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PubMed1999

Port site metastases from gallbladder cancer after laparoscopic cholecystectomy. Results of a Swedish survey and review of published reports.

OBJECTIVE: To investigate the incidence of port site metastases from unsuspected gallbladder cancer after laparoscopic cholecystectomy. DESIGN: Retrospective national multicentre study, 1991-94. SETTING: All 8 university and 24 central hospital, Sweden. SUBJECTS AND INTERVENTIONS: All 32 hospitals were interviewed by means of a written questionnaire. The registers of all Swedish Oncological Centres and the registers of the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for cholecystectomy. To detect laparoscopic interventions incorrectly registered as open operations, all cholecystectomies registered as open were matched against the Swedish Registry of Laparoscopic Cholecystectomy for the years 1991-93 and all patients records for 1994 were scrutinised. RESULTS: Replies were obtained from 30/32 clinics (94%) and 11976 laparoscopic cholecystectomies were done. Of 447 patients with verified gallbladder carcinoma 270 had their gallbladders removed, 55 (20%) laparoscopically. 9 of these (16%) developed port site metastases and 6 died from their disease at a median of 18 months (range 5-22). Two patients are alive, 54 and 45 months after cholecystectomy. One patient has been lost to follow-up. CONCLUSIONS: Port site metastases from gallbladder cancer may be more common than previously thought. A laparoscopic procedure should not be done if cancer of the gallbladder is suspected.

Adult↗

PubMed1972

Permeable junctional complexes. The movement of lanthanum across rabbit gallbladder and intestine.

Ionic lanthanum has been used to study transepithelial ion permeation in in vitro rabbit gallbladder and intestine (ileum) by adding 1 mM La(3+) to only the mucosal bathing solution. Transepithelial fluid transport electrical potential differences (p.d.), and resistances were measured. During La(3+) treatment the gallbladder's rate of active solute-coupled fluid transport remained constant, the resistance increased, and the 2:1 NaCl diffusion p.d. decreased. Mucosa-to-serosa fluxes of (140)La(3+) were measured and indicate a finite permeability of the gallbladder to La(3+). La(3+) also increased the transepithelial resistance and p d. of ileum. Electron microscopic examination of La(3+)-treated gallbladder showed: (a) good preservation of the fine structure, (b) electron-opaque lanthanum precipitates in almost every lateral intercellular space, most frequently near the apical end of the lateral spaces close to or within the junctional complex, (c) lanthanum among the subjacent muscle and connective tissue layers, and (d) lanthanum filling almost the entire length of so-called "tight" junctions. No observations were made which unequivocally showed the penetration of lanthanum into the gallbladder cells. Electron micrographs of similar La(3+)-treated ilea showed lanthanum deposits penetrating the junctional complexes. These results coupled with other physiological studies indicate that the low resistance pathway for transepithelial ion permeation in gallbladder and ileum is through the tight junctions A division of salt-transporting epithelia into two main groups, those with "leaky" junctional complexes and those with tight junctional complexes, has been proposed.

Animals↗

PubMed1998

Gallbladder duplication and laparoscopic management.

Gallbladder duplication can present a significant challenge to the laparoscopic surgeon, primarily due to difficulties with diagnosis and recognition. Previous reports of attempted laparoscopic cholecystectomy in patients with gallbladder duplication resulted in incomplete or staged multiple procedures. The case report of a 35-year-old woman with successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Preoperatively when evaluating radiologic studies a high index of suspicion is necessary in interpreting atypical findings. To further evaluate these abnormalities, liberal use of preoperative ERCP is helpful, and specific endoscopic techniques may be necessary as well. Intraoperatively, the findings may be confusing, and cholangiography can help clarify ductular anomalies, especially if the gallbladder duplication is contained within a common serosal coat. Missing a second gallbladder can result in persistent symptoms postoperatively necessitating further surgery. Laparoscopic cholecystectomy in the management of gallbladder duplication can be safely done and an awareness is necessary to avoid complications or multiple procedures.

Adult↗

PubMed1989

Gallstone growth, size, and risk of gallbladder cancer: an interracial study.

