A case of transanal barotrauma by high-pressure compressed air leading to transverse colon perforation with extensive colon serosal tear.

INTRODUCTION AND IMPORTANCE: Compressed air is used to apply paint, wash vehicles or machines, and remove water droplets after washing the precision instrument. Barotrauma due to high-pressure compressed air is extremely rare. CASE PRESENTATION: We report a case of transverse colon perforation caused by a compressed air gun in a 20-year-old male. He used a compressed air machine to dust after work, and a coworker inserted compressed air transanally as a joke. Although he returned home once, he consulted a former hospital with worsening abdominal pain. Radiography and computed tomography (CT) revealed a massive amount of free air. The patient was admitted to our hospital. The patient underwent emergency surgery. Transverse colon perforation with extensive serosal tears and massive air bubbles inside the omental bursa were observed. Double-barrel colostomy using transverse colon perforation point for decompression and diverting the stoma at the ileum end was performed with serosal tear repair and abdominal cleaning drainage. Four months after the surgery, the patient underwent colostomy and diverting stoma closure. CLINICAL DISCUSSION: The management of colon injury due to compressed air has two aspects: tension pneumoperitoneum and colon injury. The initial management of tension pneumoperitoneum is converted to open pneumoperitoneum and early emergency operation for colon injury is recommended as soon as full-thickness perforation is diagnosed. CONCLUSION: Transanal high-pressure compressed air can cause lethal situations, and we encountered a similar case that required surgical intervention.

Should Lymph Nodes Be Retrieved in Patients with Intrahepatic Cholangiocarcinoma? A Collaborative Korea-Japan Study.

BACKGROUND: This study was performed to investigate the oncologic role of lymph node (LN) management and to propose a surgical strategy for treating intrahepatic cholangiocarcinoma (IHCC). METHODS: The medical records of patients with resected IHCC were retrospectively reviewed from multiple institutions in Korea and Japan. Short-term and long-term oncologic outcomes were analyzed according to lymph node metastasis (LNM). A nomogram to predict LNM in treating IHCC was established to propose a surgical strategy for managing IHCC. RESULTS: A total of 1138 patients were enrolled. Of these, 413 patients underwent LN management and 725 did not. A total of 293 patients were found to have LNM. The No. 12 lymph node (36%) was the most frequent metastatic node, and the No. 8 lymph node (21%) was the second most common. LNM showed adverse long-term oncologic impact in patients with resected IHCC (14 months, 95% CI (11.4-16.6) vs. 74 months, 95% CI (57.2-90.8), p < 0.001), and the number of LNM (0, 1-3, 4≤) was also significantly related to negative oncologic impacts in patients with resected IHCC (74 months, 95% CI (57.2-90.8) vs. 19 months, 95% CI (14.4-23.6) vs. 11 months, 95% CI (8.1-13.8)), p < 0.001). Surgical retrieval of more than four (≥4) LNs could improve the survival outcome in resected IHCC with LNM (13 months, 95% CI (10.4-15.6)) vs. 30 months, 95% CI (13.1-46.9), p = 0.045). Based on preoperatively detectable parameters, a nomogram was established to predict LNM according to the tumor location. The AUC was 0.748 (95% CI: 0.706-0.788), and the Hosmer and Lemeshow goodness of fit test showed p = 0.4904. CONCLUSION: Case-specific surgical retrieval of more than four LNs is required in patients highly suspected to have LNM, based on a preoperative detectable parameter-based nomogram. Further prospective research is needed to validate the present surgical strategy in resected IHCC.

A rare case of meningeal carcinomatosis and internal auditory canal metastasis presenting with the deafness for gastric cancer.

BACKGROUND: Meningeal carcinomatosis is a very rare metastatic site of gastric cancer and meningeal carcinomatosis without other metastatic sites is much extremely rare. Herein, we report our experience with a very rare case of meningeal carcinomatosis which was difficult to diagnose the recurrence by general systemic examination and was found due to the deafness despite the sustained high tumor markers. CASE PRESENTATION: A 68-year-old man consulted a hospital with vomiting and hematemesis. Laboratory tests revealed severe anemia. He was referred to our hospital and underwent an emergency gastroscopy, which revealed Borrman type 3 tumor and oozing of blood. Biopsy specimen showed gastric cancer. After several examinations, total gastrectomy was performed and tegafur-gimeracil-oteracil potassium (S-1) was initiated as adjuvant chemotherapy one month after surgery. Tumor marker levels (CEA and CA19-9) remained high for three months after surgery. S-1 was continued while shortening the imaging study follow-up period. Nine months after surgery, he noticed difficulty in hearing with facial paralysis, dizziness, tinnitus, and appetite loss. He was diagnosed with meningeal carcinomatosis and bilateral internal auditory canal metastasis. He died approximately two months later. CONCLUSION: Meningeal carcinomatosis should be considered if bilateral deafness and vestibulopathy develop after gastrectomy, even if no recurrence is apparent in the abdominal cavity.

