Gastric heterotopia in the gallbladder

This is a case report of a 7 year old patient with acute noncalculous cholecystitis due to gastric heterotopia in the gall bladder.     

���Ե����׵��ҽ�ʯ�б������г����ҵ������빲ʶ

??Controversy and Consensus of reserve or removal gall bladder for Chronic Cholecystitis and Gallstone LU Qi-ping. Department of General Surgery, Wuhan General Hospital of Guangzhou Military Command, Wuhan 430070, China
Abstract Cholecystectomy has been used for hundreds of years as the standard treatment model of the disease. The therapeutic principle that “Removal the pathology gallbladder with stone with the addition of managing complications outside the gall bladder properly should be the standard treatment, except implement gallbladder fistula operation for acute cholecystitis in case of emergency” performed by academician Huang Zhi-qiang has reached a consensus in biliary tract surgery field. “Cholelithotomy ” or “cholecystectomy ”is the focus of discussion for nearly a decade. There are still no standards for indication and technical operation, especially the problem of postopreation recurrence of stone is not resolve successfully yet, so cholelithotomy should not widely carried out in the absence of large amount of prospective study to confirm the exact curative effect. Which is recommended only on condition of clinical symptoms mild, gall bladder function is well , no family history of metabolic syndrome, elderly in emergency and patients with high-risk. While the former should pay attention to take effective measures to prevent the postoperative recurrence of stones, and ready for cholecystectomy; the latter is only for patients who can’t tolerate emergency cholecystectomy, and elective cholecystectomy should be performed after remission. Relevant clinical and basic researches should move forward under the idea of precise surgery. At the same time, relevant clinical and basic research should be further strengthened, and improve the technology management of surgical treatment for chronic cholecystitis and gallstone disease needs to be improved further.     

慢性胆囊炎胆囊结石行保留及切除胆囊的争议与共识

胆囊切除术作为慢性胆囊炎胆囊结石的标准治疗模式已沿用百余年。黄志强院士所提出的“除了在紧急情况下实施胆囊造瘘术治疗急性胆囊炎外,胆囊结石的外科治疗是切除含结石的病理胆囊,并适当地处理结石的胆囊外并发症”的治疗原则在胆道外科学界已达成共识。近10余年来,我国出现了对于该病“保胆”与“切胆”之争。国内的保胆取石术尚缺乏规范化的适应证标准和技术操作标准,尤其是有关结石复发问题尚未得以解决,在无大宗病例前瞻性研究报告证实其确切疗效之前,还不宜作为标准术式广泛推广开展。建议仅在临床症状轻微、胆囊功能良好、无代谢综合征和家族史、且个人意愿强烈病人和急症条件下的老年、高危病人中试行。应进一步加强相关的临床与基础研究,完善对慢性胆囊炎胆囊结石病手术治疗的技术管理。     

Haemoperitoneum and haemobilia due to cystic artery tear associated with gall bladder perforation in acute cholecystitis complicating pregnancy. Case report.

A case of haemoperitoneum and haemobilia due to tearing of the cystic artery following rupture of the gall bladder during acute cholecystitis in a pregnant women is reported. The relevant literature is reviewed.     

Laparoscopic management of a two staged gall bladder torsion

Gall bladder torsion (GBT) is a relatively uncommon entity and rarely diagnosed preoperatively. A constant factor in all occurrences of GBT is a freely mobile gall bladder due to congenital or acquired anomalies. GBT is commonly observed in elderly white females. We report a 77-year-old, Caucasian lady who was originally diagnosed as gall bladder perforation but was eventually found with a two staged torsion of the gall bladder with twisting of the Riedel’s lobe (part of tongue like projection of liver segment 4A). This together, has not been reported in literature, to the best of our knowledge. We performed laparoscopic cholecystectomy and she had an uneventful post-operative period. GBT may create a diagnostic dilemma in the context of acute cholecystitis. Timely diagnosis and intervention is necessary, with extra care while operating as the anatomy is generally distorted. The fundus first approach can be useful due to altered anatomy in the region of Calot’s triangle. Laparoscopic cholecystectomy has the benefit of early recovery.     

