Histological changes of the gallbladder and liver after extracorporeal shock wave lithotripsy for gallbladder

The histological changes of the gallbladder and liver following extracorporeal shock wave lithotripsy (ESWL) were investigated in a canine model. After performing ESWL on human cholesterol stones placed in the gallbladder of 8 dogs, the gallbladder and livers were removed for pathological study. The mucosa of the gallbladder showed erosion and ulceration in three of the eight dogs. Edema and bleeding were found in the stroma of the gallbladder beds. Hemorrhagic necrosis and vacuolar degeneration occured in liver parenchyma adjacent to the gallbladder bed, but the portal area was fairly well preserved. It can be said that ESWL caused damage to both the liver and the gallbladder, but its effects on the liver may be only slight because of the preservation of the portal area.     

Computed tomography after ESWL of gallbladder calculi.

Computed tomography (CT) was performed on 88 patients before and after extracorporeal shock wave lithotripsy (ESWL) of gallstones to find the effects of ESWL on the gallbladder and surrounding liver tissue. Post-ESWL scans demonstrated a thickening of the gallbladder wall in 25 (28.4%) cases. In one patient an intrahepatic bilioma beside the gallbladder was seen 3 days after ESWL treatment. Hematoma of the gallbladder wall or the adjacent liver tissue was not seen, and neither a hydrops nor biliary-induced pancreatitis was observed. The authors conclude that while some patients undergoing ESWL will show some posttreatment abnormality on CT scans, the procedure is associated with a low frequency of serious gallbladder and liver trauma.     

Effect of extracorporeal shock-wave lithotripsy on gallbladder emptying in patients with solitary and multiple gallbladder stones

In a prospective study, we investigated the effect of extracorporeal shock-wave lithotripsy (ESWL) on gallbladder contractility and on fasting and residual gallbladder volume in patients with solitary and multiple gallbladder stones with stone densities<100 Hounsfield units (HU) and adequate gallbladder function. Twenty-five patients (seven males and 18 females, mean age 48.5±11.7 years) treated with ESWL were assigned to either group I, consisting of 13 patients with solitary stones<20 mm diameter, or group II, including patients with two to three stones and maximum stone diameter of 30 mm. ESWL was performed with the MPL 9000 lithotripter. Gallbladder ejection fraction was determined using the method of Dodds after a 12-hr fast and following application of a standard stimulative meal. Gallbladder volume was measured by ultrasound over 90 min at 10-min intervals before ESWL, then at 1, 30, 120, and 210 days after ESWL. At 24 hr after ESWL, residual gallbladder volume increased in group I from 7.4 ml to 13.9 ml (P=0.0567) and in group II from 6.5 ml to 20.2 ml (P=0.0076). Thereafter, residual volumes returned to pre-ESWL levels. In group II, post-ESWL fasting volumes were significantly increased over initial values at all time intervals. Correspondingly, only at 24 hr after ESWL, ejection fractions decreased from 73.1% to 64.9% in group I and from 76.5% to 62.7% in group II. No statistically significant differences in gallbladder contractility between the two groups were observed at any point of the follow-up period. ESWL exerts a no more than transient effect on gallbladder motility, regardless of stone count prior to ESWL. We postulate that changes in residual gallbladder volume and reductions in ejection fraction may be due to transitory disturbances in the gallbladder epithelium and resultant gallbladder wall edema.     

Alternative treatment for gallbladder stones in portal venous thrombosis

BACKGROUND/AIMS: Cholecystectomy for treatment of gallbladder stones in patients with portal vein thrombosis can be a hazardous procedure. Dissection into an area of thin-walled collateral vessels can trigger troublesome bleeding and consequent blood coagulation disorders. METHODOLOGY: In order to avoid dissection, cholecysto-jejunostomy was used as the treatment of choice in three patients with symptomatic gallbladder stones and portal vein thrombosis. RESULTS: Surgical procedure was uneventful, blood or plasma transfusions were not required either at surgery or afterwards. Pre- and postoperative hematocrit evaluations showed no difference, as well as liver function tests. The procedure was well tolerated and patients were discharged from day 5 to 7. Follow-up ranged from 2 to 3 years, no biliary complications were found during this period. CONCLUSIONS: Choleysto-jejunostomy is a safe procedure and can be used as an effective treatment of symptomatic gallbladder stones in patients with portal vein thrombosis.     

