Laparoscopic management of remnant gall bladder with stones: Lessons from a tertiary care centre's experience

Objective:Laparoscopic cholecystectomy is currently the gold standard for treating symptomatic gallstone disease.Despite its success,approximately 10%of patients may experience persistent biliary symptoms,leading to the post-cholecystectomy syndrome.A remnant gallbladder with cystic duct or bile duct stones is one of the causes of this syndrome.The objective of this study was to shed light on the clinical manifestations,evaluation,therapeutic strategies,and outcomes associated with laparoscopic management of symptomatic remnant gallbladders.Methods:This was a retrospective study,conducted over a five-year period(January 2017 to December 2022)at Apollo Hospitals in South India.All patients who underwent laparoscopic completion cholecystectomy for a remnant gall bladder were included.The following data were collected:patient demographics,symptoms,preoperative investigations,intraoperative details and post operative outcomes.Results:In total,36 patients were included and analysed.The majority of patients were male(25,69.4%),with a mean age of 50.7±12.1 years.The most common presentation was pain in the upper abdomen or right upper quadrant region(24,66.7%).The laparoscopic approach was attempted in all patients,with a success rate of 94.4%.Two patients required conversion to open surgery.Cholecystoenteric fistula to the colon was observed in one patient.Choledocholithiasis was observed in 7 patients(19.4%),and stone clearance was successfully achieved using endoscopic retrograde cholangiopancreatography in all patients preoperatively.Conclusion:Incomplete gall bladder removal either intentionally or unintentionally leaves a remnant gall bladder that is at risk for stone formation and infection.Patients who have this clinical entity with symptoms require a redo or complete cholecystectomy,a complex procedure associated with certain risks.This study highlights the feasibility and safety of laparoscopic completion cholecystectomy for the management of remnant gallbladder with cystic duct or bile duct stones.

Identification of genes associated with gall bladder cell carcinogenesis:Implications in targeted therapy of gall bladder cancer

Gall bladder cancer(GBC)is becoming a very devastating form of hepatobiliary cancer in India.Every year new cases of GBC are quite high in India.Despite recent advanced multimodality treatment options,the survival of GBC patients is very low.If the disease is diagnosed at the advanced stage(with local nodal metastasis or distant metastasis)or surgical resection is inoperable,the prognosis of those patients is very poor.So,perspectives of targeted therapy are being taken.Targeted therapy includes hormone therapy,proteasome inhibitors,signal transduction and apoptosis inhibitors,angiogenesis inhibitors,and immunotherapeutic agents.One such signal transduction inhibitor is the specific short interfering RNA(siRNA)or short hairpin RNA(shRNA).For developing siRNAmediated therapy shRNA,although several preclinical studies to evaluate the efficacy of these key molecules have been performed using gall bladder cells,many more clinical trials are required.To date,many such genes have been identified.This review will discuss the recently identified genes associated with GBC and those that have implications in its treatment by siRNA or shRNA.

Gall Bladder Stone in a Tertiary Care Teaching Hospital in Mogadishu-Three Year Retrospective Study

Introduction: Gallstone disease, also known as gallbladder stones or GBS, is almost always asymptomatic but can result in a number of problems, including ascending cholangitis and obstructive jaundice. The frequency of gallbladder stones among patients who were sent for abdominal ultrasound at Mogadishu Somali Turkey Training and Research Hospital, Mogadishu, Somalia, during the period between January 2018 and June 2022 was assessed in this study. Methods: This is a record-based study that was carried out at the radiology department of Mogadishu Somali Turkey Training and Research Hospital on patients who were chosen for abdominal ultrasounds during the months of January 2018 and January 2022. The study focused on cases that occurred within those periods. Reports of abdominal ultrasounds served as the source of the collected data. Results: Records from 2352 patients are included in this study. They were divided into 451 (19.1%) males and 1901 (80.8%) females. Patients with GBS were present in 76.4 percent of cases. 73.2 percent of patients had big stones larger than 5 mm, while 53.4 percent of patients had several stones. GBS 1474 (77.5%) was substantially more common in females than in males (71.6%: 323/451) (P 0.008). The presence of small stones (less than 5 mm) was also shown to be significantly different between males and females (P = 0.015). Furthermore, compared with men, females had a considerably higher frequency of big GBS (5 mm) (P 0.015). Conclusion: In this study, it was discovered that females were significantly more likely than males to have GBS. Small stones were found much more frequently in the males. When compared to men, females had a considerably higher frequency of large GBS.

