Primary carcinoma of the gallbladder: review of 25 cases.

The records of 25 patients with carcinoma of the gallbladder occurring during a 5 year period were reviewed. The frequent relation of the disease with cholelithiasis and benign tumors has been widely recognized. Stones were present in the gallbladder in 92 per cent of the patients. In the majority of cases, a diagnosis of carcinoma of the gallbladder was not made clinically. The most common preoperative diagnosis was benign biliary tract disease. The mean survival time after operation was 7 months, and only five patients had a curative resection. The best hope for reducing the mortality from this disease lies in earlier cholecystectomy in patients with benign gallbladder disease.     

胆囊癌141例临床分析

目的探讨胆囊癌的诊治方法。方法回顾性分析我院1992年10月~2002年10月141例胆囊癌病人的临床资料。诊断采用术中探查、即时冷冻切片及影像学检查等方法。治疗采用根治性手术、二次手术、复发再手术等综合性手段。结果术前确诊87例。其中,有12例未作手术。术前未予确诊的54例,经手术或冷冻切片确诊42例,术后病理切片证实12例。随访97例。住院期内共死亡15例,出院3个月内死亡32例。累计存活1年以上者34例,3年者10例,5年者6例。其中,存活5年及5年以上者均为术后病理发现而行二次根治手术者。结论胆囊癌的诊断易受结石、黄疸、炎症等影响。术中疏忽和未作冰冻切片可影响术中再诊断和恰当的治疗。根治性手术、二次手术及复发再手术可提高胆囊癌病人的生存率。     

Preoperative evaluation to predict technical difficulties of laparoscopic cholecystectomy on the basis of histological inflammation findings on resected gallbladder

BACKGROUND: No papers have heretofore documented histological studies of cases involving the inflammation of resected gallbladder or examined surgical difficulties on the basis of pathological findings. METHODS: On the basis of the histological inflammation findings on the resected gallbladders of 437 patients who underwent laparoscopic cholecystectomy (LC), the factors affecting the technical difficulty of the operation were examined through preoperative clinical findings (13 items), diagnostic imaging (22 items), and blood test findings (6 items), using multivariate analysis. RESULTS: In accordance with the four-stage classification of inflammation findings for the resected gallbladder, the inflammation findings on the resected gallbladder indicated a higher correlation with the time required for gallbladder dissection (30.2 +/- 16.3 minutes) than with the operation time (77.6 +/- 32.7 minutes). Thus, the technical difficulty of the operation was judged according to the time required for gallbladder dissection. For the preoperative findings on 418 patients who underwent successful LC, the most influential factors on the time required for gallbladder dissection were the presence of abnormal findings on computed tomography, the degree of fever, obesity index, nonvisualized gallbladder cholangiography, and cystic duct length. According to the multiple regression equation of these five factors, the gallbladder dissection for the 19 patients who underwent conversion to open cholecystectomy (OC) due to extreme inflammation was calculated to require 61.9 +/- 12.3 minutes, and the patients who showed a gallbladder dissection time longer than 49.6 minutes were judged to have high technical difficulty predicted from the preoperative evaluation. In the preoperative evaluation, sensitivity was 79.6%, specificity was 97.6%, accuracy was 95.0%, positive predictive value was 85.0%, and negative predictive value was 96.6%. Next, each finding was scored on the basis of a multiple regression equation of five factors, and the technical difficulty of the operation was quantified using these scores. The score of the patients who underwent conversion to OC was 8.0 +/- 2.0, and the patients who showed a score higher than 6 were judged to have high technical difficulty. Almost the same results as in the aforementioned preoperative evaluation were obtained using these scores. CONCLUSION: The judgment using the scores was satisfactory in terms of the simplicity of evaluating the technical difficulties associated with each patient and the ease of obtaining information for each factor. The quantification of technical difficulty using the scores is useful for preoperative prediction of which patients will have difficulties in gallbladder dissection and the conversion to OC in LC. Our results suggest that the consideration of technical difficulties is important for conducting safe operations with avoiding intraoperative complications.     

