Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.     

Gallbladder ejection fraction and its relationship to sphincter of Oddi dysfunction

Theoretically, relative distal common bile duct obstruction due to sphincter of Oddi dysfunction may be a cause of poor gallbladder evacuation observed on quantitative cholescintigraphy. In this study, the relationship of sphincter of Oddi dysfunction to the gallbladder ejection fraction by quantitative cholescintigraphy was explored. Eighty-one patients with biliary-type pain and otherwise normal evaluations underwent quantitative cholescintigraphy, sphincter of Oddi manometry, and ERCP. Abnormalities of stimulated quantitative cholescintigraphy and/or sphincter of Oddi manometry were present in 70% of this study group. Manometric evidence of sphincter dysfunction was present in patients with similar frequency irrespective of the degree of gallbladder evacuation. In conclusion, abnormalities of quantitative cholescintigraphy and sphincter manometry appear to be independent factors, although frequent findings in this patient population.     

Die akute Gallenkolik

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.     

Experience with Laparoscopic Cholecystectomy

Abstract: Laparoscopic cholecystectomy is rapidly replacing conventional cholecystectomy as the treatment of choice for gallbladder stone disease because of its lower morbidity. Our study began on 29th May, 1990 and continued until February 28th, 1991. 40 laparoscopic cholecystectomies were successfuly performed. 4 patients had an open cholecystectomy instead because of bleeding in 1, dense adhesions in 2 and Mirizzi's Syndrome in 1. The two technical measures taken to avoid common bile duct injury, were 1) exposure of both the cystic duct and cystic artery in the same field before clipping and division 2) demonstration of the continuity between the cystic duct and the Hartman's pouch. Technical difficulties often encountered were extensive adhesions, multiple or giant stones, inflamed gallbladder and a short or dilated cystic duct. There were 4 complications; one diaphragmatic injury resulting in a pneumothorax, one periumbilical subcutaneous emphysema and 2 mild bile leaks. On average, each patient required 1.3 intramuscular analgesic injections and spent 10 days recuperating in hospital. In Japan, many patients insist on staying longer in hospital. We believe that laparoscopic cholecystectomy will rapidly become the preferred treatment for gallbladder stone disease.     

Acute biliary colic. Etiology,diagnosis and therapy

Acute biliary pain represents the main symptom of gallbladder stones, less frequently of common bile duct stones or functional disorders of the biliary tract. The pain lasts at least 15 minutes, is typically localized to the epigastrium or the right upper quadrant of the abdomen and my radiate to the right shoulder. Diagnosis of biliary pain is primarily based on clinical criteria, ultrasound allows detection of causative gallstones with high sensitivity and specificity. Analgesics and laparoscopic cholecystectomy are widely accepted as standard therapy for the majority of patients.     

Pain attacks in non-complicated and complicated gallstone disease have a characteristic pattern and are accompanied by dyspepsia in most patients: The results of a prospective study

Objective. The cardinal indication for surgical treatment of gallstones is pain attacks. However, following cholecystectomy, 20% of patients remain symptomatic. It is unclear to what extent post-cholecystectomy symptoms can be ascribed to persistence of preoperative symptoms or to new pathology. The pain and digestive pattern in gallstone patients has not been defined in a recent setting with ultrasonography as the diagnostic method. The aim of this study was to characterize a pain pattern that is typical for gallstone disease and to describe the extent of associated dyspepsia. Material and methods. A total of 220 patients with symptomatic gallstone disease including complicated disease (acute cholecystitis and common bile duct stones) were interviewed using detailed questionnaires to disclose pain patterns and symptoms of indigestion. Results. All patients had pain in the right upper quadrant (RUQ) including the upper midline epigastrium. The pain was localized to the right subcostal area in 20% and to the upper epigastrium in 14%, and in the rest (66%) it was more evenly distributed. An area of maximal pain could be defined in 90%. Maximal pain was located under the costal arch in 51% of patients and in the epigastrium in 41%, but in 3% behind the sternum and in 5% in the back. The pain was referred to the back in 63% of the patients. The mean visual analogue scale (VAS) score was very high: 90 mm on a 0–100 scale. A pattern of incipient or low-grade warning pain with a subsequent relatively steady state until subsiding in the same fashion was present in 90% of the patients. An urge to walk around was experienced by 71%. Pain attacks usually occurred in the late evening or at night (77%), with 85% of the attacks lasting for more than one hour and almost never less than half an hour. Sixty-six percent of the patients were intolerant to at least one kind of food, but only 48% to fatty foods. Symptoms of functional indigestion (gastroesophageal reflux, dyspepsia or irritable bowel symptoms) were seen in the vast majority in association with attacks. Conclusions. Gallstone-associated pain follows a certain pattern in the majority of patients. The pain is located in a defined area with a point of maximum intensity, is usually referred, and occurs mainly at night with duration of more than one hour. The majority of patients experience functional indigestion, mainly of the reflux type or dyspepsia.     

