Diagnostic value of ultrasound combined with MRI in cholecystolithiasis: A protocol for systematic review and meta analysis.

BACKGROUND: Early diagnosis of cholecystolithiasis is significant for prevention of further development of situation. Ultrasound is the best choice for the diagnosis of cholecystolithiasis with a sensitivity of >95% and specificity of practically 100%. However, ultrasound is not perfect for it is not so clear sometimes. So, MRI is needed to assist the diagnosing of cholecystolithiasis. Some studies have been conducted to investigate the diagnostic value of ultrasound combined with MRI in cholecystolithiasis, however, the evidence was not enough. METHODS: We will search the following sources for the identification of trials: The Cochrane Library, PubMed, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure Database (CNKI), Chinese Science and Technique Journals Database (VIP), and the Wanfang Database. The searches were limited to articles published before 1st, April, 2021, and the language were limited to Chinese and English. Statistical analyses will be conducted with Sata 14.0 software and the evaluation of the quality of the included studies will be performed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). RESULTS: This study will provide a rational synthesis of current evidences for MRI combined with ultrasound for cholecystolithiasis. CONCLUSION: The conclusion of this study will provide evidence for the diagnostic value of MRI combined with ultrasound for cholecystolithiasis. ETHICS AND DISSEMINATION: This protocol will not evaluate individual patient information or affect patient rights and therefore does not require ethical approval. Results from this review will be disseminated through peer-reviewed journals and conference reports. PROSPERO REGISTRATION NUMBER: INPLASY202130003.

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.

Sarcomatous intrahepatic cholangiocarcinoma: Case report and literature review.

RATIONALE: Sarcomatous intrahepatic cholangiocarcinoma is a rare histological variant of cholangiocarcinoma (ICC). Previous medical literature has not mentioned the prevalence of this kind of disease, but a poorer prognosis than that of ordinary ICC was indicated. The diagnosis of the sarcomatous ICC is established on histopathological and immunohistochemical examinations. In this article, we present a new case of a patient with sarcomatous ICC who had no radiographic sign of intrahepatic tumor preoperatively. PATIENT CONCERNS: A 63-year-old man was noted with cholecystolithiasis and right upper abdominal pain. Liver function was within normal limits, although the gamma-glutamyl transpeptidase level was elevated. Serum carbohydrate antigen 19-9 level was elevated. Radiography showed atrophy of the left lobe of the liver, high-intensity signals on T1 weighted images, and low/high-intensity signals on T2 weighted images in hepatic ducts. DIAGNOSES: The preoperative diagnoses were hepatolithiasis, choledocholithiasis, and cholecystolithiasis. INTERVENTIONS: Exploratory laparotomy, adhesion release, cholecystectomy, choledocholithotomy, and T tube drainage were performed. During the surgery, an ill-defined tumor was detected on the atrophic left lateral lobe of the liver. Hepatic left lateral lobectomy was performed to remove the mass. OUTCOMES: The final diagnosis of sarcomatous ICC was made by histopathology after surgery. No evidence of local recurrence or distant metastasis was noted on imaging during follow-up. LESSONS: Although rare, sarcomatous ICC does exist in patients presented with cholecystolithiasis and liver atrophy. Surgeons should be aware of the existence of sarcomatous ICC due to the poor prognosis. We recommend that multidisciplinary approaches may be key to improve prognosis, including adjuvant chemotherapy or radiotherapy.

Visceral adiposity but not subcutaneous fat associated with improved outcome of patients with acute cholecystitis.

BACKGROUND: The aim of this study to study the effect of visceral and subcutaneous fat tissue mass on short- and long-term prognosis of patients with acute calculus cholecystitis (ACC). METHODS: Retrospective analysis of medical records. Included were all patients admitted because of ACC. Computed tomography images at the level of L3 were analyzed for body composition using designated software (Slice-O-matic; TomoVision, Montreal, Quebec, Canada). General linear model was used to analyze the effect of body composition on length of hospital stay, and Cox regression analysis was used to ascertain the effect of the different parameters on 1-y survival. RESULTS: Included were 159 patients (mean age: 71.7 ± 15.8 y, 54.7% males). Fat was the most abundant tissue (401 ± 175 cm2 of the computed tomography slices surface area), and visceral fat was 45.8 ± 14.1% of the fat area measured. Using the general linear model, we found that American Society of Anesthesiologists score, disease severity index, and age were positively associated with higher length of stay, whereas high visceral fat was associated with lower length of stay (estimated marginal means at 7.4 ± 1.4 d compared to 12.7 ± 1.4 d among patients with lower visceral fat surface area, P = 0.010). The Cox regression model showed that 1-y survival risk was significantly reduced by age, the Charlson Comorbidity Index and high muscle mass. High visceral adiposity was associated with improved survival (odds ratio: 0.216, 95% confidence interval: 0.064-0.724, P = 0.013). Subcutaneous adiposity did not affect prognosis. CONCLUSIONS: Visceral adiposity is associated with shorter length of stay and improved 1-y survival among patients hospitalized with ACC.