S-1 and CPT-11 Plus Ramucirumab (IRIS+Rmab) as Second-Line Chemotherapy for Patients with Oxaliplatin-Refractory Metastatic Colorectal Cancer (mCRC): A Multicenter Phase II Study in Japan (N-DOCC-F-C-1701).

This multicenter phase II N-DOCC-F-C-1701 trial is being planned in order to investigate the efficacy and safety of CPT-11+S-1 +Ramucirumab (IRIS+Rmab), which is anticipated to have a stronger anti-tumor effect than IRIS+Bmab in patients with metastatic colorectal cancer (mCRC) previously treated with oxaliplatin (L-OHP) containing regimen, in consideration of the result of RAISE, FIRIS and some phase II trials of IRIS+Bevacicizumab (Bmab). The number of patients is set at 38 for the statistical analysis, assuming an expected median PFS of 5.0 months (threshold: 3.0 months). The primary endpoint of the study is the progression free survival (PFS), and the secondary endpoints are the overall response rate (ORR), overall survival (OS), adverse events (AE), quality of life (QOL) and review of nausea and vomiting. This trial is registered in the UMIN Clinical Trials Registry as UMIN000028170. We intend to start conducting the trial in September 1, 2017. If this trial meets the endpoint, IRIS+Rmab might be supported as a new optional standard regimen for mCRC.

The Feasibility and Efficacy of Laparoscopic Extended Total Mesorectal Excision for Locally Advanced Lower Rectal Cancer.

BACKGROUND/AIM: Extended total mesorectal excision (ETME) is defined as en bloc resection of the adjacent organs outside the mesorectal fascia, that is indicated in cases with locally advanced lower rectal cancer (T4 tumor). The aim of this study was to evaluate the clinical and oncological outcomes of laparoscopic ETME (L-ETME) for locally advanced lower rectal cancer. PATIENTS AND METHODS: The present study analyzed clinical outcomes and oncological outcomes of 11 consecutive patients who underwent L-ETME for cT4 lower rectal cancer in Nagasaki Medical Center between 2012 and 2015. RESULTS: Of the 11 patients, 7 underwent neoadjuvant therapy, and 7 underwent pelvic node dissection. One case (7.1%) underwent resection of anterior organs (prostate), 6 cases (54.5%) had resection of the lateral organs (neurovascular bundle, hypogastric nerve, pelvic plexus, ovary, and internal iliac blood vessels) and 4 cases (36.4%) had resection of both anterior and lateral organs. In all cases enrolled in this study, R0 resection was achieved. The median operation time and intraoperative blood loss were 416 min and 350 ml, respectively. The postoperative complication rate was 18.2% (2/11). The 3-year overall survival rate was 79.5%, and the 3-year local recurrence-free survival rate was 87.5%. There was no mortality and no re-operation in this series. CONCLUSION: The results of the present study suggest that L-ETME is feasible and has efficacy for locally advanced lower rectal cancer.

Clinical and Oncological Outcomes of Laparoscopic Lateral Pelvic Lymph Node Dissection in Advanced Lower Rectal Cancer: Single-institution Experience.

AIM: The aim of this study was to compare the clinical outcomes of laparoscopic versus open surgery for total mesorectal excision (TME) with lateral pelvic lymph node dissection (LPLD) in advanced lower rectal cancer. PATIENTS AND METHODS: Forty-four patients who underwent TME with LPLD for lower rectal cancer (pStage II/III) between January 2008 and December 2014 were divided into two groups according to the type of surgical approach as follows: open LPLD group (OLD, n=17) and laparoscopic LPLD group (LLD, n=27). RESULTS: Operative time was comparable between the groups (p=0.15), whereas intraoperative blood loss and complication rates were significantly less in LLD than in OLD. Postoperative hospital stay was shorter in LLD than in OLD. Overall survival and local recurrence-free survival were similar in the two groups. Disease-free survival was better in LLD than in OLD, although the difference was not significant. CONCLUSION: Laparoscopic TME with LPLD is safe and feasible.

