Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma

Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum,provoked biliary dilatation and jaundice,and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder,extrahepatic bile duct,and hilar lymph nodes,as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases,the best option may be radical resection following oncological principles performed by expert surgeons,in order that postoperative complications may be minimized if not avoided altogether.

Surgical treatment of xanthogranulomatous cholecystitis:experience in 33 cases

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe fibrosis and foam cells, and can be a cause of difficulty in cholecystectomy. Patients with XGC are frequently misdiagnosed intraoperatively as having carcinoma of the gallbladder and are treated with extensive excision. This study aimed at providing proper surgical treatment for patients with XGC. METHODS: The clinical data of 33 patients with XGC definitely diagnosed by pathological examination over a period of 10 years were analyzed retrospectively (mean age of onset, 60 years; male/female ratio, 1.5: 1). RESULTS: Preoperatively, the 33 patients were examined by abdominal B-ultrasonography while 20 of them were further examined by computed tomography (CT). Intraoperatively, XGC associated with cholecystolithiasis was found in 97.0% of the patients, thickening of the gallbladder wall in 90.9%, xanthogranulomatous tissue invading into other tissues in 87.9%, XGC associated with choledocholithiasis in 15.2%, and Mirizzi syndrome in 9.1%. In addition, a gallbladder fistula was observed in 4 patients. Open cholecystectomy was performed on 15 patients, partial cholecystectomy on 7, cholecystectomy and partial liver wedge resection on 5, and gallbladder cancer radical correction on 6. The intraoperative misdiagnosis rate was 24.2%. Frozen-section examination was carried out in 9 patients. Postoperative complications were observed in 5 patients. CONCLUSIONS: XGC is difficult to diagnose either preoperatively or intraoperatively and definite diagnosis depends exclusively on pathological examination. Firm adhesions of the gallbladder to neighboring organs and tissues are common and lead to difficulty in surgical treatments. The mode of operation depends on specific conditions in varying cases, and since frozen-section examination plays an important role in determining the nature of the lesions, intraoperative frozen-section examination should be carried out to differentiate XGC from carcinoma of the gallbladder.

Extended surgical resection for xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma: A case report and review of literature

Xanthogranulomatous cholecystitis （XGC） is a destructive inflammatory disease of the gallbladder, rarely involving adjacent organs and mimicking an advanced gallbladder carcinoma. The diagnosis is usually possible only after pathological examination. A 46 year-old woman was referred to our center for suspected gallbladder cancer involving the liver hilum, right liver lobe, right colonic flexure, and duodenum. Brushing cytology obtained by endoscopic retrograde cholangiography （ERC） showed high-grade dysplasia. The patient underwent an en-bloc resection of the mass, consisting of right Iobectomy, right hemicolectomy, and a partial duodenal resection. Pathological examination unexpectedly revealed an XGC. Only six cases of extended surgical resections for XGC with direct involvement of adjacent organs have been reported so far. In these cases, given the possible coexistence of XGC with carcinoma, malignancy cannot be excluded, even after cytology and intraoperative frozen section investigation. In conclusion, due to the poor prognosis of gallbladder carcinoma on one side and possible complications deriving from highly aggressive inflammatory invasion of surrounding organs on the other side, it seems these cases should be treated as malignant tumors until proven otherwise. Clinicians should include XGC among the possible differential diagnoses of masses in liver hilum.

Presentation and surgical management of xanthogranulomatous cholecystitis

Background:Xanthogranulomatous cholecystitis(XGC)is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and most of the times requires surgical management.In addition,distinguishing XGC from gallbladder cancer preoperatively is still a challenge.The aim of the present systematic review was to outline the clinical presentation and surgical approach of XGC.Data sources:The present systematic review was designed using the PRISMA and AMSTAR guidelines.We searched MEDLINE,Scopus,Clinicaltrials.gov,EMBASE,Cochrane Central Register of Controlled Trials(CENTRAL)and Google Scholar databases from inception until June 2020.Results:The laparoscopic cholecystectomy rate(34%)was almost equal to the open cholecystectomy rate(47%)for XGC.An important conversion rate(35%)was observed as well.The XGC cases treated by surgery were associated with low mortality(0.3%),limited intraoperative blood loss(58-270 m L),low complication rates(2%–6%),along with extended operative time(82.6–120 minutes for laparoscopic and 59.6–240 minutes for open cholecystectomy)and hospital stay(3–9 days after laparoscopic and 8.3–18 days after open cholecystectomy).Intraoperative findings during cholecystectomies for XGC included empyema or Mirizzi syndrome.In addition,complex surgical procedures,like wedge hepatic resections and bile duct excision were required during operations for XGC.Conclusions:XGC seemed to be a rare,benign inflammatory disease that presents similar features as gallbladder cancer.The mortality and complication rates of XGC were low,despite the complex surgical procedures that might be required in some cases.

