Preoperative diagnoses and identification rates of unexpected gallbladder cancer

Background

Unexpected gallbladder cancer (UGBC) is sometimes found in the resected gallbladder of patients during or after surgery. Some reports have indicated UGBC identification rates for all gallbladder surgeries, but scarce data are available for the UGBC identification rates for specific gallbladder diseases. The present study was performed to clarify UGBC rates and the factors suspicious for UGBC categorized according to preoperative diagnoses, in patients undergoing laparoscopic cholecystectomy (LSC).

Methods

We recorded data for all LSC surgeries performed in the Department of Surgery, Sada Hospital, Japan since 1991, and analyzed the 28-year data. We used the chi-square test and Kaplan–Meier analysis for this retrospective case–control study.

Results

The UGBC identification rate was 0.69% (63/9186 patients). The UGBC identification rates categorized according to the preoperative diagnoses were 1.3% (13/969) for acute cholecystitis, 2.4% (16/655) for benign tumor, 2.0% (28/1383) for chronic cholecystitis or cholecystitis, and 0.054% (3/5585) for cholecystolithiasis. The percentage of older patients (≥ 60 years) was significantly higher in UGBCs compared with cases finally diagnosed as benign in each group categorized according to the preoperative diagnoses (p≤0.0014), except for cholecystolithiasis. In cases pre-diagnosed as benign tumor, UGBCs were associated with higher rates of thickened gallbladder wall compared with benign tumor (69.2% vs. 27.9%, respectively; p = 0.0011). UGBCs pre-diagnosed as acute cholecystitis had higher T2–T4 rates (100% vs. 64.3%, respectively; p<0.05) and lower survival rates (p = 0.0149) than UGBCs pre-diagnosed with chronic cholecystitis.

Conclusions

UGBC identification rates depend on the preoperative diagnosis and range from 0.054% to 2.4%. Older age (≥ 60 years) could be related to UGBC, and a pre-diagnosis of acute cholecystitis might indicate more advanced cancer compared with a pre-diagnosis of chronic cholecystitis.

[Bouveret's syndrome - a rare complication in connection with cholecystolithiasis and a variant of gallstone ileus]

Bouveret's syndrome is a very rare complication to cholecystolithiasis resulting in gallstone ileus. It is caused by ectopic gallstones in the duodenum due to a bilioenteric fistula. Symptoms may include vomiting and upper abdominal pains. The condition is associated with high mortality, making it important to recognize. The treatment includes surgical removal of the gallstone. However, the optimal therapeutic approach has still not been found. In this case report a 59-year-old female with Bouveret's syndrome is presented.

[Clinical and laboratory diagnosis of an acute biliary pancreatitis]

In 126 patients, suffering an acute biliary pancreatitis (ABP), clinical examination was conducted. In 65 patients (1-st group) the isolated cholecystolithiasis was noted; in 35 (2-nd group)--cholelithiasis, which did not cause obturation of common biliary duct; in 26 (3-rd group)--cholelithiasis, which caused the biliary ways obturation (including calculi, which were incorporated into the duodenal papilla magna ostium). Clinical course of an ABP have differed depending on localization of calculi of extrahepatic biliary ducts. In patients, suffering ABP, a biochemical signs of hepatocytes functional disorders were observed, impacting the need for hepatoprotector preparations inclusion into complex of perioperative conservative therapy. Determination of activity of pancreatic α-amylase in the blood serum and conduction of the ACTIM Pancreatitis test con- stitute the most sensitive and specific methods of the ABP biochemical diagnosis.

Abdominal regional fat distribution on MRI correlates with cholecystolithiasis

AIMS

To determine whether abdominal regional fat distribution pattern on MRI is correlated with cholecystolithiasis.

METHODS

Magnetic resonance imaging (MRI) of 163 patients with cholecystolithiasis and 163 non-cholecystolithiasis control subjects admitted to our institution between March 2011 and September 2013 were included in this cross-sectional evaluation. There were 98 women and 65 men in cholecystolithiasis group with an average age of 57±16 years (range 25-86 years). There were 87 women and 76 men in the control group with an average age of 41±16 years (range 14-77 years). Visceral adipose tissue (VAT), abdominal subcutaneous adipose tissue (SAT) and total abdominal adipose tissue (TAT) of all the subjects at navel level were measured on abdominal MRI. According to the visceral adipose area (cut-off point VAT = 100 cm2), study subjects were divided into 1) increased accumulation of intra-abdominal fat and 2) normal distribution of intra-abdominal fat. Logistic regression was used to assess the association of fat with the presence of cholecystolithiasis, adjusted for age and sex.