Preoperative diagnosis of gallbladder torsion by magnetic resonance cholangiopancreatography

The patient was a 78-year-old woman who was diagnosed as having gallbladder torsion preoperatively. This is the first reported case diagnosed by magnetic resonance cholangiopancreatography (MRCP). Signs and symptoms of this condition are often subtle. Radiologic evaluation by ultrasonography and computed tomography (CT) showed acute cholecystitis with stone. Drip-infusion cholangiography CT failed to outline the gallbladder, and distortion of the extrahepatic bile ducts and interruption of the cystic duct were observed. MRCP showed 1) a v-shaped distortion of the extrahepatic bile ducts due to traction by the cystic duct, 2) tapering and twisting interruption of the cystic duct, 3) a distended and enlarged gallbladder that was deviated to the midline of the abdomen, and 4) a difference in intensity between the gallbladder and the extrahepatic bile ducts and the cystic duct. A definitive diagnosis of gallbladder torsion (volvulus) was made by MRCP preoperatively. If treated surgically, gallbladder detorsion before cholecystectomy is a helpful technique to avoid bile duct injury. This condition should be suspected in elderly women with acute cholecystitis or acute abdominal pain of unknown origin, and MRCP may be very useful in making a definitive diagnosis.     

Preoperative Diagnosis of Gallbladder Torsion by Magnetic Resonance Cholangiopancreatography

The patient was a 78-year-old woman who was diagnosed as having gallbladder torsion preoperatively. This is the first reported case diagnosed by magnetic resonance cholangiopancreatography (MRCP). Signs and symptoms of this condition are often subtle. Radiologic evaluation by ultrasonography and computed tomography (CT) showed acute cholecystitis with stone. Drip-infusion cholangiography CT failed to outline the gallbladder, and distortion of the extrahepatic bile ducts and interruption of the cystic duct were observed. MRCP showed 1) a v-shaped distortion of the extrahepatic bile ducts due to traction by the cystic duct, 2) tapering and twisting interruption of the cystic duct, 3) a distended and enlarged gallbladder that was deviated to the midline of the abdomen, and 4) a difference in intensity between the gallbladder and the extrahepatic bile ducts and the cystic duct. A definitive diagnosis of gallbladder torsion (volvulus) was made by MRCP preoperatively. If treated surgically, gallbladder detorsion before cholecystectomy is a helpful technique to avoid bile duct injury. This condition should be suspected in elderly women with acute cholecystitis or acute abdominal pain of unknown origin, and MRCP may be very useful in making a definitive diagnosis.     

Usefulness of cholescintigraphy with lipid meal loading for diagnosis and determination of cholecystectomy in a patient with gallbladder dysfunction

A 47-year-old woman was admitted to our hospital because of upper abdominal and back pain. Abdominal ultrasonogram, computed tomogram, endoscopic retrograde cholangiopancreatography and arteriography examination did not reveal any abnormalities. As cholescintigraphy after lipid meal loading detected dysfunction of the gallbladder, we diagnosed dyskinesia of the gallbladder. And the output ratio of the gallbladder from scintigraphy was less than 1%. Cholecystectomy completely relived her from symptoms. Histological examination disclosed chronic cholecystitis and arteritis causing dysfunction of the gallbladder. This case suggested the usefulness of cholescintigraphy with lipid meal loading for gallbladder dysfunction in determining whether or not to do cholecystectomy.     

Evaluation of Hepatobiliary Function by Hepatobiliary Scintigraphy in Hepatoma Patients after Transcatheter Arterial Embolization

Background: Transcatheter arterial embolization (TAE) is the treatment of choice for inoperable hepatocellular carcinoma. However, altered and impaired gallbladder function due to gallbladder infarction and bile duct necrosis following TAE have been reported. Methods: Hepatobiliary function was evaluated using quantitative Tc-99m DISIDA hepatobiliary scintigraphy in 40 hepatoma patients before and after TAE. The patients were separated into two groups: group 1 (20 patients), who received pre-cystic artery TAE, and group 2 (also 20 patients), who received post-cystic artery TAE. Results: After TAE, there were no significant changes in liver or bile duct function in the patients of either group. However, for group 1 patients, significantly decreased gallbladder function was found after TAE. Conclusions: Altered and impaired gallbladder function is common in hepatoma patients who receive pre-cystic artery TAE, and Tc-99m DISIDA cholescintigraphy may be useful for evaluating hepatobiliary function in hepatoma patients who receive TAE.     