To investigate gallstone size, growth, and the relation between stone size and gallbladder cancer we have used cholecystectomy reports from 1676 female subjects (169 Whites, 531 Blacks, and 976 Native American Indians). Although the prevalence of gallstones differs markedly in these groups it appears that the estimated growth rate of gallstones in younger subjects, 2.0 mm per year (95% confidence interval: 1.7-2.3 mm) is homogeneous for all three groups. In both Indian and non-Indian populations the proportion of small stones diminished and the proportion of large stones increased over time. We found a strong relationship between gallstone size and gallbladder cancer. Large stones (greater than or equal to 3 cm) were found in 40% of patients with gallbladder cancer but in only 12% of all subjects of similar age. The relative risk for gallbladder cancer in subjects with stones greater than or equal to 3 cm was 9.2 compared with subjects with stones less than 1 cm. (95% confidence interval: 2.3-37). We estimate that one-third of all gallbladder cancers in subjects with calculi will be associated with large (greater than or equal to 3 cm) stones. We believe that stone size might be used to determine the risk of gallbladder cancer in patients with gallstones.

Adult↗

PubMed1989

Combined oral contraceptives and gallbladder cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives.

The relationship between combined oral contraceptives and primary gallbladder cancer was examined in 58 cases and 355 controls participating in an international hospital-based, case-control study. Use of combined oral contraceptives at any time was not associated with the risk of developing gallbladder cancer (RR = 0.6, 95% Cl 0.3, 1.3), and no clear patterns of risks were observed according to the duration of use, or time since first or most recent use. There was also no evidence that oral contraceptives effected risk of gallbladder cancer in women with or without a prior history of gallbladder disease. A history of gallbladder disease or gallstones was a strong risk factor for gallbladder cancer (RR = 2.3,95% Cl 1.2,4.4).

Adult↗

PubMed1999

Immunohistochemical demonstration of cytokeratin is useful for detecting micrometastatic foci from gallbladder carcinoma in regional lymph nodes.

BACKGROUND: The histological detection of lymph node metastasis in patients with gallbladder carcinoma is of major prognostic significance. However, it may be difficult to identify nodal involvement by conventional pathological examination of hematoxylin-eosin (HE)-stained sections when metastases are of microscopic size. In the present study, an attempt was made to detect lymph node metastasis precisely from gallbladder carcinoma, even by low-power microscopic examination, using immunohistochemistry with an anti-cytokeratin antibody. METHODS: A total of 431 lymph node specimens dissected during surgery from 33 patients with carcinoma of the gallbladder were investigated. A pair of mirror-image sections were obtained from each of the dissected lymph nodes and then stained using standard HE and immunohistochemical methods utilizing a monoclonal antibody against cytokeratin 7. The HE- and immunohistochemically stained sections were examined for the presence of tumor cells using light microscopy. RESULTS: All 78 lymph nodes from 12 patients with early gallbladder carcinoma were negative for both HE- and cytokeratin-positive cancer cells. Of 353 lymph nodes from 21 patients with advanced gallbladder carcinoma, HE staining showed that 98 were metastasis-positive. Among these 98 lymph nodes, 95 (97%) proved to be positive for metastasis based on cytokeratin immunostaining. On the other hand, the remaining 255 lymph nodes were cancer-free on the basis of HE staining results. Of the 255 HE-negative lymph nodes, seven (2.7%) were found to be positive for micrometastasis on the basis of cytokeratin staining. CONCLUSIONS: Cytokeratin staining of dissected lymph nodes is a useful new diagnostic tool for detecting micrometastatic foci in regional lymph nodes of patients with gallbladder carcinoma.

Adult↗

PubMed2000

Stromal tumor of the gallbladder with phenotype of interstitial cells of Cajal: a previously unrecognized neoplasm.

We report a small, well-demarcated stromal tumor of the gallbladder in a 69-year-old woman. The tumor and associated cholelithiasis led to chronic cholecystitis symptoms. The wall of the gallbladder contained a 2.4-cm hypocellular nodule composed of bland spindle-shaped cells that were immunoreactive for vimentin, CD34, and CD117. With the latter antibody, which stains interstitial cells of Cajal (ICC), the neoplastic cells appear fusiform with elongated bipolar projections or dendritic-like cytoplasmic projections. The gallbladder wall adjacent to the tumor contained numerous CD117-positive cells in close contact with the normal smooth muscle cells, whereas two of 10 gallbladders with minimal chronic cholecystitis showed only a few CD117-positive cells. These findings provide evidence that this stromal tumor of the gallbladder shows ICC differentiation similar to some stromal tumors of the gut. The presence of numerous ICC in the uninvolved gallbladder wall suggests that this tumor might have evolved through hyperplasia of ICC.

