Histological examination of frozen sections for patients with acute cholecystitis during cholecystectomy

BACKGROUND:Unexpected gallbladder cancer may present with acute cholecystitis-like manifestations.Some authors recommended that frozen section analysis should be performed during laparoscopic cholecystectomy for all cases of acute cholecystitis.Others advocate selective use of frozen section analysis based on gross examination of the specimen by the surgeon.The aim of the present study was to evaluate whether surgeons could effectively identify suspected gallbladder with macroscopic examination alone.If not,is routine frozen section analysis worth advocating?METHODS:A total of 1162 patients with acute cholecystitis who had undergone simple cholecystectomy in our hospital from February 2009 to February 2014 were enrolled in the study.The data of patients with acute cholecystitis especially those with concurrent gallbladder cancer in terms of clinical characteristics,operative records,frozen section diagnosis and histopathology reports were analyzed.RESULTS:Thirteen patients with acute cholecystitis were found to have concurrent gallbladder cancer,with an incidence of 1.1%in acute cholecystitis.Forty patients with acute cholecystitis were suspected to have gallbladder cancer by macroscopic examination and specimens were taken for frozen section analysis.Six patients with gallbladder cancer were correctly identified by macroscopic examination alone but 7patients with gallbladder cancer missed,including 3 patients with advanced cancer(2 T3 and 1 T2).Meanwhile,in 6 gallbladder cancer specimens sent for frozen section analysis,3 early gallbladder cancers(2 Tis and 1 T1a)were missed by frozen section analysis.However,the remaining 3 patients with advanced gallbladder cancers(2 T3 and 1 T2)were correctly diagnosed.CONCLUSIONS:The incidence of comorbidity of gallbladder cancer and acute cholecystitis is higher than that of non-acute cholecystitis.The accurate diagnosis of gallbladder cancer by surgeons is poor and frozen section analysis is necessary.     

Do we need histology for a normal-looking gallbladder?

Background/Purpose

Gallbladder cancer (GBC) is a rare malignancy with poor overall prognosis. Simple cholecystectomy is curative if the cancer is limited to mucosa. We aimed here to investigate the need for routine histological examination of gallbladder.

Methods

We carried out a retrospective review of 2890 final pathology reports of processed gallbladder specimens following cholecystectomy due to gallstones disease. The review covered the 10-year period from 1994 to 2004. The notes of all cases of gallbladder cancer were scrutinized, with particular emphasis on presentation, preoperative diagnostic tools using abdominal ultrasound and computed tomography scan, operative findings, and the histology results.

Results

Gallbladder cancer (GBC) was detected in five specimens (0.17%), dysplasia in six (0.2%), and secondaries to gallbladder in three (0.1%). Histological findings confirmed gallstone disease in 97% and rare benign pathology in 3%. The median age of patients with GBC was 61 years (range, 59–84 years). In all five patients, cancer was isolated from thickened fibrotic wall on macroscopic appearance and spread through all layers of the gallbladder wall. The percentage of thickened-wall gallbladder in this study was 38.02% and the cancer incidence in the thickened wall was 0.45%.

Conclusions

A selective policy rather than routine histological examination of nonfibrotic or thickened-wall gallbladder has to be considered. This will reduce the burden on pathology departments, with significant cost savings.

     

Routine Histopathological Examination of the Specimen After Laparoscopic Cholecystectomy: Can We Be Brave Enough to Give Up?

Background: Selective versus routine histopathological examination after cholecystectomy is still in debate. This study aims to investigate the effect of histopathology results on treatment modality and surgery strategy. The validity of the selective histopathology approach was questioned.Methods: The data of patients undergoing laparoscopic cholecystectomy between January 2009 and December 2019 were retrospectively analyzed. The demographics and histopathology results, whether the operation was emergent or elective, and the reasons for conversion to open surgery were recorded. Malignant and precursor histopathology diagnoses were examined, and their relationship with the surgical strategy was questioned.Results: A total of 2723 patients were included in the study. Of these patients, 2600 (95.5%) were operated under elective, while 123 (4.5%) were operated under emergency conditions. While the surgery was completed laparoscopically in 2685 (98.6%) patients, it was converted to open surgery in 38 (1.4%) patients. Age, gender, the presence of primary gallbladder cancer, acute cholecystitis, and xanthogranulomatous cholecystitis in histopathological examination were found to be independent predictive factors for conversion to open surgery (P < .05). The rate of primary invasive carcinoma in the series was 0.1%.Conclusion: Routine histopathological examination of the gallbladder is important for demonstrating a wide spectrum of pathological changes in this organ. Invasive cancer or precursor lesions can be detected even in patients without any macroscopic abnormality. Histopathological examination also plays a role in determining follow-up, further examination, and treatment modality in addition to the diagnosis in these patients.     

