Variations in the cystic duct: frequency and the relationship among insertion sides and heights on the bile duct.

BACKGROUND: Evaluation of the cystic duct anatomy prior to bile duct or gallbladder surgery is important, to decrease the risk of bile duct injury. This study aimed to clarify the frequency of cystic duct variations and the relationship between them. METHODS: Data of 205 patients who underwent cholecystectomy after imaging at Sada Hospital, Japan, were analyzed. The Chi-square test was used to analyze the relationships among variations. RESULTS: The lateral and posterior sides of the bile duct were the two most common insertion points (92 patients, 44.9%), and the middle height was the most common insertion height (135 patients, 65.9%). Clinically important variations (spiral courses, parallel courses, low insertions, and right hepatic duct draining) relating to the risk of bile duct injury were observed in 24 patients (11.7%). Regarding the relationship between the insertion sides and heights, we noticed that the posterior insertion frequently existed in low insertions (75.0%, P < 0.001) and did not exist in high insertions. In contrast, the anterior insertion coexisted with high and never low insertions. Spiral courses have two courses: anterior and posterior, and anterior ones were only found in high insertion cases. CONCLUSIONS: The insertion point of the cystic duct and the spiral courses tended to be anterior or lateral superiorly and posterior inferiorly. Clinically significant variations in cystic duct insertions are common and surgeons should be cautious about these variations to avoid complications.

Usefulness of several factors and clinical scoring models in preoperative diagnosis of complicated appendicitis.

BACKGROUND: The preoperative distinction between uncomplicated and complicated appendicitis is important to determine the appropriate treatments, such as antibiotics, surgery, or interval appendectomy. Computed tomography (CT) plays an important role; however, combining clinical and imaging factors may make preoperative evaluation more reliable. This study evaluated and analyzed cases and the usefulness of several preoperative factors and clinical scoring models to detect complicated appendicitis. METHODS: A total of 203 patients preoperatively diagnosed with acute appendicitis at our facility were included. Complicated appendicitis was defined as appendicitis with gangrene, perforated appendix, and/or abscess formation. Preoperative factors were collected from published clinical scoring models; patient information, symptoms, signs, results of laboratory tests, and findings of CT. Factors were analyzed using a chi-squared test and the Mann-Whitney U test. RESULTS: The preoperative factors were compared between 151 uncomplicated and 52 complicated appendicitis patients. The significant factors were age ≥40, duration of symptoms >24 hours, body temperature ≥37.3°C, high levels of CRP, findings in CT scan (appendix diameter ≥10 mm, stranding of the adjacent fat, presence of fluid collection, and suspicion of abscess or perforation). We also evaluated the usefulness of clinical scoring models for the detection of complicated appendicitis and found the Appendicitis Inflammatory Response score and two prediction models (Atema score and Imaoka score) showed significance (p < 0.05). High serum CRP level was significantly associated with complicated appendicitis (p < 0.001), and the predicted existence rates of complicated appendicitis were 52.7% for serum CRP level ≥50mg/L, 74.4% for ≥100mg/L, and 82.6% for ≥150mg/L. CONCLUSION: The results demonstrated several preoperative factors and clinical scoring models to increase suspicion of complicated appendicitis. Specifically, high serum levels of CRP may be a useful factor in predicting complicated appendicitis prior to surgery when supported by clinical findings and imaging; however, further research is needed.

Effect of gallbladder polyp size on the prediction and detection of gallbladder cancer.

BACKGROUND: Gallbladder polyps are relatively common. Although most gallbladder polyps are benign, some are malignant. Current guidelines state that malignancy should be suspected for polyps ≥ 10 mm in diameter. We clarified the cancer detection rates in accordance with the size distribution of gallbladder polyps, and evaluated the effectiveness of the reported risk factors in predicting malignancy. METHODS: In this retrospective case-control study, our institutional database was searched to identify patients who underwent laparoscopic cholecystectomy for benign or malignant gallbladder polyps at Sada Hospital, Japan. The chi-squared test was used to analyze the risk factors for malignancy. RESULTS: There were 227 protruding gallbladder lesions. The 206 benign polyps had a diameter of 2-21 mm, while the 21 malignant polyps were 7-60 mm. The cancer detection rates were 16.4% for lesions ≥ 10 mm, 55.9% for lesions ≥ 15 mm, and 94.1% for lesions ≥ 20 mm. Of the benign lesions, cholesterol polyps were the most frequent (50-100%) in all size ranges, even in large lesions (≥ 15 mm). The sessile lesion morphology was significantly more frequent in malignant (60%) than benign lesions (3.4%, p < 0.00001). Multiple polyps were frequently diagnosed not only as cholesterol polyps (81.1%), but also as adenomas (60%); adenomas were found as a single adenoma within other types of polyps. There were two cases of malignant small gallbladder polyps (< 10 mm); these lesions met the surgical indications of a size increase during observation or a sessile morphology. CONCLUSIONS: The cancer detection rate increased significantly with an increase in the lesion size. Risk factors such as a sessile polyp morphology or an increase in lesion size were effective in predicting malignancy for small gallbladder polyps. It might be difficult to accurately predict the pathologic diagnoses of gallbladder polyps preoperatively, as cholesterol polyps were most frequent, even in the large size range.

Preoperative diagnoses and identification rates of unexpected gallbladder cancer.

