Mass-forming Xanthogranulomatous Cholecystitis Masquerading as Gallbladder Cancer

Background

Mass-forming xanthogranulomatous cholecystitis (XGC), an uncommon inflammatory pathology of gallbladder (GB), masquerades as gallbladder cancer (GBC) and diagnosis is often a histological surprise.

Methods

A retrospective analysis of prospectively collected database of patients with GB mass operated between August 2009 and September 2012 was conducted to determine clinical, radiological, and intraoperative findings that might aid in the preoperative diagnosis of mass-forming XGC and ascertain their optimal management strategy.

Results

Of the 566 patients with GB mass and suspected GBC, 239 were found to be inoperable on preoperative workup and 129 patients had unresectable disease on staging laparoscopy/laparotomy. Of the 198 with resectable disease, 31 were reported as XGC on final histopathology (Group A), while 167 were GBC (Group B). Of these 31 patients, six with an intraoperative suspicion of benign pathology underwent cholecystectomy with segments IVb and V resection, and frozen section histopathology. Twenty-five underwent radical cholecystectomy, with (n?=?10) or without (n?=?15) adjacent organ resection. In comparison, anorexia and weight loss were significantly more in Group B (p?=?0.001 and <0.001). Intraoperatively, empyema and associated gallstones were more common in Group A (p?=?0.011 and <0.001). On computed tomography (CT) of the abdomen, continuous mucosal line enhancement and intramural hypodense bands were significantly more in Group A (p?<?0.001 and 0.025). While CT abdomen revealed one or more features suggestive of XGC in 64.5 % (20/31) of patients in Group A, 11(35.5 %) did not have any findings suggestive of XGC on imaging.

Conclusion

Mass-forming XGC mimics GBC, making preoperative and intraoperative distinction difficult. While imaging findings can help in suspecting XGC, definitive diagnosis require histopathological examination. Presence of typical radiological findings, however, can help in avoiding extended radical resection in selected cases.     

‘Lewisham Scoring System’ to Facilitate the Clinical Diagnosis of Empyema

Introduction: Patients with empyema of gall bladder have a higher mortality rate. We hypothesised a scoring system, which we call the Lewisham Score, to predict the development and diagnosis of empyema Material and Methods: Patient with histologically proven acute cholecystitis who underwent operation over a five year period (2004–2009) were selected and a retrospective cohort analysis of those who developed empyema vs. simple acute cholecystitis was performed. Various parameters and the Lewisham score were compared

Results: Patients with empyema were elderly females with a higher C-reactive protein and had a higher Lewisham Score of > 5 and those with simple cholecystitis had a lower Lewisham score (< 4) and lower C-reactive protein. Discussion: Patients with proven acute cholecystitis and a Lewisham score > 5 should undergo cholecystectomy at the same admission     

Is laparoscopic cholecystectomy safe for acute cholecystitis in the presence of ventriculo-peritoneal shunt?

Introduction

In patients with ventriculo-peritoneal shunts, laparoscopic procedures were previously contraindicated for the potential risks of elevating intra-cranial pressure resulting from increased intra-abdominal pressure and shunt malfunction/infection.

Presentation of case

Here we present a case of a patient with ventriculo-peritoneal shunt who successfully and uneventfully underwent laparoscopic cholecystectomy for acute cholecystitis without any shunt manipulation or intra-cranial pressure monitoring.

Discussion

Several methods have been suggested to decrease the risks of increased intra-cranial pressure during laparoscopic cholecystectomy in patients with ventriculo-peritoneal shunts, but have not been routinely used.

Conclusion

Standard technique laparoscopic cholecystectomy can be safely used to manage patients with VP shunts presenting with acute gall bladder disease.     

A case of xanthogranulomatous cholecystitis suspected to be adenocarcinoma based on the intraoperative peritoneal washing cytology

INTRODUCTION

Xanthogranulomatous cholecystitis (XGC) is a variant of chronic cholecystitis. XGC remains difficult to distinguish from gallbladder cancer radiologically and macroscopically.