Synchronous but separate neuroendocrine tumor and high-grade dysplasia/adenoma of the gall bladder:A case report

BACKGROUND Gall bladder neuroendocrine tumors(GB-NETs)are rare,accounting for less than 0.5%of all NETs.They usually lack specific symptoms and are difficult to diagnose preoperatively.In most cases,GB-NETs are incidentally found after cholecystectomy for large polyps or cholelithiasis,causing acute or chronic cholecystitis.The coexistence of GB-NET and GB adenocarcinoma is very rare.CASE SUMMARY We report a case of synchronous but separate GB-NET and adenoma with high-grade dysplasia in a patient who had undergone surgery for a progressively growing GB polypoid lesion.To the best of our knowledge,simultaneous separation of NETs and cancer in the GB has not been reported.CONCLUSION Coexistent GB carcinoid tumor and adenocarcinoma is rare.A surveillance program is needed for these large GB polyps.

Outcome of gall bladder polypoidal lesions detected by transabdominal ultrasound scanning: A nine year experience

AIM: To determine the outcome of polypoidal lesions within the gall bladder (PLG) diagnosed by trans-abdominal scanning.METHODS: A nine-year (1993-2002) retrospective casenote review of all patients who underwent ultrasound scanning after referral to a single Upper GI Surgeon at a District General Hospital was conducted. Patients who were diagnosed with a PLG were included in our study. A database was constructed and patient details, investigations including ultrasound scan (USS) findings, treatment and histology and final diagnosis were recorded. RESULTS: Twenty-three (out of 651) patients were diagnosed pre-operatively by USS to have a polyp-likegall bladder lesion (PLG). Post cholecystectomy histological examination revealed 12 gallstones, 7 cholesterol polyps, 3 adenocarcinomas within polyps and 1 normal gall bladder. The specificity of USS in the diagnosis of PLG was 92.3%. All the true polyps were malignant. Overall USS had 66.66% sensitivity and 100% specificity in the pre-operative suspicion of malignancy. Using size greater than 10 mm as measured on USS as a cut-off, we find 100% sensitivity and 86.95% specificity with a positive predictive value of 50% in the diagnosis of malignancy in PLG.CONCLUSION: A large number of PLG are in fact calculi within diseased gall bladder. In cases of gall bladder polyps more then 10 mm in size on USS further imaging (crosssectional and/or EUS) is indicated prior to surgery. This will help in the optimal management of patients and avoid histological surprises.

Surgical outcome of carcinosarcoma of the gall bladder:A review

Carcinosarcoma,which comprises less than one percent of all gall bladder neoplasms,is characterized by the presence of variable proportions of carcinomatous and sarcomatous elements.Recently,several reports have described patients suffering from carcinosarcoma of the gall bladder.However,there are no large studies regarding the clinicopathologic features,therapeutic management,and surgical outcome of this disease because the number of patients who undergo resection of gall bladder carcinosarcoma at a single institution is limited.A Medline search was performed using the keywords 'gall bladder' and 'carcinosarcoma'.Additional articles were obtained from references within the papers identified by the Medline search.Optimal adjuvant chemotherapy and/or radiotherapy protocols for carcinosarcoma of the gall bladder have not been established.Curative surgical resection offers the only chance for long-term survival from this disease.The outcome of 36 patients who underwent surgical resection for carcinosarcoma of the gall bladder was poor;the 3-year overall survival rate was only 31.0% and the median survival time was 7.0 mo.Since the postoperative prognosis of carcinosarcoma of the gall bladder is worse than that of adenocarcinoma,new adjuvant chemotherapies and/or radiation techniques are essential for improvement of surgical outcome.

