The impact of routine histopathological examination on cholecystectomy specimens from an Asian demographic

INTRODUCTION

Most gallbladder carcinoma cases are suspected pre-operatively or intra-operatively. In Malaysia histopathological examination of cholecystectomy specimens has become routine practice. The aim of this study was to assess the impact of routine histological examinations on cholecystectomy specimens from an Asian demographic, which may differ from a Caucasian demographic.

METHODS

A retrospective study was performed of all histopathoiogy reports for choiecystectomies (Iaparoscopic and open) undertaken over a period of 12 years (1997-2008) in a single teaching hospital.

RESULTS

A total of 1,375 gallbladder specimens were sent for histopathological analysis, with 7 (0.5%) being reported as malignant while only three (0.2%) were found to contain primary gallbladder carcinoma. Other premalignant findings included two specimens with dyspiastic changes of the mucosa and one tubuioviiious adenoma with a dyspiastic epithelium. From the ten malignant and premalignant specimens, seven were diagnosed pre-operatively, two were suspected intra-operatively and one was diagnosed with dyspiastic changes on the histopathoiogy report post-operatively.

CONCLUSIONS

This study supports earlier research carried out in the UK and the demographic difference does not affect the impact of the histology examination on cholecystectomy specimens in diagnosing this disease. A selective policy is recommended in Malaysia.     

Laparoscopic management of cholecystocolic fistula

Introduction

Cholecystocolic fistula is a rare complication of gallbladder disease. Its clinical presentation is variable and nonspecific, and the diagnosis is made, mostly, incidentally during intraoperative maneuver. Cholecystectomy with closure of the fistula is considered the treatment of choice for the condition, with an increasingly reproducible tendency to the use of laparoscopy.

Aim

To describe the laparoscopic approach for cholecystocolic fistula and ratify its feasibility even with the unavailability of more specific instruments.

Technique

After dissection of the communication and section of the gallbladder fundus, the fistula is externalized by an appropriate trocar and sutured manually. Colonic segment is reintroduced into the cavity and cholecystectomy is performed avoiding the conversion procedure to open surgery.

Conclusion

Laparoscopy for resolution of cholecystocolic fistula isn''t only feasible, but also offers a shorter stay at hospital and a milder postoperative period when compared to laparotomy.     

The correlation between ultrasonography and histology in the search for gallstones

INTRODUCTION

The majority of published data on the sensitivity and specificity of ultrasound in the diagnosis of gallbladder pathology was conducted over 30 years ago and, since the 1990s, ultrasound imaging has been the accepted gold standard. The quality and resolution of ultrasonography has improved significantly since then and we have, therefore, set out to assess whether the progression in technology has translated into improved diagnostic accuracy.

PATIENTS AND METHODS

In the period December 2005 to December 2008, a total of 2100 patients underwent laparoscopic cholecystectomy for symptoms related to gallbladder disease. All patients underwent ultrasound examination prior to their surgery and histopathological analysis of their gallbladder postoperatively. We undertook a retrospective analysis of these patients comparing their pre-operative ultrasound scan and their histopathology report for the presence or absence of gallstones. Ultrasound scans were performed by a combination of radiologists and ultrasonographers.

RESULTS

The study identified a sensitivity of 0.85 and a specificity of 1 for ultrasound in the identification of gallstones. We found a sensitivity of 0.84 and 0.83 for the radiologists and ultrasonographers, respectively.

CONCLUSIONS

This study suggests that, despite an evolution in the resolution of ultrasound imaging, there has not been a corresponding improvement in sensitivity. There is a false positive rate of 16% which remains unchanged since the early 1990s.     

Spilled gallstones during laparoscopic cholecystectomy

Introduction

Incidental gallbladder cancer is found in 0.6–2.1% of patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. Patients with Tis or T1a tumours generally undergo no further intervention. However, spilled stones during surgery may have catastrophic consequences. We present a case and suggest aggressive management in patients with incidental gallbladder cancer who had spilled gallstones at surgery.