Gallbladder Hypoplasia, a Congenital Abnormality of the Gallbladder: A Case Report.

BACKGROUND There are different variations in the anatomy of the gallbladder. Congenital abnormalities of the gallbladder such as agenesis and hypoplasia are rare conditions and difficult to diagnose with imaging studies. Patients are usually asymptomatic or have symptoms that mimic gallstone disease. The diagnosis is often made intraoperatively and is established by histopathological examination. CASE REPORT We report a case of a 62-year-old male who had cholelithiasis symptoms and was falsely diagnosed with gallstone disease by abdominal ultrasound scan. The patient underwent an operation which revealed a rudimentary gallbladder. The histology result showed hypoplastic gallbladder tissue. CONCLUSIONS This case suggests that surgeons need to take into consideration congenital anomalies of the gallbladder intraoperatively in order to avoid any iatrogenic injury to biliary tract during a routine laparoscopic cholecystectomy. Intraoperative cholangiography can be a useful tool to avoid unnecessary surgical risky interventions.

Predictive Factors for Long Operative Duration in Patients Undergoing Laparoscopic Cholecystectomy After Endoscopic Retrograde Cholangiography for Combined Choledochocystolithiasis.

PURPOSE: Choledochocystolithiasis and its associated complications such as cholangitis and pancreatitis are managed by endoscopic retrograde cholangiography (ERC), with endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). However, affected patients present with complex conditions linked to operative difficulties in performing LC. The aim of this study was to elucidate the predictive factors for a prolonged LC procedure following ERC for treating patients with choledochocystolithiasis. MATERIALS AND METHODS: The medical records of 109 patients who underwent LC after ERC for choledochocystolithiasis from September 2012 to August 2014 were evaluated retrospectively. The cases were divided into long and short operative duration groups using a cutoff operative time of 90 minutes. We used univariate and multivariate analyses to investigate predictive factors associated with long operative duration according to clinical variables, ERC-related factors, and peak serum levels of laboratory test values between the initial presentation and LC (intervening period). RESULTS: Seventeen patients needed >90 min to complete LC. The presence of acute cholecystitis, placement of percutaneous transhepatic gallbladder drainage, higher peak serum white blood cell count and levels of C-reactive protein (CRP), and lower peak serum levels of lipase during the intervening period were associated with prolonged operative duration. Multivariate analysis showed that the independent predictive factors for long operative duration were the presence of acute cholecystitis (hazard ratio, 5.418; P=0.016) and higher peak levels of CRP (hazard ratio, 1.077; P=0.022). CONCLUSION: When patients with choledochocystolithiasis are scheduled for LC after ERC, the presence of acute cholecystitis and high CRP levels during the intervening period could predict a protracted operation.

Differentiation between gallbladder cancer with acute cholecystitis: Considerations for surgeons during emergency cholecystectomy, a cohort study.