All cholecystectomy specimens must be sent for histopathology to detect inapparent gallbladder cancer

Objectives

Traditionally, a gallbladder removed for presumed benign disease has been sent for histopathological examination (HPE), but this practice has been the subject of controversy. This study was undertaken to compare patients in whom gallbladder cancer (GBC) was diagnosed after cholecystectomy on HPE with GBC patients in whom the gallbladder was not sent for HPE and who therefore presented late with symptoms.

Methods

A retrospective analysis of prospectively collected data for 170 GBC patients diagnosed after cholecystectomy was conducted. All patients presented to one centre during 2000–2011. These patients were divided into two groups based on the availability of histopathology reports: Group A included patients who presented early with HPE reports (n = 93), and Group B comprised patients who presented late with symptoms and without HPE reports (n = 77).

Results

The median time to presentation in Group A was significantly lower than in Group B (29 days vs. 152 days; P < 0.001). Signs or symptoms suggestive of recurrence (pain, jaundice or gastric outlet obstruction) were present in four (4.3%) patients in Group A and all (100%) patients in Group B (P < 0.001). Patients deemed operable on preoperative evaluation included all (100%) patients in Group A and 38 (49.4%) patients in Group B (P < 0.0001). The overall resectability rate (69.9% vs. 7.8%) and median survival (54 months vs. 10 months) were significantly higher in Group A compared with Group B (P < 0.0001).

Conclusions

Patients in whom a cholecystectomy specimen was sent for HPE presented early, had a better R0 resection rate and longer overall survival. Hence, routine HPE of all cholecystectomy specimens should be performed.     

Incidental gallbladder cancer during laparoscopic cholecystectomy: managing an unexpected finding

AIM: To evaluate the impact of incidental gallbladder cancer on surgical experience.METHODS: Between 1998 and 2008 all cases of cholecystectomy at two divisions of general surgery, one university based and one at a public hospital, were retrospectively reviewed. Gallbladder pathology was diagnosed by history, physical examination, and laboratory and imaging studies [ultrasonography and computed tomography (CT)]. Patients with gallbladder cancer (GBC) were further analyzed for demographic data, and type of operation, surgical morbidity and mortality, histopathological classification, and survival. Incidental GBC was compared with suspected or preoperatively diagnosed GBC. The primary endpoint was disease-free survival (DFS). The secondary endpoint was the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention.RESULTS: Nineteen patients (11 women and eight men) were found to have GBC. The male to female ratio was 1:1.4 and the mean age was 68 years (range: 45-82 years). Preoperative diagnosis was made in 10 cases, and eight were diagnosed postoperatively. One was suspected intraoperatively and confirmed by frozen sections. The ratio between incidental and nonincidental cases was 9/19. The tumor node metastasis stage was: pTis (1), pT1a (2), pT1b (4), pT2 (6), pT3 (4), pT4 (2); five cases with stage Ia (T1 a-b); two with stage Ib (T2 N0); one with stage IIa (T3 N0); six with stage IIb (T1-T3 N1); two with stage III (T4 Nx Nx); and one with stage IV (Tx Nx Mx). Eighty-eight percent of the incidental cases were discovered at an early stage (≤ II). Preoperative diagnosis of the 19 patients with GBC was: GBC with liver invasion diagnosed by preoperative CT (nine cases), gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum (one case), porcelain gallbladder (one case), gallbladder adenoma (one case), and chronic cholelithiasis (eight cases). Every case, except one, with a T1b or more advanced invasion underwent IVb + V wedge liver resection and pericholedochic/hepatoduodenal lymphadenectomy. One patient with stage T1b GBC refused further surgery. Cases with Tis and T1a involvement were treated with cholecystectomy alone. One incidental case was diagnosed by intraoperative frozen section and treated with cholecystectomy alone. Six of the nine patients with incidental diagnosis reached 5-year DFS. One patient reached 38 mo survival despite a port-site recurrence 2 years after original surgery. Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5-year DFS.CONCLUSION: Laparoscopic cholecystectomy does not affect survival if implemented properly. Reoperation should have two objectives: R0 resection and clearance of the lymph nodes.     