Left-sided gallbladder： Its clinical significance and imaging presentations

AIM： To assess the importance of preoperative diagnosis and presentation of left-sided gallbladder using ultrasound （US）, CT and angiography.
METHODS： Retrospective review of 1482 patients who underwent enhanced CT scanning was performed. Left-sided gallbladder was diagnosed if a right-sided ligamentum teres was present. The image presentations on US, CT and angiography were also reviewed.
RESULTS： Left-sided gallbladder was diagnosed in nine patients. The associated abnormalities on CT imaging included portal vein anomalies, absence of umbilical portion of the portal vein in the left lobe of the liver, club-shaped portal vein in the right lobe of the liver, and difficulty in identifying segment Ⅳ. Angiography in six of nine patients demonstrated abnormal portal venous system （trifurcation type in four of six patients）. The main hepatic arteries followed the portal veins in all six patients. The segment Ⅳ artery was identified in four of six patients using angiography, although segment Ⅳ was difficult to define on CT imaging. Hepatectomy was performed in three patients with concomitant liver tumor and the diagnosis of left-sided gallbladder was confirmed intraoperatively.
CONCLUSION： Left-sided gallbladder is an important clinical entity in hepatectomy due to its associated portal venous and biliary anomalies. It should be considered in US, CT and angiography images that demonstrate no definite segment Ⅳ ,absence of umbilical portion of the portal vein in the left lobe, and club-shaped right anterior portal vein.     

Left-Sided gallbladder with intrahepatic portal venous anomalies

The congenital anomaly in which the gallbladder is found on the left of the round and falciform ligaments (left-sided gallbladder) is rare. We report two patients with left-sided gallbladder in whom intrahepatic portal venous anomalies were identified. Computed tomography and intraoperative ultrasonography were used to define the portal venous anomaly. A long straight left main portal vein was demonstrated, which did not have the typical umbilical portion. The right anterior segmental portal branch (case 1), or the right main portal vein (case 2) were shown to course in a ventral direction and terminate as a cul de sac. The round ligament (right round ligament) was attached to this venous termination, forming the right umbilical portion. The left medial segmental portal venous branches originated from the right umbilical portion, and coursed to the left. In contrast, cholangiography disclosed that the left medial segmental bile duct coursed to the right after arising from the left hepatic duct (case 1), or the common hepatic duct (case 2). The essence of this anomalous condition is not a left-sided gallbladder, but a right round ligament, which is an embryologic abnormality of the umbilical vein. A review of the English language literature revealed no reports of left-sided gallbladder with intrahepatic portal venous anomalies.     

Impaired gallbladder mucosal function in aged gallstone patients suppresses gallstone recurrence after successful extracorporeal shockwave lithotripsy

BACKGROUND: Absorption of water, as well as emptying of bile, are important functions of the gallbladder. We studied the changes of gallbladder function with age in gallstone patients and their influence on the outcome of extracorporeal shockwave lithotripsy (ESWL). METHODS: (i) A total of 123 consecutive patients with complete stone clearance by ESWL were examined. Gallbladder emptying was assessed before treatment using intravenous cholecystography. After stone clearance, the recurrence of gallstones was monitored by using ultrasonography. Cox regression analysis was used to determine the risk factors associated with stone recurrence. (ii) Gallbladder bile was sampled from 59 gallstone patients during surgery. Biliary cholesterol, phospholipids, and total bile acids were simultaneously quantified by using gas-liquid chromatography. RESULTS: Impaired gallbladder function, but not gallstone recurrence, was more frequently observed in older patients (>/=65 years old) than in younger patients (<65 years old). Cox regression analysis revealed that poor gallbladder emptying was an independent predictor of stone recurrence after ESWL in the total study population, but not in the older patients (>/=65 years old). Analysis of bile from surgically treated patients with cholesterol stones showed a significantly higher total lipid concentration and a shorter nucleation time in the younger group (<65 years old), but the cholesterol saturation index did not differ between the younger and older groups. CONCLUSIONS: Our data suggest that the reduced concentrating function of the gallbladder in elderly gallstone patients helps to counteract stone recurrence despite their abnormal gallbladder motility. Therefore, aged gallstone patients may be preferentially treated by a non-surgical strategy.     

Adenosquamous carcinoma of the gallbladder with tumor thrombus in left portal trunk

We report a surgically resected case of adenosquamous carcinoma of the gallbladder accompanied by portal tumor thrombosis, which is regarded as a rare complication. A 73-year-old man was admitted to our hospital because of epigastralgia. Preoperative examinations led to a diagnosis of advanced gallbladder carcinoma with liver metastasis, and operation was performed. Since intraoperative ultrasonography showed a tumor thrombus in the left main portal trunk originating from the metastatic lesion in the left medial segment of the liver, extended left lobectomy with extrahepatic bile duct resection and lymph node dissection was performed, instead of right trisegmentectomy, as proposed preoperatively. Histological examination revealed adenosquamous carcinoma of the gallbladder with medullary growth that was similar to the hepatocellular carcinoma, most notably in the metastatic lesion of the liver and in the portal tumor thrombus. We discuss the relation between portal tumor thrombosis and medullary tumors, and note the atypical operative method employed.     

Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones

BACKGROUND: A critical review of the experience with extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is needed to clarify whether this method should continue to be applied to patients. METHODS: Patients with symptomatic gallbladder stones were treated by piezoelectric ESWL according to a prospective protocol between 1988 and 1997. ESWL treatment was limited to a maximum of three (solitary stones <20 mm diameter) to five sessions (larger solitary or multiple stones) and 3000 pulses per session. Univariate and multivariate analyses of pretreatment and treatment variables were performed to investigate their impact on fragmentation efficacy and stone clearance. A tree-based analysis was used to identify prognostically homogenous subgroups of individuals with maximum benefit from ESWL. RESULTS: Four hundred and eight patients, 76% female and 24% male, with a mean age of 46 (SD, 13) years, were selected for evaluation. Cox regression analysis identified three pretreatment variables with significant prognostic impact: (1) number of gallstones >1 (relative risk, 2.6 (95% CI, 1.9-3.5)), (2) size of stones >17 mm (1.7 (1.4-2.2)), and (3) computed tomography (CT) density of stones >55 Hounsfield units (H) (1.4 (1.1-1.8)). According to tree-based analysis, the stone clearance rate after 1 year was 85% (95% CI, 75-91%) for solitary stones <16 mm, 79% (70-86%) for solitary stones > or =16 mm with a CT density <84 H, 45% (32-55%) for solitary stones > or =16 mm with a CT density > or =84 H, and 42% (30-51%) for multiple stones. Five years after stone clearance, recurrence occurred in 43% of patients (95% CI, 39-47%). CONCLUSIONS: ESWL treatment showed an acceptable stone clearance in the case of small solitary gallbladder stones (<16 mm) or larger solitary stones with a CT density <84 H, but a very low success rate in the case of multiple stones. The poor long-term success, however, is an important argument against the use of ESWL of gallbladder stones.     

Occult gallbladder perforation: an unusual complication of gallstone lithotripsy.

Three days following extracorporeal shock-wave lithotripsy of a solitary, calcified gallstone, a 69-year-old white male patient was re-admitted with E. coli sepsis and fever of up to 39.4 degrees C. Ultrasound and CT both revealed a smooth-rimmed hypodense paravasate in the middle portion of the left liver lobe adjacent to the gallbladder, with a density identical to gallbladder fluid. The evidence for perforation was based on CT scanning, and a diagnosis of occult gallbladder perforation was made. Conservative treatment was performed successfully. Following elective cholecystectomy two months thereafter, gallbladder histology showed signs of chronic cholecystitis and E. coli was isolated in bile cultures. The paravasate had granulated and finally cicatrized. By combining ESWL and chemical dissolution, treatment of multiple, calcified and pigment gallstones is possible and this approach has become an attractive alternative therapy modality for a selected group of gallstone patients. Further assessments of the efficacy and safety of this technique are necessary. Conservative treatment of occult gallbladder perforation is possible and should be performed in high-risk patients.     

Xanthogranulomatous cholecystitis mimicking stage IV gallbladder cancer

Patients with xanthogranulomatous cholecystitis often undergo excessive surgical resections because of difficulty in distinguishing their condition from gallbladder cancer. Herein we present a patient with xanthogranulomatous cholecystitis mimicking stage IVA gallbladder cancer who underwent a hepatopancreatoduodenectomy. The 64-year-old man was admitted to the local hospital with a chief complaint of high fever, hypochondrolgia and jaundice. One month later, he transferred to Tsukuba University Hospital with a hard palpable fixed large tumor in the right hypochondrium. Computed tomography and ultrasonography showed a tumor originating from the gallbladder extending to the adjacent liver parenchyma, as well as nodes in the hepatoduodenal ligaments approaching the head of the pancreas. Endoscopic retrograde cholangiopancreatography failed to exhibit the gallbladder despite the visualization of irregular narrowing of the common hepatic duct. Angiography demonstrated encasement of the right hepatic artery and narrowing of the right portal vein. On the other hand, the level of serum carbohydrate antigen 19-9 was within normal range. Based on those findings, a right hepatic lobectomy with pancreaticoduodenectomy was conducted under the preoperative and intraoperative diagnosis of gallbladder cancer; stage IVA. The gross findings of the surgical specimen showed an ill-defined yellowish hard mass, but microscopic examination demonstrated xanthogranulomatous cholecystitis. The presented case shows that xanthogranulomatous cholecystitis can mimic an advanced gallbladder carcinoma when the severe chronic inflammatory changes have extended to the liver hilum down to the head of the pancreas. However, the normal level of tumor markers in all clinical courses might be a reason to consider xanthogranulomatous cholecystitis instead of gallbladder cancer. Even when the correct diagnosis is made, the possibility that the adjacent organs should be resected is not remote.     