Aged↗

PubMed1976

Abnormalities in gallbladder morphology and function in patients with cholelithiasis.

Thirty-seven symptomatic cholelithiasis patients who had cholecystectomy were studied to determine the relationships between clinical manifestations, histologic findings and gallbladder absorptive capability. A clinical score was calculated from clinical data which we thought might be predictive of abnormal gallbladder histology. Histologic parameters indicative of gallbladder disease were used to calculate a histologic score. Shortcircuit current measurements, which reflect gallbladder sodium absorption,were used to assess absorptive function. Patients with very high clinical scores, indicative of pronounced clinical score was not predictive of histologic findings or absorptive function of the gallbladder is directly related to the degree of histologic abnormality, and that absorptive capability is not an all-or-none phenomenon. The data also show that visualization on oral cholecystography is an unreliable measure of gallbladder absorptive capability.

Cholecystography↗

PubMed1981

Gallbladder injuries resulting from blunt abdominal trauma: an experience and review.

Over a seven-year period from 1973 through 1979, 31 patients with blunt gallbladder trauma were treated at the Maryland Institute for Emergency Medical Services Systems. Twenty patients had contusions, ten patients had avulsions and one patient had a perforation of the gallbladder. None of the gallbladder injuries were suspected preoperatively. Twenty-eight of the 31 patients had a diagnostic peritoneal lavage performed on admission, all were positive for blood; bile was not grossly evident. Among the 30 patients, there were 75 associated intraabdominal injuries; there were 25 liver injuries. Five patients died, none as a result of their gallbladder injury. Cholecystectomy is suggested as the definitive procedure of choice for severe contusions and for perforating and avulsive injuries to the gallbladder. Cholecystostomy is indicated in a few patients and should be regarded as a temporary procedure. A review of the English literature shows a total of 101 patients (including the 31 of this study) with gallbladder injuries secondary to blunt trauma. The most commonly reported injury was perforation. The 20 contusions described in the present study are the first such injuries reported.

Accidents, Traffic↗

PubMed1982

Primary carcinoma of the gallbladder.

The records of patients with primary carcinoma of the gallbladder treated at Charity Hospital, New Orleans, Louisiana, from 1965 through 1978 were reviewed. Eighty patients had histologically proven primary carcinoma of the gallbladder. Sixty-nine patients had sufficient data available for evaluation. Only one patient (1.4%) was clinically free of disease at five years. Surgical procedures were performed in 45 of the 69 patients. The remainder of the patients had their disease proved at autopsy. Thirty-five patients had widespread metastatic disease at the time of operation. None of these patients survived more than one year. Only 10 patients had potentially curable lesions. The diagnosis of carcinoma of the gallbladder was not made at operation in eight of these patients. The only five-year survivor was in this subgroup. This patient had papillary adenocarcinoma confined to the mucosa and muscularis, and had a cholecystectomy alone. This report reinforces the difficulty in diagnosis and the dismal prognosis for patients with primary carcinoma of the gallbladder. Intraoperative examination of the gallbladder, earlier operation for documented gallbladder disease, and more aggressive surgical therapy should improve survival figures.

Adenocarcinoma↗

PubMed2003

Cohort study of surgical bypass to the gallbladder or bile duct for the palliation of jaundice due to pancreatic cancer.

OBJECTIVE: To compare patterns in mortality and the use of subsequent biliary drainage interventions (surgical, endoscopic, and percutaneous) associated with the different types of biliary bypass. SUMMARY BACKGROUND DATA: Surgical palliation of obstructive jaundice due to pancreatic cancer is often accomplished with an intestinal bypass to either the gallbladder or the bile duct. It is not known whether a gallbladder bypass, which is a simpler operation and more amenable to laparoscopic surgery, performs as well as a bypass to the bile duct. METHODS: The authors conducted a retrospective cohort study of 1,919 patients 65 years of age or older who had a surgical biliary bypass for pancreatic cancer diagnosed between 1991 and 1996 using Medicare claims data and the Surveillance, Epidemiology and End Results (SEER) database. RESULTS: At 1, 2, and 5 years, 7.5%, 17.4%, and 26.0% of 945 patients initially treated with a gallbladder bypass had additional biliary interventions, as compared with 2.9%, 11.0%, and 13.3% of 974 patients initially treated with a bile duct bypass. Patients who initially had a gallbladder bypass were 4.4 times as likely to have additional biliary surgery and 2.9 times as likely to have any subsequent biliary intervention as were patients who initially had a bile duct bypass. Median survival was longer following bile duct bypass. The adjusted hazard ratio for death associated with gallbladder bypass was 1.2. CONCLUSIONS: Compared to patients whose initial biliary bypass was to the bile duct, the risk of having one or more additional surgical, endoscopic, or percutaneous biliary drainage procedures is substantially greater in patients whose initial bypass was to the gallbladder.