Cholecystectomy by mini-laparotomy access. Retrospective analysis of the 10-year work

Ten-year experience of operative treatment of cholelithic disease using mini-access cholecystectomy (MACH) in 920 patients was summarized. There were operated on 167 patients for an acute cholecystitis, chronic calculous cholecystitis--716, gall bladder polyposis--36, gall bladder cancer--1. In 48 patients the MACH was matched with choledochus drainage, in 9--choledocholithotomy was performed, in 1--choledochoduodenostomy. In 6 observations the MACH were done simultaneously inguinal herniotomy, in 10--umbilical herniotomy, in 7--uterine extirpation, in 13--operation for ovarial cyst. The bile leakage from gall bladder bed occurred in 3 observations, the operative wound suppuration--in 4. Duration of stationary treatment was 4.1 days at average.     

GRIPPING THE DIFFICULT GALL BLADDER DURING LAPAROSCOPIC CHOLECYSTECTOMY

Grasping a tense, inflamed gall bladder during laparoscopic cholecystectomy for acute cholecystitis is often a problem. Although many surgeons have developed techniques to deal with this, the published work lacks information about how to manage this problem. To collate experience about how to deal with this we interviewed 20 experienced Australian surgeons and compiled a repertoire of tactics that might help deal with this clinical situation. Most surgeons indicated that they deflated the gall bladder using a needle and suction as a preliminary step. Most respondents also described the use of a specific type of forceps for the task. Various manoeuvres, such as displacement of the gall bladder with forceps, dislodging an impacted stone to make it easier to grasp, the use of a retraction suture through the gall bladder were described. The various tactics are summarized in the paper. A range of strategies applied by experienced surgeons for the task of gripping a difficult gall bladder has been documented in this paper. The variety of approaches suggests that surgeons should be prepared to flexibly apply different approaches to this task.     

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.     

Band ligation of the perforated gall bladder during laparoscopic cholecystectomy

Perforation of the gall bladder is a frequent complication during laparoscopic cholecystectomy. Grasping the perforated part of the gall bladder, clip application, or endoscopic loop application are possible solutions to prevent spillage. We propose laparoscopic rubber band application to close the perforated part of the gall bladder as an easy and safe method. We performed rubber band application after iatrogenic perforation of the gall bladder during laparoscopic cholecystectomy in 5 patients. Two-millimeter-wide multiple rubber rings, cut from a 14-Fr Foley catheter, are loaded on a grasper. When a perforation occurred during the dissection of the gall bladder, the hole is grasped with this instrument and 1 of the rings is placed on the gall bladder by the aid of a dissector. Thus, the grasper remained available for traction of the Hartmann's pouch during further dissection of the gall bladder. The rubber bands were placed successfully in all cases. Two perforations occurred in 1 case, and 2 bands were placed with ease. Bile leakage or gall stone spillage did not occur. Operation time was not prolonged. Rubber band ligation of perforation of the gall bladder is a simple, safe, inexpensive, and effective method to prevent spillage of the bile or gallstones in laparoscopic surgery.     

Spontaneous biliary tract perforations: an unusual cause of peritonitis in pregnancy. Report of two cases and review of literature

Spontaneous perforations of the biliary tract are rare in adults and even more so during pregnancy. Perforation of the gall bladder is a potentially fatal complication of cholecystitis. The infrequency of perforation in the setting of calculous disease of the gall bladder is probably due to the thickened wall of the organ that has long been the seat of chronic inflammation. Common bile duct perforations have been reported in adults most commonly in association with choledocholithiasis. The diagnosis of biliary tract perforations is often delayed due to their non specific symptoms, which results in high morbidity. Early diagnosis and aggressive therapy are mandatory to alleviate this condition. Delayed diagnoses and treatment may have more serious consequences for pregnant women than for other patients. Very few cases of biliary tract perforations have been reported in pregnant women. We report two such cases in pregnancy: first of a gall bladder perforation associated with cholelithiasis and the second of a common bile duct perforation in pregnancy in which no apparent cause was found.     

