The presence of the gallbladder is associated with the severity of acute biliary pancreatitis

Summary Conclusion The presence of the gallbladder at the onset of acute biliary pancreatitis is associated with increased severity of the disease. One possible explanation is that gallbladder contraction might induce bile reflux into the pancreatic duct during the transfer of a gallstone through the ampulla. Background In clinical practice there is an impression that the presence of the gallbladder in patients with biliary pancreatitis may be associated with increased severity of the disease, compared to patients who have undergone cholecystectomy. Methods To test this hypothesis, we studied 266 cases with biliary pancreatitis. Patients were divided into two groups: (A) those who had a gallbladderin situ at the onset of biliary pancreatitis (n=234, 88%) and (B) those who had undergone previous cholecystectomy (n=32, 12%). Results Pancreatitis was more severe in group A than in group B, according to Glasgow criteria (≥3 positive, 66/210=31% vs 4/29=14%,p=0.04); development of complications (77/234=33% vs 4/32=13%,p=0.01); and mortality (40/234=17% vs 1/32=3%,p=0.03). Furthermore, serum C-reactive protein levels on admission were over 150 mg/L twice as often in group A as in group B.     

Aberrant gallbladder situated beneath the left lobe of liver

BackgroundAberrant gallbladder beneath the left liver is a rare congenital anomaly that is found in 0.1–0.7 per cent of the population and causes confusion on imaging and at operation.Two such cases are presented.Case outlinesA man of 83 yr was explored for obstructive jaundice due to a hilar tumour, but the gallbladder was ‘missing’. Exploration of a cystic mass to the left of the falciform ligament revealed a gallbladder attached to segment III of the liver. Laparotomy for gallstones in a woman of 70 yr failed to reveal the gallbladder until further dissection was carried out to the left of the falciform ligament. In each of these cases the cystic duct described a hairpin bend before joining the common hepatic duct on its right-hand side.ConclusionA left-sided gallbladder can be truly ectopic or may just appear so because the falciform ligament is aberrantly placed to the right. In either case preoperative imaging can be misleading, and a careful search is needed at operation. The incidence of disease seems no commoner than in orthotopic gallbladders.     

Hypogenesis of intramural vascularity and perivascular plexuses of gallbladder in patients with congenital biliary dilatation

Background

We hypothesized neuronal disorders of the biliary tract as the cause of congenital biliary dilation (CBD).

Methods

Gallbladders were removed from a total of 15 patients who were categorized into two study groups: a CBD group (eight patients) and in a control group (neuroblastoma, acute myelogenous leukemia, wandering gallbladder, Wilms’ tumor, glycogen storage disease, familial amyloid polyneuropathy; seven patients). Whole-mount preparations of the gallbladders were made to immunostain the intramural nerves.

Results

The intramural vascularity in the gallbladders of the CBD group (5.5 ± 1.9/cm²) was significantly lower than that in the control group (27.6 ± 14.4/cm²). The rate of perivascular plexuses on the surface of intramural vessels was also significantly lower in the CBD group than in the controls (37.7 ± 18.1 vs. 80.2 ± 17.4%, respectively). The numbers of ganglion cells per visual field were 38.5 ± 24.0 and 42.3 ± 20.6, respectively, in the CBD and control groups; this difference was not statistically significant.

Conclusions

There may be a mechanism in CBD causing contractile failure and dilatation of the biliary tract as a result of decreased intramural blood flow that accompanies the diminished vascularity.     

Preliminary experience for reducing biliary complication in adult-to-adult living donor liver transplantation using right lobe graft

Aim: To report the author's preliminary experience with adult-to-adult living donor liver transplantation (LDLT) using right lobe liver grafts. Methods: From January 2002 to July 2006, 50 adult patients underwent LDLT using right lobe grafts at West China Hospital, Sichuan University Medical School, China. At present, 24 recipients have been followed up for over nine months. Results: There were no deaths amongst the donors. Biliary reconstruction for 35 hepatic duct orifices from 24 donor grafts was performed, which included 19 reconstructions of duct-to-duct anastomoses and 16 cholangio-jejunostomy. Two recipients had biliary complications including one bile leakage and one slight biliary stricture. Conclusion: With the improved methods for biliary reconstruction, we achieved good results in 24 recipients of adult-to-adult LDLT. We consider that microsurgical technique and fixed operator could decrease the biliary complications of LDLT.     