RESULTS

The incidence of increased intra-abdominal fat accumulation in the cholecystolithiasis group was significantly higher than that of the control group (P = 0.000). After adjusting for age and sex, cholecystolithiasis was associated with a one standard deviation increment in the waist circumference (WC) (OR = 1.44; 95%CI: 1.01,1.93; p = 0.00), VAT (OR = 4.26; 95%CI: 1.85,5.29; p = 0.00), VAT/SAT (OR = 8.66; 95%CI: 1.60,12.63; p = 0.00), and VAT/TAT (OR = 6.73; 95%CI: 4.24,12.18; p = 0.00), but not with fat content in the abdominal subcutaneous fat (p = 0.19).

CONCLUSIONS

The visceral adipose tissue and distribution proportion of abdominal adipose tissue are correlates of cholecystolithiasis.

[Cholecystolithiasis as a cause of local hepatitis]

In an acute inflammation of gallbladder inflammatory process spreads on surrounding tissues, including hepatic tissue, what causes the regional hepatitis occurrence. In some patients, suffering calculous cholecystitis on background of transition of inflammatory process from gallbladder to hepatic tissue likewise a regional hepatitis, hyperbilirubinemia, the skin yellowness are revealed, what simulates choledocholithiasis and obturation jaundice.

[Application of cholecystectomy in surgical treatment of chronic calculous cholecystitis]

Morphological peculiarities of the excised gallbladder were studied in 106 patients, ageing from 24 to 74 yrs, who were treated for chronic calculous cholecystitis. Interrelationship between results of ultrasound investigation preoperatively and morphologic forms was established, what have permitted to select the operative intervention procedure, including conduction of organ preserving operations--cholecystolithotomy.

Biliary dyskinesia and symptomatic gallstone disease in children: two sides of the same coin?

BACKGROUND

Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis.

AIMS

We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH).

METHODS

Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh.

RESULTS

Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy.

CONCLUSIONS

A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.

A newly developed oval-shaped port device (E•Z ACCESS Oval type) for use in reduced port surgery: initial clinical experiences with cholecystectomy

We recently developed an oval-shaped E•Z Access device designed exclusively for use with the LAP PROTECTOR™ Oval type device (Hakko Co. Ltd., Tokyo, Japan). The transverse abdominal opening diameter made by round-shaped (Alexis® Wound Retractor, Applied Medical, Rancho Santa Margarita, CA; and LAP PROTECTOR™ Round type) and oval-shaped (LAP PROTECTOR™ Oval type) wound retractors was measured and compared in 5 patients with cholecystolithiasis. Each device was placed through a single 25-mm longitudinal umbilical incision, and the length of trocar separation was compared. LESS cholecystectomy was then performed using the oval-shaped E•Z ACCESS/LAP PROTECTOR™. The transverse abdominal opening diameter was maximized with the LAP PROTECTOR™ Oval type device. The average distance between the working-ports for the glove method, round-shaped, and oval-shaped E•Z ACCESS/LAP PROTECTOR™ devices in the 25-mm umbilical incisions were 20 ± 0.8 mm, 24 ± 1.5 mm, and 35 ± 0.8 mm, respectively. Wider trocar separation was achieved using the oval-shaped device, making the surgical procedures easier to perform. No perioperative port-related or surgical complications were observed. LESS cholecystectomy using the E•Z ACCESS Oval type device was found to be technically feasible. The Oval type device appears to allow for wider trocar separation, thereby reducing stress on the surgeon, ensuring patient safety, and providing cosmetic benefits.

[Combined laparoscopic operations in patients with acute appendicitis and biliary calculous disease]

The experience of surgical treatment was summarized in patients, suffering an acute appendicitis, in whom simultaneously a biliary calculous disease was revealed. The procedure and technical aspects of performance of simultant laparoscoplic operation were depicted, the indications and contraindications for simultant operation conduction were determined, a consequence of the operative stages performance was determined. The main advantages of simultant laparoscopic operations were proved and the results of treatment analyzed.