Candida tropicalis infection in a term neonate with gall bladder masses and infective endocarditis

Candida endocarditis is extremely rare in term neonates,and gall bladder involvement due to candidemia has never been reported amongst neonates and infants.A term,appropriate for gestational age neonate developed Candida tropicalis blood stream infection in second week of life.He was started on conventional amphotericin B.However,he failed to show any clinical improvement,and candidemia keep on persisting.Repeat sanctuary sites screening revealed multiple echogenic masses in heart(vegetations) and gall bladder.On changing the treatment to liposomal amphotericin B and fluconazole,he recovered clinically,echogenic masses in gall bladder disappeared,and intracardiac vegetations decreased in size.

Laparoscopic management of a two staged gall bladder torsion

Gall bladder torsion(GBT) is a relatively uncommon entity and rarely diagnosed preoperatively. A constant factor in all occurrences of GBT is a freely mobile gall bladder due to congenital or acquired anomalies. GBT is commonly observed in elderly white females. We report a 77-year-old, Caucasian lady who was originally diagnosed as gall bladder perforation but was eventually found with a two staged torsion of the gall bladder with twisting of the Riedel's lobe(part of tongue like projection of liver segment 4A). This together, has not been reported in literature, to the best of our knowledge. We performed laparoscopic cholecystectomy and she had an uneventful postoperative period. GBT may create a diagnostic dilemma in the context of acute cholecystitis. Timely diagnosis and intervention is necessary, with extra care while operating as the anatomy is generally distorted. The fundus first approach can be useful due to altered anatomy in the region of Calot's triangle. Laparoscopic cholecystectomy has the benefit of early recovery.

Is gall bladder cancer a bad cancer per se?

Gall bladder cancer(GBC) has one of the poorest outcomes of all cancers. Early GBC is difficult to diagnose on even computed tomography. GB has no submucosa and the cancer infiltrates directly into the muscularis propria. GB wall is thin and important adjacent organs viz. liver, duodenum and pancreas get easily infiltrated. Tumor in the GB neck often needs extended right hepatectomy. Infiltration of duodenum/pancreas may necessitate pancreato-duodenectomy or evenhepato-pancreato-duodenectomy. Mortality of surgical procedures, when performed for GBC, is higher than when performed for other cancers. Survival in GBC, even after R0 resection, is poor. There is no proven role of neo-adjuvant or adjuvant therapy for loco-regionally advanced GBC. There is no role of palliative surgery in metastatic GBC. Early GBC is diagnosed incidentally after cholecystectomy for stones and requires reoperation for completion extended cholecystectomy but unfortunately, most surgeons are not aware of this. GBC has a peculiar epidemiology and is uncommon in the West and has, therefore, not received much attention. Preventive cholecystectomy for asymptomatic stones is not recommended and there is no serum marker for screening. With all factors pitched against it, it does appear that GBC is a bad cancer per se!

Neuro Endocrine Tumor of the Gall Bladder: A Case Report

Neuroendocrine tumors (NET) of the gallbladder are a rare entity with only 0.2% of all NET located in the gall bladder. Well-differentiated NETs occur at a relatively lower age group unlike other gallbladder tumors, whereas neuroendocrine carcinoma (NEC) occurs in an older category of patients. The aim of our study is to discuss the current level of evidence regarding this pathological entity by means of a rare case report on a neuroendocrine carcinoma of the gall bladder in a 63-year-old patient with a history of diabetes. Patient underwent cholecystectomy for acute cholecystitis. Pathology findings on surgical specimen came back for neuroendocrine tumour.