PRESENTATION OF CASE

A 63-year-old female was referred to our hospital because of a gallbladder tumor. Abdominal CT and MRI revealed a thickened gallbladder that had an obscure border with the transverse colon. FDG-PET showed a high uptake of FDG in the gallbladder. Therefore, under the preoperative diagnosis of an advanced gallbladder cancer with invasion to the transverse colon, a laparotomy was performed. Because adenocarcinoma was suspected based on the intraoperative peritoneal washing cytology (IPWC), cholecystectomy and partial transverse colectomy were performed instead of radial surgery. However, the case was proven to be XGC with no malignant cells after the operation.

DISCUSSION

In patients with gallbladder cancer who underwent surgery in our institute from 2000 to 2009, the prognosis after the operation of patients with only positive IPWC tended to be better than that of patients with definitive peritoneal disseminated nodules. It is true that in some cases, it is difficult to differentiate XGC from gallbladder carcinoma pre- and intra-operatively.

CONCLUSION

Surgical procedures should be selected based on the facts that there are long-term survivors with gallbladder cancer diagnosed with positive IPWC, and that some patients with XGC are initially diagnosed to have carcinoma by IPWC, as was seen in our case.     

Xanthogranulomatous cholecystitis: catching the culprit - clinical and imaging analysis

Background: Radiological and intraoperative findings of xanthogranulomatous cholecystitis (XGC) mimic carcinoma gallbladder (CaGB) leading to extended surgical resections and increased morbidity. We reviewed the clinical and CECT findings of histopathologically proven XGC and compared them with those of CaGB. Methods: The clinical and CECT findings from 22 patients with XGC were compared with 15 patients with CaGB manifesting as diffuse wall thickening. Results: GB wall thickness was similar in both groups (XGC 12.4 ± 3 mm, CaGB 13.9 ± 6.5 mm; p = 0.61). Intramural hypoattenuating nodules occupying >60% of the GB wall were suggestive of XGC, while the absence of nodules suggested CaGB (p = 0.017). The mucosal lining was intact and enhancing in XGC (20/22) and disrupted in CaGB (10/15; p = 0.001). Among adjacent organ infiltration, bile duct invasion resulting in obstruction was a significant finding in patients with CaGB (p = 0.04). Among XGC patients, 11 patients underwent radical cholecystectomy, 10 had open cholecystectomy and frozen section and 1 underwent bypass. Conclusions: Though there is an overlap between XGC and CaGB, the presence of intramural hypoattenuating nodules occupying >60% of the diffusely thickened GB wall with intact mucosal line and the absence of obstructive features suggest XGC. In the presence of such imaging features, frozen biopsy should be done before proceeding with mutilating radical surgery.     

黄色肉芽肿性胆囊炎的诊疗特点

目的探讨黄色肉芽肿性胆囊炎(xanthogranulomatous cholecystitis,XGC)的诊断与手术治疗特点。方法回顾性分析13例经病理确诊的XGC病人的临床资料。术前B超检查13例,CT检查5例,MRI检查3例,ERCP检查1例,术前均误诊。结果11例行术中冰冻切片病理检查,确诊9例。9例行胆囊切除术,1例行胆囊切除加胆总管探查T管引流术,1例行胆囊大部切除加十二指肠瘘修补术,2例行胆囊切除加胆囊床部肝组织切除。均治愈,无死亡病例。结论XGC是一种少见的特殊类型的慢性胆囊炎,术前诊断困难,确诊依赖病理检查,开腹胆囊切除是基本手术方式。     

Cost Effectiveness of Routine Laparoscopic Ultrasound for Assessment of Resectability of Gallbladder Cancer

Background

In addition to a diagnostic laparoscopy (DL), a routine laparoscopic ultrasound (LUS) has been proposed to identify undetected hepatic metastases and/or anatomically advanced disease in patients with T2 or higher gall bladder cancer (GBC) patients planned for surgical resection. It was hypothesized that a routine LUS is not a cost-effective strategy for these patients.

Methods

Decision tree modeling was undertaken to compare DL-LUS vs. DL at the time of definitive resection of GBC (with no prior cholecystectomy). Costs in US dollars (payer’s perspective), quality-adjusted life weeks (QALWs), and incremental cost-effectiveness ratios (ICER) were calculated (horizon: 6 weeks, willingness-to-pay: $1,000/QALW or $50,000/QALY).