Differential Diagnosis between the Gallbladder Cancer and Xanthogranulomatous Cholecystitis by Multiple Percutaneous Biopsies

Xanthogranulomatous cholecystitis (XGC) is a rare form of chronic inflammatory disease that is often mistaken for gallbladder (GB) cancer. Differential diagnosis based on clinical features or imaging scan is virtually impossible and pathological confirmation is crucial for diagnosis. A 72-year-old man was referred to an oncologist for suspicion of unresectable GB cancer with liver metastasis. He was admitted and underwent three percutaneous needle biopsies. However, all specimens showed non-neoplastic hepatic parenchyma with the third biopsy indicating xanthogranulomatous inflammation with abscess formation. The final biopsy changed the diagnosis from GB cancer to XGC. He was prescribed oral antibiotics and discharged after multiple ERBD stenting because of benign biliary stricture. He regularly visited an outpatient clinic and a follow-up CT scan showed a decrease of gallbladder mass. In conclusion, xanthogranulomatous cholecystitis should be considered in the differential diagnoses of GB mass and clinical suspicion is very important for a precise diagnosis.

Xanthogranulomatous cholecystitis: What every radiologist should know

Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis characterized by xanthogranulomatous inflammation of the gallbladder. Intramural accumulation of lipid-laden macrophages and acute and chronic inflammatory cells is the hallmark of the disease. The xanthogranulomatous inflammation of the gallbladder can be very severe and can spill over to the neighbouring structures like liver, bowel and stomach resulting in dense adhesions, perforation, abscess formation, fistulous communication with adjacent bowel. Striking gallbladder wall thickening and dense local adhesions can be easily mistaken for carcinoma of the gallbladder, both intraoperatively as well as on preoperative imaging. Besides, cases of concomitant gallbladder carcinoma complicating XGC have also been reported in literature. So, we have done a review of the imaging features of XGC in order to better understand the entity as well as to increase the diagnostic yield of the disease summarizing the characteristic imaging findings and associations of XGC. Among other findings, presence of intramural hypodense nodules is considered diagnostic of this entity. However, in some cases, an imaging diagnosis of XGC is virtually impossible. Fine needle aspiration cytology might be handy in such patients. A preoperative counselling should include possibility of differential diagnosis of gallbladder cancer in not so characteristic cases.

Xanthogranulomatous cholecystitis:Difficulty in differentiating from gallbladder cancer

AIM: To compare cases of xanthogranulomatous cholecystitis(XGC) and advanced gallbladder cancer and discuss the differential diagnoses and surgical options.METHODS: From April 2000 to December 2013, 6 XGC patients received extended surgical resections. During the same period, 16 patients were proven to have gallbladder(GB) cancer, according to extended surgical resection. Subjects chosen for analysis in this study were restricted to cases of XGC with indistinct borders with the liver as it is often difficult to distinguish these patients from those with advanced GB cancer. We compared the clinical features and computed tomography findings between XGC and advanced GB cancer. The following clinical features were retrospectively assessed: age, gender, symptoms, and tumor markers. As albumin and the neutrophil/lymphocyte ratio(NLR) are prognostic in several cancers, we compared serum albumin levels and the NLR between the two groups. The computerized tomography findings were used to compare the two diseases, determine the coexistence of gallstones, the pattern of GB thickening(focal or diffuse), the presence of a hypoattenuated intramural nodule, and continuity of the mucosal line.RESULTS: Based on the preoperative image findings, we suspected GB carcinoma in all cases includingXGC in this series. In addition, by pathological examination, we found that the group of patients with XGC developed inflammatory disease after surgery. Patients with XGC tended to have abdominal pain(4/6, 67%). However, there was no significant difference in clinical symptoms, including fever, between the two groups. Serum albumin and NLR were also similar in the two groups. Serum tumor markers, such as carcinoembryonic antigen(CEA) and carbohydrate antigen 19-9(CA19-9), tended to increase in patients with GB cancer. However, no significant differences in tumor markers were identified. On the other hand, gallstones were more frequently observed in patients with XGC(5/6, 83%) than in patients with GB cancer(4/16, 33%)(P = 0.0116). A hypoattenuated intramural nodule was found in 3 patients with XGC(3/6, 50%), but in only 1 patient with GB cancer(1/16, 6%)(P = 0.0024). The GB thickness, continuous mucosal line, and bile duct dilatation showed no significant differences between XGC and GB cancer.CONCLUSION: Although XGC is often difficult to differentiate from GB carcinoma, it is possible to obtain an accurate diagnosis by careful intraoperative gross observation, and several intraoperative frozen sections.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma:An analysis of 42 cases

