Incidental carcinoma gall bladder during laparoscopic cholecystectomy for symptomatic gall stone disease

Introduction  Carcinoma gall bladder (CaGB) is a disease with high mortality and is usually diagnosed as an incidental case among patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gall stone disease. Methods  A total of 3205 LC done between January 2004 and August 2007 for symptomatic gall stone disease were retrospectively searched for incidental CaGB (detected on histopathology). None of these cases had preoperative suspicion of malignancy and their whole data was analyzed with special attention to preoperative and intraoperative findings which could raise suspicion of CaGB. In November 2007, patients were followed up telephonically about their present status of health. Results  Nineteen patients (14 female and 5 male) with incidental CaGB (incidence 0.59%) were detected. Mean age of the patients was 56 years. Only two of these patients had clinical jaundice and both had common bile duct (CBD) stones. The majority of the patients were in early pathological stages (pT) and none was in pT3 and pT4 stage. Seventeen patients could be followed up telephonically in November 2007 and of those 14 patients were alive at a mean follow-up duration of 21.2 months, with one of them having evidence of metastatic disease. Conclusion  Gall bladder (GB) malignancy may be curable if diagnosed in early stages as an incidental finding and LC may not worsen the prognosis in such cases. In our series, incidental CaGB was detected in 0.59% patients undergoing LC. No association could be found between preoperative and intraoperative findings that could raise a suspicion of malignancy of gall bladder and so use of retrieval bag as a routine measure in cases with bile spillage may reduce the incidence of port-site metastasis.     

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.     

Therapeutic efficacy of laparoscopic cholecystectomy in the treatment of biliary dyskinesia

BACKGROUND: The outcome of laparoscopic cholecystectomy for patients who present with "classic" biliary colic without evidence of cholelithiasis or acute inflammation (biliary dyskinesia) is not well documented. This study evaluates whether a cholecystokinin dimethyl iminodiacetic acid (CCK-HIDA) scan can predict relief of symptoms in this group of patients. METHODS: Patients who underwent laparoscopic cholecystectomy after a normal ultrasound and with an abnormal dimethyl iminodiacetic acid scan were retrospectively reviewed. Symptomatic improvement was correlated with degree of dyskinesia, histologic findings, sex, and age. RESULTS: One hundred seventy-six patients were studied and 69% were available for followup at a mean interval of 16 months. One hundred fourteen patients (94%) had complete or partial relief of symptoms. No correlation was found between degree of relief and degree of impaired ejection (31% to 50% versus <30%), the histologic findings, sex, or age. CONCLUSIONS: Abnormal cholecystokinin dimethyl iminodiacetic acid scan effectively predicts relief of symptoms in patients undergoing laparoscopic cholecystectomy for biliary dyskinesia.     

腹腔镜治疗胆囊颈部结石临床体会

目的探讨腹腔镜胆囊切除术胆囊颈部结石的处理方法。方法 2002年10月至2008年10月间,我们对286例胆囊颈部结石分别采用腹腔镜胆囊顺行切除、逆行切除和顺逆结合切除术治疗。结果手术均获成功,术后恢复顺利,无严重并发症出现。结论腹腔镜胆囊切除术中对不同情况的胆囊颈部结石采用不同的处理方法,可以有效避免术中胆管损伤等严重并发症。     

Predicting iatrogenic gall bladder perforation during laparoscopic cholecystectomy: a multivariate logistic regression analysis of risk factors

BACKGROUND: Seventeen independent risk factors were examined using multivariate logistic regression analysis to develop a profile of patients most likely at risk from iatrogenic gall bladder perforation (IGBP) during laparoscopic cholecystectomy. METHODS: Since 1989, a prospectively maintained database on 856 (women, 659; men, 197) consecutive laparoscopic cholecystectomies by a single surgeon (R. J. F.) was analysed. The mean age was 48 years (range, 17-94 years). The mean operating time was 88 min (range, 25-375 min) and the mean postoperative stay was 1 day (range, 1-24 days). There were 311 (women, 214; men, 97) IGBP. Seventeen independent variables, which included sex, race, history of biliary colic, dyspepsia, history of acute cholecystitis, acute pancreatitis and jaundice, previous abdominal surgery, previous upper abdominal surgery, medical illness, use of intraoperative laser or electrodiathermy, performance of intraoperative cholangiogram, positive intraoperative cholangiogram, intraoperative common bile duct exploration, presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively and success of the operation, were analysed using multivariate logistic regression for predicting IGBP. RESULTS: Multivariate logistic regression analysis against all 17 predictors was significant (chi(2) = 94.5, d.f. = 17, P = 0.0001), and the variables male sex, history of acute cholecystitis, use of laser and presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively were individually significant (P < 0.05) by the Wald chi(2)-test. CONCLUSION: Laparoscopic cholecystectomy, using laser, in a male patient with a history of acute cholecystitis or during an acute attack of cholecystitis is associated with a significantly higher incidence of IGBP.     