Significance of tumour markers in cancer of gall bladder

In India, GI tract cancer is one of the ten leading cancers. Among Indian males it stands second to oral cancer and in females, it shares the third place. Most common malignant disorder of GIT is seen in our country that of liver, bile, gall bladder, pancreas, bileduct and colorectal. Aim: To see the significance of tumour markers in gall bladder cancer. Materials and Methods:This study comprise 225 cases of GI tract cancers was carried for more than two years. Of these, 22 subjects had gallbladder cancer. Tumour markers viz. CA19-9, CEA and AFP were assayed pre and post-operative cases and their role in gallbladder cancer was evaluated. Results: It was observed that serum concentration of CA 19-9 increased with advancing stage, but the same is not true for AFP and CEA. Sensitivity of these markers AFP, CA 19-9 and CEA in the detection of gall bladder cancer was determined. CA 19-9 is the most sensitive of all the three tumour markers in the detection of gall bladder cancer. Conclusion: The combination of CA19-9 and CT (or US) is a reasonable, cost-effective, noninvasive approach to establishing the diagnosis of pancreatic, cholangitic, or biliary cancer in nonicteric patients.

Imaging in Double Gall Bladder with Acute Cholecystitis—A Rare Entity

Duplication of gall bladder is a rare congenital anomaly of the hepatobiliary system. It is a very important entity in clinical practice as preoperative diagnosis plays a significant role in the management and to avoid unnecessary bile duct injury during surgery. We report a case of duplicated gall bladder presenting as acute cholecystitis.

Isolated traumatic gallbladder injury: A case report

BACKGROUND Isolated gallbladder injury(GI)(IGI)directly induced by abdominal trauma is rare.Symptoms,indications,and imaging examinations of IGI are frequently non-specific,posing tremendous diagnostic challenges,which are simple to overlook and may have severe implications.Improving doctors'understanding of gallbladder injury(GI)facilitates early detection and decreases the likelihood of severe consequences,including death.CASE SUMMARY We report a case of IGI caused by blunt violence(after falling from three meters with the umbilicus as the stress point)and performed laparoscopic repair of the gallbladder rupture,which helps clinicians understand IGI and reduce the severe consequences of delayed diagnosis.Through extensive medical history and dynamic abdominal ultrasound evaluation,doctors can identify GI early and begin surgery,thereby decreasing the devastating repercussions of delayed diagnosis.CONCLUSION This article aims to improve clinicians'understanding of IGI and propose a method for the diagnosis and treatment of GI.

Post-Traumatic Gallbladder Injury in Children: Case Rapport

Post-traumatic injuries of the gall bladder are rare. We report through a clinical description of its physio-pathological and evolutionary aspects. A 14-year-old boy was received 48 hours after a stabbing attack. After initial haemorrhage, the patient presented clinical improvement;then a sudden deterioration with vague symptoms and disturbance of the hepatic balance. The abdominal CT scan revealed a perivesicular hematoma with a focus on hepatic contusion. Laparoscopy showed a penetrating sore of the liver, but the exploration was limited by an important inflammation of the digestive tract. The diagnosis of gall bladder perforation was made during the operation. We performed a cholecystectomy by laparotomy. Postoperative evolution was simple, removal of the slides at D + 4 and discharged at D + 7 postoperative after improvement. At the 6th month, he presented an acute intestinal obstruction on bridles, managed at emergency by open surgery. After one year of follow up, the patient has no symptoms. We note that the vague clinical presentation and the limit of imaging examinations made the early diagnosis of a vesicular perforation a real challenge for the clinician. Cholecystectomy remains the optimal treatment.

Gallbladder cancer harboring ERBB2 mutation on the primary and metastatic site: A case report