Features of surgical strategy in acute cholecystitis in old patients

Results of treatment of 197 patients at the age of 75-years and older with acute cholecystitis in terms of active (early operations) and active-delaying (delayed and elective operations) policy were analyzed. It was established that changes of gall bladder wall in old patients with acute cholecystitis are of ischemic genesis, of primary-destructive and irreversible nature leading to gangrene and phlegmon of gall bladder wall in 84% cases. In 2/3 cases clinical picture doesn't reflect destructive nature of the disease. Severity of the patients state and its dynamics may be assessed most objectively by APACHE III. Conservative treatment doesn't prevent progress of destructive-inflammatory process and complications development. Cholecystectomy from laparotomy is the operation of choice in this group of patients. Early radical operation for acute cholecystitis in old patients permits to decrease postoperative lethality to 3.3%. The score of APACHE III at hospitalization is the criterion of the scope and terms of surgery. If APACHE III is more than 55 points, it is necessary to carry out complex preoperative correction of somatic disorders. Minimally invasive palliative operations are indicated for 10% patients of this category.     

胆石性肠梗阻的诊断与治疗

胆石性肠梗阻是一种较为少见的机械性肠梗阻,多因胆囊巨大结石通过胆肠内瘘排入肠道引起阻塞性肠梗阻.治疗的关键是梗阻原因的诊断,治疗方法主要为手术治疗.2013年4月苏州大学附属第二医院收治了1例老年胆石性肠梗阻患者.术前经X线片和CT检查胆囊壁增厚与十二指肠粘连窦道形成,左髂区机械性肠梗阻（胆源性结石直径约4 cm）,内科治疗3d后行急诊剖腹探查＋取石术治疗肠梗阻,术中见胆囊无结石,与家属沟通后未切除胆囊,术后随访观察.随访至2013年12月患者恢复较好,复查B超胆囊肠道内瘘口未显示,胆囊炎症消退.     

Agenesis of gall bladder in laparoscopic cholecystectomy—A case report

IntroductionAgenesis of gallbladder is a rare congenital anomaly of biliary tree that may be associated with other biliary and extra biliary congenital anomalies.Case presentationA 43- year- old female presented with a 4 months history of upper abdominal pain associated with nausea and vomiting. It was associated with dyspeptic symptoms and become worse following ingestion of high-fat meal contents. Clinically, a differential of gall stone disease was considered. Ultrasonography of abdomen revealed a contracted gallbladder with multiple stones with normal wall thickness, so the fact of clinical diagnosis considering finding cholithiasis. She was submitted to laparoscopic exploration which revealed that the gall bladder was absent within gall bladder fossa.DiscussionIn this case, the differential of cholithiasis symptoms considered support by ultrasonography, symptomatic gall stones presented more than half of cases of gall bladder agenesis, Diagnosis of gall bladder disease usually done by ultrasound modality, it must be done by expert one. Awareness of this entity by clinicians, surgeons and radiologists are essential because many of these patients present with biliary symptoms and have unnecessary operations.ConclusionAgenesis of gallbladder should be kept in mind whenever the gall bladder was improperly visualized in routine imaging methods. Ultrasonography operated dependent we must not depend on single one or even multiple done by the same person. Avoid a needless surgical exploration, which might be risky. Non-visualized gall bladder during laparoscopic cholecystectomy is challenging should not convert to open unless sure that the gall bladder was present.     

New scoring system for differentiating xanthogranulomatous cholecystitis from gall bladder carcinoma: a tertiary care centre experience

Background

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis, characterized by a focal or diffuse destructive inflammatory process. The importance of XGC is that it mimics gall bladder carcinoma (GBC) both preoperatively and intra‐operatively, as it can present with pericholecystic infiltration, hepatic involvement and lymphadenopathy. As a result of a misdiagnosis, which is not infrequent, the patient may undergo an unnecessary radical cholecystectomy rather than only a cholecystectomy, which is associated with a greater morbidity and mortality. The main aim of the study is to formulate a simple preoperative scoring system for diagnosis of XGC which might benefit patients by avoiding radical procedures.

Methods

A retrospective study was done from all the patients who underwent gall bladder and gall bladder‐related operations (benign and malignant), during a 5‐year time period from 2010 to 2014 in a tertiary care centre were reviewed (n = 462).