Donor ductal anomaly is not a contraindication to right liver lobe donation

BackgroundData of living-donor liver transplantation (LDLT) suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors. This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in right-lobe LDLT (RLDLT) is related to donor biliary anatomy type.MethodsWe analyzed our RLDLT recipients’ clinical data and those of their graft donors. The recipients were divided into 2 groups: with and without postoperative biliary stricture. The 2 groups were compared. The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence; the secondary endpoints were 1-, 3- and 5-year graft and patient survival rates.ResultsTotally 127 patients were included in the study; 25 (19.7%) of them developed biliary anastomotic stricture. In these 25 patients, 16 had type A biliary anatomy, 3 had type B, 2 had type C, 3 had type D, and 1 had type E. In the 127 donors, 96 (75.6%) had type A biliary anatomy, 13 (10.2%) had type B, 6 (4.7%) had type C, 10 (7.9%) had type D, and 2 (1.6%) had type E. Biliary stricture was seen in 2 donors, who had type A biliary anatomy. None of the recipients or donors developed bile leakage. No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found (P = 0.527).ConclusionsThe incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type. As postoperative complications were similar in whatever type of donor bile duct anatomy, donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.     

Abnormal arrangement of the pancreato-biliary ductal system associated with advanced gallbladder cancer diagnosed 3 years after follow-up ultrasonography

We herein report a case of abnormal arrangement of the pancreato-biliary ductal system (AAPB) followed by advanced gallbladder cancer 9 years after the initial endoscopic retrograde cholangiopancreatography (ERCP) diagnosis and almost 3 years after follow-up ultrasonography (US). A 65-year-old woman was referred to our department from a private clinic because of difficulty in controlling her diabetes mellitus. The patient had no complaints, and physical examination revealed no jaundice in her skin or conjunctiva. ERCP demonstrated the presence of AAPB (bile duct-main type) without congenital dilatation of the bile duct or irregularity in the gallbladder wall. She did not wish to undergo cholecystectomy. Follow-up transabdominal US revealed no change in the gallbladder. Two years and 9 months after this US examination, she developed advanced gallbladder cancer involving the liver and bile duct, with paraaortic lymph node metastases confirmed by US, computed tomography, and ERCP. This case re-emphasizes the necessity for patients with AAPB to undergo intensive follow-up examinations or cholecystectomy when the diagnosis of AAPB has been established.     

Multiseptate gallbladder: A case report and literature review

Rationale:Multiseptate gallbladder (MSG) is a rare congenital gallbladder anomaly. Between 1963 and June 2021, only 56 cases were reported. There is currently no treatment guideline for pediatric or adult cases of MSG.Patient concerns:A 14-year-old woman visited our out-patient clinic in September 2020 for epigastric pain that last for 6 months. Honeycomb appearance of the gallbladder was noted under ultrasonography.Diagnosis:The patient was diagnosed with MSG. The diagnosis was confirmed through computed tomography and magnetic resonance cholangiopancreatography.Interventions:Cholecystectomy was performed.Outcomes:Epigastric pain showed limited improvement after the surgery. Since she was diagnosed with gastritis at the same time, a proton-pump inhibitor was prescribed. Epigastric pain was eventually resolved.Lessons:MSG cases can undergo cholecystectomy and show good recovery without complications. However, concomitant treatment may be required to resolve in the presence of other symptoms such as epigastric pain.     

Adult-to-adult living-related liver transplantation using the right lobe Case report

In the last few years an increase in the number of candidates for liver transplantation has been observed. However, the donor pool has not increased proportionally so that the lack of available donor organs remain a major concern. Living-related liver transplantation is actually one of the strategies to maximize donor organ use not only for paediatric but also for the adult patient population. The authors report their experience with the first adult-to-adult living-related liver transplantation using the right lobe. Despite a donor portal anomaly, the donor operation and the transplantation were uneventful. After six months' follow-up, donor and recipient are in excellent clinical state.     

Left-sided gallbladder associated with congenital liver cyst

Background. A left-sided gallbladder is a rare congenital anomaly defined as a gallbladder attached to the lower surface of the left lateral segment of the liver, i.e. to the left of the interlobar fissure and round ligament. Case outlines. In two women aged 42 and 70 years a left-sided gallbladder was associated with a congenital cyst of the liver. In the first patient, the ectopic gallbladder was an incidental finding at operation for a symptomatic liver cyst; as the gallbladder was normal it was not removed. The second patient underwent operation for chronic calculous cholecystitis, when the left-sided gallbladder and congenital liver cyst were found. An operative cholangiogram was normal, the cystic duct joining the common bile duct from the right side. The gallbladder was removed, and the cyst was de-roofed. Both patients had an uneventful recovery and remain symptom-free at 12 and 9 years respectively. Discussion. To the best of our knowledge, the association of these two congenital anomalies has not been described previously.     