胆囊癌16例误诊分析

目的探讨术中意外胆囊癌的临床表现及病理特点,分析术前误诊的原因及影响预后的因素。方法对我院1996年1月～2006年12月术中发现的胆囊癌16例的临床病理学资料进行回顾性分析。结果本组16例术前影像学检查均误诊为胆囊结石或胆囊息肉,行胆囊癌根治切除术15例。本组3年生存率为31.3%,5年生存率为6.3%。结论意外胆囊癌的临床表现缺乏特异性,早期诊断困难,术前误诊率高。行胆囊癌根治术是延长病人生命的必要措施。     

Laparoscopic cholecystectomy during pregnancy

Cholecystectomy is after appendectomy the second most frequent surgical procedure made in pregnant women. The operation is indicated in all cases of symptomatic gallbladder stones which do not respond to medical treatment and all complicated forms such as acute cholecystitis or acute pancreatitis. Laparoscopic cholecystectomy, considered in the beginning as a high risk procedure both for mother and child, is nowadays safer and useful comparing to open surgery. Our limited experience can confirm this. There were operated two pregnant (2nd and 6th month of pregnancy) with acute cholecystitis. There were no intraoperative incidents or accidents, no postoperative complications and no problems in pregnancy evolution after operation. This presentation emphasis the particular technical problems due to pregnancy during laparoscopic cholecystectomy, aspects concerning anesthesia and preoperative monitoring of mother and child.     

Cholecystectomy, liver resection, and pyloruspreserving pancreaticoduodenectomy for gallbladder cancer: Report of five cases

Carcinoma of the gallbladder is an uncommon yet highly malignant disease with a poor overall prognosis. Surgical resection offers the only hope for cure in patients with this type of cancer, but resection is often impossible because of advanced disease at the time of presentation. Patients with locally dvanced gallbladder cancer, however, may occasionally be amenable to management by adding pancreaticoduodenectomy to cholecystectomy and liver resection. A retrospective review of patient records at the Johns Hopkins Hospital identified five patients with gallbladder cancer with peripancreatic lymph node involvement, who were treated by surgical resection including pancreaticoduodenectomy. The preoperative evaluation, operative technique, pathologic findings, and outcome were reviewed for each patient. Follow-up was obtained via clinic visit or telephone contact. All five patients underwent resection of the gallbladder cancer with an operation that included pylorus-preserving pancreaticoduodenectomy to remove the peripancreatic lymph nodes. In addition, four of the five patients underwent a nonanatomic liver resection. There were no in-hospital deaths. Two patients had postoperative complications; one had persistent drainage from a T-tube site and one had an anastomotic leak from the hepaticojejunostomy. Four patients have died of recurrent tumor during follow-up at intervals ranging from 11 months to 23 months. The fifth patient is alive and free of clinical disease at 42 months after operation. Carcinoma of the gallbladder is a highly malignant disease that is often not amenable to surgical cure. There is a select group of patients, however, in whom adding a pylorus-preserving pancreaticoduodenectomy can result in a potentially curative operation by removing extensive regional spread to the peripancreatic lymph nodes.     

Coexistence of gallbladder disease and morbid obesity

To further investigate the relationship between gallbladder disease and morbid obesity, 92 morbidly obese patients underwent routine cholecystectomy at the time of their bariatric procedures. The preoperative ultrasonographic findings were positive in only 20 patients. Of the 92 patients who underwent cholecystectomy, 87 (95 percent) had pathologic evidence of gallbladder disease. This included cholecystitis, cholesterolosis, cholelithiasis, or some combination of the three. The incidence of postoperative cholecystitis, the technical difficulty of reoperation, the unnecessary expense and exposure to a second hospitalization and a second operation are all completely eliminated when routine cholecystectomy is performed in concert with elective bariatric procedures.     