Results

Initial analyses of all the clinical and imaging parameters were done. Patients with a long history of recurrent abdominal pain with leucocytosis and who on imaging are found to have a diffusely thickened gall bladder wall, cholelithiasis, choledocholithiasis and submucosal hypoattenuated nodules are likely to have XGC while those with anorexia, weight loss, focal thickening of the gall bladder wall on imaging and dense local organ infiltration are more likely to have GBC. The presence of lymph nodes on imaging and the loss of a fat plane interface between the liver and gall bladder are not differentiating factors. A scoring system was made by taking statistically significant features (n = 13) of clinical and imaging parameters in initial assessment to identify the features of XGC. The same scoring system was subsequently applied to the patients who underwent cholecystectomy to study the effectiveness and the results were reviewed.

Conclusion

High value scores (≥11/13) helps in diagnosing XGC in preoperative setting. Hence, intra‐operative frozen section analysis can be avoided in such cases to differentiate XGC and GBC. However in difficult cases with high suspicion of malignancy based on clinical experience, definitive diagnosis still remains a histopathological examination to avoid radical resection in patients who have a benign condition.     

Current management of gall bladder perforations

BACKGROUND: Gall bladder perforation is a serious complication of acute cholecystitis. The purpose of the present study is to evaluate the presenting symptoms, diagnosis and management of patients with gall bladder perforations. METHODS: A retrospective study was undertaken of 31 consecutive patients with gall bladder perforation in a single unit of a tertiary referral hospital, between January 1996 and December 2001. RESULTS: The incidence of gall bladder perforation was 5.9% of all cases of acute cholecystitis. Associated comorbidity was quite common (58%). Ultrasound and computed tomography scans of the abdomen are sensitive investigations. Ultrasound guided percutaneous drainage helps in tiding over the emergency. The morbidity (35%) and mortality (9.6%) is considerable. CONCLUSION: The patterns of presentations, diagnosis and management of gall bladder perforation are changing. But there is scope for improvement.     

老年人腹腔镜胆囊切除术85例临床分析

本文对从１９９１年１月至１９９４年１２月入院的８５例６０岁以上老年人胆囊疾病患者行腹腔镜胆囊切除结果进行了总结。其中慢性胆囊炎、胆囊结石７１例，急性或化脓性胆囊炎６例，胆囊息肉７例，胆囊癌１例。结果表明，老年人可以耐受腹腔镜胆囊切除术，并安全、可靠。但良好的围手术期处理，术前对并存病进行有效的控制及术中、术后加强监测至关重要。     

Evaluation of prostacyclin production by human gallbladder

The prostanoids have been demonstrated to be involved in gallbladder physiology and disease. In previous reports, prostaglandin E (PGE) compounds were found to be increased in inflamed human gallbladders. Prostaglandin synthetase inhibition decreased PGE formation by human gallbladders; however, the relief of symptoms of cholecystitis did not correlate well with the decrease in PGE formation. This suggested that other prostanoids may be involved in cholecystitis. The purpose of this study was to evaluate the production of the proinflammatory arachidonic acid metabolite prostacyclin by gallbladders from patients with calculous cholecystitis. The formation of PGE and 6-ketoprostaglandin F1 alpha (6-keto-PGF1 alpha), the stable metabolite of prostacyclin, in normal human gallbladder mucosal cells and muscle tissue was compared with that produced by diseased mucosal cells and muscle tissue. Normal human gallbladders produced small amounts of 6-keto-PGF1 alpha, and no differences in formation rates were evident when muscle tissue was compared with mucosal cells. Diseased gallbladders produced significantly greater amounts of 6-keto-PGF1 alpha than did normal gallbladders, and diseased gallbladder muscle produced approximately four times greater amounts of 6-keto-PGF1 alpha than did diseased gallbladder mucosa. Prostacyclin formation is increased in diseased human gallbladders and may be an important mediator of the inflammatory changes of cholecystitis.     

Gall bladder carcinoma presenting as multiple cavitary pulmonary metastases — a rare event

Carcinoma of the gall bladder is the commonest malignancy of the biliary tract. It is either detected incidentally during routine imaging or presents as lump in right hypochondrium or with signs of jaundice. Rarely, it may present with multiple cavitary metastatic lesions in the pulmonary parenchyma. The authors, report such a rare case of gall bladder carcinoma that presented with extensive, bilateral pulmonary cavitary metastases with no evidence of any nodal disease and where the diagnosis was delayed due to this rare presentation.