Results

DL-LUS was cost effective at the base case scenario (costs: $30,838 for DL vs. $30,791 for DL-LUS and effectiveness 3.81 QALWs DL vs. 3.82 QALW DL-LUS), resulting in a cost reduction of $9,220 per quality-adjusted life week gained (or $479,469 per QALY). DL-LUS became less cost effective as the cost of ultrasound increased or the probability of exclusion from resection decreased.

Conclusions

Routine LUS with DL for the assessment of resectability and exclusion of metastases is cost effective for patients with GBC. Until improvements in preoperative imaging occur to decrease the probability of exclusion, this appears to be a feasible strategy.     

Factors Associated with Premalignant Epithelial Changes in Chronic Calculous Cholecystitis: A Case–Control Study

Introduction

Gallstones are known to be associated with premalignant changes in the gallbladder epithelium that range from atypical hyperplasia, metaplasia, dysplasia to carcinoma. Recognition of factors associated with these changes in patients with gallstones can potentially be helpful in identifying patients to whom prophylactic cholecystectomy can be offered to reduce the chances of developing carcinoma.

Objective

To identify factors associated with premalignant epithelial changes including atypical hyperplasia, metaplasia, and dysplasia in gallbladder mucosa in patients with chronic calculus cholecystitis.

Materials and methods

This was retrospective case–control study conducted over a period of 10 years from 2004 to 2014. Cases were patients with reported histopathological premalignant epithelial changes along with chronic calculus cholecystitis, and controls were patients without premalignant epithelial changes but chronic calculus cholecystitis. Controls were twice the number of the cases.

Results

Over study period, 92 patients were reported to have premalignant epithelial changes on gall bladder histopathology for whom 184 controls were selected. Of cases, 61 (66%) patients had atypical hyperplasia, while metaplasia and dysplasia were present in 26 (28%) and 5 (5%) cases, respectively. Mean age was 47.5 ± 14.5 years, and 74% of the study population were female. Wall thickness of more than 3 mm (OR = 4.14, p value < 0.001) turned out to be statistically significant independent variables associated with premalignant lesions in gallbladder mucosa.

Conclusion

Odds of premalignant epithelial change in gall bladder mucosa in patients with gall bladder wall thickness of more than 3 mm is four times the odds of patients with wall thickness less than 3 mm, and the effect is statistically significant. Prophylactic cholecystectomy should be considered for this group of patients.

     

术中冰冻检查在诊断黄色肉芽肿性胆囊炎中的作用

目的探讨术中冰冻切片检查在诊断黄色肉芽肿性胆囊炎(xanthogranu lom atous cholecystitis,XGC)中的作用。方法统计我院10年间确诊XGC的33例病例,其中9例行术中冰冻切片检查。结果9例患者术前均行B超及CT检查,术前诊断为慢性结石性胆囊炎3例,胆囊癌5例,胆囊占位1例。所有患者的术中所见均有胆囊壁明显增厚,胆囊与肝脏胆囊床面、大网膜等周围组织明显粘连。行术中冰冻切片检查后,快速病理回报提示,3例明确诊断XGC,4例为慢性胆囊炎性病变,2例提示胆囊壁蜂窝组织炎样改变。4例行胆囊切除术,4例行部分胆囊切除术,1例行胆囊癌根治术。术后病理均诊断为XGC。结论XGC是一种特殊类型的慢性胆囊炎性病变,在临床上非常少见。胆囊慢性炎症使胆囊壁增厚,并与肝脏或临近组织粘连浸润,影像学上和大体上易误诊为胆囊癌。确诊XGC需依赖病理检查。术中冰冻切片检查可明确病变性质,排除胆囊恶性病变,对手术方式的选择有直接影响,避免了术中盲目扩大切除的可能。     