Effect of nitric oxide on gallbladder motility in patients with acalculous biliary pain: a cholescintigraphic study

The aim of the present study was to evaluate the influence of the exogenous nitric oxide donor glyceryl trinitrate on cerulein-induced gallbladder contraction in patients with acalculous biliary pain. Quantitative hepatobiliary scintigraphy was performed on 33 patients. From the 60th min cerulein (1 ng/kg body wt/min for 10 min intravenous) then from the 90th min the same dose of cerulein plus glyceryl trinitrate (0.5 mg sublingually) (21 patients) or placebo (12 patients) were administered and the gallbladder ejection fraction was measured repeatedly. After the first dose of caerulein, the gallbladder ejection fraction was less than 35% in 23 of 33 patients (nonresponders), while it was more than 35% in the remaining 10 patients (responders). After the second dose of cerulein in 16 nonresponder patients glyceryl trinitrate administration significantly increased the previously impaired gallbladder ejection fraction while in 7 nonresponder patients placebo administration had no effect. In conclusion, normalization of the gallbladder ejection fraction in the majority of patients following glyceryl trinitrate administration suggests that impairment of gallbladder emptying is caused by a functional motility disorder rather than any organic disease.     

Long-term survival of patients with biliary tract cancers with lymph node involvement

In extrahepatic biliary tract malignancies, the prognostic value of lymph node involvement remains unclear. For a total of 161 tumors of the gallbladder (GBC) and bile duct (BDC) resected between 1982 and 1992, the number and extent of metastatic nodes were investigated according to the location of the primary tumor. In GBCs and upper two-third BDCs, more than half of node-positive tumors involved multiple nodes (58% and 63%), and node-positive tumors were associated with a significantly poorer rate of patient survival compared with node-negative tumors. However, GBCs with one or two nodes involved resulted in a longer survival time than those with three or greater (P = 0.0045). In lower one-third BDCs, even patients with node-positive tumors showed a 60% 5-year survival rate. There were 15 long-term survivors (i.e., survived for more than 5 years after surgery) with node-positive tumors in the GBC group, 4 in the upper BDC group, and 6 in the lower BDC group. Thirteen GBCs had one or two involved nodes, and 12 of the 13 GBCs positive nodes were located within the hepatoduodenal ligament. In upper and lower BDCs, pericholedocal nodes and nodes around the pancreatic head respectively, were most frequently involved. We concluded that lymphatic spread is an important prognostic determinant in both GBCs and upper BDCs. The prognosis of GBCs is especially influenced by the number of nodes involved. In lower BDCs, lymphatic metastasis does not necessarily preclude long-term survival.     

Gemcitabine with carboplatin for advanced biliary tract cancers: a phase II single institution study

Background:

Only recently has a standard chemotherapy regimen, gemcitabine plus cisplatin, been established for advanced biliary tract cancers (BTCs) based on a phase III randomized study. The aim of this phase II single-institution trial was to assess the efficacy and safety of gemcitabine combined with carboplatin in the first-line treatment of patients with advanced BTCs.

Methods:

Patients with histologically proven BTCs, including cholangiocarcinoma or gallbladder and ampullary carcinomas, were treated with a maximum of nine cycles of intravenous (i.v.) gemcitabine at 1000 mg/m² over 30 min on days 1 and 8 with i.v. carboplatin dosed at an area-under-the-curve (AUC) of 5 over 60 min on day 1 of a 21-day cycle.

Results:

A total of 48 patients with advanced BTCs (35 cholangiocarcinoma, 12 gallbladder and 1 ampullary cancer) were enrolled. A median of four cycles were administered (range: 1–9). The overall response rate for evaluable patients was 31.1%. Median progression-free survival, overall survival and 6-month survival rates are 7.8 months, 10.6 months and 85.4%, respectively. The most common grade 3–4 toxicities include neutropenia and thrombocytopenia. Grade 3 or 4 non-haematological toxicities were rare.

Conclusions:

Gemcitabine combined with carboplatin has activity against advanced BTCs. Our results are comparable to other gemcitabine-platinum or gemcitabine-fluoropyrimidine combinations in advanced BTCs.     

Benign gallbladder lesions mimicking cancer infiltrating the liver

Considering the current improved resectability of advanced gallbladder cancers, differentiation from benign gallbladder lesions mimicking advanced cancer is now a significant problem to be overcome so that unnecessary extended operations can be avoided. During the 4 years from January 1989 to December 1992, we experienced 63 patients with elevated lesions of the gallbladder, including cancer. Among the 59 patients who underwent resection, preoperative imaging diagnostic procedures were suggestive of cancer in 27. In particular, the lesions of 14 patients appeared to be cancerous with hepatic infiltration. Frozen section histological examinations were performed on the specimens of 4 of these patients in whom the findings were inconsistent; all of them were shown non-cancerous. The final diagnoses in these 4 patients were: hyperplastic polyp with foreign body granuloma, xanthofibromatous granulation, localized type adenomyomatosis, and chronic cholecystitis. Resections were performed on the remaining 10 patients who had lesions suspected to be cancerous with infiltration to the liver. Nine lesions were confirmed as cancer by histological examination of the resected specimen. However, the lesion of the remaining patient, who underwent hepatopancreatoduodenectomy, proved after operation, to be a hamartoma with foreign body granuloma. Of the imaging diagnostic procedures, a combination of endoscopic or intraoperative ultrasonography and computerized tomography was most valuable for making the differential diagnosis between gallbladder cancer and benign gallbladder lesions mimicking cancer infiltrating the liver. However, frozen section histological examination should not be omitted before the extended operations are performed, even though en bloc resection is preferable because the procedures used to obtain the specimens have the potential to disseminate viable cancer cells.     