胆囊癌癌前病变的新认识与处理原则

原发性胆囊癌作为最常见的胆道恶性肿瘤,恶性程度较高,术前明确诊断率低,临床上确诊时大多属中晚期,总体预后较差。胆囊癌病因迄今未明确,胆囊黏膜的不典型增生和胆囊腺瘤是目前公认的胆囊癌癌前病变。而部分胆囊炎、胆囊结石、胆囊息肉样病变以及先天性胰胆管合流异常等胆囊良性疾病可能通过一定的病理生理过程而逐渐演变成胆囊癌癌前病变,进而发展成为胆囊癌。因此,重视胆囊癌癌前病变,把握合理的手术时机,以提高胆囊癌的存活率。     

Gallbladder function before and after fundoplication

No study has reported an association between gastroesophageal reflux disease (GERD) or its therapies and gallbladder function. We compared pre- and postoperative gallbladder function in patients undergoing fundoplication to determine the following: (1) whether patients with chronic GERD have preexisting gallbladder motor dysfunction; (2) whether medical or surgical therapy alters gallbladder function; and (3) whether division of the hepatic branch of the anterior vagus nerve is detrimental to gallbladder motility. Nineteen patients with documented GERD consented to a preoperative cholecystokinin-stimulated technetium hepatobiliary (CCK-HIDA) scan to quantify the gallbladder ejection fraction (GBEF). All patients underwent laparoscopic Nissen fundoplication. One month after fundoplication, 12 patients completed a repeat CCK-HIDA scan for determination of GBEF, with comparison to the preoperative GBEF. Among patients with preoperative GERD, 11 (58%) of 19 met the scintigraphic criteria for gallbladder dysfunction (GBEF <35%), which is a ratio comparable to that in patients undergoing a CCK-HIDA scan for presumed biliary dyskinesia during the same time period (31 [60%] of 53;P=NS, chi square test) and exceeds the rate of abnormal GBEF reported in healthy volunteers (3%). Six of seven patients with a low preoperative GBEF who underwent repeat evaluation postoperatively had normalization of the GBEF (P=0.05, paired t-test). In the 12 patients who underwent postoperative CCK-HIDA scanning, there was no association between preservation or division of the hepatic branch of the anterior vagus nerve and postoperative gallbladder dysfunction (P=NS, chi-square test). Unexpectedly, 58% of patients with GERD demonstrated gallbladder motor dysfunction prior to fundoplication, with improvement to normal occurring in most of those studied postoperatively. These data support controlled trials to determine the effect of chronic GERD and antisecretory therapy on gallbladder and global gastrointestinal smooth muscle function. Preservation of the hepatic branch of the anterior vagus nerve during fundoplication offered no clear benefit with regard to early postoperative gallbladder function. Presented at The Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

腹腔镜胆道手术并发症的腹腔镜处理体会:附17例临床报告

目的 探讨腹腔镜胆道手术并发症的同期或再次腹腔镜下处理的可行性和有效性.方法 对17例腹腔镜胆道手术并发症经腹腔镜下处理的方法 和结果 进行总结分析.结果 术中发现肝总管损伤3例,胆囊床肝中静脉损伤出血3例,胆囊管残端同缩和十二指肠损伤各1例;术后发现胆漏6例,胆囊床和胆囊动脉出血各1例,戳孔疝1例.该组病例均经同期或再次腹腔镜处理治愈,未增加腹部戳孔,术后平均住院3.7 d.胆管修复者平均随访7.7个月,无胆管狭窄发生.结论 腹腔镜胆道手术并发症,对已掌握丰富微创技术者,大多数能在腹腔镜下获得安全、有效处理.     