Xanthogranulomatous Cholecystitis: Analysis of 108 Patients

The aim of this study was to evaluate the clinical and radiological features of xanthogranulomatous cholecystitis (XGC) and the results of surgical treatment. This retrospective study concerns clinical, radiological, and surgical data as well as histopathological findings and postoperative results of 108 patients with XGC who were identified after evaluating 7916 cholecystectomy specimens between 2004 and 2014 in a single institute. One hundred eight patients with XGC were evaluated (56 males and 52 females, mean age 62.3 years). Clinical findings at referral included acute and chronic cholecystitis, Mirizzi’s syndrome, choledocholithiasis, cholangitis, and acute pancreatitis. Ultrasound was performed in all patients, CT in 25, contrast-enhanced MRI in 29, and magnetic resonance cholangiopancreatography (MRCP) in 25 patients. None of the patients were diagnosed preoperatively, but mild-moderate degrees of wall thickening were present in most. Fifty-four patients received open cholecystectomy, while 54 received laparoscopic intervention, among whom 23 were converted to open. Partial cholecystectomy was performed in 11 patients. Two patients with gallbladder adenocarcinoma were treated with radical cholecystectomy. XGC has nonspecific clinical and radiological 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.     

黄色肉芽肿性胆囊炎误诊为胆囊癌十例分析

目的 分析黄色肉芽肿性胆囊炎（xanthogranulomatous cholecystitis,XGC）误诊为胆囊癌的原因.方法 分析我院1996-2005年间确诊为黄色肉芽肿性胆囊炎的33例的临床资料,其中10例在术前和术中误诊为胆囊癌.结果 10例患者中B超和CT均诊断为胆囊癌5例,慢性胆囊炎1例;B超诊断为胆囊癌而CT诊断为慢性胆囊炎2例;B超诊断为慢性胆囊炎而CT诊断为胆囊癌2例;术中均见有胆囊壁增厚,胆囊与肝、大网膜等周围组织粘连.3例行胆囊切除＋肝部分切除术,6例行胆囊切除＋肝部分切除术＋肝十二指肠韧带清扫术,1例行部分胆囊切除＋胆囊空肠吻合＋横结肠部分切除.术后病理为黄色肉芽肿性胆囊炎.结论 黄色肉芽肿性胆囊炎影像学表现和肉眼所见易误诊为胆囊癌.确诊需依赖病理检查.术中冰冻组织学检查有助于明确病变性质.     

Xanthogranulomatous Inflammatory Strictures of Extrahepatic Biliary Tract: Presentation and Surgical Management

Background Xanthogranulomatous cholecystitis (XGC) is a benign, invasive variant of chronic cholecystitis. Invasion of common bile duct (CBD), termed as xanthogranulomatous choledochitis, may mimic malignancy. We describe clinico-pathological features and management of xanthogranulomatous inflammatory biliary strictures. Methods A review of a prospectively maintained database for XGC was performed. Results Out of 6,150 cholecystectomies performed, 620 patients had XGC (10% incidence). Four patients had biliary strictures with xanthogranulomatous choledochitis on final histology. All four patients presented with jaundice and history of cholangitis. Ultrasonography revealed gallstones and thick-walled gallbladder in all. Two patients had hilar strictures: one had mid-CBD stricture and one had a lower-CBD stricture with a dilated pancreatic duct. In all four patients, preoperative diagnosis of malignancy was entertained. Three patients underwent resection—CBD excision for mid-CBD stricture, pancreaticoduodenectomy for lower-end stricture, and right hepatectomy for hilar stricture with atrophy-hypertrophy complex. One patient with unresectable hilar stricture underwent hepaticojejunostomy. Conclusion Xanthogranulomatous choledochitis may be considered as one of the differential diagnosis in patients with biliary stricture especially in a geographical area with a high incidence of XGC, when a patient harbors gall stones and had thick-walled gall bladder on imaging. This stricture can be found anywhere in the biliary tree from hepatic hilum to the lower end. However, preoperative imaging and cytology are unreliable both in confirming the diagnosis or ruling out malignancy. Therefore, resection of the stricture should be attempted wherever feasible.     

Impact of comorbidities on the postoperative outcomes of acute cholecystitis following early cholecystectomy

Purposes

The purpose of this study was to evaluate the influence of comorbidities on the surgical outcomes of early cholecystectomy for acute cholecystitis.

Methods

Data were retrospectively collected for patients with acute cholecystitis who underwent early cholecystectomy. Patients were separated into three groups based on the cholecystitis severity grade, and the surgical outcomes of early cholecystectomy were analyzed. Patients with mild and moderate cholecystitis were subdivided into a comorbidity group (n?=?10) and a non-comorbidity group (n?=?83).