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: An analysis of 42 cases

AIM: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis (XGC) clinically.METHODS: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our hospital, among which 42 were misdiagnosed as gallbladder carcinoma (GBC) based on preoperative radiographs and/or intra-operative findings. The clinical characteristics, preoperative imaging, intra-operative findings, frozen section (FS) analysis and surgical procedure data of these patients were collected and analyzed.RESULTS: The most common clinical syndrome in these 42 patients was chronic cholecystitis, followed by acute cholecystitis. Seven (17%) cases presented with mild jaundice without choledocholithiasis. Thirty-five (83%) cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging, and 29 (69%) cases presented with abnormal enhancement in hepatic parenchyma neighboring the gallbladder, which indicated hepatic infiltration. Intra-operatively, adhesions to adjacent organs were observed in 40 (95.2%) cases, including the duodenum, colon and stomach. Thirty cases underwent FS analysis and the remainder did not. The accuracy rate of FS was 93%, and that of surgeon’s macroscopic diagnosis was 50%. Six cases were misidentified as GBC by surgeon’s macroscopic examination and underwent aggressive surgical treatment. No statistical difference was encountered in the incidence of postoperative complications between total cholecystectomy and subtotal cholecystectomy groups (21% vs 20%, P > 0.05).CONCLUSION: Neither clinical manifestations and laboratory tests nor radiological methods provide a practical and effective standard in the differential diagnosis between XGC and GBC.     

Stones from cancerous and benign gallbladders are different: A proton nuclear magnetic resonance spectroscopy study

Aim: Gallbladder cancer (GBC) is frequently associated with gallstones (GS). At the same time, however, a very small number of patients with GS develop GBC. Cholesterol and metal salts are the common constituents of all GS. To understand their role in the etiopathogenesis of GBC, cholesterol, calcium, and magnesium composition in GS is compared in cancerous and benign gallbladders. Methods: GS from patients with GBC (n = 11), chronic cholecystitis (CC; n = 23), and xanthogranulomatous cholecystitis (XGC; n = 11) undergoing cholecystectomy were analyzed using proton nuclear magnetic resonance spectroscopy. The diagnosis of the gallbladder disease was based on histopathological examinations. Cholesterol, calcium, and magnesium in the GS of GBC, XGC, and CC were analyzed, compared, and correlated using statistical methods. Results: The quantity of cholesterol was significantly less in the GS of GBC than in benign gallbladder diseases (CC or XGC, P < 0.0001 for both). Both calcium and magnesium were significantly higher in GBC than in benign disease (calcium: P < 0.0005 and magnesium: P < 0.0001 for GBC vs CC; calcium: P < 0.02 and magnesium: P < 0.04 for GBC vs XGC). In all the GS, calcium was higher than magnesium. Calcium and magnesium were positively correlated in GBC (R = 0.69) and XGC (R = 0.75), and cholesterol and calcium were negatively correlated in CC (R =?0.61). Conclusion: Differences in the GS composition between malignant and benign gallbladder patients may provide useful clues to the etiopathogenesis of GBC. These clues could lead to the identification of patients with GS in vivo who are at high risk of developing GBC, and advocate prophylactic cholecystectomy to prevent GBC.     

