Xanthogranulomatous Cholecystitis and Misdiagnosis Analysis

The incidental finding of xanthogranulomatous cholecystitis: a report of 10 cases

There is insufficient clinical knowledge about xanthogranulomatous cholecystitis (XGC) due to biased reporting. This study aims to investigate the incidence of XGC and evaluate the clinical outcome regarding operative time, rate of conversion and intraoperative or postoperative complications. We included 1141 patients who underwent surgery for gallbladder disease between January 2019 and December 2021. Of 1141 patients who underwent cholecystectomy, XGC was seen in 10 (0.87%). The average age is 47 (24–81 years old) with a male to female ratio of 3:2. Biliary pancreatitis and obstructive jaundice are seen in two patients who did ERCP and stenting before surgery. One patient presented with a 4 cm necrotizing soft-tissue granuloma. The BMI was high, with class I obesity in five patients. Symptoms last from 1 to 12 weeks. One patient was only diagnosed preoperatively as XGC. Four out of 10 (40%) required more than 72 h of hospitalization. All patients underwent elective sitting surgery, with eight successfully managed by laparoscopy and one converted to open. The average operative time was 90 min (43–193 min), and a postoperative drain was inserted in four patients. The median follow-up is after 24 months (11–30 months), with no postoperative collection, bleeding, complication or readmission. XGC is a rare benign entity requiring no further action upon incidental discovery. Surgical resection is the cornerstone of management, with the laparoscopic approach considered feasible and safe. Four out of 10 patients might need more than 3 days of hospitalization. In the presence of mass, the frozen section can help guide the management.

An Important Gallbladder Pathology Mimicking Gallbladder Carcinoma: Xanthogranulomatous Cholecystitis: A Single Tertiary Center Experience

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is an uncommon, focal, or diffuse destructive inflammatory disease of the gallbladder mimicking or being together with the gallbladder carcinoma. This study aimed to evaluate the diagnosis, treatment, and outcomes of patients with XGC as a single tertiary center experience in the light of literature.

MATERIALS AND METHODS

Data about 34 patients with XGC identified after evaluating 2212 cholecystectomy specimens between January 2013 and December 2018 in a single tertiary center were documented to determine demographics (sex, age), clinical symptoms and findings, biochemical and imaging clues and operative findings, duration of hospitalization, postoperative complications, and histopathologic results.

RESULTS

Thirty-four patients with XGC were evaluated (17 male and 17 female patients with a mean age of 53; range, 25 to 78). Preoperative diagnosis was chronic calculous cholecystitis in 5 patients, cholelithiasis in 12 cases, acute calculous cholecystitis in 16 and emphysematous cholecystitis in 1 patient. Ultrasound was performed in all patients, computerized tomography in 11, contrast-enhanced magnetic resonance imaging in 9, and magnetic resonance cholangiopancreatography in 7 patients. None of the patients were diagnosed preoperatively. All patients received laparoscopic cholecystectomy, among whom 9 were converted to open. Partial cholecystectomy was performed in 1 patient. One patient with gallbladder adenocarcinoma was treated with radical cholecystectomy. XGC has nonspecific clinical and radiologic findings; thus, preoperative diagnosis is generally absent. Open cholecystectomy is the recommended treatment modality. Conversion to open is frequently necessary after laparoscopy. Complete cholecystectomy is the ultimate goal; however, partial cholecystectomy may be preferred to protect the structures of the hepatic hilum. Preoperative imaging studies (ultrasound or computerized tomography) of 34 patients showed a gallbladder stone in 18 patients, microlithiazis in 12 patients, sludge in 10 patients, and gallbladder sclerosis in 5 patients.

CONCLUSIONS

Diagnosis of XGC and differentiation from gallbladder carcinoma may be difficult through preoperative or peroperative studies, even imaging is useful; the definitive diagnosis depends exclusively on pathologic examination. The surgeon should be prepared for every possibility.