PURPOSE: Gallbladder cancer (GBCA) is an uncommon malignancy with vague and non-specific symptoms. GBCA is sometimes diagnosed after emergency cholecystectomy for acute cholecystitis. We investigated the differential diagnosis between GBCA with acute cholecystitis. MATERIALS AND METHODS: Thirteen patients were diagnosed with GBCA after emergency cholecystectomy carried out for acute cholecystitis. A radiologist who was blinded to the final diagnoses retrospectively reviewed the computed tomography (CT) scans of the patients with GBCA and 25 patients with acute cholecystitis. We retrospectively reviewed the medical records of these patients and compared the clinical characteristics and CT findings between patients with GBCA and those with acute cholecystitis. We also investigated the prognostic factors in patients with GBCA who underwent emergency cholecystectomy. RESULTS: Gallbladder (GB) stones were found more often in patients with acute cholecystitis (n = 17, 68%) than in patients with GBCA (n = 7, 53.8%) (p = 0.486). Patients with GBCA showed typical GB masses or focal enhanced wall thickening when compared to diffuse wall thickening in patients with acute cholecystitis. Some GBCA patients showed irregular mural thickening and GB enhancement. Differentiating carcinoma from acute cholecystitis might sometimes not possible, but the latter group of patients had significantly lower C-reactive protein (CRP) levels (p = 0.033) and less regional fat stranding (p = 0.047). Survival was significantly affected by aggressive tumor characteristics (lymphatic invasion [p = 0.025], depth of tumor invasion [p = 0.004]) or R0 resection (p = 0.013) rather than bile spillage (p = 0.112). CONCLUSIONS: Surgeons deciding on emergency cholecystectomy for elderly patients with acute cholecystitis must suspect GBCA in patients with a low CRP level, irregular mural thickening or enhancement of GB without regional fat stranding.

Gallstone recurrence after minimally-invasive cholecystolithotomy with gallbladder reservation: a follow-up of 720 cases.

OBJECTIVE: To discuss the hazards of cholecystolithiasis recrudesce after cholecystolithotomy with gallbladder reservation; To provide a theoretical basis for reducing the recurrence rate of gallstone. PATIENTS AND METHODS: The patients who were followed up for at least one year after minimally-invasive operation with gallbladder reservation because of cholecystolithiasis were selected. In this population, the patients with recurrence after surgery were as the case group, those patients with no recurrence after surgery were as the control group. Through collection of general data of selected cases, relevant information of Ultrasound Examinations of gallbladder and history data of the patients questionnaires were completed. Relevant factors of gallstone recurrence of patients, were observed through statistic analysis. Main factors go as follows: gender, age, nation, career, BMI, whether or not the patient had the history of chronic superficial gastritis, and regulation of gallbladder emptying function, family history, etc. The information of selected cases is complete. RESULTS AND CONCLUSIONS: The main hazards of cholecystolithiasis recurrence were BMI, family history of gallstone disease, and emptying function of gallbladder.

[Clinical and laboratory diagnosis of an acute biliary pancreatitis].

In 126 patients, suffering an acute biliary pancreatitis (ABP), clinical examination was conducted. In 65 patients (1-st group) the isolated cholecystolithiasis was noted; in 35 (2-nd group)--cholelithiasis, which did not cause obturation of common biliary duct; in 26 (3-rd group)--cholelithiasis, which caused the biliary ways obturation (including calculi, which were incorporated into the duodenal papilla magna ostium). Clinical course of an ABP have differed depending on localization of calculi of extrahepatic biliary ducts. In patients, suffering ABP, a biochemical signs of hepatocytes functional disorders were observed, impacting the need for hepatoprotector preparations inclusion into complex of perioperative conservative therapy. Determination of activity of pancreatic α-amylase in the blood serum and conduction of the ACTIM Pancreatitis test con- stitute the most sensitive and specific methods of the ABP biochemical diagnosis.

[Coverage of the gallbladder cancer prevention strategy in Chile: results from the 2009-2010 National Health Survey]. / Cobertura de la estrategia preventiva de cáncer de vesícula biliar en Chile: Resultados de la Encuesta Nacional de Salud 2009-2010.

BACKGROUND: In Chile, gallbladder cancer (GBC) is one of the most important causes of death and gallstone disease (GSD) is its main risk factor. Abdominal ultrasonography (AU) is used for the diagnosis of GSD and cholecystectomy is used to prevent it. AIM: To estimate GSD prevalence in the general population and to assess the diagnostic and therapeutic coverage of GSD as a preventive strategy for GBC in Chile. MATERIAL AND METHODS: A standardized digestive symptoms questionnaire of the 2009-2010 Chilean National Health Survey was answered by 5412 adults over 15 years old. Self-reports of AU, GBD and cholecystectomies were recorded. RESULTS: The prevalence of biliary-type pain was 7.1%. During the last five years, the prevalence of AU was 16%. GSD was reported in 20% of these tests and 84% of them were asymptomatic. The prevalence of AU was significantly lower in Araucanía region and among people with less than 12 years of education. Life cholecystectomy prevalence was 11% and reached 40% in people aged over 60 years. Women accounted for 75% of total cholecystectomies. Twenty-one percent of individuals who referred biliary-type pain, were studied with an AU. Only 60% of people with GSD confirmed by AU underwent a cholecystectomy. CONCLUSIONS: GSD affects at least 27% of the Chilean adult population. Important deficits and inequities in GSD diagnostic and therapeutic coverage were identified.