[Psychosomatic aspects of pathology of biliary passages]

The work was designed to study psychological features of patients with hypomotor dysfunction of biliary passages, chronic non-calculous cholecystitis with and without opistorchosis and cholelithiasis before and after cholecystectomy. A total of 343 patients were examined between 1997 and 2007. The control group comprised 100 age- and sex-matched healthy subjects. All patients signed the informed consent. Significance of the difference between absolute and relative parameters was estimated using Student's t-test at three significance levels (0.05, 0.001, 0.001---??). There were no differences between psychological status of patients with biliary duct pathology, but they were significantly different from controls as regards this variable. Patients with different forms of biliary duct pathology showed unidirectional changes of psychological symptoms that deteriorated with severity of the main disease. The psychological portrait of the patients suggested emotionally labile, hypochondriac, irritable, self-confident, highly anxious and neurotic personality type.

Clinico-pathological spectrum of gallbladder disease in children

AIM

Because of wide variation in clinico-pathological spectrum of gallbladder disease in children the world over, the data of gallbladder disease from this stone belt of India were analysed.

METHODS

Children who underwent cholecystectomy over a period of 8 years January 2002-December 2009 were reviewed.

RESULTS

Out of 7076 cholecystectomies, 56 (0.79%) were in children. Thirty-nine (69.6%) children were 11-16 years of age. Thirty-seven (66.07%) children were girls and nineteen (33.9%) were boys. In 12 (21.4%) children, cholecystitis was acalculus. Five (8.9%) children had associated haemolytic disease and 4 (7.1%) children had congenital anomaly in the form of choledochal cyst. Ultrasound findings were available in 44 cases and showed cholelithiasis in 36 cases. Twenty-two (39.3%) children had mixed cholelithiasis, 8 (14.2%) pigment cholelithiasis, 10 (17.8%) combined cholelithiasis and 4 (7.1%) patients had small concretions. Microscopically, changes of chronic cholecystitis were seen in 98.2% while 1.7% showed acute on chronic cholecystitis. There was single unusual case of cysticercus in the wall of the gallbladder.

CONCLUSIONS

The frequency of gallstone disease is 0.79%. Nonhaemolytic type of cholelithiasis is more common than haemolytic type in this region. Presence of cysticercus in the gallbladder wall in one case was an unexpected finding.

[The role of laparoscopy in the surgical treatment of scleroatrophic cholecystitis]

Atrophic cholecystitis is a chronic inflammatory complication of biliary lithiasis which occurs after many years of evolution and causes many problems in the surgical therapy. Authors analyze a 39 patients cohort and present the difficulties encountered during the treatment, especially in laparoscopic approach. These particular difficulties lead to a increase in conversion rate, 11.1%, much higher that in average laparoscopic cholecystectomy. The conclusion of this study is that this disease still remains a challenge for surgeons, especially in laparoscopic approach, and the conversion an elegant way to avoid severe intraoperative accidents.

[Relationship of gallstone formation after radical gastrectomy with the polymorphisms of apolipoprotein B Xba I and lipoprotein lipase Hind III gene]

OBJECTIVE

To investigate the relationship of gallstone formation after radical gastrectomy with the polymorphisms of apolipoprotein B (ApoB) Xba I gene and lipoprotein lipase (LPL) Hind III gene.

METHODS

A total of 80 gastric cancer patients who underwent radical gastrectomy at our hospital between January 2006 and December 2006 were divided into different groups according to the polymorphisms of ApoB Xba I gene and LPL Hind III gene. The gene polymorphism was detected by polymerase chain reaction-restriction fragment length polymorphism. Gallstone formation 2 years after radical gastrectomy was compared among different genotype groups.

RESULTS

Eight patients were lost to follow-up. According to the genotype detection, 72 patients were divided into X(+)X(-) group (10 cases), X(-)X(-) group (62 cases), H(-) group (27 cases) and H(-) deletion group (45 cases). The incidence of gallstone was significantly higher in X(+)X(-) group than that in X(-)X(-) group (60.0% vs 6.5%, P<0.01). The serum levels of total cholesterol TC and low density lipoprotein were significantly higher in X(+)X(-) group than those in X(-)X(-) group (P<0.05), but the level of ApoB was not significantly different between the two groups. The incidence of gallstone was not significantly different between H(-) group and H(-) deletion group (14.8% vs 13.3%). The level of triglyceride in H(-) group was significantly lower than that in H(-) deletion group before operation, however the difference disappeared after operation.

CONCLUSION

X(+) allele may be associated with gallstone formation after radical gastrectomy, while H(-) may not.