Analysis of the Outcomes in Central Venous Access Port Implantation Performed by Residents via the Internal Jugular Vein and Subclavian Vein.

OBJECTIVE: The central venous access port (CVAP) has played an important role in the safe administration of chemotherapy and parenteral nutrition. The aim of the present study was to clarify the optimal access vein for CVAP implantation when performed by residents rather than attending surgeons. METHODS: A consecutive cases of CVAP implantation via the subclavian vein (SV) using a landmark-guided technique or via the internal jugular vein (JV) using an ultrasound-guided technique were divided into 2 groups according to whether the intervention was performed by a resident or an attending surgeon. Early and late complications were compared retrospectively between the 2 groups, and the outcomes of the CVAPs were compared between those implanted via the SV and those implanted via the JV in resident group. RESULTS: A total of 207 cases of CVAP implantation were performed. Overall, 114 implantations were performed by residents, and another 93 implantations were performed by attending surgeons. Early complications were seen more frequently in the resident group (6.1%) than in the attending-surgeon group (1.1%), but the difference was not significant. No differences in operating time or late complications were observed between the 2 groups. In the resident group, CVAP implantations via the JV using the ultrasound-guided technique were associated with a shorter operating time compared with the SV approach. CONCLUSIONS: Residents can perform CVAP implantations safely using both the SV and JV approaches. However, the JV approach using an ultrasound-guided technique can be performed in less time than the SV approach.

Clinical and Oncological Outcomes of Laparoscopic Versus Open Surgery for Advanced Rectal Cancer.

AIM: To compare the clinical and oncological outcomes of laparoscopic and open approaches in patients with advanced rectal cancer. PATIENTS AND METHODS: In this study, 78 patients who underwent surgery for advanced middle and lower rectal cancer (pStage II - III) were divided into two groups according to type of surgical approach: laparoscopic surgery (LS group; n=40) and open surgery (OS group: n=38). The clinical outcomes and oncological outcomes were compared between the two groups. RESULTS: The operation time was comparable, whereas operative blood loss and complication rates were significantly less in the LS group compared to the OS group. Cancer-specific survival (CSS) and local recurrence-free survival (LRFS) were similar in the two groups. Disease-free survival (DFS) was better in the LS group than in the OS group. CONCLUSION: LS for advanced rectal cancer was safe and not inferior to OS in clinical and oncological outcomes.

Interleukin-6 expression on the biliary epithelia during inflammation-associated biliary carcinogenesis in bilioenterostomized hamsters.

BACKGROUND: Chronic inflammatory conditions of the biliary tree strongly predispose patients to biliary carcinoma. The aim of this study was to evaluate the role of interleukin-6 (IL-6) expression during biliary carcinogenesis in bilioenterostomized hamsters. MATERIALS AND METHODS: Syrian hamsters were subjected to either a choledochoduodenostomy (CD, n=11) or a simple laparotomy (SL, n=10) and then received N-nitrosobis(2-oxopropyl)amine (BOP) treatment. The animals were sacrificed 20 wk after surgery and the development of biliary carcinoma, the presence and degree of cholangitis, and IL-6 expression on the biliary epithelia were examined histologically. RESULTS: In the CD group, eight hamsters (73%) demonstrated persistent cholangitis and six (55%) of them developed intrahepatic biliary carcinoma, while no hamster without cholangitis showed any biliary carcinoma. In the SL group, cholangitis was recognized in four hamsters (40%) and no development of biliary carcinoma was identified. A significantly high incidence of tumor development (P=0.024) and a close correlation between the presence of cholangitis and the occurrence of biliary carcinoma (P =0.013) were thus evident in the CD group. Moreover, the degree of cholangitis was significantly higher in the CD hamsters (P=0.041) and an IL-6 overexpression was identified in five hamsters that had undergone a CD, with a scattered expression on the intra- and extrahepatic biliary epithelia. Despite the fact that the induced biliary carcinomas showed a multicentric occurrence in the liver, these tumors originated from within the restricted area where IL-6 was expressed. CONCLUSIONS: A deregulated IL-6 overexpression on the biliary epithelia may therefore be involved in inflammation-associated biliary carcinogenesis in hamsters that have undergone a bilioenterostomy.