Gallbladder ejection fraction: an accurate evaluation of symptomatic acalculous gallbladder disease

The use of cholecystokinin stimulation during cholescintigraphy to calculate the gallbladder ejection fraction has been associated with variable clinical results as a preoperative indicator for chronic acalculous cholecystitis and postoperative relief of biliary symptoms. A series of 56 consecutive patients was analyzed to determine the accuracy of a decreased gallbladder ejection fraction as a preoperative indicator for acalculous cholecystitis. Each patient had symptoms compatible with biliary disease. Each patient had a decreased gallbladder ejection fraction calculated by cholescintigraphy. The gallbladder ejection fraction was calculated using a 30-minute intravenous infusion of cholecystokinin at a dose of 0.02 microg/kg during cholescintigraphy. There was a 100% correlation found in this series of patients between a decreased gallbladder ejection fraction during cholescintigraphy, preoperative symptoms of gallbladder disease, and postoperative pathology evidence of acute or chronic cholecystitis. Only 1 patient had less than a complete resolution of her preoperative symptomatology after laparoscopic removal of her gallbladder. This patient had irritable bowel disease, which was diagnosed postoperatively. Six symptomatic patients with a gallbladder ejection fraction between 35% and 60% were also treated by laparoscopic removal of the gallbladder with complete resolution of their preoperative symptomatology. The use of a 30-minute infusion of cholecystokinin at a dose of 0.02 microg/kg to calculate the gallbladder ejection fraction during cholescintigraphy is an accurate test to preoperatively predict acalculous cholecystitis and postoperative relief of biliary symptoms. The gallbladder ejection fraction of less than 35% was abnormal. Cholecystectomy may be considered for patients whose gallbladder ejection fractions were calculated to be between 35% and 60% if the patient's symptoms were classical for biliary disease and have been present for 1 year. The use of a 30-minute intravenous infusion of cholecystokinin at a dose of 0.02 microg/kg to calculate the gallbladder ejection fraction during cholescintigraphy is an accurate test to preoperatively predict acalculous cholecystitis and postoperative relief of biliary symptoms.     

Endoscopic retrograde cholangiopancreatography

The ERCP report in the patient's chart was compared with findings on common duct exploration or cystic duct cholangiography in 72 patients and found to have a sensitivity of 90.4 percent, a specificity of 98 percent, and an accuracy of 95.8 percent. Factors having the potential to influence the accuracy of ERCP were errors in interpretation by the surgeon and the radiologist and the operative technique of cholecystectomy. Also, the interval between the performance of the procedure and operation was particularly important in the patient with multiple small gallstones or small common duct stones. Small gallstones may spontaneously pass from the gallbladder to the common duct, or small common duct stones may spontaneously pass into the duodenum; therefore, the longer the interval between ERCP and operation, the greater the likelihood of a discrepancy. At operation, gallstones may be squeezed into the common duct during manipulation of the gallbladder unless the cystic duct is obstructed before manipulation of the gallbladder. We found ERCP sufficiently accurate to make cystic duct cholangiography unnecessary in most patients with cholelithiasis having a preoperative ERCP examination     

医源性胆管损伤的原因及处理(附66例报告)

目的探讨胆管损伤和狭窄的防治方法。方法回顾性分析６６例胆囊切除（或伴）胆总管探查术发生胆管损伤及狭窄的原因和治疗。结果１３例胆管损伤在术中发现并立即修复,其中１２例手术治愈,１例术后发生胆管狭窄。５３例胆管狭窄或胆漏在术后被诊断,其中４例行胆管对端吻合（术后均复发狭窄）;４４例行胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合,３６例治愈;５例吻合口狭窄经再手术治愈。８例死亡（死于胆漏感染５例,胆汁性肝硬化３例）。结论胆管损伤若能术中发现并妥善修复常可避免发生狭窄。胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合治疗胆管狭窄可取得较好疗效。     

Triplication of the gallbladder with cholecystitis, cholelithiasis, and papillary adenocarcinoma

A case of triplication of the gallbladder is presented. Two of the gallbladders were surgically removed, one showing acute cholecystitis and cholelithiasis and the second containing papillary adenocarcinoma. The third gallbladder was demonstrated by T tube cholangiogram but not identified during the operation and is assumed to be intrahepatic.     