True left-sided gallbladder with variations of bile duct and cholecystic vein

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.     

Effect of enterohepatic circulation on bile production in regenerating liver.

In an investigation of the role of portal blood flow in bile production and of changes in the enterohepatic circulation of bile in the regenerating liver, various branches of the portal vein were ligated in dogs, bile was collected from the liver lobes supplied by ligated and by nonligated portal branches, and the composition of the bile was analyzed. 1. Bile flow and bilirubin excretion from the ligated, atrophic liver lobes decreased with a disappearance of glycine-conjugated bile acids, but bilirubin excretion and especially bile flow increased greatly without any changes in bile acids composition in the nonligated, regenerating liver lobes as the portal blood flow to them per liver weight increased. 2. Infusion of gallbladder bile into the terminal ileum stimulated bile secretion in the nonligated lobes in the postoperative period, but not in the ligated lobes except immediately after the ligation of the portal vein branches supplying two-thirds of the liver. These findings indicate that bile secretion by the ligated lobes could be stimulated via the hepatic artery and the nonligated lobes might be via both the portal vein and the hepatic artery after the infusion during early postoperative period.     

Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment

Twenty years ago, in January 1985, extracorporeal shock wave lithotripsy (ESWL) was first applied successfully in a patient with gallbladder stones. In the following years, the conditions which influence the success rate of ESWL have been extensively investigated. It was shown that the characteristics of the stones, gallbladder emptying and the degree of stone fragmentation are the most important factors which determine the clearance of all fragments from the gallbladder after ESWL. Severe side effects, such as biliary pancreatitis and liver haematoma, were found to be rare and no deaths related to the procedure have been reported. One or more episodes of biliary pain were observed in about one third of patients within the first 3-4 months after ESWL. Follow-up studies after successful treatment, however, have shown that stone recurrence is considerable, limiting the use of ESWL as a non-invasive therapeutic option. Stone recurrence varies between different subgroups of patients indicating that gallbladder motor function and other less well defined factors may be of importance. The recurrence of stones after ESWL is one of the reasons why laparoscopic cholecystectomy has become the standard treatment of symptomatic gallbladder stones today. ESWL has kept its role only in the treatment of bile duct stones resistant to endoscopic extraction. Unless stone recurrence can be decreased by better patient selection and/or other measures to prevent gallstone recurrence, ESWL of gallbladder stones has little chance of surviving.     

Detection of perfusion areas of the gallbladder vein on computed tomography during arterial portography (CTAP)--the background for dual S4a.S5 hepatic subsegmentectomy in advanced gallbladder carcinoma

BACKGROUND/AIMS: It has been speculated that the veins of the gallbladder join the intrahepatic portal veins supplying the Couinaud's S4a-S5. This has been the theoretical ground for the resection of these 2 hepatic subsegments in advanced gallbladder carcinoma. However, no consensus has been reached on this concept. METHODOLOGY: The current study describes the non-neoplastic perfusion defects in connection with the gallbladder bed in 100 consecutive hepatic CTAP (computed tomographies during arterial portography). The suitability of S4a and S5 subsegmentectomies of the liver for advanced gallbladder carcinoma was also investigated by examining CTAP images of the branches of the portal vein involved in the perfusion defect. RESULTS: Two types of gallbladder venous perfusion were observed: 1) sphenoid distribution from the gallbladder bed into the P4a (37%), P5 (52%) and P6 (3%), and 2) perfusion into the P4 (9%) or directly into the middle hepatic vein (9%) after communicating with the hepatic hilum at the dorsal side of S4. CONCLUSIONS: These results support liver resection at S4a and S5 as the surgical approach for cases of advanced gallbladder carcinoma.     

Staining in the liver surrounding gallbladder fossa on hepatic arteriography caused by increased cystic venous drainage

In 8 patients with gallbladder disease in whom no extension of the disease to the liver was confirmed by surgery, wedge-shaped (segmental) staining of the liver just adjacent to the gallbladder fossa (gallbladder bed) on hepatic arteriography was seen. This was always accompanied by definite visualization of the cystic veins with the drainage directed to the gallbladder bed and became most dense following the peak of the opacification of the cystic veins. We therefore concluded that the increased cystic venous drainage to the intrahepatic portal vein causes the staining in the nondiseased gallbladder bed on hepatic arteriography.     