Chemopreventative effect of an inducible nitric oxide synthase inhibitor, ONO-1714, on inflammation-associated biliary carcinogenesis in hamsters.

The present study was designed to investigate whether an inducible nitric oxide synthase (iNOS)-specific inhibitor, ONO-1714 [(1S, 5S, 6R, 7R)-7-chloro-3-imino-5-methyl-2-azabicyclo[4.1.0] heptane], could prevent inflammation-associated biliary carcinogenesis in bilioenterostomized hamsters. Syrian golden hamsters underwent choledochojejunostomy and then received subcutaneous injections of the chemical carcinogen N-nitrosobis(2-oxopropyl)amine every 2 weeks at a dose of 10 mg/kg body wt, starting 4 weeks after surgery and continuing for 18 weeks. The hamsters were divided into two groups according to their oral intake of either a standard pelleted diet containing ONO-1714 at 100 p.p.m. for 18 weeks (ONO group, n = 15) or an ordinary diet alone (control group, n = 15). The animals were killed 22 weeks after surgery, and the development of biliary tumors was examined histologically. The presence and degree of cholangitis, cell kinetic status of the biliary epithelium and iNOS expression were evaluated. Intrahepatic biliary adenomas developed in all control animals, whereas they developed in only seven (47%) hamsters treated with ONO-1714 (P < 0.05). Intrahepatic biliary carcinomas were present in 13 (87%) hamsters in the control group and in only 6 (40%) hamsters in the ONO groups (P < 0.05). Histological and immunohistochemical examinations demonstrated a significant decrease in the degree of cholangitis, biliary epithelial cell kinetics and the expression of iNOS in the biliary epithelium in the ONO group in comparison with the control (P < 0.05). These results indicate that ONO-1714 represses N-nitrosobis(2-oxopropyl)amine-induced biliary carcinogenesis in bilioenterostomized hamsters and inhibits iNOS expression in the biliary epithelium. ONO-1714 may therefore be a promising agent for the prevention of biliary carcinoma in various inflammation-associated biliary disorders.

Chemopreventative effect of hochu-ekki-to (TJ-41) on chemically induced biliary carcinogenesis in hamsters.

BACKGROUND: Bilioenterostomy is a common surgical technique that is widely used. Recently, clinical studies have revealed that biliary carcinomas can occur after bilioenterostomy. The present study was designed to evaluate whether hochu-ekki-to (TJ-41), a Japanese herbal drug, could prevent chemically induced biliary carcinomas in bilioenterostomized hamsters. MATERIALS AND METHODS: Syrian golden hamsters were subjected to choledochojejunostomy and then received subcutaneous injections of N-nitrosobis(2-oxopropyl) amine every 2 weeks at a dose of 10 mg/kg. N-nitrosobis(2-oxopropyl) amine administration was started 4 weeks after surgery. The animals were simultaneously p.o. administered TJ-41 in water every day at a dose of 1000 mg/kg (TJ-41 group). The control hamsters were administered water alone. The hamsters were sacrificed 22 weeks after surgery, and the development of biliary carcinomas, the presence and degree of cholangitis, and the cell kinetic status of the biliary epithelium were evaluated histologically. RESULTS: Intrahepatic bile duct carcinomas developed in 15/17 (88%) hamsters in the control group and in only 8/17 (47%) hamsters in the TJ-41 group (P < 0.05). The degree of cholangitis was not different between the two groups. However, the proliferating cell nuclear antigen labeling index of the biliary epithelium in the TJ-41 group (6.46%) was significantly lower than the controls (9.67%) (P < 0.05). These findings indicated that TJ-41 reduced accelerated biliary epithelial cell kinetics after bilioenterostomy, resulting in the prevention of carcinogenesis. CONCLUSION: TJ-41 has a preventive effect on chemically induced carcinoma of the biliary tract after bilioenterostomy.

Parapapillary choledochoduodenal fistula associated with cholangiocarcinoma.