意外发现的早期胆囊癌的诊断与处理

目的探讨意外发现的胆囊癌早期诊断与处理。方法回顾性总结1993年1月至2003年7月我院收治的64例胆囊癌属意外发现的早期胆囊癌的诊治经验。结果9例属手术意外发现,开腹手术7例,腹腔镜胆囊切除2例。术中快速冰冻切片或术后病理切片均证实为早期胆囊癌(NevinⅡ期)。7例于术中施行了标准的根治术,2例术后确诊再行根治。结论早期胆囊癌术前诊断困难,术中对可疑者做快速冰冻切片检查有助于意外发现早期胆囊癌;一旦确诊即予施行根治术。     

急性胆囊炎合并胆囊结石行腹腔镜胆囊切除术的困难因素分析

目的:分析急性胆囊炎合并胆囊结石患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的困难因素,以提高手术安全性,减少术后并发症的发生。方法:随机选取219例急性胆囊炎合并胆囊结石行LC的患者,观察术前发作次数、伴随疾病、术前住院时间、手术时间、术后住院时间等指标。应用ANOVA单因素分析与多重线性回归分析统计结果。结果:胆囊大小、患者性别与手术操作难度相关,胆囊壁厚度、胆囊炎发作次数与手术时间、出血量、术后住院时间的关系较小,同时非上腹部大手术不会影响手术时间、出血量及术后住院时间。结论:胆囊大小、患者性别与手术操作难度存在一定联系,而胆囊壁厚度、胆囊炎发作次数可能并不是影响LC手术难度的主要因素,同时下腹部手术、上腹部微创手术都不会影响手术的操作难度。     

Significance of preoperative ultrasound measurement of gallbladder wall thickness

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (> or =3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.     

Double gallbladder-a laparoscopic management

A rare case of gallbladder duplication, an unusual biliary anomaly is reported in a young female patient presenting with acute cholecystitis. After a confirmed diagnosis of double gallbladder was made by sonography, endoscopic retrograde cholangio-pancreaticography (ERCP), and magnetic retrograde cholangio-pancreaticography(MRCP), both gallbladders were removed laparoscopically. On histology both gallbladders showed cholesterolosis. Detailed preoperative investigations are required for an accurate preoperative diagnosis before considering laparoscopic cholecystectomy to avoid inadvertent damage to biliary ductal system and overlooking of second gallbladder during surgery.     

Early diagnosis of gallbladder malignancy

The treatment of gallbladder malignancy has been rather unrewarding because of the difficulty in establishing diagnosis in early stage. A review of 34 cases of malignant gallbladder neoplasm encountered during the past 17 years has been made in order to aide diagnosis by careful evaluation of the case history, presenting signs, laboratory findings and radiological studies. Tenderness and a mass in right upper quadrant and nonvisualization of the gallbladder by cholecystography seem to be the most frequent presenting signs for suspecting gallbladder malignancy. Recent advance of celiac angiography seems to hold promise in establishing preoperative diagnosis thus allowing initiation of early effective treatment.     

原发性胆囊癌术前误诊分析及预防

目的：分析原发性胆囊癌术前误诊原因,探索有效的预防误诊的措施。方法：对收治的52例原发性胆囊癌患者的临床资料进行回顾性分析,着重分析术前误诊原因。结果：术前明确诊断19例(36.5%)。术前误诊33例(63.5%),其中误诊为胆囊结石13例,胆囊息肉样变8例,萎缩性胆囊炎4例,肝门部胆管癌3例,肝占位病变4例,Mirizzi综合征1例。术前误诊的33例术中明确诊断29例(55.8%),另有4例术后常规病理检查才明确诊断(7.7%)。误诊的原因较多,如缺乏特异性临床表现、并发胆囊其他疾病、过分依赖影像学检查、术中对可疑病灶未做快速冷冻病理检查等。结论：对存在胆囊癌高危因素的可疑者应定期进行影像学检查,必要时进行有创性检查,甚至手术探查,术中进行快速冷冻切片病理检查,可做到早发现,早治疗,有助于改善胆囊癌患者预后。