Aged↗

PubMed1987

Disorders of gallbladder function related to duodenogastric reflux in technetium-99m DISIDA hepatobiliary scintigraphy.

Controversy exists over the relation between gallbladder dysfunction and the propensity for duodenogastric reflux. To evaluate this, Tc-99m DISIDA hepatobiliary imaging studies in 120 patients were reviewed, excluding patients who had had cholecystectomy or subtotal gastrectomy before scintigraphy. Serial images were obtained at 5, 10, 15, 30, 45, and 60 minutes and up to 24 hours, if indicated, after intravenous injection of 5-10 mCi of Tc-99m DISIDA. Normally, the liver, bile ducts, gallbladder, common bile duct, and bowel are visualized sequentially. Reversal of the normal sequence of gallbladder (GB) and bowel visualization indicates GB dysfunction; nonvisualization of the GB reflects cystic duct obstruction or absent GB function. Duodenogastric reflux is identified by radiotracer localized in the area just below or immediately adjacent to the tip of the left hepatic lobe. The intragastric location of the tracer may be verified by oral administration of 300 uCi of Tc-99m sulfur colloid. Twenty-nine patients had duodenogastric reflux between 10 and 60 minutes after injection. Of the 29 patients, 22 had a nonvisualized gallbladder, four had reversal of appearance of GB and bowel activity, and three had a normal study. GB dysfunction or nonfunction is more frequently demonstrated when duodenogastric reflux is present than with normal gallbladder function (P less than 0.001). In conclusion, gallbladder malfunction is closely associated with duodenogastric reflux, an abnormality that may be diagnosed noninvasively by Tc-99m DISIDA hepatobiliary scintigraphy.

Adult↗

PubMed1989

Hepatobiliary and gallium imaging findings in gallbladder perforation: a case report and review of the literature.

Gallbladder perforation is an unusual condition with a high mortality rate. Early detection with prompt surgical intervention can increase the survival rate. Hepatobiliary imaging using Technetium-99m-labeled iminodiacetic acid has been used for the diagnosis of gallbladder perforation. However, the results vary and are somewhat confusing. The authors report a case of gallbladder perforation with hepatobiliary imaging and an unusual gallium image; review the literature; and propose a classification of three different imaging patterns: 1) visualization of the gallbladder with bile leakage, 2) nonvisualization of the gallbladder with a photopenic fluid collection, and 3) nonvisualization of the gallbladder with bile leakage. These patterns may provide pathophysiologic information for surgeon.

Adult↗

PubMed2000

Gallbladder ejection fraction: correlation of scintigraphic and ultrasonographic techniques.

PURPOSE: The assessment of gallbladder function and ejection fraction using sincalide-enhanced biliary scintigraphy is a useful way to evaluate patients with recurrent right upper quadrant pain but no gallstones. MATERIALS AND METHODS: We wanted to determine whether gallbladder contraction measured by ultrasonography could be used in place of biliary scintigraphy. Biliary scans with an infusion of sincalide and concurrent ultrasonography were performed in 17 patients with histories of recurrent abdominal pain and no evidence of gallstones by ultrasound. RESULTS: Gallbladder ejection fractions calculated by ultrasound and scintigraphy using standard techniques showed only a weak correlation. The poor performance of ultrasound appears to arise because the variable shape of the gallbladder invalidates the calculation of its volume by the formula for a prolate spheroid. When gallbladders that were ellipsoidal were subselected, correlation was improved. The level of training of the sonologist did not have a significant effect on the results. CONCLUSION: Gallbladder ejection fraction calculated by ultrasonography cannot be used routinely as a substitute for biliary scintigraphy.

Abdominal Pain↗

PubMed2000

Refinement of the positive predictive value of gallbladder nonvisualization after morphine administration for acute cholecystitis based on the temporal pattern of common bile duct activity.