Altered gallbladder concentration of biliary lipids during early cholesterol gallstone formation

Whether gallbladder absorptive function is altered during formation of cholesterol gallstones is unclear. We tested the hypothesis that alterations in biliary lipid composition present during early cholesterol gallstone formation enhance gallbladder absorption, as manifested by an increase in the ratio of gallbladder to hepatic bile lipid concentrations. Prairie dogs received either control or a 0.4% cholesterol-enriched chow for two or six weeks. The bile acid pool of each animal was labeled with [¹⁴C]cholic acid. Gallbladder and hepatic bile were analyzed for lipid composition with calculation of indices for cholesterol saturation, gallbladder stasis, and gallbladder absorption. Animals maintained on cholesterol-enriched chow for two weeks had a significant increase, as compared to controls, in the ratio of gallbladder to hepatic bile concentrations of cholesterol (8.66±1.09 vs 5.76±0.48), phospholipids (4.76±0.42 vs 3.21±0.34), bile acids (6.42±2.20 vs 3.54±0.46), and total lipid content (6.22±0.94 vs 3.64±0.43). These changes occurred at a time when gallbladder stasis is present and cholesterol crystals are forming but prior to stone formation. Similar findings were noted in six-week cholesterol-fed prairie dogs. We propose that the uniformly increased ratios of biliary lipids result from enhanced gallbladder absorption of water and sodium. The resulting increase in solute concentration may promote nucleation and, therefore, may be an important etiologic factor in cholesterol gallstone formation.Presented in part at the Surgical Forum, American College of Surgeons, San Francisco, California, October 22, 1984.     

Incidental adenocarcinoma of the gallbladder in a patient with Y insertion gallbladder duplication in the context of recurrent biliary colic: A video case report

Rationale:Gallbladder cancer is the most common malignancy of the biliary tree. Despite this, the only curative therapy remains surgical resection of the lesion achieving microscopically clear margins before malignant spread has occurred. Gallbladder duplication is an uncommon anatomical variance which occurs globally. It can present in a range of ways dependent on the embryological origin of the variance.Case:A 52-year-old female presented for planned laparoscopic cholecystectomy in the context of cholelithiasis resulting in recurrent biliary colic. The patient had no personal history of malignancy or significant medical comorbidities.Diagnosis:Intraoperatively, the patient was found to have Y-insertion variation of gallbladder duplication. Histopathology of the resected gallbladders showed an incidental invasive gallbladder adenocarcinoma affecting one of the gallbladders.Intervention:Both gallbladders were laparoscopically resected en-bloc.Outcomes:The patient underwent oncology staging, which found no evidence of metastatic spread. Regular surveillance is attended with no recurrence of disease identified.Conclusion:There are few reported cases detailing the occurrence of gallbladder adenocarcinoma in the presence of duplication of the gallbladder. This case demonstrates the clinical benefit of R0 surgical resection of gallbladder cancer, whilst highlighting the difficulties of diagnosing duplication of the gallbladder or gallbladder adenocarcinoma.     

Agenesis of the gallbladder: difficulties in management

Gallbladder agenesis is a rare congenital biliary anomaly that may be associated with other biliary and extrabiliary congenital anomalies. Awareness of this entity by clinicians and radiologists is essential because many of these patients present with biliary symptoms and have unnecessary operations. In the present article, the relative epidemiological, etiological (embryology and development), pathophysiological, diagnostic tools and pitfalls and management aspects of this rare anatomic anomaly are briefly discussed through review of the literature. Particular reference to the difficulty in preoperative diagnosis is highlighted. The importance of the possibility of preoperative diagnosis to avoid unnecessary surgery is stressed.     

Biliary complications after right lobe living donor liver transplantation: a single-centre experience

Background

Biliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre.

Methods

From 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed.

Results

Of a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures).

Conclusion

Identification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.     

Adult-to-adult right lobe living donor liver transplantation： Comparison of endoscopic retrograde cholangiography with standard T2-weighted magnetic resonance cholangiography for evaluation of donor biliary anatomy

INTRODUCTIONOver the past decade, a critical shortage of cadaveric organs for adults in need of liver transplants has developed. The current mortality for patients awaiting liver transplantation (LTx) ranges from 20% to 30%. During this time, the waiting …