Acalculous biliary pain: cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy

A 45-minute infusion of an octapeptide of cholecystokinin (Kinevac; Squibb Diagnostics, New Brunswick, NJ) was used to measure the gallbladder ejection fraction during cholescintigraphy in 40 normal volunteers. Cholecystokinin cholescintigraphy was shown to be a reproducible test. The maximum mean gallbladder ejection fraction occurred 15 minutes after cholecystokinin infusion and was 74.5% +/- 1.9% (mean +/- SEM). A gallbladder ejection fraction greater than 40% (mean -3SD) was arbitrarily defined to be normal. The gallbladder ejection fraction test was then used to identify patients with acalculous biliary symptoms who may respond to cholecystectomy. A total of 103 patients was tested; 21 had abnormal gallbladder ejection fractions and were randomized into two groups, cholecystectomy or no operation. These patients were followed up symptomatically at 3-month intervals for 13-54 months (mean, 34 months). Of the 11 patients who underwent cholecystectomy, 10 (91%) lost their symptoms and 1 improved. Of the 10 patients in the group that did not undergo surgery, all continued to be symptomatic, 2 of whom requested cholecystectomy after 13 and 24 months, respectively. Of the 13 gallbladders obtained from surgery, 12 showed evidence of chronic cholecystitis, muscle hypertrophy, and/or narrowed cystic duct. A normal gallbladder ejection fraction was recorded in 82 patients, and further treatment was left to the discretion of their referring clinician. On follow-up, 50 patients were asymptomatic and 10 were symptomatic without specific treatment of the biliary tract; 14 underwent cholecystectomy, 8 of whom were asymptomatic. Pathological abnormalities were recorded in 6 of the removed gallbladders. It is concluded that the gallbladder ejection fraction obtained after a 45-minute infusion of cholecystokinin during cholescintigraphy is a reproducible measure of gallbladder emptying, and that cholecystectomy alleviates the biliary-type pain of patients with a reduced gallbladder ejection fraction.     

Morphologic factors of biliary trees are associated with gallstone-related biliary events

AIM: To determine the risk factors for gallstone-related biliary events.METHODS: This retrospective cohort study evaluated magnetic resonance cholangiopancreatography imagesfrom 141 symptomatic and 39 asymptomatic gallstone patients who presented at a single tertiary hospital between January 2005 and December 2012.RESULTS: Logistic regression analysis showed significant differences between symptomatic and asymptomatic patients with gallstones in relation to the number of gallstones,the angle between the long axis of the gallbladder and the cystic duct,and the cystic duct diameter.Multivariate analysis showed that the number of gallstones(OR = 1.27,95%CI: 1.03-1.57; P = 0.026),the angle between the long axis of the gallbladder and the cystic duct(OR = 1.02,95%CI: 1.00-1.03; P = 0.015),and the diameter of the cystic duct(OR = 0.819,95%CI: 0.69-0.97; P = 0.018) were significantly associated with biliary events.The incidence of biliary events was significantly elevated in patients who had the presence of more than two gallstones,an angle of 92° between the gallbladder and the cystic duct,and a cystic duct diameter 6 mm.CONCLUSION: These findings will help guide the treatment of patients with asymptomatic gallstones.Clinicians should closely monitor patients with asymptomatic gallstones who exhibit these characteristics.     

The Effects of Morphine on Biliary Dynamics: A Scintigraphic Study with 99mTc-HIDA

The effect ot morphine on bilixy dynamics was studied by cholescintigraphy with ^99mTc-HIDA. Among 30 normals without morphine injection 3 did not demonstrate intestinal radioactivity after I h. whereas all visualized the gallbladder. Eight normals with morphine injection did nor demonstrate intestinal radioactivity after 2 h. hut all had gallbladder visualization wry early. Variables of the time-activity curves from liver areas did not point to impaired uptake or excretion. Morphine-induced increase in resistance to passage from the common duct to the intestines in normals is of a magnitude that forces the tutal amount of bile to accumulate in the gallbladder. Results from 11 patients aftcr chokcystectomy indicate that the increase in pressure illess than the nraximal secretory pressure of the liver. The resorptive capacity and the compliance of the gallblsdder cnable these events to take place without signs of secondary liver impairment.     