Intraoperative endoscopic retrograde cholangio-pancreatography: a useful tool in the hands of the hepatobiliary surgeon.

AIM: To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) for patients with gall bladder stones (GS) and common bile duct stones (CBDS). METHODS: Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram (TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS. RESULTS: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed stones in 6 cases (7.9%); short lower end stricture with small stones present in two cases (2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case (1.3%) which was treated by open hepaticojejunostomy; and one case (1.3%) was proved to be ampullary carcinoma and whipple's operation was scheduled. CONCLUSION: The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.

Laparoscopic remnant cholecystectomy and transcystic common bile duct exploration for gallbladder/cystic duct remnant with stones and choledocholithiasis after cholecystectomy.

BACKGROUND: Postcholecystectomy syndrome has been a long-standing source of frustration for surgeons. The objective of this study was to assess the feasibility and safety of laparoscopic remnant cholecystectomy (LRC) and laparoscopic transcystic common bile duct (CBD) exploration (LTCBDE) when adopted as the management for gallbladder/cystic duct remnant with stones and choledocholithiasis (GRSC) after cholecystectomy. PATIENTS AND METHODS: This is a retrospective study of 11 patients who underwent surgeries for GRSC: the first 4 patients (Group 1) underwent open remnant cholecystectomy and CBD exploration, whereas the last 7 patients (Group 2) underwent LRC with LTCBDE successfully. Demographic data and perioperative parameters were analyzed and compared between the two groups. RESULTS: All 11 patients had undergone cholecystectomy for symptomatic gallstone diseases. These patients had a mean age of 62 years. The time interval between cholecystectomy and the diagnosis of GRSC ranged from 4 years to 23 years (mean, 13 years). There was a significant reduction in postoperative hospital stay (5.00±1.41 versus 2.14±1.77 days, P=.034) and blood loss (35.00±10.00 versus 14.29±7.87 mL, P=.011) in Group 2 compared with Group 1. The 30-day morbidity rate was 9.1%. At a mean follow-up of 24 months (range, 6-45 months), no symptoms had recurred, and no mortality was recorded in this study. CONCLUSIONS: LRC and LTCBDE for GRSC are safe and feasible and could be offered as a choice in centers performing advanced laparoscopic procedures.

Pseudoaneurysm of anomalous cystic artery due to calculous cholecystitis.

Pseudoaneurysm of the cystic artery is a rare cause of haemobilia resulting from either an inflammatory process in the abdomen or abdominal trauma. We report a case of a patient with chronic calculous cholecystitis associated with a pseudoaneurysm arising from an anomalous cystic artery who presented with haemobilia. The patient was managed successfully with multimodality treatment that included angioembolisation of the pseudoaneurysm and stenting of the common bile duct to relieve jaundice followed by elective open cholecystectomy.

[Clinical review and case report of ceftriaxone-associated gallbladder pseudolithiasis in adult].

Although ceftriaxone can be used safely in most instances, it can sometimes induce biliary sludge or stone formation. Most of the patients remain asymptomatic and children are more susceptible to develop this condition, but adults can be affected as well. Because sludge or stones disappear after discontinuing ceftriaxone, this condition is referred to as ceftriaxone-associated pseudolithiasis. A 54-year-old woman was admitted to a local clinic for management of ileus. During admission, she had received ceftriaxone and metronidazole, and had been on nil per os for the past 6 days. She was then referred to our hospital for cholecystectomy due to persistent right upper quadrant pain. Although imaging studies showed gallbladder sludge, pseudolithiasis was suspected because of ceftriaxone administration history and prolonged fasting. After careful watch-and-wait, the condition resolved spontaneously after ceftriaxone discontinuation. Our clear understanding on ceftriaxone-associated gallbladder pseudolithiasis allowed us to avoid an unnecessary cholecystectomy. Herein, we report the case of a 54-year-old woman with ceftriaxone-associated gallbladder pseudolithiasis that was successfully managed by ceftriaxone discontinuation alone.