Longest gallbladder: A case report

IntroductionA gallbladder mucocele is the distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow, decreased gallbladder motility, and altered absorption of water from the gallbladder lumen are predisposing factors to biliary sludge. However, it is more likely to be a small part of a complex disease process involving inflammation of the gallbladder wall and changes to the lining of the gallbladder changing the consistency of its secretions. We would like to present a case of mucocele gallbladder operated successfully by laparoscopic cholecystectomy.Case reportHerein, we present a case of 46 year old female presenting with symptoms of pain in right hypochondrium with ultrasonographic diagnosis of cholelithiasis undergone successful laparoscopic cholecystectomy with Intraoperative findings of: 1. The length of the gallbladder was measured to be 30 cm. 2. A large stone was impacted at the neck of gallbladder, which was leading to mucocele formation.ConclusionMucocele of gallbladder present an important hurdle in successful laparoscopic cholecystectomy. A habit of calm and slow dissection with precautions should be developed. Clearance of the calot's triangle with limited use of electro cautery should be done before proceeding towards ligation or clip application to various structures.     

Percutaneous transhepatic gallbladder stenting for recurrent acute acalculous cholecystitis after failed endoscopic attempt

Endoscopic gallbladder stenting is useful palliative therapy for acute cholecystitis in high-risk patients. Although the success rate of endoscopic gallbladder stenting is 79%–100%, an alternative method has not been reported. We succeeded in employing a method for percutaneous gallbladder stenting (PTGS) and herein describe this new method. A patient with acute acalculous cholecystitis related to ischemic atherosclerotic vascular disease, cholangitis due to Lemmel syndrome, and severe congestive heart failure underwent PTGS through the cystic duct from the gallbladder to the duodenal papilla, because an endoscopic method failed in the treatment of Lemmel syndrome. Because we were unable to place endoscopic transpapillary gallbladder drainage, percutaneous transhepatic gallbladder drainage (PTGBD) was performed and both the cholecystitis and cholangitis ceased. PTGS was performed as an alternative to endoscopic gallbladder stenting. Access to the cystic duct and gallbladder was obtained by the PTGBD route, using a guidewire (0.035-inch diameter) and seeking catheter (6.5 Fr) under fluoroscopic control. A 7-Fr 12-cm double-pigtail biliary polyethylene stent was placed. The patient remained asymptomatic for 3 months after the PTGS until he died, of an acute recurrent myocardial infarction. This new PTGS placement is an alternative treatment for symptomatic gallbladder disease in patients with increased operative risk when the endoscopic method is unsuccessful.     

胆囊切除术后残余胆囊的诊断及治疗

目的探讨胆囊切除术后残余胆囊的诊断和治疗方法。方法对26例胆囊切除术后残余胆囊的病例资料从诊断和治疗两方面进行了总结和归纳。结果采用超声、MRCP和ERCP等影象学方法均可在术前明确诊断残余胆囊。手术切除残余的胆囊和/或其中的结石(18/26)可解除病人的症状。结论胆囊切除时对预防残余胆囊的发生是关键;手术切除是治疗该病的有效方法。     

Unexpected gallbladder cancer during laparoscopic cholecystectomy

Background/Purpose In the present study, we investigated the effectiveness of surgeons in determining incidental gallbladder pathologies at laparoscopic cholecystectomy (LC).Methods This study included 548 patients with gallstones who underwent LC between May 1, 2001 and October 15, 2003. The surgeon made an incision on the gallbladder wall for inspection, and palpated the mucosa after removing the gallbladder from the abdominal cavity to look for unsuspected pathologies. If an abnormal mucosa was observed or palpated, it was marked with a silk suture and then histopathologic examination was performed.Results Fifty of 548 LC specimens were found to be suspi-cious by the surgeon. Histopathological examination of frozen sections revealed incidental pathologies in 15 of these specimens. Strikingly, 5 of these specimens were considered to have gallbladder cancer (GBC). The other incidental pathologies were consistent with adenomyomatosis, xanthogranulomatous cholecystitis, and fibroepithelial and hyperplastic polyps. Four of the other 498 specimens revealed incidental pathologies at definitive histopathological examination, and all of them were consistent with gastric metaplasia. The sensitivity and specificity of the procedure was 78.9% and 93%, respectively.Conclusions A simple prosedure; that is, incision and inspection, and palpation of the gallbladder, seems to be useful for the diagnosis of incidental gallbladder pathologies.     