Intestinal metaplasia in gallbladders: prevalence study

CONTEXT AND OBJECTIVE

Gallbladder cancer is usually diagnosed at a late stage and generally results in death. Discovery of predisposing factors for this neoplasia could prevent this outcome. In this study, we assess the presence of one of these factors: intestinal metaplasia in gallbladders with stones and inflammatory processes.

DESIGN AND SETTING

Cross-sectional study in Hospital do Servidor Público Estadual de São Paulo.

METHOD

The first 80 gallbladders from patients who underwent elective cholecystectomy between April and August 2002, presenting stones and chronic inflammation, were studied. The patients were divided into groups according to their age: CC1, from 15 to 40 years; CC2, from 41 to 60 years; and CC3, from 61 to 85 years.

RESULTS

Twenty-one patients (26%) were male, while 59 (74%) were female. In the group CC1, intestinal metaplasia was present in 85.71% of the 21 patients studied; in CC2, in 79.41% of 34 patients; and in CC3, in 56.00% of 25 patients. These differences presented statistical significance (p = 0.04542).

CONCLUSION

Intestinal metaplasia is extremely frequent in gallbladders with inflammation and lithiasis, especially in younger patients.

Behavior of the common bile duct diameter before and 12 years after choledochostomy for cholecystolithiasis and choledocholithiasis. A prospective study

INTRODUCTION

In patients with common bile duct (CBD) stones, the diameter of the CBD is usually dilated. After surgery, the behavior of CBD diameter is not clearly known.

OBJECTIVE

To determine at a late follow-up the width of CBD before and after choledochostomy for CBD stones.

MATERIAL AND METHODS

In this prospective study, 39 patients with gallstones and CBD stones were included. They were 30 women and 9 men with a mean age of 52.6 years. In all ultrasound, determination of the CBD caliber before and 12 years after surgery was performed.

RESULTS

The mean value of the inner diameter of the CBD before surgery was 11.6 and 12.3 mm in patients below or above 60 years, respectively. Measurement 12 years after surgery showed a mean decrease of nearly 50% of preoperative values, which was highly significant (p < 0.0001). However, either below or above 60 years, only 75% of the patients showed this decrease, whereas 25% remained unchanged.

CONCLUSION

The dilated preoperative CBD returns to normal or near normal values in 3/4 of the patients after surgical exploration of the CBD and extraction of the stones.

[Laparoscopic cholecystectomy for acute cholecystitis]

Laparoscopic cholecystectomy is considered the "gold standard" for the planned treatment of symptomatic cholecystolithiasis. Currently this method is used in 88% of cholecystectomy according to world database. There are evidences that laparoscopic cholecystectomy for acute cholecystitis is a quite safe method which is not connected with many complications.

AIM OF THE STUDY

Assessment of the post-operative complication risk and hospitalization time in cases of acute cholecystitis had undergone laparoscopic cholecystectomy in comparison with classic cholecystectomy. Evaluation of non-specific inflammation process based on C-reactive protein (CRP) levels in patients' serum analysis.

MATERIAL AND METHODS

Eighty patients (58 women and 22 men) aged 22-74 (mean 53.6) were included to the study. They were undergone cholecystectomy in the Department of Gastroenterological, Oncological and General Surgery because of acute cholecystitis. There were two groups of patients: 38 patients who underwent laparoscopic cholecystectomy (group I) and 42 patients who underwent "classic" cholecystectomy (group II). No statistical differences of clinical and demographic characteristics were found in the studied groups. There was also the third group of patients distinguished in the study - the control group of 42 patients who underwent "planned" laparoscopic cholecystectomy because of chronic cholecystolithiasis. The patients were qualified for the groups I and II in accordance with randomization rule. The CRP-level of the patients' serum was evaluated in the group I and II twice: before and in the 2nd day after cholecystectomy.

RESULTS

The mean operating time was significantly shorter in the group I (laparoscopic cholecystectomy) compared with the group II ("open" cholecystectomy) 63.24 and 86.31 minutes respectively (p < 0.05) and 58 minutes in the control group. The mean period of hospital stay was also significantly shorter in the group I (4.12 day) compared with the group II (7.19), (p < 0.05), however there was no statistically significant difference between group I and the control group (3.1 day). The level of serum CRP measured before surgery was not significantly different in groups I and II although in the 2nd day after the operation statistically significant difference between studied groups was obtained: patients who were undergone laparoscopy (group I) had a lower level of serum CRP.

CONCLUSIONS

Laparoscopic cholecystectomy is a safe method of treatment both acute cholecystitis and chronic cholecystolithiasis.