Gallbladder cancer in northern Jordan

BACKGROUND AND AIM: To highlight the epidemiological, clinical, and pathological features of gallbladder cancer in Jordan as a model for the Middle East. Only scattered reports are available from this region. METHODS: The histopathological reports and the hospital records for all cholecystectomies performed at Princess Basma Teaching Hospital between 1994-2000 were retrospectively reviewed to identify all patients with gallbladder carcinoma. All the histological slides for the cancer group were reviewed and reclassified by a single pathologist. RESULTS: Of 4502 cholecystectomies performed, 33 cases (0.73%) of gallbladder carcinoma were found. The mean age was 61.4 years (range 39-80 years). The male : female ratio was 1 : 3.7. Biliary colic and/or acute cholecystitis were the main presentations. Gallstones were present in 88% (29/33) of the patients. The spectrum of histological subtypes was similar to other series. Only three cases were diagnosed preoperatively, making the incidence of incidental gallbladder cancer 0.66% (30/4502). Simple cholecystectomy was performed for 13 patients. The remaining 20 patients underwent cholecystectomy and portal lymphadenectomy with (five cases) or without (15 cases) extrahepatic resection of the bile ducts. The mean follow up was 22 months (SD +/- 18.95 months; range 1-96 months). The 2-year survival rates for stages I, II, III, and IV were 100%, 42.9%, 10.8%, and 0%, respectively (P = 0.0013). CONCLUSIONS: The importance of a high index of suspicion when dealing with cholelithiasis in elderly patients, particularly with large sized stones, cannot be over-emphasized. Proper gross inspection in the theater should be a routine procedure performed by all surgeons. Routine ultrasound for suspected gallbladder stones should always be performed under the supervision of senior radiologists.     

Single-port versus multi-port cholecystectomy for patients with acute cholecystitis: a retrospective comparative analysis

BACKGROUND: Trans-umbilical single-port laparoscopic cholecystectomy for chronic gallbladder disease is becoming increasingly accepted worldwide. But so far, no reports exist about the challenging single-port surgery for acute cholecystitis. The objective of this study was to describe our experience with single-port cholecystectomy in comparison to the conventional laparoscopic technique. METHODS: Between August 2008 and March 2010, 73 patients with symptomatic gallbladder disease and histopathological sign...     

Unexpected gallbladder cancer during laparoscopic cholecystectomy

Background/Purpose

In the present study, we investigated the effectiveness of surgeons in determining incidental gallbladder pathologies at laparoscopic cholecystectomy (LC).

Methods

This study included 548 patients with gallstones who underwent LC between May 1, 2001 and October 15, 2003. The surgeon made an incision on the gallbladder wall for inspection, and palpated the mucosa after removing the gallbladder from the abdominal cavity to look for unsuspected pathologies. If an abnormal mucosa was observed or palpated, it was marked with a silk suture and then histopathologic examination was performed.

Results

Fifty of 548 LC specimens were found to be suspi-cious by the surgeon. Histopathological examination of frozen sections revealed incidental pathologies in 15 of these specimens. Strikingly, 5 of these specimens were considered to have gallbladder cancer (GBC). The other incidental pathologies were consistent with adenomyomatosis, xanthogranulomatous cholecystitis, and fibroepithelial and hyperplastic polyps. Four of the other 498 specimens revealed incidental pathologies at definitive histopathological examination, and all of them were consistent with gastric metaplasia. The sensitivity and specificity of the procedure was 78.9% and 93%, respectively.

Conclusions

A simple prosedure; that is, incision and inspection, and palpation of the gallbladder, seems to be useful for the diagnosis of incidental gallbladder pathologies.

     

Xanthogranulomatous cholecystitis: differentiation from associated gall bladder carcinoma.

Xanthogranulomatous cholecystitis (XGC) is a destructive form of chronic cholecystitis. In some patients it coexists with gall bladder carcinoma (GBC) and is often difficult to differentiate between the two. Present study was performed with an aim to identify differentiating features of XGC and those of XGC with associated Gall bladder carcinoma (XGC ass. GBC). A retrospective analysis of prospectively maintained data of 4800 cholecystectomies performed from January 1988 to December 2003 was carried out. On histopathology 453 cholecystectomy specimens revealed XGC. These patients were divided into two groups, those with associated GBC (n=26) and those without GBC (n=427). Clinical, radiological and operative findings were compared in these two groups. P value of < 0.05 was considered statistically significant. The incidence of associated GBC in present series was 6%. XGC patients with associated GBC, at presentation were older than those with XGC alone and there was male preponderance. XGC patients with associated GBC were more likely to present with anorexia, weight loss, palpable lump and jaundice. Gall stones were present in majority of patients in both the groups. GB wall thickening, GB mass, enlarged abdominal lymph nodes may be found on imaging in both the groups but more so in patients with associated GBC. Both preoperative FNAC and peroperative FNAC/imprint cytology failed to reveal the associated GBC with XGC in some patients.     