UNLABELLED: The authors previously reported two major patterns in the time-activity curve of the common hepatic bile duct (BD) after morphine administration in patients with gallbladder nonvisualization. The first pattern consists of a gradual increase in BD activity (of variable duration) occurring during a simultaneous decrease in liver parenchymal activity (BD increase), representing the physiologic effects of morphine administration. The second pattern consists of a continuous decrease in BD activity that parallels the activity in the liver parenchyma (BD decrease), representing lower or no physiologic effects of morphine administration. The authors hypothesize that gallbladder nonvisualization associated with a continuous decrease in BD activity after morphine administration will have a lower positive predictive value (PPV) for acute cholecystitis than gallbladder nonvisualization associated with an increase in BD activity. METHODS: Thirty-six patients who had morphine-augmented cholescintigraphy were divided into two groups: 19 with BD increase after morphine administration and 17 with BD decrease. RESULTS: Of the 36 patients, 22 had acute cholecystitis. The positive predictive value (PPV) of gallbladder nonvisualization was 61%. All of the remaining 14 had chronic cholecystitis. Of 19 patients with BD increase, 15 had acute cholecystitis (PPV = 79%), whereas only 7 of 17 patients with BD increase (PPV = 41 %) had acute cholecystitis (P = 0.023 by the one-tailed and 0.038 by the two-tailed Fisher exact tests). CONCLUSIONS: Gallbladder nonvisualization after morphine administration with the pattern of BD decrease is not as reliable (intermediate probability in this series) for the diagnosis of acute cholecystitis as is nonvisualization of the gallbladder in patients with a pattern of BD increase (high probability).

Acute Disease↗

PubMedDate not supplied

The role of cholecystokinin in radiographic opacification of the gallbladder.

Studies of the effect of cholecystokinin (CCK) on hepatic elimination of intravenously administered iopanoate and on gallbladder opacification were performed using nonoperated dogs with intact enterohepatic circulation and normal endogenous bile salt pool. Intravenous administration of CCK (3 units/kg) resulted in a 32% increase in apparent transport maximum (maximum rate of elimination) of iopanoate and earlier and enhanced gallbladder opacification. This increase in apparent transport maximum was abolished by cholecystectomy, indicating that the increase was a result of the release of bile salts from the gallbladder rather than a direct effect of the hormone on the hepatic elimination of iopanoate. The early gallbladder opacification and increased density of contrast material in the gallbladder were related to CCK-induced emptying of the gallbladder and subsequent filling with opacified bile.

Animals↗

PubMed1986

Cystic duct occlusion and transcatheter sclerosis of the gallbladder in the rabbit.

We have identified a reliable sclerosant of the gallbladder in rabbits. After ligating the cystic ducts with a silk ligature in 24 rabbits and aspirating the bile from the gallbladder, we instilled a mixture of 95% ethanol and either 2 M% trifluoroacetic acid (TFA) or 5 M% TFA into the gallbladder. The animals were killed after 6 or 8 weeks. Ethanol with TFA resulted in replacement of gallbladder lumen with fibrous tissue in 22 rabbits. The two sclerosants were equally reliable and produced quantitatively similar fibrosis in the rabbits. The tendency for normal biliary mucosa to repopulate a sclerosed gallbladder can be obviated by complete occlusion of the cystic duct. The parameters for successful transcatheter sclerosis of the gallbladder have now been defined in an animal model.

Animals↗

PubMed1996

Ultrasound demonstration of gallbladder wall thickening as a method to differentiate cirrhotic ascites from other ascites.

RATIONALE AND OBJECTIVES: Gallbladder wall thickness was measured by ultrasound in 16 patients with ascites caused by liver cirrhosis and in 16 noncirrhotic patients with ascites. This study was performed to evaluate if gallbladder wall thickening could differentiate cirrhotic ascites from ascites due to other causes. METHODS: Gallbladder thickness was measured by duplex ultrasound in 16 cirrhotic patients with ascites and in 16 noncirrhotic patients with ascites. Measurements of portal vein flow and serum albumin also were performed. RESULTS: Gallbladder wall thickness was 0.76 +/- 0.21 cm in cirrhotic patients and 0.24 +/- 0.09 in noncirrhotic patients (P < 0.001, Student's t test for unpaired data). Gallbladder wall thickening was significantly more frequent in patients with cirrhotic ascites than in patients with noncirrhotic ascites (P < 0.001, chi-square test). CONCLUSIONS: The authors feel that the ultrasound finding of gallbladder wall thickening in patients with ascites is highly predictive of liver cirrhosis diagnosis.

Aged↗