Parapapillary choledochoduodenal fistula is a rare disorder. We herein report a case of parapapillary choledochoduodenal fistula associated with cholangiocarcinoma. A 61-year-old woman was admitted to our hospital for further examination of a liver tumor. She had no clinical symptoms, but computed tomography scans showed an irregularly contoured liver tumor which was histologically confirmed to be adenocarcinoma, by a needle biopsy examination. Duodenal fiberscopy revealed a fistula orifice 1.0 cm proximal to the orifice of the papilla of Vater, and endoscopic retrograde cholangiography through the fistula showed a communication to the common bile duct. Hypotonic duodenography demonstrated reflux of contrast material into the choledochoduodenal fistula. The bile sample collected from the common bile duct showed extremely high levels of pancreatic enzymes, including amylase, phospholipase-A2, and elastase-I. Furthermore, Helicobacter DNA was detected in bile by polymerase chain reaction (PCR) analysis. This experience suggests to us that parapapillary choledochoduodenal fistula may be a risk factor for biliary tract carcinoma, and surgical management is the treatment of choice for this rare condition, even when the patient has no significant clinical symptoms.

Chemopreventative effect of a cyclooxygenase-2-specific inhibitor (etodolac) on chemically induced biliary carcinogenesis in hamsters.

The present study was designed to evaluate whether etodolac, a cyclooxgenase-2 (COX-2)-specific inhibitor, could prevent chemically induced biliary carcinogenesis in bilioenterostomized hamsters. Syrian golden hamsters were subjected to choledochojejunostomy and then received subcutaneous injections of N-nitrosobis(2-oxopropyl)amine (BOP) every 2 weeks at a dose of 10 mg/kg body wt. BOP administration was started 4 weeks after surgery, and continued for 18 weeks. The animals were simultaneously orally administered etodolac three times per week at a dose of 10 mg/kg body wt in 0.5% methylcellose solution (etodolac group). The control hamsters were administered methylcellose solution alone. The hamsters were killed 22 weeks after surgery, and the biliary carcinomas were evaluated histologically. The presence and degree of cholangitis and the cell kinetic status of the biliary epithelium were also evaluated with special reference to biliary carcinogenesis. Intrahepatic bile duct carcinomas developed in 15 of 17 (88%) hamsters in the control group, and in only six of 18 (33%) hamsters in the etodolac group (P < 0.01). The incidence and number of developing biliary carcinomas were well correlated with the degree of cholangitis, and severe cholangitis was evident in the controls. The cell kinetic study demonstrated that the proliferating cell nuclear antigen-labeling index of the biliary epithelium was 9.67 and 5.14% in the control and etodolac groups, respectively (P < 0.05). The mean levels of prostaglandin E(2) (PGE(2)) products in the liver tissue were 14.14 +/- 3.31 pg/total protein (TP) mg in the control group, and 7.46 +/- 2.34 pg/TP mg in the etodolac group (P < 0.05). These findings indicated that etodolac reduced both the occurrence of severe cholangitis and the acceleration of biliary epithelial cell kinetics after bilioenterostomy, resulting in the prevention of BOP-induced biliary carcinogenesis in hamsters. In conclusion, COX-2-specific inhibitor (etodolac) may be a possible agent against not only reflux cholangitis, but also biliary carcinoma after bilioenterostomy.

Acceleration of spontaneous biliary carcinogenesis in hamsters by bilioenterostomy.

Biliary carcinomas can occur as a delayed complication of bilioenterostomy. The aim of this study was to determine whether bilioenterostomy influences biliary carcinogenesis in hamsters. Syrian hamsters were subjected to three different surgical procedures: simple laparotomy (SL), choledochoduodenostomy (CD) and choledochojejunostomy (CJ). They were given no carcinogens, and five to six hamsters from each group were killed every 20 weeks up to 120 weeks after surgery. Thirty-seven, 32 and 38 hamsters were sampled from the SL, CD and CJ groups, respectively. Cholangiocarcinomas developed in 5.4, 15.6 and 23.7% of hamsters in the SL, CD and CJ groups, respectively. The incidence of biliary carcinoma was significantly higher in the bilioenterostomy groups, especially CJ (P < 0.05), than in SL. The tumor latency period after surgery was 20-40 weeks shorter in the bilioenterostomy groups than in SL. Persistent cholangitis and bile stasis were frequent in the bilioenterostomy groups, and a significant correlation between cholangitis and biliary carcinogenesis was noted in the CD group. The proliferative cell nuclear antigen (PCNA) labeling index was higher in the biliary epithelium of the bilioenterostomy groups. In conclusion, persistent cholangitis after bilioenterostomy accelerates biliary carcinogenesis through activation of biliary epithelial cell kinetics.

Comparative analysis of Helicobacter DNAs and biliary pathology in patients with and without hepatobiliary cancer.