Clinical relevance of gallbladder polyps; is cholecystectomy always necessary?

BackgroundGallbladder polyps are common incidental findings during abdominal ultrasonography. Cholecystectomy is recommended for polyps equal or greater than 10 mm on ultrasound due to their malignant potential. However, the majority of lesions appear to be pseudopolyps with no malignant potential. Our aim was to determine the correlation between ultrasonographic findings and histopathological findings after cholecystectomy for gallbladder polyps in two institutions.MethodA retrospective analysis was performed at two Dutch institutions of patients who underwent cholecystectomy. All cholecystectomies for suspected gallbladder polyps between January 2010 and August 2017 were included. Ultrasonographic and histopathological reports were analyzed.ResultsA total of 108 patients underwent cholecystectomy for gallbladder polyps. At abdominal ultrasound sixty-five patients (60.2%) were diagnosed with multiple gallbladder polyps. The mean diameter of the polyps was 11 mm. On pathological examination after cholecystectomy, only three specimens harbored true polyps. No anomalies were found in 48 (44%) patients and 51 (47%) had cholesterolosis.ConclusionThe prevalence of true gallbladder polyps was much lower in this study than reported in literature. After cholecystectomy for gallbladder polyps diagnosed by ultrasound, 97% of patients had non-neoplastic or not identifiable lesions in the gallbladder. These findings question the usefulness of current guidelines for management of suspected gallbladder polyps.     

Prognostic significance of nuclear hepatoma-derived growth factor expression in gallbladder cancer

AIM: To assess the expression of nuclear hepatoma-derived growth factor (HDGF) in benign and malignant gallbladder lesions and to determine its clinicopathological significance.METHODS: We studied 40 patients with gallbladder cancer (GBC) and a control group of 40 patients with cholelithiasis. All diagnoses of GBC and cholelithiasis were confirmed by histopathological examination after surgery. None of the patients received chemotherapy or radiotherapy before surgery. All tissue samples were fixed in 4% formalin immediately after removal and embedded in paraffin for immunohistochemical staining. The HDGF expression in the GBC and cholelithiasis specimens was examined by immunohistochemical staining. The relationship between the HDGF expression and the clinicopathological parameters of GBC was analyzed.RESULTS: Nuclear HDGF expression was significantly higher (77.5%) in GBC than in chronic cholelithiasis (21.5%, P < 0.001). High nuclear HDGF levels were associated with histopathological subtype (P < 0.05), clinical stage (P < 0.01), and perineural invasion (P < 0.01) but not with sex, age, history of gallstones, or lymph node metastasis. A univariate Kaplan-Meier analysis showed that positive nuclear HDGF expression was associated with decreased overall survival (P < 0.01). Multivariate Cox regression analysis showed that nuclear HDGF expression and lymph node metastasis were independent risk factors for disease-free survival.CONCLUSION: The expression of nuclear HDGF might be closely related to the carcinogenesis, clinical biological behaviors, and prognosis of gallbladder adenocarcinoma.     

Verres needle decompression of distended gallbladder to facilitate laparoscopic cholecystectomy in acute cholecystitis: a prospective study

