-term follow up of the patients (up to 10 years), no disease recurrences were noted. We provide supporting evidence that primary gallbladder hydatidosis presents a different pathophysiological and clinical course, having better prognosis, when compared with the usual liver disease.

Cholecystocolonic fistula preoperatively diagnosed by endoscopic ultrasound of the colon

The patient was a 58-year-old woman. Gallbladder stones and occult blood in feces were detected during a physical check-up, then the patient was referred to Nagoya University Hospital. In this case the fistula was difficult to diagnosed by ultrasound and endoscopic ultrasound (EUS) of the upper intestinal tract because the gallbladder was filled with stones. Barium enema and endoscopic retrograde cholangiopancreatography did not reveal fistula. Curved-linear array EUS of the colon showed fistula.