Results

There were 57 (55.3%) patients with mild cholecystitis, 36 (35.0%) with moderate cholecystitis, and 10 (9.7%) with severe cholecystitis. The surgical outcomes were significantly worse for patients with severe cholecystitis than for patients with mild or moderate cholecystitis. There were no postoperative deaths after cholecystectomy. There were no significant differences in the complication rate (P?=?0.629), conversion rate (P?=?0.114), or intraoperative blood loss (P?=?0.147) between the comorbidity and non-comorbidity groups.

Conclusion

Our findings suggest that early cholecystectomy can be performed safely for patients with mild and moderate cholecystitis even if comorbidities are present. Early cholecystectomy may be an alternative treatment strategy for patients with severe cholecystitis who are candidates for anesthesia and surgery.

     

黄色肉芽肿性胆囊炎的诊治探讨

目的 探讨黄色肉芽肿性胆囊炎的(XGC)的诊断与治疗。方法 回顾10例XGC的临床资料。结果 B超检查10例，CT、检查3例，术前全部误诊，术后病检确诊10例。9例行胆囊切除，1例行胆囊大部切除，其中2例行胆囊床肝脏楔形切除并肝十二指肠韧带淋巴结清扫，1例加胃大部切除。9例治愈，1例死亡。结论 XGC是一种少见特殊类型的慢性胆囊炎，影像学检查易与胆囊癌混淆，确诊依赖病理检查，手术切除胆囊是早期诊断治疗的最佳途径。术中冰冻切片病检．避免手术盲目扩大化。     

Xanthogranulomatous cholecystitis in laparoscopic surgery

Xanthogranulomatous cholecystitis (XGC) is one presentation of cholecystitis and can be a cause of difficulty in cholecystectomy. We reviewed the clinical files of 12,426 patients who had undergone cholecystectomy. In this group, there were 182 cases of XGC, and 41 of these patients had undergone laparoscopic surgery. Patients with XGC represented 1.46% of the cholecystectomies that were performed. Of the 41 patients whounderwent laparoscopic surgery, 27 weremen (66%) and 14 were women (34%) (average age, 52 years). A total of 36 patients (88%) presented with a chronic condition. XGC was found to be associated with lithiasis in 85%, with jaundice in 22%, and with cancer in 2.4% (one patient). A total of 33 patients (80%) required conversion to open surgery, because of technical difficulties; of these patients, 64% underwent partial cholecystectomy. We conclude that XGC creates difficulty at laparoscopy and therefore any preoperative suspicion of XGC should cause the clinician to consider open cholecystectomy.     

Extranodal extension in node-positive bladder cancer: the continuing controversy

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Although extranodal extension in node‐positive patients may provide prognostic information in certain urological malignancies, contradictory results have been reported in node‐positive patients after radical cystectomy for bladder cancer. We examined whether extranodal extension could have an impact on the outcomes of node‐positive patients who underwent radical cystectomy for bladder cancer in a single large tertiary hospital. We have shown that the presence of extranodal extension was not an independent prognostic factor in node‐positive patients after radical cystectomy and pelvic lymphadenectomy for bladder cancer.

OBJECTIVE

? To examine whether extranodal extension (ENE) has an impact on the outcome of node‐positive patients who underwent radical cystectomy for bladder cancer.

PATIENTS AND METHODS

? Of 543 consecutive patients who underwent radical cystectomy for urothelial carcinoma of the bladder between 1990 and 2007, 112 patients with lymph node metastasis detected on histological examination were evaluated with regard to recurrence‐free survival (RFS) and disease‐specific survival (DSS) based on ENE status.

RESULTS

? The overall 5‐year RFS and DSS rates were 22.3% and 33.8%, respectively. ENE was observed in 41 (36.6%) of the 112 patients. ? The presence of ENE was associated with advanced pathological nodal status (P= 0.004), more positive lymph nodes (P= 0.006), and higher lymph node density (P < 0.001). ? The incidence of positive ENE increased with large positive lymph node diameter (P < 0.001). ? Multivariate analysis showed that lymph node density (hazard ratio (HR) = 2.39, 95% CI 1.09–5.24, P= 0.029; and HR = 3.13, 1.43–6.84, P= 0.004) and use of adjuvant chemotherapy (HR = 1.80, 1.02–3.20, P= 0.041; and HR = 2.07, 1.13–3.79, P= 0.018) were significant predictors of RFS and DSS, respectively. ? After adjustment for other prognostic factors, ENE was not significantly related to RFS (P= 0.825) and DSS (P= 0.961) by multivariate analysis.