Several Helicobacter species have recently been isolated from the bile and hepatobiliary systems of murine species, and are well recognized as a pathogen of the hepatobiliary disorder. This study was planned to investigate whether Helicobacter species possess a causative potential for human hepatobiliary disease, especially for hepatobiliary carcinogenesis. Bile and hepatobiliary tissue samples from 19 patients with hepatobiliary cancer and 19 patients with benign biliary diseases were subjected to polymerase chain reaction analyses for the detection of Helicobacter DNAs. Using a proliferating cell nuclear antigen (PCNA) staining technique, we also investigated the biliary epithelial cell kinetics with special reference to the presence of Helicobacter DNAs in the hepatobiliary system. We found that Helicobacter DNAs were positive in 10 (52.6%) of the 19 patients with hepatobiliary cancer. The incidence was significantly higher than that (15.7%) in the benign cases (P = 0.03). The PCNA labeling index in the biliary epithelium in Helicobacter DNA-positive patients was statistically higher than that in Helicobacter DNA-negative ones, regardless of whether the patient was suffering from hepatobiliary cancer and/or biliary inflammation. A close correlation between the presence of Helicobacter DNAs and an elevation of the PCNA labeling index in the biliary epithelium was demonstrated by multiple regression analysis. Our findings suggest that Helicobacter species may play a role in the pathogenesis of hepatobiliary cancer through an acceleration of biliary cell kinetics.

Helicobacter pylori accelerates the biliary epithelial cell proliferation activity in hepatolithiasis.

BACKGROUND/AIMS: Several authors have reported the presence of H. pylori in the human biliary tract. The aim of this study was to investigate the influence of the presence of H. pylori on the epithelial cell proliferation activity in the biliary tract with hepatolithiasis. METHODOLOGY: A histopathological examination and polymerase chain reaction were used to detect the presence of H. pylori from fourteen patients with hepatolithiasis. The cell proliferation activity in the biliary epithelia was determined using proliferating cell nuclear antigen staining. RESULTS: A histopathological examination and polymerase chain reaction analysis demonstrated H. pylori to be detected in 5 (37%) and 4 (29%) out of 14 patients, respectively. The proliferating cell nuclear antigen labeling index was significantly higher in the H. pylori-positive patients (28.3%) than in the H. pylori-negative individuals (4.9%). CONCLUSIONS: H. pylori is present in the biliary tract of patients with hepatolithiasis, while H. pylori promotes the formation of stones in the biliary tract. The development of intrahepatic cholangiocarcinoma might therefore be linked to the presence of H. pylori because of the accelerated activity of cell kinetics in the epithelium of the biliary tract.

Pre- and intraoperative evaluation of biliary system for successful laparoscopic cholecystectomy in porcelain gallbladder patients.

BACKGROUND/AIMS: A porcelain gallbladder is generally thought to be a relative contraindication for laparoscopic cholecystectomy because of the difficulties in grasping the calcified wall of the gallbladder with forceps and making a retraction which would create a good operation field. The aim of this study was to define the clinical criteria for safe laparoscopic cholecystectomy in the treatment of porcelain gallbladders. METHODOLOGY: Between January 1993 and December 2000, 4 patients with porcelain gallbladders underwent laparoscopic cholecystectomy in our department. The significant features of the biliary system which contributed to the surgical results were investigated in these patients. RESULTS: All 4 patients were successfully treated by means of laparoscopic cholecystectomy. The confluence of the cystic duct was clearly demonstrated on the preoperative cholangiogram in all patients. Furthermore, the neck portion of the gallbladder wall, revealed no calcification on the CT scans of 3 patients, although the whole wall of the gallbladder, including the neck portion, showed a circumferential calcification in the remaining patient. Laparoscopic exposure and dissection of the Calot's triangle was relatively easy to perform in the former and was difficult in the latter, and thus, an anterograde laparoscopic cholecystectomy was the procedure of choice. Intraoperative cholangiography clearly demonstrated the confluence of the cystic duct in all of the patients. CONCLUSIONS: Porcelain gallbladder is an indication for laparoscopic cholecystectomy, especially in cases of a patent cystic duct and an uncalcified wall in the neck portion of the gallbladder. Laparoscopic cholecystectomy might be an indication for selected patients with porcelain gallbladder when an uncalcified and patent cystic duct are evident in pre- and intraoperative cholangiograms.