Case History

A 37-year-old woman underwent a laparoscopic cholecystectomy for symptomatic gallstones, during which some stones were spilled into the peritoneal cavity. Subsequent histological examination confirmed incidental pT1a gallbladder cancer. Hepatopancreatobiliary multidisciplinary team discussion agreed on regular six-monthly follow-up. The patient developed recurrent pain two years after surgery. Computed tomography revealed a lesion in segment 6 of the liver. At laparotomy, multiple tumour embedded gallstones were found on the diaphragm. Histological examination showed features (akin to the original pathology) consistent with a metastatic gallbladder tumour.

Conclusions

This case highlights the potential for recurrence of early stage disease resulting from implantation of dysplastic or malignant cells carried through spilled gallstones. It is therefore important to know if stones were spilled during original surgery in patients with incidental gallbladder cancer following a laparoscopic cholecystectomy. Aggressive and early surgical management should be considered for these patients.     

Aberrant Presentation of the Gallbladder During Laparoscopic Cholecystectomy

Background:

Aberrant gallbladder transposed to the left side is a rare congenital anomaly that has been seen in as many as 0.7% of the population. These gallbladders are situated under the left lobe of the liver between Segment III and IV and to the left of the falciform ligament. Many preoperative studies fail to identify the anomaly, causing confusion to the surgeon during laparoscopic resection. Selective use of intraoperative cholangiography and meticulous dissection can aid in safe resection.

Methods:

A 61-year-old female was admitted with ultra-sound confirmation of cholecystitis and subsequently taken to the operating room for a laparoscopic cholecystectomy.

Results:

Evaluation of the gallbladder under laparoscopic view revealed an inflamed left aberrant gallbladder. An intraoperative cholangiogram was obtained to delineate the biliary anatomy that showed the cystic duct entering the common hepatic duct on the right side.

Conclusion:

A left aberrant gallbladder is a rare presentation that requires awareness of biliary anatomy and selective use of intraoperative cholangiography to aid in the safe laparoscopic resection of the gallbladder.     

Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques

INTRODUCTION

Left-sided gallbladder is a rare anatomical variation. Usually it is discovered intra-operatively and is accompanied by anatomic variations that can prove quite challenging during laparoscopy.

PRESENTATION OF CASE

From a total of almost 3000 laparoscopic cholecystectomies performed in our institution, two cases of left sided gallbladder were unexpectantly identified intraoperatively. There were no indications for the ectopy preoperatively. In both cases modifications of the standard laparoscopic technique were mandatory. They were performed safely with no post-operative complications. Modifications consisted of transposition of the subxiphoid entry port and alteration in the direction of traction of the rest of the graspers. A review of the literature for methods of safe laparoscopic cholecystectomy was conducted.

DISCUSSION

The surgeon must be aware of the anatomic variances in the rare occasion of a left sided gallbladder, since preoperative diagnosis is very difficult.

CONCLUSION

Knowledge of potential hazards and modifications of laparoscopic technique is mandatory in order to avoid complications.     

Gallbladder Volvulus with Gangrene Case Report and Review of the Literature

Background:

Volvulus of the gallbladder is an unusual event. Over 300 cases have appeared in the literature since first reported by Wendel in 1898,¹ ranging in age from 2 to 100 years old. Unusual mobility of the gallbladder due to congenital anomalies is a constant factor in all occurrences.

Case Report:

This is a report of a laparoscopic cholecystectomy in an 82-year-old white female with volvulus of the gallbladder presenting with a chief complaint of chest pain.

Conclusion:

The patient had an uneventful recovery and was discharged within 72 hours after surgery, indicating that with the proper technique laparoscopic cholecystectomy is both feasible and safe in gallbladder volvulus.     

Gallbladder perforation: A rare complication of enteric fever

INTRODUCTION

Gallbladder perforation is a rare complication of acute calculous cholecystitis in adults. Perforation of gallbladder due to enteric fever is extremely rare condition. Pre-operative diagnosis is rarely made and mortality is high.