BACKGROUND Bile duct cancer constitutes gallbladder cancer(GBC),intrahepatic cholangiocarcinoma(ICA),and extrahepatic cholangiocarcinoma(ECA).These three entities show morphological and immunohistochemical resemblance so that it is difficult to differentiate between primary ICA and liver metastasis of GBC,which sometimes becomes a point of discussion in clinical practice.Although these cancers demonstrate significant differences in their mutational landscape,several reports demonstrated shared genomic alteration in paired primary and metastatic site aids in distinguishing metastatic recurrence from second primary cancers.CASE SUMMARY We present a 73-year-old female patient who underwent curative resection for GBC harboring epidermal growth factor receptor 2(ERBB2)activating mutation on next-generation sequencing(NGS)-based genomic testing.One year later,a hepatic lesion was observed on follow-up imaging and she underwent surgical resection for a pathological diagnosis.The histological findings of the hepatic lesion were similar to those of the primary lesion.Additionally,using NGS panel testing,the hepatic lesion was found to have ERBB2 activating mutation,which is the identical mutation detected in the sequencing result of the primary site.ERBB2 activating mutation occurs more frequently in GBC than ICA and ECA.Therefore,in the present case,we think this molecular finding potentiated the diagnosis of the liver mass toward a metastatic recurrence.Additionally,this patient underwent HER2-targeted treatment with lapatinib in combination with capecitabin and obtained clinical benefit.CONCLUSION This case illustrated NGS panel usefulness in distinguishing GBC recurrence from second primary cancer and HER2-targeted agent efficacy on ERBB2 mutated GBC.

苯并芘对鲤鱼胆囊的毒性效应及响应机制

为探讨苯并芘对鲤鱼胆囊的毒理机制,以鲤鱼(Cyprinus carpio)为试验材料,采用15 d慢性毒性试验(苯并芘质量浓度分别为0、0.025和0.25 mg/L),通过检测鲤鱼胆囊中苯并芘质量分数、抗氧化参数、转录应答及免疫基因表达。结果显示:胆囊组织中的苯并芘质量分数积累随着苯并芘胁迫质量浓度显著升高,侧面反映了胆囊在解毒和排毒过程中扮演着重要角色;B[a]P暴露后胆囊抗氧化酶活性(超氧化物歧化酶、过氧化氢酶及谷胱甘肽过氧化物酶)和丙二醛浓度均升高,表明机体可通过激活抗氧化酶系统以应对氧化应激;低质量浓度B[a]P暴露会引起鲤胆囊组织的免疫应答,激活Notch受体信号通路,进而引起细胞凋亡并消除自身组织中过多或异常的细胞;而高质量浓度B[a]P暴露会抑制RIG-I和Notch受体信号通路,引起胆囊免疫稳态失衡,细胞凋亡受到抑制,从而延长异常细胞的存活时间,并进一步激活免疫细胞,导致自身组织的损伤。本研究初步揭示了鲤胆囊细胞应对苯并芘暴露的可能自我保护机制,实现对水环境中多环芳烃污染的早期预警及生态风险评估提供理论基础。

幽门腺腺瘤16例临床病理学观察

目的探讨幽门腺腺瘤(pyloric gland adenoma,PGA)的临床病理学特征。方法收集16例PGA的临床资料,采用免疫组化EnVision法检测PepsinogenⅠ、p53、MUC6、MUC5AC、CgA、Syn、CD56、Ki67、CDX-2、MUC2、β-catenin、CD10的表达,并分析其与临床病理特征及预后的关系。结果16例PGA患者中男性7例,女性9例。平均年龄58岁(范围26~81岁)。肿瘤平均最大径1.3 cm(范围0.2~4 cm)。肿瘤位于胃6例(胃体3例和胃底3例),十二指肠3例,胆囊7例。低级别PGA 7例,镜下见幽门腺样腺管紧密排列,内衬单层立方至低柱状细胞,核圆形、卵圆形,位于基底侧,核仁不明显,胞质透明或嗜酸性,呈毛玻璃样外观,细胞缺乏黏液帽;高级别PGA 1例,镜下见腺体结构紊乱、细胞核拥挤、核极向消失;其余8例混合低级别和高级别成分。5例发现鳞状桑葚样化生。根据免疫表型特点,16例中混合型(MUC5AC+,MUC6+)8例,纯幽门型(MUC5AC-,MUC6+)8例,未发现小凹优势型(MUC5AC+,MUC6-)。结论PGA是消化系统少见肿瘤,具有特征性形态学特点和免疫表型,因其有向恶性转化的风险,需提高警惕,尽量做到早发现、早诊断和早治疗。