BACKGROUND/AIMS: Grasping a thick and distended gallbladder is one of the most common technical difficulties of laparoscopic cholecystectomy in acute cholecystitis. This prospective study was conducted to investigate the use of the Verres needle decompression method to facilitate laparoscopic cholecystectomy in acute cholecystitis. METHODOLOGY: Between April 1998 and April 2002, patients with acute cholecystitis scheduled to receive laparoscopic cholecystectomy emergently were included. A Verres needle was applied through the subcostal area to decompress the acute inflamed distended gallbladder after establishing pneumoperitoneum. RESULTS: In total 54 patients, 30 male and 24 female with mean age 53.50 years (range 21-80), consented to the operation. Laparoscopic cholecystectomy was performed successfully in 44 patients. The conversion of laparoscopic cholecystectomy to open surgery was needed in 10 patients (conversion rate: 18.5%). The failure to identify the triangle of Calot is the only risk factor associated with conversion. The more severe acute cholecystitis is, the higher the conversion rate is (11.5% in uncomplicated cholecystitis, 31.6% in complicated cholecystitis). No bile duct injury was noted. Postoperative morbidity happened in three cases: two port-site discharge and one subphrenic abscess. No mortality occurred. CONCLUSIONS: Verres needle decompression of the acute inflamed gallbladder did facilitate laparoscopic cholecystectomy in acute cholecystitis with low conversion rate.     

The risk of incidental gallbladder cancer is negligible in macroscopically normal cholecystectomy specimens

Background

Cholecystectomy is usually carried out for benign indications. Most perform routine histopathologic examination to detect incidental gallbladder cancer (GBC).

Estudio histopatológico de la presencia de bacterias tipo Helicobacter pylori en especímenes quirúrgicos con colecistitis crónica

Introduction

Helicobacter species have recently been found to be associated with some diseases of the biliary tree but this relationship remains unclear and further studies are required. The aim of this study was to determine the presence of H. pylori-type bacteria in patients with a diagnosis of chronic cholecystitis through histopathological study of surgical gallbladder specimens.

Materials and methods

Surgical gallbladder specimens from patients with a diagnosis of chronic cholecystitis were examined histopathologically. The macroscopic characteristics of the specimens were identified. Histopathological slices were stained with hematoxylin-eosin and Giemsa.

Results

Of the 68 patients who underwent cholecystectomy, 56 (81%) were women and 12 (19%) were men. The mean age was 39.56 + 11.94 years. H. pylori-type bacteria were found in 6%.

Conclusions

The results of this study do not allow us to conclude that the presence of H. pylori-type bacteria is a major factor in the etiology and/or pathogenesis of chronic cholecystitis. In patients with chronic cholecystitis undergoing cholecystectomy included in the present study, the etiology of the disease may be more closely linked with the presence of gallstones.     

Spontaneous necrosis of solid gallbladder adenocarcinoma accompanied with pancreaticobiliary maljunction

A 71-year-old Japanese man with acute cholecystitis and an incarcerated gallbladder （GB） stone was admitted. Plain ultrasonography （US） incidentally detected a mass-like lesion in the fundus. Doppler US revealed that this elevated lesion had no blood flow. Computed tomography showed a relatively low-density mass, measuring 5 cm x 4 cm in diameter, with no positive enhancement. Magnetic resonance imaging showed a mass in the fundus with a slightly low intensity on Tl-weighted images and a slightly high intensity on T2-weighted images. We were agonized in making the qualitative diagnosis of mass-like lesions of the fundus, such as a benign tumor, cancer, or debris. We performed laparoscopic cholecystectomy, because the incarcerated GB stone clearly caused acute cholecystitis. Intra-operative cholangiography clearly revealed pancreaticobiliary maljunction. Amylase levels in the common bile duct and gallbladder were quite high. The elevated lesion in the fundus dearly showed severe necrosis. Although this necrotic nodule included non-viable adenocarcinoma cells, viable cancer cell nests were located in the muscularis propria and subcutaneous layer. Histopathological examination confirmed a solid adenocarcinoma. Thus, we diagnosed it as a gallbladder cancer, based on histopathological analysis of the resected specimen. We therefore undertook radical surgery, including wedge resection of the liver, radical dissection of regional lymph nodes, and resection of the extrahepatic bile duct. Histopathological findings revealed no cancer, hyperplasia or dysplasia in the additionally resected specimens. The patient was finally staged as T2, N0, H0, P0, M（-）, stage Ⅱ. We present the first case of spontaneous necrosis of solid gallbladder adenocarcinoma, with a review of previous studies.     