老年血吸虫肝病合并胆囊疾病的影响因素

目的 目的 了解老年血吸虫肝病患者合并胆囊疾病状况, 探讨血吸虫肝病合并胆囊疾病的影响因素。方法 方法 280例 老年血吸虫肝病患者分为2组, 慢性肝纤维化组198例, 肝硬化组82例, 对胆囊B超检查结果及肝功能回顾性分析, 进行统 计学处理。结果 结果 280例老年血吸虫肝病患者中, 合并胆囊疾病者157例, 占56.1%。其中胆囊壁增厚为28.2% （79/280）, 胆结石为13.6% （38/280）, 胆囊炎为11.1% （31/280）, 胆囊息肉为3.2% （9/280）。血吸虫肝病肝硬化组患者胆囊壁增厚、 胆囊 炎、 胆结石的发病率较纤维化组明显增高, 2组差异有统计学意义 （χ2 =4.568, P＜0.05）。结论 结论 老年血吸虫病患者合并胆 囊疾病的主要影响因素为年龄、 病程、 肝硬化及门脉高压程度     

Ultrasonographic evaluation of gallbladder function in patients with Schistosoma mansoni infection

Gallbladder function was studied in 22 patients with portal hypertension due to advanced Schistosoma mansoni infection and in 17 healthy adults. The fasting volume of the gallbladder was significantly less in patients than in controls. The gallbladder wall was grossly thickened in the study group. There was a significant difference between the patients and controls in the reduction of gallbladder volume following a fatty meal. Although the portal vein diameter and the splenic volume were significantly larger in study patients, no significant correlation could be detected between the reduction in volume or wall thickness of the gallbladder and any of the relevant sonographic features of schistosomiasis-induced portal hypertension.     

Metastasis of primary gallbladder carcinoma in lymph node and liver

AIM: To evaluate the patterns with metastasis of gallbladder carcinoma in lymph nodes and liver. METHODS: A total of 45 patients who had radical surgery were selected. The patterns with metastasis of primary gallbladder carcinoma in lymph nodes and liver were examined histopathologically and classified as TNM staging of the American Joint Committee on Cancer. RESULTS: Of the 45 patients, 29 (64.4%) had a lymph node positive disease and 20 (44.4%) had a direct invasion of the liver. The frequency of involvement of lymph nodes was strongly influenced by the depth of the primary tumor (P= 0.0001). The postoperative survival rate of patients with negative lymph node metastasis was significantly higher than that of patients with positive lymph node metastasis (P= 0.004), but the postoperative survival rate of patients with Nl lymph node metastasis was not significantly different from that of patients with N2 lymph node metastasis (P= 0.3874). The postoperative survival rate of patients without hepatic invasion was significantly better than that of patients with hepatic invasion (P= 0.0177). CONCLUSION: Complete resection of the regional lymph nodes is important in advanced primary gallbladder carcinoma (PGC). The initial sites of liver spread are located mostly in segments IV and V. It is necessary to achieve negative surgical margins 2 cm from the tumor. In patients with hepatic hilum invasion, extended right hepatectomy with or without bile duct resection or portal vein resection is necessary for curative resection.     

Carcinosarcoma of the gallbladder: A case report and review of the literature

A rare case of a huge carcinosarcoma of the gallbladder is presented. Despite a tumor thrombus in the portal vein, this tumor was resected successfully by extended right hepatic lobectomy with right caudate lobectomy and gastroduodenectomy. However, hepatic metastases developed rapidly, and the patient died only 3 months after surgery. Macroscopically, a whitish tumor filled the body and neck of the gallbladder and involved the right lobe and left medial segment of the liver, stomach, and duodenum. Microscopically, the neoplasm consisted of both carcinomatous and sarcomatous components. The former contained adenocarcinoma and squamous cell carcinoma, which were observed in the wall of the gallbladder. The latter comprised the bulk of the mass and contained malignant cartilage and osteoid. Immunohistochemically, the sarcomatous cells reacted to antibodies for epithelial membrane antigen and cytokeratin, but were negative for vimentin antibody, Although stromal differentiation into osteoid and cartilage was noted, the sarcomatous component was felt to be derived from mesenchymal metaplasia of the carcinomatous cells. Only 14 cases of carcinosarcoma of the gallbladder have been reported in the English language literature since 1967.