黏蛋白1在胆囊癌中的表达和意义

目的探讨黏蛋白1(MUC1)在原发性胆囊癌组织中的表达及其在胆囊癌诊断和免疫治疗中的意义。方法采用免疫组化方法检测42例原发性胆囊癌组织和17例正常胆囊组织中MUC1的表达。结果MUC1在胆囊癌组织中的阳性表达率为76.19%,明显高于正常胆囊组织(29.41%),两组存在统计学差异(P<0.05)。MUC1在胆囊癌组织中阳性表达率与胆囊癌组织病理类型、组织学分化、淋巴结转移及Nevin分期也有相关关系。但与有无合并胆囊结石无相关关系。结论MUC1可作为胆囊癌患者预后评价指标,有可能作为肿瘤微转移的诊断及免疫治疗的靶抗原。     

黏蛋白1在胆囊癌中的表达和意义

目的 探讨黏蛋白1（MUC1）在原发性胆囊癌组织中的表达及其在胆囊癌诊断和免疫治疗中的意义。方法 采用免疫组化方法检测42例原发性胆囊癌组织和17例正常胆囊组织中MUC1的表达。结果 MUC1在胆囊癌组织中的阳性表达率为76．19％，明显高于正常胆囊组织（29.41％），两组存在统计学差异（P〈0．05）。MUC1在胆囊癌组织中阳性表达率与胆囊癌组织病理类型、组织学分化、淋巴结转移及Nevin分期也有相关关系。但与有无合并胆囊结石无相关关系。结论 MUC1可作为胆囊癌患者预后评价指标，有可能作为肿瘤微转移的诊断及免疫治疗的靶抗原。     

Laparoscopic cholecystectomy for biliary dyskinesia in children provides durable symptom relief

Purpose

The purpose of this study was to determine the effectiveness of laparoscopic cholecystectomy in children with biliary dyskinesia.

Methods

Reports of children with an abnormal cholecystokinin (CCK)-stimulated HIDA scan between January 2001 and July 2006 who underwent laparoscopic cholecystectomy were reviewed. Postoperatively, a 23-item Likert scale, symptom questionnaire was administered to parents.

Results

Sixty-four children with chronic abdominal pain and no gallstones on ultrasound had an abnormal CCK-HIDA scan. Twenty-three children (median age, 14 years; 16 girls), with mean (SD) ejection fraction of 17% (8), underwent laparoscopic cholecystectomy and were further analyzed. Preoperatively, these children had right upper quadrant/epigastric pain (78%), nausea (52%), vomiting (43%), and generalized abdominal pain (22%) lasting for a median of 3 months (range, 1 month to 2.5 years). Median postoperative follow-up was 2.7 years. Sixteen (70%) parents completed the questionnaire. Of those who responded, 63% indicated that their children had no abdominal pain, 87% had no vomiting, and 69% had no nausea in the month preceding the questionnaire. Overall, 67% of parents indicated that their children's symptoms were completely relieved after cholecystectomy, whereas 7% indicated that the symptoms were not relieved.

Conclusion

Laparoscopic cholecystectomy is effective in providing both short-term and long-term improvement of symptoms in children with biliary dyskinesia.     

Bone metastases as the initial presentation of carcinoma of gall bladder: a rarity

Distant metastases are rare form of presentation of carcinoma gall bladder. Bony pain as initial presentation is quite unusual. A 50-year-old woman presented with the pain in right shoulder. Investigation showed metastatic adenocarcinoma in the head of humerus and the primary was found in the gall bladder. She received local radiotherapy for bone metastases and undergoing systemic chemotherapy. Carcinoma gall bladder is a common abdominal malignancy, mostly presenting in advanced stage with abdominal symptoms and obstructive jaundice. In presence of metastasis, the management is palliative and role of chemotherapy is limited for palliation symptoms.     

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.     

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.     

胆囊颈部结石的腹腔镜切除治疗

目的:探讨胆囊颈部结石伴发胆囊炎的腹腔镜切除方法。方法:226例胆囊颈部结石,根据胆囊炎的不同情况,分别采用胆囊顺行切除、逆行切除和顺逆结合切除方法进行治疗。结果:手术均获成功,术后恢复顺利,并发症发生率较低。结论:腹腔镜胆囊切除术中对不同情况的胆囊颈部结石采用不同的处理方法,可以有效避免术中胆管损伤等严重并发症。     

经皮经肝胆囊穿刺置管引流治疗合并肝硬化的急性胆囊炎

【摘要】〓目的〓探讨经皮经肝胆囊穿刺置管引流治疗对合并肝硬化门静脉高压症的急性胆囊炎患者的安全性及疗效。方法〓回顾性分析于2013年9月到2014年12月进行经皮经肝胆囊穿刺置管引流术治疗的合并肝硬化高压症急性胆囊炎患者12例。其中,肝功能Child-pugh A级7例,Child-pugh B级5例,分析12例患者经皮经肝穿刺胆囊置管引流术后并发症发生情况、术后炎症消退情况、术前后肝功能变化情况。结果〓12例患者均通过皮经肝胆囊穿刺置管引流术治疗后胆囊炎症消退,并择期成功行腹腔镜下胆囊切除术。其中,有2例患者因穿刺出现腹腔内出血,后经保守治疗后出血停止。无胆瘘发生。术后部分患者肝功能有所改善。结论〓经皮经肝穿刺胆囊置管引流治疗对合并肝硬化的急性胆囊炎是一种安全的治疗方法,可作为后续安全地施行腹腔镜下胆囊切除术的过渡。     