PRESENTATION OF CASE

We report a case of acalculous gallbladder perforation following enteric fever in a 14-year-old boy, who presented as acute abdomen and responded very well after emergency laparotomy and cholecystectomy.

DISCUSSION

Enteric fever is common in tropics and a common cause of bowel perforation. Acute cholecystitis is a rare complication of typhoid and gallbladder perforation is extremely rare complication. Ultrasound and CT lack specificity to detect gallbladder perforation. Diagnosis is usually made intra-operatively. Cholecystectomy is treatment of choice in such cases and provides good result.

CONCLUSION

Gallbladder perforation secondary to enteric fever requires a high degree of clinical suspicion. In typhoid endemic region, it should be considered as a differential diagnosis in patient presenting with a history of prolonged fever and signs of peritonitis. Early diagnosis and immediate surgical intervention are very important in reducing the morbidity and mortality. Cholecystectomy is the choice with a good outcome.     

Relapse of acute myeloid leukemia manifested by cholecystitis: A case report and review of the literature

INTRODUCTION

AML is the most common form of leukemia in adults. In rare circumstances AML may present in the form of extra-medullary disease. Gallbladder infiltration with myeloblasts is rare and only a few cases exist in the literature describing this entity.

PRESENTATION OF CASE

We present a rare case of AML relapse in the form of extramedullary infiltration of the gallbladder in a 50-year-old male patient. The leukemic infiltration presented as symptomatic cholecystitis and sepsis. A laparoscopic cholecystectomy was performed and the gallbladder was pathologically examined. Histopathologic examination demonstrated multiple scattered, highly atypical single cells admixed with some plasma cells, small lymphocytes and macrophages consistent with leukemic infiltration. The abnormal cells demonstrated immunohistochemical staining for CD68, CD33 and CD117. The patient did well post-operatively but the relapse precluded him from bone marrow transplantation.

DISCUSSION

Although AML is relatively common, 3 cases per 100,000 population, extramedullary disease in the form of gallbladder infiltration is exceedingly rare. An extensive review of the literature revealed only four cases of myeloid infiltration of the gallbladder. To our knowledge this is the only case of relapsing disease in the form of gallbladder infiltration presenting as symptomatic cholecystitis in a pre-bone marrow transplantation patient.

CONCLUSION

This case highlights the importance of maintaining a high index of suspicion of atypical manifestations of AML when managing refractory sepsis. Extramedullary manifestations of AML in the form of gallbladder infiltration must be considered in the differential diagnosis of patients with a history of myeloid malignancies and for patients whom fail conventional non-operative management.     

Giant gallbladder: A case report and review of literature

INTRODUCTION

Reports of a giant gallbladder are rare.

PRESENTATION OF CASE

A 77-year-old woman was admitted with complaints of dull pain in the right half of the abdomen and a palpable mass at the same place. A computerized tomography scan revealed an extremely enlarged gallbladder. Open cholecystectomy was performed. The volume of the removed organ was as much as 3.35 L.Follow-up after 18 months showed that the patient was well. Examination revealed no significant acquired or congenital anomalies that might explain the excessive enlargement of the gallbladder.

DISCUSSION

We define a ‘giant’ gallbladder as an extreme enlargement of the organ with a volume exceeding 1.5 L, so that its weight is comparable to or even exceeds the mean (estimated) weight of the adult liver (1.5 kg). The first clinical presentation of such an enlargement is likely to differ from any other gallbladder disease, but rather to resemble a tumour or cyst of the abdominal cavity.

CONCLUSION

A giant gallbladder is a special clinical and pathological entity in surgical practice, of unknown origin. It may develop in patients of any age, and mimics a large abdominal tumour or peritoneal cyst. Both the diagnostic process and surgical treatment demand non-routine approaches. Early and late follow-up results seem to be favourable.     

Adrenal Schwannoma

Background:

Adrenal schwannomas are very rare tumors that are difficult to diagnose preoperatively. We report the case of a left adrenal schwannoma incidentally discovered in a 55-year-old man during a postoperative checkup for a cutaneous malignant melanoma.