基于深度学习在CT图像上分割胆囊的研究

目的:基于深度学习方法训练模型,研究其用于腹部CT图像上分割胆囊并自动测量的可行性。方法:从本院PACS系统搜集2016年1月12日至2021年5月28日行腹部CT检查的患者,从中选取1154位患者的1181次CT检查图像,共得到2559个图像序列用于训练模型。由2位影像科医师标注胆囊,将全部数据按8:1:1的比例随机分为训练集(n=2043)、调优集(n=245)和测试集(n=271),训练3D U-net模型分割胆囊并自动测量。另搜集2022年9月10-19日的腹部CT扫描图像,随机选取共141位患者的141次检查的270个图像序列作为外部验证数据集。以外部验证集的预测结果评价模型的效能。使用Dice相似系数(DSC)、体积相似度(VS)和Hausdorff距离(HD)定量评价模型分割胆囊区域的效能。使用Bland-Altman分析评价模型自动测量的胆囊体积、径线、平均CT值与医师标注测量值的一致性。结果:外部验证集的DSC、VS、HD分别为0.980(0.970,0.980)、0.990(0.990,1.000)、1.69(1.27,2.45)mm,各数据集之间DSC、VS和HD的差异均有统计学意义(P均<0.001)。外部验证集中模型预测和医师标注测量的胆囊体积、CT值、三维径线的95%一致性界限(LoA)的可信区间分别为(-2.07,3.36)、(-1.55,1.15)、(-1.28,1.47)、(-3.34,4.07)和(-1.11,2.15),分别有2.6%、3.7%、3.7%、1.1%和3.7%的点落在95%LoA以外。结论:基于深度学习模型可在腹部CT图像上自动分割胆囊区域,是将来进一步胆囊病变智能诊断的基础。

不同手术方式对T_(1b)期胆囊癌患者的治疗效果

目的探讨不同手术方式对T_(1b)期胆囊癌患者的治疗效果。方法根据手术方式的不同将64例T_(1b)期胆囊癌患者分为对照组(n=32)和观察组(n=32),对照组患者采取腹腔镜下胆囊切除术,观察组患者采取腹腔镜下胆囊切除+胆囊床2 cm楔形切除+区域淋巴结清扫术。比较两组患者的手术相关指标、炎症因子[肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、C反应蛋白(CRP)]水平、凝血指标[凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)]、并发症发生率及5年随访结果。结果两组患者的术中出血量、术后排气时间、术后胃肠功能恢复时间、术后住院时间比较,差异均无统计学意义(P>0.05)。术后,两组患者的血清IL-6、TNF-α、CRP水平均高于本组术前,PT、APTT、TT均长于本组术前,差异均有统计学意义(P<0.05)。术后,两组患者的血清IL-6、TNF-α、CRP水平及PT、APTT、TT比较,差异均无统计学意义(P>0.05)。两组患者腹腔出血、胆漏、切口感染或腹腔感染发生率比较,差异均无统计学意义(P>0.05)。随访5年,观察组患者的生存率高于对照组(P<0.05);两组患者的肿瘤复发转移率比较,差异无统计学意义(P>0.05)。结论腹腔镜下胆囊扩大切除+区域淋巴结清扫术治疗T_(1b)期胆囊癌可提高患者的5年生存率,不会加重患者的炎症反应,也不会增加并发症发生率。

大豆苷元对豚鼠胆囊收缩运动的影响

目的:研究大豆苷元对胆囊收缩运动的影响。方法:采用豚鼠胆囊肌条观察大豆苷元拮抗乙酰胆碱、组胺、高K^+、ca^(2+)所致豚鼠离体胆囊收缩运动的影响。结果:大豆苷元可明显拮抗乙酰胆碱、组胺、高K^+所致胆囊收缩运动及拮抗累积ca^(2+)引起豚鼠离体胆囊收缩运动。结论:大豆苷元可明显拮抗豚鼠离体胆囊收缩。