A rare case of early carcinoma of the gallbladder

A 38-year-old woman was diagnosed preoperatively to have a benign polyp of the gallbadder with a delineated polypoid mass, as demonstrated with drip infusion cholangiography and ultrasonography. Cholecystectomy was performed. Postoperatively, however, this tumor proved to be an early stage carcinoma of the gallbladder. In the neck of the gallbladder, there was a protruded polypoid elastic tumor of 1.1×0.9 cm in width and 2.5 cm in height. The tumor was supported by a stem of 0.1 cm in diameter and 0.2 cm in height. Hispotopathological examination revealed a well differentiated papillotubular adenocarcinoma, which exhibited no invasion of the stem itself or its basal region. This is a rare case of early carcinoma of the gallbladder (Stage I) which grew only towards the lumen of the gallbladder cavity, and did not invade the wall. Postoperatively, cholecystectomy alone was thought to be sufficient for cure.     

优思弗对预防保胆取石术后结石复发的临床研究

目的 评价优思弗(UDCA)对预防保胆取石术后胆囊结石复发的临床价值.方法 回顾性分析我院2006年4月～2008年4月行腹腔镜辅助胆道镜保胆取石术36例的临床资料,术后常规每晚睡前顿服优思弗胶囊50Omg,服药6～12月,并观察其疗效.结果 术后随访1～3年,无结石复发病例,B超检查胆囊壁光整无增厚（2mm）,测定胆...     

Early carcinoma of the gallbladder accompanied by hemobilia: Report of a case

The majority of cases of hemobilia are of traumatic or vascular origin; however, we report herein the rare case of a 51-year-old man with early carcinoma of the gallbladder accompanied by hemobilia. He had been diagnosed as having gallbladder polyps during an admission to a local hospital for treatment of cardiac failure. Preoperative evaluation in our hospital suggested that the polypoid lesion was an advanced carcinoma of the gallbladder. Laparotomy revealed that the gallbladder contained blood clots, and a cholecystectomy was performed. Histological examination confirmed the main lesion to be IIb-type early carcinoma of the gallbladder and proved that the blood clots had been misinterpreted as polyps or advanced carcinoma before the operation. The diagnostic approaches and characteristics of hemobilia in the gallbladder are discussed with a review of the literature.     

腹腔镜胆囊切除术后残余胆囊结石的外科处理

目的探讨腹腔镜胆囊切除术后残余胆囊结石的治疗和预防方法。方法回顾分析16例腹腔镜胆囊切除术后残余胆囊结石患者的诊治经过。结果结合彩超、MRCP、ERCP等检查方法均可确定诊断,通过开腹或腹腔镜下残余胆囊切除术,术后患者临床症状均有效缓解,无严重并发症。结论对于残余胆囊应该重视初次手术中的预防。腹腔镜下残余胆囊切除术安全可靠。当合并胆总管结石时,可联合内镜和腹腔镜分次治疗。术中胆道造影或胆道镜检查可增加手术安全。     

胆囊结石患者全麻术中胆囊压力升高的影响因素分析

[摘要] 目的 探讨胆囊结石患者全麻术中胆囊压力升高的影响因素。方法 选择2014年1月至2015年12月大连大学附属中山医院收治的胆囊结石患者168例,分组观察单因素（结石部位、结石数量、最大结石直径、胆囊壁厚度、胆囊收缩功能、胆囊分隔）对全麻术中胆囊压力的影响。结果 168例患者中,胆囊腔内结石146例,胆囊管结石22例,两者压力差异有统计学意义（ t =8.033, P ＜0.001）。146例胆囊腔内结石中,胆囊壁厚3 mm共94例,4 mm共40例,5 mm及以上共12例,3 mm与5 mm以上压力相比,差异有统计学意义（ t =2.056, P =0.042）。134例胆囊壁厚小于5 mm中,单枚结石33例,2～10枚83例,≥11枚18例,平均压力组间差异无统计学意义（ P ＞0.05）;最大结石直径≤10 mm共79例,10～20 mm共40例,≥20 mm共15例,组间差异无统计学意义（ P ＞0.05）;胆囊排空指数≤30%共19例,30%～50%共24例,≥ 50%共55例,平均压力组间差异无统计学意义（ P ＞0.05）;有胆囊分隔27例,无胆囊分隔107例,两者压力差异无统计学意义（ P ＞0.05）。结论 胆囊管结石及胆囊壁增厚是引起全麻术中胆囊压力升高的主要因素。     