Methods:

The biological evaluation was unremarkable, and the radiological examination revealed the adrenal mass that was first considered a metastatic lesion. Adrenalectomy was performed by the laparoscopic approach.

Results:

The postoperative course was uneventful. Histological examination established the correct diagnosis of schwannoma, which was also confirmed by immunohistochemical staining.

Conclusions:

A nonsecreting adrenal mass can be easily misjudged, especially in the context of a recently operated on malignancy. Unilateral adrenal metastasis needs pathological confirmation, as it can dramatically affect prognosis. Unusual tumors of the adrenal gland may be found incidentally, and a malignant context will generate difficulties in establishing the right management. Complete laparoscopic excision is the treatment of choice whenever feasible and will also clarify pathology.     

Laparoscopic Splenectomy Coupled with Laparoscopic Cholecystectomy

Background and Objectives:

The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases.

Methods:

Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients.

Results:

The mean operative time was 100 minutes (range, 80–160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred.

Conclusion:

Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.     

Acalculous gallbladder disease: the outcomes of treatment by laparoscopic cholecystectomy

INTRODUCTION

The treatment of symptomatic patients with the presence of gallstones is well established, with laparoscopic cholecystectomy being the treatment of choice for symptomatic cholelithiasis. The results of surgery in symptomatic patients without gallstones are highly variable. These patients are often referred to as having acalculous gallbladder disease and represent between 5% and 30% of laparoscopic cholecystectomies performed annually. We retrospectively reviewed the outcomes of patients who underwent laparoscopic cholecystectomy for acalculous gallbladder disease in our institution.

PATIENTS AND METHODS

We retrospectively analysed the period from February 2005 to January 2006 where 20 laparoscopic cholecystectomies had been performed specifically for a preoperative diagnosis of acalculous gallbladder disease. The histology of all laparoscopic cholecystectomies performed during this year was analysed and it was found that a further 46 patients had histological specimens that demonstrated the absence of gallstones in the presence of an intact gallbladder specimen. These patients were therefore included in the study group for acalculous gallbladder disease. All patients were sent a questionnaire comparing their state of health before and after surgery.

RESULTS

After laparoscopic cholecystectomy, 66% of patients were completely pain free. The remainder, however, experienced infrequent, moderate pain with occasional pain on eating. Following surgery, all patients were able to conduct their activities of daily living without any limitation.

CONCLUSIONS

We therefore conclude that laparoscopic surgery for patients with acalculous gallbladder disease is effective in symptom control and allowing patients to return to their normal lifestyle.     

Gallbaldder perforation causing a subcutaneous abscess

INTRODUCTION

This is a report of a rare case of an old woman with a large round mass in the right hypochondrium that was proven to be an abscess.

PRESENTATION OF CASE

A 82-year old woman with a firm round mass in the right hypochondrium was admitted for evaluation. The abdominal CT showed an abscess produced by a gallbladder perforation, and a gallstone impacted at the Hartmann''s pouch.

DISCUSSION

The abscess was treated with a transcutaneous paracentesis, while the stone passed to the gastrointestinal tract through a cholecystoenteric fistula, without causing any further problems.

CONCLUSION

Gallbaldder perforation can rarely create a subcutaneous abscess especially in thin, elder subjects. Abscess drainage is the first line of treatment.     

Routine versus selective histological examination after cholecystectomy to exclude incidental gallbladder carcinoma

Introduction

Gallstone disease is treated commonly with cholecystectomy. Malignant disease of the gallbladder may present similarly and has a poor prognosis. It is common for cholecystectomy specimens to be sent for histological examination to exclude malignancy. However, the incidence of incidental gallbladder carcinoma (IGBC) is low and it has therefore been suggested that macroscopic inspection of the gallbladder by the surgeon, followed by selective histological examination of abnormal specimens, may be safe and cost saving.