A case of double cystic duct with cholecystolithiasis treated by laparoscopy

A case of cholecystolithiasis with double cystic duct treated successfully by laparoscopic surgery is reported. The patient was a 50-year-old female who presented with abdominal pain in the right upper quadrant. On admission, extracorporeal ultrasonography (US) revealed a hyperechoic area accompanied by an obscure acoustic shadow in the gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) revealed two cystic ducts that led separately from the same cluster of the gallbladder. After preoperative examination around the biliary tree, we determined that laparoscopic cholecystectomy was the treatment of choice. Intraoperative color Doppler US was useful for distinguishing the cystic duct from vessels. An ultrasound aspirator (UA) was also extraordinarily useful for skeltonizing the cystic ducts and the cystic artery. The postoperative course was not eventful. Our findings suggest that laparoscopic cholecystectomy, using an UA, is indicated in patients with an anomalous arrangement of the biliary system, since the use of the UA provides a clear delineation of the anatomy of Calot's triangle.     

Relationship between cystic duct diameter and the presence of cholelithiasis

We sought to measure cystic duct diameter in patients without biliary calculi and in those with cholelithiasis or choledocholithiasis. Using endoscopic retrograde cholangiopancreatography (ERCP), we visualized the cystic duct in 168 patients referred to our unit. These patients were distributed into three groups based on findings at ERCP: Group I (N=57), no calculi in the gallbladder or common bile duct; group II (N=27), stones found in the gallbladder but absent from the common bile duct; and group III (N=34), stones present in the common bile duct with or without gallbladder stones. The diameter of the cystic duct was measured at its widest and narrowest dimensions. The largest diameter measured was greater in group III (7.72±2.29 mm) than in groups I (2.63±0.67 mm) and II (4.59±1.13 mm) (P<0.001). The same differences were found in measurement of the smallest diameter (5.00±0.99 mm, 3.10±0.62 mm, and 1.83±0.53 mm, for groups III, II, and I, respectively) (P<0.001). Maximal and minimal cystic duct diameter show a progressive increase at each level of disease. This increase in cystic duct size may facilitate the migration of gallstone fragments after lithotripsy and facilitate the instrumentation of the cystic duct during ERCP and laparoscopic cholecystectomy.     

Nonvisualized gallbladder on oral cholecystography: implications for lithotripsy

Currently, most protocols evaluating the efficacy of gallstone lithotripsy require a visualized gallbladder on oral cholecystography (OCG). The primary purpose of the OCG is to establish that the cystic duct is patent. When the gallbladder is visualized on OCG, it can also be used to number and size gallstones accurately. Patients with non-visualization of the gallbladder on OCG are excluded from consideration for lithotripsy. The purpose of this study was to evaluate retrospectively the ultrasonographic findings (i.e., number and sizes of stones in 32 patients with nonvisualization on the OCG). In 11 patients (34%) ultrasound (US) did not detect any stone, and it is presumed that the gallbladder failed to visualize for other reasons. Six patients (19%) had one or two stones and 15 (47%) patients had more than three stones. This suggests that 20% of patients with nonvisualization of the gallbladder on OCG would otherwise be eligible for lithotripsy provided that patency of the cystic duct can be demonstrated by other means, such as computed tomographic (CT) examination with oral biliary contrast or cholescintigraphy.     

A case of gallbladder cancer associated with a common bile duct neuroma,and a cystic lesion of the liver with histologic findings similar to those of an inflammatory pseudotumor

We report a rare case of gallbladder cancer associated with a common bile duct neuroma, and a cystic liver lesion with histologic findings similar to an inflammatory pseudotumor, in a patient who had had no previous abdominal surgery. The patient was a 62-year-old man whose major complaint was fever. Ultrasonography and a computed tomography scan revealed gallstones, an elevated lesion in the gallbladder, and a cystic liver lesion. Endoscopic retrograde cholangiopancreatography demonstrated stenosis of the common bile duct. Cultures of the cystic fluid and gallbladder bile were positive forStaphylococcus aureus. The patient underwent hepatectomy (inferior S4, S5, and S6), cholecystectomy, resection of the common bile duct, and right hemicolectomy. The resected specimens revealed gallbladder cancer with the microscopic appearance of a papillary adenocarcinoma, and a 12×4.5×3.5 cm cystic liver lesion with a wall 7 mm thick. Histologic studies of the wall of the cystic liver lesion revealed infiltration by histiocytes and plasma cells, and the presence of fibrous connective tissue, which findings are characteristic of inflammatory pseudotumors. A 9×6 mm elevated lesion, with the microscopic appearance of a neuroma, was resected from the common bile duct.     