胆囊切除术中及术后意外胆囊癌的处理

胆囊切除术术中及术后意外胆囊癌是指术前诊断为胆囊良性疾病而行胆囊切除术,在术中或术后病理检查发现胆囊癌者,其发生率为0.25%～3.00%,在胆囊癌高发区更为常见。由于胆囊癌恶性程度高、进展迅速,对胆囊切除术术中及术后意外胆囊癌的处理正确与否至关重要,它直接影响着病人的远期疗效。目前对术中及术后意外胆囊癌的处理尚缺乏统一的规范,有些方面尚存在一定的争议。     

Idiopathic perforation of the gallbladder: Report of a case and a review of the Japanese literature

A 79-year-old man was admitted to our hospital because of severe epigastric pain. Ultrasonography and computed tomography revealed a slightly distended gallbladder with a small amount of free intraabdominal fluid. At emergency laparotomy, perforation of the gallbladder was recognized and thus a cholecystectomy was performed. Histopathologically, localized necrosis was seen at the site of perforation; however, the inflammation of the surrounding tissue was mild and no thrombus was detected within the intramural vessels. In addition, the gallbladder contained no stones and a bile culture was negative. Postoperatively, the diagnosis of idiopathic perforation of the gallbladder was established. The findings of this case help to emphasize the importance of considering this disorder in elderly patients presenting with peritonitis of unknown origin.     

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.     

《美国超声放射医师学会胆囊息肉管理共识（2022）》解读

2021年美国超声放射医师学会召集胆囊研究领域的多学科专家（放射科、外科、病理科、胃肠病学、超声科等），基于循证医学证据，根据胆囊息肉的形态学特征将胆囊息肉分为“极低风险”、“低风险”与“不确定风险”3个类别，“极低风险”表现为球-壁相连或有细蒂，“低风险”表现为宽蒂、宽基底或无蒂，“不确定风险”类别为息肉连接处胆囊壁处局灶增厚（≥4 mm）。《美国超声放射医师学会胆囊息肉管理共识（2022）》综合息肉生长速度与最大直径提出了胆囊息肉的管理建议，“极低风险”及“低风险”类别息肉直径＞15 mm为手术阈值，“不确定风险”类别直径＞7 mm为手术阈值，另外息肉1年内直径增大4 mm及以上亦为手术指征；＜9 mm的“极低风险”或＜6 mm的“低风险”类别息肉无须随访；其余情况建议对息肉进行3年随访。     

胆囊癌的综合治疗

原发性胆囊癌是胆道系统中占首位的恶性肿瘤,预后差,5年存活率低,仅为5%~13%,手术切除是治愈胆囊癌的最有效方法,胆囊癌外科手术方式的选择主要取决于病人的一般情况、肿瘤局部病变情况和胆囊癌的分期,目前早期胆囊癌Nevin I期行单纯胆囊切除术,II~V期胆囊癌多需扩大切除范围包括肝脏、胆囊床切除,以及清扫包括胆囊三角淋巴结及周围的区域淋巴结,化疗、放疗均能有效延长病人生存期。     

胆囊结石及胆囊癌与ABO血型相关性研究

目的 探讨胆囊结石及胆囊癌的发病机会与ABO血型分布有无关联。方法 分析600例胆囊结石和57例胆囊癌病人的ABO血型分布情况,并与2363例自然人群的血型分布做对比研究。结果本组胆囊结石病人的ABO血型分布与对照组相比无显著性差异（P>0.05）,而胆囊多发性结石较多发生于A血型病人（P<0.05）;与对照组相比,A型血者患胆囊癌的机会明显增加（P<0.05）。结论 胆囊癌的发病机会与A血型有明显关联,而胆囊结石的发病机会与ABO血型无关。     

胆囊结石时胆囊粘膜的病理改变和癌胚抗原的分布特征

为了探讨结石对胆囊粘膜的病理影响，观察１０７例胆囊结石患者结石的性状、大小．对新鲜胆囊粘膜上皮用单克隆抗体癌胚抗原（ＣＥＡ）标记，观察ＣＥＡ的存在、程度、分布，分析了胆囊粘膜的病理改变情况。结果表明：随着年龄的增加．胆囊粘膜的病理性损害逐渐加重．结石的物理性状在良性与恶性病变组间有相关关系；结石的大小．特别是结石直径≥１０ｍｍ时．不仅使这种病理演变过程更加明显．而且引起胆囊癌变的危险因素也显著增加。通过对本组１０７例胆囊粘膜ＣＥＡ标记．我们发现ＣＥＡ膜型阳性难以区分胆囊粘膜的病变程度．但ＣＥＡ浆型阳性对胆囊癌细胞及癌前病变具有特征性意义。     