CONCLUSIONS

? The presence of ENE was not an independent prognostic factor in node‐positive patients after radical cystectomy for bladder cancer. ? Additional prospective studies are needed to determine the independent prognostic role of ENE.     

Meta‐analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

Background:

In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy.

Methods:

A systematic review was performed with meta‐analysis of randomized clinical trials of early laparoscopic cholecystectomy (ELC; performed within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (performed at least 6 weeks after symptoms settled) for acute cholecystitis. Trials were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Risk ratio (RR) or mean difference was calculated with 95 per cent confidence intervals (c.i.) based on intention‐to‐treat analysis.

Results:

Five trials with 451 patients were included. There was no significant difference between the two groups in terms of bile duct injury (RR 0·64 (95 per cent c.i. 0·15 to 2·65)) or conversion to open cholecystectomy (RR 0·88 (95 per cent c.i. 0·62 to 1·25)). The total hospital stay was shorter by 4 days for ELC (mean difference ?4·12 (95 per cent c.i. ?5·22 to ?3·03) days).

Conclusion:

ELC during acute cholecystitis appears safe and shortens the total hospital stay. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Incidentally Detected Carcinoma Gallbladder in Patients Undergoing Cholecystectomy

Gall bladder carcinoma (GBC) is most prevalent in the northern and northeastern states of India. The term ‘Incidental gall bladder carcinoma’ (IGBC) refers to the diagnosis coming as a surprise finding upon histopathological examination of the cholecystectomy specimen and its incidence varies from 0.35–2%. The conventional practice of submitting all excised gall bladder specimens for histopathological examination has also been challenged by some authors who feel that a selective approach should be adopted, in order to save costs and time. Our experience in this respect, from a tertiary level teaching hospital in southwestern India, is presented here along with a review of literature. Data in respect of all patients who underwent cholecystectomy for benign disorders from 01 Dec 2012 to 30 Nov 2014 was collected prospectively. In addition, retrospective collation of data from hospital records for the previous 2 years was undertaken. Gall bladder wall thickness ≥ 4 mm, on USG examination, was taken as abnormal. All excised gall bladder specimens were opened and examined immediately after surgery in the operation theatre and then submitted for histopathological examination. Statistical analysis was performed using SPSS 19.0. A p value of less than 0.05 was considered significant. A total of 1123 patients underwent cholecystectomy for benign gallbladder pathologies. IGBC was detected in seven (three male and four female) patients. Only one, out of these seven patients, had focal gallbladder wall thickening at the fundus while the other six cases did not have any macroscopic abnormality of the gallbladder wall or mucosa. The mean age of the patients with IGBC was 63.86 years and it was significantly higher as compared to those with benign histology (p value = 0.001). Furthermore, an age of more than 50 years was found to be significantly associated with IGBC (X ² = 9.446, p value = 0.002). In this series, IGBC was present in 0.62% of patients undergoing cholecystectomy for benign gall bladder pathologies. A patient’s age of more than 50 years was significantly associated with IGBC and we did not find any correlation between the symptomatology, ultrasound findings and macroscopic appearance of the specimen and the presence of IGBC. Hence, we feel that the practice of routine submission of all excised gall bladders for HPE should continue.     

Partial Cholecystectomy Safe and Effective

Patients undergoing surgical treatment for calculous disease were considered to have had a partial cholecystectomy performed when a part of the gall bladder wall was retained for technical reasons. Forty patients underwent partial cholecystectomy: for chronic cholecystitis (20), acute cholecystitis (4), Mirizzi''s syndrome (14), portal hypertension or partially accesible gall bladder (one patient each). Four patients (10%) developed infective complications and two patients had retained common bile duct stones. In a mean follow up period of 13 months (range 1–36 mths), only 3 patients have ongoing mild dyspeptic symptoms while the rest have remained asymptomatic. Partial cholecystectomy has been found to be a safe and effective procedure in difficult cholecystectomy situations, since it combines the merits of cholecystectomy and cholecystostomy.