Methods

All cholecystectomies performed between 1 May 2003 and 1 September 2009 were identified from clinical coding. Pathology records were used to identify gallbladder malignancies; these were searched manually to identify IGBC. Pathology reports and case notes were cross-referenced to determine whether there were macroscopic abnormalities present. Annual cost savings were estimated by comparing the number of gallbladder specimens over one year (May 2013 – April 2014) with the total number of cholecystectomies performed in that time.

Results

Of 4,776 cholecystectomies identified, 12 (0.25%) were cases of IGBC. These cases had a higher median age (68 vs 54 years, p<0.001) and a higher proportion were emergency operations (50% vs 12%, p<0.001). All cases had some form of macroscopic abnormality, most commonly wall thickening (n=6, 50%). Only two cases (17%) had a visible tumour present.

Conclusions

All cases of IGBC in this study had a macroscopically abnormal gallbladder. Our findings suggest it is safe to adopt a selective approach to histological examination. Savings of almost £20,500 per annum have been achieved.     

Early cystic duct carcinoma of new classification

Introduction

Classically defined cystic duct carcinoma is extremely rare owing to its strict diagnostic criteria, which are not suitable in actual clinical settings. Recently, several new classifications of cystic duct carcinoma were reported, which defined it as a tumor with its center located in the cystic duct. On the other hand, the incidence of cystic duct carcinoma, based on the new classifications, is not rare, but all reported cases are advanced.

Presentation of case

A 77-year-old man with dilatation of the common bile duct, a stricture at the level of the cystic duct junction, and a filling defect of contrast medium into cystic duct in endoscopic retrograde cholangiopancreatography was diagnosed with cystic duct carcinoma. Radical cholecystectomy with bile duct resection was performed. In the resected specimen, we found that a 2 cm tumor whose center was located in the cystic duct and vertically limited to the mucosal layer. Horizontally, the tumor was superficially spread in the gallbladder, which were also limited to the mucosal layer.

Discussion

Here we report a first case of early cystic duct carcinoma diagnosed according to a new classification that had spread superficially into the gallbladder. When treating an early cystic duct carcinoma, it is important to note that even localized carcinoma can potentially invade into adjacent organs or metastasize to regional lymph nodes due to the location of cystic duct.

Conclusion

It is suggested that perform radical resection such as cholecystectomy with gallbladder fossa resection, extrahepatic bile duct resection and regional lymphadenectomy is the treatment of choice.     

Portal Vein Thrombosis After Laparoscopic Cholecystectomy

Introduction:

Portal vein thrombosis (PVT) is a relatively uncommon complication after abdominal surgery.

Case Report:

We report an even more unusual case of PVT 10 days after an uncomplicated laparoscopic cholecystectomy, believed to be only the fourth reported case in the literature of this rare complication.

Conclusion:

Albeit extremely rare, PVT should be included in the differential diagnosis for abdominal symptoms and/or elevated hepatic function tests after laparoscopic cholecystectomy.     

Primary ovarian leiomyoma: A case report

INTRODUCTION

Primary ovarian leiomyoma is a rare benign tumour of the ovary seen in women between 20 and 65 years old. It is usually diagnosed incidentally during pelvic examination or pathologic examination after surgery.

PRESENTATION OF CASE

We describe a case of unilateral, ovarian leiomyoma. Transvaginal ultrasonography and magnetic resonance imaging (MRI) revealed a right adnexial mass. Unilateral salpingo-oophorectomy was performed, and histological examination revealed a leiomyoma arising primarily in the ovary. The diagnosis was confirmed immunohistochemically.

DISCUSSION

The tumour may be asymptomatic or may manifest with lower abdominal pain like in our case. The definitive diagnosis of these lesions is difficult prior to surgical removal. Because there is no pathognomonic symptoms or characteristic imaging findings. The correct diagnosis of an ovarian leiomyoma requires identification of the smooth muscle nature of the tumour.

CONCLUSION

This rare tumour of the ovary should be considered in the differential diagnosis of solid ovarian masses. An immunohistochemical analysis is recommended for definitive diagnosis.