Ectopic Liver Tissue Attached to the Gallbladder

A 55-year old woman underwent cholecystectomy for cholelithiasis. The removed gallbladder showed a serosal encapsulated nodule, measuring 14 χ 6 mm, that histologically was an ectopic functioning liver. This nodule had no connection with the main liver. Accessory liver tissue is nearly always an incidental finding in the course of operations and postmortem examinations. It arises in the neighbourhood of the gallbladder from residual liver cells in the caudal part of the embryonic liver; it may also be found in some other organs and structures in close proximity to the liver during fetal life.     

Kidney metastasis from gallbladder cancer

A case of kidney metastasis from primary gallbladder cancer is presented. Five years after operation for gallbladder cancer, a 73-year-old woman exhibited hematuria. Imaging disclosed a 5×4cm solid mass in the right kidney and enlarged lymph nodes behind the inferior vena cava adjacent to the right renal vein. The right kidney and adjacent tissues, including retroperitoneum and regional lymph nodes, were resected en bloc. The renal tumor was diagnosed as a metastasis from the primary adenocarcinoma of the gallbladder, based on histological similarities, absence of other primary adenocarcinoma, and fluctuations in CA19-9 levels during the progress and after the resection of the metastatic tumor. The initial operation had been an extended cholecystectomy with wedge resection of the liver bed, plus regional lymphadenectomy. The excised gallbladder had a 2.3 ×1.2cm nodular tumor in the fundus. Histological examination indicated the gallbladder tumor to be a moderately differentiated tubular adenocarcinoma invading the subserosal layer. Mild lymphatic invasion was recognized in the gallbladder wall, although lymph node metastasis was negative. We believe this patient represents the first case of kidney metastasis from gallbladder cancer. The mode of spread of the gallbladder cancer to the kidney appeared to be lymphogenous.     

Cancer of the gallbladder associated with pancreaticobiliary maljunction without bile duct dilatation in a european patient

A rare case of pancreaticobiliary maljunction (PBM) without dilatation of the biliary tract (DBT) associated with gallbladder carcinoma is described herein. A 62-year-old European woman with a long history of right upper abdominal pain was diagnosed as having PBM without DBT by endoscopic retrograde cholangiopancreatography and other examinations. Excision of the gallbladder and biliary duct with a Roux-en-Y hepaticojejunostomy was performed, and subsequent pathological examination of the surgical specimen showed a well differentiated adenocarcinoma of the gallbladder. She had no clinical symptoms for 58 months postoperatively. PBM allows reflux of pancreatic juice into the biliary tract. Recent findings support the idea that epithelial hyperplasia plays an important role in gallbladder carcinogenesis with PBM, and also support the concept that gene mutations are involved in the carcinogenesis of biliary epithelium in patients with PBM. For these reasons, we advocate that resection of the extrahepatic biliary tract in PBM patients without bile duct dilatation, rather than cholecystectomy alone, is the treatment of choice for preventing bile duct carcinoma. Received for publication on Dec. 15, 1999; accepted on Feb. 22, 2000     

Total laparoscopic removal of accessory gallbladder: A case report and review of literature

Accessory gallbladder is a rare congenital anomaly occurring in 1 in 4000 births, that is not associated with any specific symptoms. Usually this cannot be diagnosed on ultrasonography and hence they are usually not diagnosed preoperatively. Removal of the accessory gallbladder is necessary to avoid recurrence of symptoms. H-type accessory gallbladder is a rare anomaly. Once identified intra-operatively during laparoscopic cholecystectomy, the surgery is usually converted to open. By using the main gallbladder for liver traction and doing a dome down technique for the accessory gallbladder, we were able to perform the double cholecystectomy with intra-operative cholangiogram laparoscopically. Laparoscopic cholecystectomy was performed in 27-year-old male for biliary colic. Prior imaging with computer tomography-scan and ultrasound did not show a duplicated gallbladder. Intraoperatively after ligation of cystic artery and duct an additional structure was seen on its medial aspect. Intraoperative cholangiogram confirmed the patency of intra-hepatic and extra-hepatic biliary ducts. Subsequent dissection around this structure revealed a second gallbladder with cystic duct (H-type). Pathological analysis confirmed the presence of two gallbladders with features of chronic cholecystitis. It is important to use cholangiogram to identify structural anomalies and avoid complications.