Relationships among symptoms, bother, and treatment satisfaction in overactive bladder patients

AIMS: We have studied the association between various symptoms, bother, and patient treatment satisfaction in overactive bladder (OAB). METHODS: Episodes of urgency, incontinence, daytime frequency and nocturia and responses to the patient perception of bladder condition scale, the urgency perception scale, and visual analog scales of limitations in daily life and of treatment satisfaction were evaluated in 3,824 OAB patients at baseline and during 9 months treatment with tolterodine ER (4 mg q.d.) in an open-label, observational study. Relationships amongst number of symptoms/ 24 hr and scales were explored. Treatment satisfaction was correlated with improvements in symptoms and scales. RESULTS: At baseline, the number of episodes of the four OAB symptoms correlated only poorly with each other and with the two bother-related scales, while the two scales assessing bother correlated much stronger with each other. Factor analysis identified four components which described "bother," "incontinence," "urgency/frequency," and "nocturia" and in combination explained 81.9% of the total variance. The component "bother" had the strongest individual effect accounting for 42.1% of the total variance. While improvements of symptoms and bother were seen with tolterodine treatment, patient treatment satisfaction correlated strongest with improvements of the two bother-related scales. CONCLUSIONS: We conclude that the counting of episodes of OAB symptoms only insufficiently describes the afflicted patients. Patient bother is the strongest individual component but only poorly explained by episodes of the four symptoms defining OAB. Alterations of bother may better reflect patient-relevant outcomes in OAB treatment than alterations in the number of symptom episodes.     

Gall bladder cancer,extrahepatic bile duct cancer and ampullary carcinoma in New Zealand: Demographics,pathology and survival

Introduction: The aim of present paper was to document the incidence of gall bladder cancer, cancer of the extrahepatic bile ducts and ampullary carcinoma in New Zealand. Methods: Data were collected from the New Zealand Cancer Registry from 1980 to 1997 and combined with national census statistics to give crude and age standardized incidence rates. Results: Over the 18‐year study period, 226 carcinomas of the ampulla of Vater, 608 gall bladder cancers, and 486 extrahepatic cholangiocarcinomas were registered. The age standardized incidence rates for gall bladder carcinoma in all New Zealanders were 0.41/100 000 in men and 0.74/100 000 in women. The age standardized incidence rates for gall bladder cancer in Maori were 1.49/100 000 in Maori men and 1.59/100 000 in Maori women. The corresponding age standardized incidence rates for extrahepatic bile duct cancers were 0.67/100 000 in men and 0.45/100 000 in women. There were insufficient cases to calculate an age standardized incidence in Maori or Pacific Islanders. For carcinoma of the ampulla, the age standardized rates were 0.34/100 000 in men and 0.25/100 000 in women. There were insufficient cases to calculate an age standardized incidence rate for Maori or Pacific Islanders. When histology was defined adenocarcinoma was the most common form of cancer occurring in 66% of gall bladder cancers, 91% of extrahepatic bile duct cancers and 70% of ampullary cancers. Most tumours were advanced at presentation with regional or distant metastases present in 72% of gall bladder cancers, 63% of extrahepatic bile duct cancers and 69% of ampullary tumours at diagnosis. Survival was poor with median survivals of 86 days, 151 days and 440 days recorded for gall bladder cancer, extrahepatic bile duct cancer and ampullary cancer, respectively. Conclusions: The demographic profile, pathology and survival of patients with gall bladder cancer, extrahepatic bile duct cancer and ampullary carcinoma are similar in New Zealand to that of other Western countries. However New Zealand Maori have a relatively high incidence of gall bladder cancer, and the incidence is equal in both Maori men and women, while cancers of the extra­hepatic bile duct and ampulla of Vater are rare in Maori. In comparison, cancers of the gall bladder, extrahepatic bile ducts and ampulla are rare in Pacific Islanders.     

Development of a symptom severity index and a symptom impact index for stress incontinence in women

Stress incontinence is a common problem among women, yet there is no adequately validated instrument for measuring women's views of its severity (disease-specific health status). The only instrument for measuring the impact or bothersomeness of symptoms (disease-specific quality of life) has poor internal consistency. This paper describes the development and psychometric assessment of two new indexes, a Symptom Severity Index and a Symptom Impact Index. Following several qualitative enquiries, a questionnaire was developed and administered to 442 women undergoing stress incontinence surgery. The face and content validity of the items comprising the indexes was good. The Severity Index (0–20) showed good variability (median 14, interquartile range 6) and adequate internal consistency (alpha 0.76). The Impact Index (0–12) also had good variability (median 5, interquartile range 3.5) and internal consistency (alpha 0.80). Convergent and discriminant validity were demonstrated for both indexes. Test-retest reliability was high. While responsiveness is still to be tested, the two indexes are psychometrically strong and can be used to measure the severity and impact of stress incontinence in women. © 1996 Wiley-Liss, Inc.