Detection of cancer cells and gene expression of cytokines in the peritoneal cavity in patients with gastric cancer

BACKGROUND

The gene expression of the cytokines interleukin-2 (IL-2) and IL-10 in peritoneal washings was examined in relation to the presence of cancer cells in the peritoneal cavity in patients with gastric cancer.

METHODS

Total RNA was extracted from 50-ml peritoneal wash samples from 124 patients (gastric cancer, n = 110; controls, n = 14). Carcinoembrionic antigen (CEA) messenger RNA (mRNA) was used to identify the number of cancer cells in peritoneal wash samples by a real-time reverse transcription-polymerase chain reaction (RT-PCR) method, which method was also used to assay the IL-2 and IL-10 gene expression levels.

RESULTS

In the 14 control samples, CEA mRNA was not detected, while CEA mRNA was detected in 2 of the 51 stage I gastric cancer patients. Thus, the specificity of this method for the detection of cancer cells in peritoneal wash samples was 97% (63/65). The CEA-based real-time RT-PCR method demonstrated greater prognostic impact than the traditional cytological method. IL-2 gene expression in peritoneal wash samples that were CEA mRNA-positive was suppressed compared with that in peritoneal wash samples that were CEA mRNA-negative, while IL-10 gene expression did not differ according to the CEA mRNA findings.

CONCLUSION

The detection of small numbers of cancer cells in peritoneal wash samples from patients with advanced gastric cancer is a good marker for peritoneal metastatic recurrence. In the peritoneal cavity, cancer cells may escape from immune surveillance by controlling the expression of cytokines.

Eosinophilic cholecystitis, with a review of the literature

Eosinophilic cholecystitis (EC) is a rare entity that presents in a manner comparable to acute cholecystitis. The diagnosis is based on classical symptoms of cholecystitis with the presence of >90% eosinophilic infiltration within the gallbladder. We report the case of a 29-yr-old man who presented with unremitting right upper quadrant pain, chills, and loss of appetite. After confirmation of the diagnosis with ultrasound and hepatobiliary scan (HIDA), a cholecystectomy was performed. Pathologic examination of the excised gallbladder demonstrated submucosal infiltration with eosinophils, consistent with EC. Peripheral eosinophilia was not observed; the subject's blood eosinophil count did not exceed 3% during the period of observation. The patient was discharged with no further symptoms. Cases of EC have been infrequently reported since its original description in 1949. EC has been reported alone or in combination with manifestations such as eosinophilic cholangitis, hypereosinophilic syndromes (HES), and parasitic infestations. The patient described herein gave no indications of such previously suggested causes of EC. This report illustrates an authentic case of idiopathic EC.

An increased frequency of gallbladder stones in rheumatoid arthritis patients. Factors related to gallbladder stone formation

OBJECTIVE

In this study, we determined the frequency of gallbladder stone (GBS) in rheumatoid arthritis (RA) patients and evaluated factors which could affect the formation of GBS--such as lipids and the GB motilities of the patients.

METHODS

One hundred and thirteen RA patients (92F, 21M, mean disease duration: 8.9 years) and 117 healthy controls (94F, 23M) were included. In all RA patients, the clinical findings were recorded down; biochemical parameters and body mass index (BMI) were determined; and, abdominal ultrasonography was performed. In addition, 16 RA patients and 20 controls who were age-matched were randomly chosen for GB emptying monitored by ultrasound at 30-minute intervals for 2 hours after a mixed meal. Fasting volume (FV), residual volume (RV) and ejection fraction (EF) for all GBs were assessed.

RESULTS

There was a tendency towards a higher frequency of GBS including cholecystectomy (11 GBS, 11 cholecystectomy, 19.5%) in RA patients when compared to controls (8 GBS, 5 cholecystectomy, 11.1%) (p = 0.08). The frequency of GBS plus cholecyctectomy in female RA patients (22.8%) was significantly higher than the control group (11.7%, p = 0.044). Logistic regression analysis showed that only older age was significantly associated with the presence of GBS in RA (OR:1.05, p = 0.048). There was no difference between the 2 groups in FV (p > 0.05). RV, PRV and EF were significantly higher in RA patients than in the control group (p < 0.05).

CONCLUSION

We diagnosed a higher frequency of GBS in female RA patients when compared to controls. Impaired GB motility in RA patients might contribute to an increased incidence of GBS development.