Double cystic duct detected by endoscopic retrograde cholangiopancreatography and confirmed by intraoperative cholangiography in laparoscopic cholecystectomy: a case report

A case of double cystic duct with cholecystolithiasis detected by preoperative endoscopic retrograde cholangiopancreatography and confirmed by intraoperative cholangiography which was treated successfully by laparoscopic surgery is reported. The patient was a 74-year-old woman who complained of abdominal pain in the right upper quadrant. On admission, ultrasonography revealed hyperechoic areas accompanied by obscure acoustic shadows in the gallbladder. Preoperative endoscopic retrograde cholangiopancreatography showed 2 cystic ducts; 1 branched from the common bile duct and the other from the right hepatic duct. After a diagnosis of double cystic ducts, we chose laparoscopic cholecystectomy. Intraoperative cholangiography via 1 of the cystic ducts revealed the presence of the other. We were able to perform laparoscopic cholecystectomy without any complications and the postoperative course was uneventful. This case suggests that preoperative endoscopic retrograde cholangiopancreatography and intraoperative cholangiography is required to avoid complications during laparoscopic cholecystectomy.     

Preoperative prediction model of outcome after cholecystectomy for symptomatic gallstones

BACKGROUND: After cholecystectomy for symptomatic gallstone disease 20%-30% of the patients continue to have abdominal pain. The aim of this study was to investigate whether preoperative variables could predict the symptomatic outcome after cholecystectomy. METHODS: One hundred and two patients were referred to elective cholecystectomy in a prospective study. Median age was 45 years; range, 20-81 years. A preoperative questionnaire on pain, symptoms, and history was completed, and the questions on pain and symptoms were repeated 1 year postoperatively. Preoperative cholescintigraphy and sonography evaluated gallbladder motility, gallstones, and gallbladder volume. Preoperative variables in patients with or without postcholecystectomy pain were compared statistically, and significant variables were combined in a logistic regression model to predict the postoperative outcome. RESULTS: Eighty patients completed all questionnaires. Twenty-one patients continued to have abdominal pain after the operation. Patients with pain 1 year after cholecystectomy were characterized by the preoperative presence of a high dyspepsia score, 'irritating' abdominal pain, and an introverted personality and by the absence of 'agonizing' pain and of symptoms coinciding with pain (P < 0.000001). In a constructed logistic regression model 15 of 18 predicted patients had postoperative pain (PVpos = 0.83). Of 62 patients predicted as having no pain postoperatively, 56 were pain-free (PVneg = 0.90). Overall accuracy was 89%. CONCLUSION: From this prospective study a model based on preoperative symptoms was developed to predict postcholecystectomy pain. Since intrastudy reclassification may give too optimistic results, the model should be validated in future studies.     

High-grade dysplasia of the cystic duct margin in the absence of malignancy after cholecystectomy

BackgroundA total of 750 000 cholecystectomies are performed annually in the USA. No data exist on patients with microscopic high-grade dysplasia at the cystic duct margin and the associated incidence of cholangiocarcinoma.MethodsPathology reports for 1992–2010 were reviewed for patients with high-grade dysplasia of the cystic duct margin in the absence of invasive gallbladder cancer. Clinical data were obtained from chart review.ResultsFive patients with high-grade dysplasia at the cystic duct margin without evidence of malignancy were identified. Radiologic imaging was abnormal in two patients. The cystic duct stump was abnormally dilated in both patients and one patient had an enlarged portacaval lymph node. All five patients underwent exploration and resection of either the cystic duct stump or the bile duct. Specimens in four of the patients showed no evidence of malignancy or dysplasia. One patient was found to have a node-positive adenocarcinoma of the cystic duct.ConclusionsHigh-grade dysplasia at the cystic duct margin without evidence of invasive gallbladder cancer is rare. Patients with this finding should undergo cross-sectional imaging and a diagnosis of an underlying cholangiocarcinoma should be considered, especially if imaging reveals any abnormalities.