BACKGROUND: Unexpected gallbladder cancer (UGBC) is sometimes found in the resected gallbladder of patients during or after surgery. Some reports have indicated UGBC identification rates for all gallbladder surgeries, but scarce data are available for the UGBC identification rates for specific gallbladder diseases. The present study was performed to clarify UGBC rates and the factors suspicious for UGBC categorized according to preoperative diagnoses, in patients undergoing laparoscopic cholecystectomy (LSC). METHODS: We recorded data for all LSC surgeries performed in the Department of Surgery, Sada Hospital, Japan since 1991, and analyzed the 28-year data. We used the chi-square test and Kaplan-Meier analysis for this retrospective case-control study. RESULTS: The UGBC identification rate was 0.69% (63/9186 patients). The UGBC identification rates categorized according to the preoperative diagnoses were 1.3% (13/969) for acute cholecystitis, 2.4% (16/655) for benign tumor, 2.0% (28/1383) for chronic cholecystitis or cholecystitis, and 0.054% (3/5585) for cholecystolithiasis. The percentage of older patients (≥ 60 years) was significantly higher in UGBCs compared with cases finally diagnosed as benign in each group categorized according to the preoperative diagnoses (p≤0.0014), except for cholecystolithiasis. In cases pre-diagnosed as benign tumor, UGBCs were associated with higher rates of thickened gallbladder wall compared with benign tumor (69.2% vs. 27.9%, respectively; p = 0.0011). UGBCs pre-diagnosed as acute cholecystitis had higher T2-T4 rates (100% vs. 64.3%, respectively; p<0.05) and lower survival rates (p = 0.0149) than UGBCs pre-diagnosed with chronic cholecystitis. CONCLUSIONS: UGBC identification rates depend on the preoperative diagnosis and range from 0.054% to 2.4%. Older age (≥ 60 years) could be related to UGBC, and a pre-diagnosis of acute cholecystitis might indicate more advanced cancer compared with a pre-diagnosis of chronic cholecystitis.

Single-incision laparoscopic cholecystectomy with needle graspers.

BACKGROUND/AIMS: Single-incision laparoscopic cholecystectomy (SILC) is a promising alternative to standard multi-incision laparoscopic cholecystectomy (LC). However, generalization of SILC is still hampered by technical difficulties mainly associated with the lack of trocars used for retraction of the gallbladder. We therefore developed a modified method of SILC with the use of needle graspers (SILC-N) for optimal retraction and exposure. METHODOLOGY: In addition to two trocars inserted through a single transumbilical incision, two needle ports were placed on the right subcostal and lateral abdominal wall, through which needle graspers were used for retraction of the gallbladder. Since December, 2009, 12 patients with symptomatic cholelithiasis were treated by SILC-N. RESULTS: SILC-N was successfully performed in all but one patient requiring a conversion to the 4-port LC with a mean operative time of 71.5 (48-107) minutes. None of the patients experienced intraoperative or postoperative complications. The transumbilical incision and pinholes for needle graspers were almost invisible on discharge. CONCLUSIONS: Our preliminary results suggest that SILC-N is a simple, safe and feasible technique of cholecystectomy offering similar postoperative recovery and better cosmetic outcome as compared to conventional LC.

[A resected case of advanced gastric cancer with multiple liver metastasis successfully treated by preoperative and postoperative S-1/CPT-11 combination chemotherapy].

CASE: A 75-year-old man was admitted for anemia, and a tar stool found by endoscopic examination revealed a type 3 advanced gastric cancer in the lower stomach. Multiple liver metastases 4 cm in diameter were shown on CT. Because we thought that the case was unresectable, S-1/CPT-11 chemotherapy was performed. S-1 (80mg/body/day) was orally administered for 2 weeks followed by a drug-free 1 week, and CPT-11 (100mg/body/day) was given intravenously on days 1 and 8. After 3 courses of chemotherapy, the primary lesion, the regional lymph nodes, and the metastatic lesion of the liver were slightly reduced in size. He was judged as clinical PR, and distal gastrectomy and lymph node dissection were performed. One month after surgery the tumor marker values became normal, and CT could hardly detect metastatic liver tumors. Now, after 3 years, the PR stage has been maintained. Combined use of peroral S-1 and CPT-11 by intravenous infusion is effective for multiple liver metastasis after gastrectomy in gastric cancer.

Completion radical surgery after cholecystectomy for accidentally undiagnosed gallbladder carcinoma.

Survival time of 73 patients with undiagnosed gallbladder carcinoma incidentally found after cholecystectomy treated between 1982 and 2000 was evaluated in relation to various variables, with special reference to the significance of the radical second resection. The most significant prognostic factor was the depth of tumor invasion as assessed by univariate and multivariate analyses (odds ratio 3.40, 95% CI 1.65-7.00, p < 0.001). None of the 23 pT1 patients received radical second resection, and all of them were doing well without recurrence at their last follow-up examination. The 3-year survival rate was 68% for patients with pT2 and 14% for patients with pT3. Patient characteristics for the 18 pT2 patients who underwent radical second resection were similar to the characteristics of the 25 pT2 patients who did not; nor did postoperative survival times differ significantly. Survival time was not correlated with the interval from initial to second surgery or the type of initial cholecystectomy (open vs laparoscopic). In 11 patients with pT2 whose surgical margin was judged positive at initial cholecystectomy, the radical second resection significantly lengthened survival time. Radical second resection tended to prolong the median survival period from 7 to 15 months in 7 patients with pT3, although the difference was not significant. In conclusion, patients with pT1 undiagnosed carcinoma need no further treatment. The redo surgery was found to prolong survival only in patients with pT2 with positive surgical margin at initial cholecystectomy.

Bilateral bipartite lunate: a case report.

A rare case of bilateral bipartite lunate is reported. Radiographs showed that the lunate was divided into palmar and dorsal parts. Computed tomography and magnetic resonance imaging were used to differentiate this variant from lunate fracture.