Carcinoma in situ of the cystic duct

Cholelithiasis and cholesterolosis associated with carcinoma in situ of the cystic duct epithelium was observed in a male patient. Ultrastructurally, small acini-like lined a thickened, reduplicated basal lamina encompassing a pleiomorphic population of cells, including typical cholecystocytes, a poorly differentiated type, and cells containing modified mucous vesicles with heterogeneous fatty deposits. Even though the etiology of this apparent neoplastic epithelium and of its thickened basal lamina is unclear, it is hypothesized to be the result of an altered control of cell adhesion mechanisms, resulting from a repeated renewal of the typical epithelium abraded by the passage of the stones and the biliary sludge, associated with inflammatory stimuli that accompany cholecystolithiasis. Based on recent studies, it is suggested that investigations of molecular markers in extrahepatobiliary tract lesions and retrospective studies of these archival tissues could clarify the association of these neoplastic changes with other hepato-biliary lesions.

[The colecistectomy in primary sclerosing cholangitis: case report and review of literature]

Primary sclerosing cholangitis (PSC) is an idiopathic chronic inflammatory condition affecting intra- and extra-hepatic biliary system. The aim of this study is to stress the importance of cholecystectomy in patients with PSC. Consideration should be given to performing a cholecystectomy in PSC patients with gallbladder adenomyomas or calculi, even asymptomatic; this happens in approximately 15% of cases.

Risk factors for acute biliary pancreatitis

BACKGROUND

Few studies have analyzed both stone-related and pancreatobiliary anatomical factors that predispose to acute biliary pancreatitis. Both of these factor types were studied by multivariate analysis.

METHODS

A total of 143 patients with (n=43) or without (n=100) recent acute biliary pancreatitis who underwent cholecystectomy for gallbladder stones after ERCP were prospectively studied. The interval between the onset of pancreatitis and ERCP ranged from 12 to 35 days (mean, 20 days). Univariate and multivariate analyses for 15 potential risk factors for acute biliary pancreatitis, including operative and ERCP findings, were performed.

RESULTS

Univariate analysis identified 5 significant predictive factors for pancreatitis: a diameter of the smallest gallbladder stone of 5 mm or less, a cystic duct diameter of 5 mm or more, 20 or more gallbladder stones, a diameter of the largest gallbladder stone of 5 mm or less, and irregular gallstone surface. Of these 5 factors, the first 3 remained significant in the multivariate analysis.

CONCLUSIONS

Both stone-related factors (small and multiple stones) and an anatomical factor (enlarged cystic duct) may contribute to the development of biliary pancreatitis. These features should be carefully considered during management of patients with gallstones.

Ascending colon cancer with hepatic metastasis and cholecystolithiasis in a patient with situs inversus totalis without any expression of UVRAG mRNA: report of a case

Situs inversus totalis refers to an inverted position of part or all of the viscera, which represents a mirror-image of the normal location, and it is a relatively rare condition that occurs in one in 4,000-8,000 people in Japan. We herein report a patient demonstrating a combination of situs inversus totalis, colon cancer with hepatic metastasis, and cholecystolithiasis, who was treated surgically. We found no expression of UVRAG mRNA in our case, thus suggesting that the UVRAG gene is partly responsible for this condition.

Distributing pattern of the bile duct of the caudate lobe on computed tomography with drip infusion cholangiography and its surgical significance

BACKGROUND/AIMS

It is important to recognize the distribution of the bile ducts in the caudate lobe of the liver for the hepato-biliary surgery. To map the spatial relationship between the bile ducts and the liver parenchyma under physiological conditions, we performed an anatomical analysis of them using computed tomography combined with drip infusion cholangiography (DIC-CT).

METHODOLOGY

We identified the bile ducts in the caudate lobe, which was divided into the Spiegel lobe, paracaval portion, and caudate process, with DIC-CT. We then investigated their number and confluence pattern in 132 patients without any abnormality in the hilar bile ducts.

RESULTS

The mean number of the bile ducts in the caudate lobe was 2.68 per liver. In the Spiegel lobe, the branches drained into the left hepatic duct system in about 83%. The confluence of the paracaval branch was the left hepatic duct, right hepatic duct, and posterior segmental branch, all with the same frequency of approximately 30%. Almost all of the caudate process branches (92.4%) drained into the posterior segmental branch.

CONCLUSIONS

DIC-CT is a useful method for the anatomical analysis of the intrahepatic bile ducts under physiological conditions, and we obtained novel and important findings for surgery.