Laparoscopic cholecystectomy in the treatment of acute cholecystitis. Prospective non-randomized study

OBJECTIVES: To evaluate the results of laparoscopic cholecystectomy in patients with acute cholecystitis and to determine the optimal timing. PATIENTS AND METHODS: From January 1993 to December 1999, 168 patients (91 women and 77 men with a mean age of 57.3 years) underwent laparoscopic cholecystectomy for acute cholecystitis confirmed by histopathological examination. Patients were divided into 2 groups (similar in age and ASA classification): group 1 (106 patients) underwent laparoscopic cholecystectomy within 3 days after the onset of symptoms of acute cholecystitis and group 2 (62 patients) underwent laparoscopic cholecystectomy after 3 days. RESULTS: There was no death. Conversion rates were 30.9%. Surgery lasted 141.3 min, postoperative morbidity was 12.5%, and the postoperative length of hospital stay was 6.9 days. The conversion rates in patients who underwent surgery before and 3 days after the onset of symptoms were respectively 21.7% and 46.7% (P=0.0007). There was no statistical difference between early and delayed surgery for time to surgery and postoperative complications. On the other hand, the total hospital stay was significantly shorter in group 1. CONCLUSION: Laparoscopic cholecystectomy for acute cholecystitis is safe and associated with a shorter postoperative stay, a lesser morbidity and a lesser mortality compared to "open" surgery. Laparoscopic cholecystectomy should be carried out soon as the diagnostic of acute cholecystitis is established and preferably before 3 days after the onset of the symptoms. Early laparoscopic cholecystectomy allows a reduction of the conversion rate and a reduction of total hospital stay that are medical and economic benefits.     

Early gallbladder carcinoma associated with primary sclerosing cholangitis and ulcerative colitis

Patients troubled with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) are at high risk for cholangiocarcinoma, whereas cancer of the gallbladder (GBC) is rarely reported to develop in that population. A Japanese man aged 62 years with a 14-year history of PSC and UC had been found to have a protruding lesion of the gallbladder by screening sonography. The preoperative examination suggested the lesion to be GBC at an early stage. Pathology examination after cholecystectomy proved that the lesion was papillary adenocarcinoma localized in the mucosal layer. Although the prognosis of GBC is poor, the outcome of cholecystectomy against early GBC is relatively good. Early detection of the tumor is required for a better prognosis of patients with GBC. According to the review of the literature, PSC and UC patients are regarded as a high-risk group not only for cholangiocarcinoma but also GBC. It is advocated that clinicians perform repeated radiographic examinations including sonography for patients with PSC and UC even if the diseases are being controlled.     

Preoperative diagnosis and management of thick-walled gallbladder based on bile cytology obtained by endoscopic transpapillary gallbladder drainage tube

BACKGROUND: It is often difficult to distinguish gallbladder cancers (GBC) from benign gallbladder diseases, which show thickened walls. OBJECTIVES: To evaluate the efficacy of bile cytology using endoscopic transpapillary gallbladder drainage (ETGD) and CT. DESIGN: Retrospective study. SETTING: Division of Gastroenterology, Tokyo Medical University, Tokyo, Japan. PATIENTS AND INTERVENTIONS: Eighty-five patients with gallbladder diseases, consisting of 27 GBC and 58 benign gallbladder diseases, were reviewed. A pigtail-type nasobilliary drainage tube was left indwelling in the gallbladder, and through this drainage tube washing cytology was performed with an ETGD tube. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy of CT and cytology. Complications and outcome were also evaluated. RESULTS: CT and cytology with the ETGD tube had 81% and 81% sensitivity, 91% and 83% specificity, and 88% and 82% accuracy, respectively (P > .05). Looking only at the 71 successful ETGD cases, CT and ETGD cytology had 82% and 100% sensitivity, 92% and 98% specificity, and 89% and 99% accuracy, respectively (P = .036 and .025, respectively). Four patients with GBC in whom CT showed benign findings underwent open cholecystectomy because ETGD cytology revealed malignant findings. In contrast, 4 patients with benign diseases in whom CT suggested malignant finding underwent LC because the findings of ETGD cytology suggested benign disease. CONCLUSIONS: Cytology using an ETGD tube is very useful in the diagnosis and management of gallbladder diseases.