AIM: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis(XGC) clinically.METHODS: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our hospital, among which 42 were misdiagnosed as gallbladder carcinoma(GBC) based on preoperative radiographs and/or intra-operative findings. The clinical characteristics, preoperative imaging, intra-operative findings, frozen section(FS) analysis and surgical procedure data of these patients were collected and analyzed.RESULTS: The most common clinical syndrome in these 42 patients was chronic cholecystitis, followed by acute cholecystitis. Seven(17%) cases presented with mild jaundice without choledocholithiasis. Thirtyfive(83%) cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging, and 29(69%) cases presented with abnormal enhancement in hepatic parenchyma neighboring the gallbladder, which indicated hepatic infiltration. Intra-operatively, adhesions to adjacent organs were observed in 40(95.2%) cases, including the duodenum, colon and stomach. Thirty cases underwent FS analysis and the remainder did not. The accuracy rate of FS was 93%, and that of surgeon's macroscopic diagnosis was 50%. Six cases were misidentified as GBC by surgeon's macroscopic examination and underwent aggressive surgical treatment. No statistical difference was encountered in the incidence of postoperative complications between total cholecystectomy and subtotal cholecystectomy groups(21% vs 20%, P > 0.05).CONCLUSION: Neither clinical manifestations and laboratory tests nor radiological methods provide apractical and effective standard in the differential diagnosis between XGC and GBC.

Xanthogranulomatous cholecystitis:a premalignant condition?

BACKGROUND:Xanthogranulomatous cholecystitis(XGC)is an uncommon variant of chronic cholecystitis,characterized by marked thickening of the gallbladder wall and dense local adhesions.It often mimics a gallbladder carcinoma(GBC), and may coexist with GBC,leading to a diagnostic dilemma. Furthermore,the premalignant nature of this entity is not known.This study was undertaken to assess the p53,PCNA and beta-catenin expression in XGC in comparison to GBC and chronic inflammation. METHODS:Sections from paraffin-embedded blocks of surgically resected specimens of GBC(69 cases),XGC(65), chronic cholecystitis(18)and control gallbladder(10)were stained with the monoclonal antibodies to p53 and PCNA, and a polyclonal antibody to beta-catenin.p53 expression was scored as the percentage of nuclei stained.PCNA expression was scored as the product of the percentage of nuclei stained and the intensity of the staining(1-3).A cut-off value of 80 for this score was taken as a positive result. Beta-catenin expression was scored as type of expression-membranous,cytoplasmic or nuclear staining. RESULTS:p53 mutation was positive in 52%of GBC cases and 3%of XGC,but was not expressed in chronic cholecystitis and control gallbladders.p53 expression was lower in XGC than in GBC(P<0.0001).PCNA expression was seen in 65%of GBC cases and 11%of XGC,but not in chronic cholecystitis and control gallbladders.PCNA expression was higher in GBC than XGC(P=0.0001),but there was no significant difference between the XGC,chronic cholecystitis and control gallbladder groups.Beta-catenin expression was positive in the GBC,XGC, chronic cholecystitis and control gallbladder groups.But the expression pattern in XGC,chronic cholecystitis and control gallbladders was homogenously membranous,whereas in GBC the membranous expression pattern was altered to cytoplasmic and nuclear.CONCLUSION:The expression of p53,PCNA and beta-catenin in XGC was significantly different from GBC and similar to chronic cholecystitis,thus indicating the inflammatory nature of XGC and may not support a premalignant nature of the lesion.

Xanthogranulomatous cholecystitis mimicking gallbladder cancer and causing obstructive cholestasis

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory disease of the gallbladder that can mimic gallbladder carcinoma. METHODS: We present the case of a 35-year-old Hispanic male complaining of right upper quadrant pain and jaundice for 2 months prior to admission. He denied a history of fever, nausea/ vomiting, and weight loss. The past medical history was relevant only for diabetes. He had no previous history of jaundice or previous operations. RESULTS: CA19-9 was slightly elevated (52 U/mL). Abdominal ultrasonography showed an irregular thickening of the gallbladder wall and no gallstones were detected. CT scan also revealed an irregular thickening of the wall of the gallbladder body suggestive of malignancy. At laparotomy, the mass was adherent to the duodenum and colon, and although the frozen section biopsy was negative, the intraoperative findings were suggestive of malignancy, and the patient underwent left liver trisegmentectomy, resection of the common bile duct and Roux-en-Y hepaticojejunostomy. Pathological examination unexpectedly revealed XGC without malignancy. CONCLUSIONS: Preoperative and intraoperative differential diagnosis of XGC from gallbladder carcinoma remains a challenge when it is associated with inflammatory involvement of surrounding tissues. Since gallbladder carcinoma and XGC may coexist, radical resection is justified when malignancy cannot be completely ruled out.

Low skeletal muscle mass and high visceral adiposity are associated with recurrence of acute cholecystitis after conservative management:A propensity score-matched cohort study

Background:Recurrent acute cholecystitis(RAC)can occur after non-surgical treatment for acute cholecystitis(AC),and can be more severe in comparison to the first episode of AC.Low skeletal muscle mass or adiposity have various effects in several diseases.We aimed to clarify the relationship between RAC and body parameters.Methods:Patients with AC who were treated at our hospital between January 2011 and March 2022 were enrolled.The psoas muscle mass and adipose tissue area at the third lumbar level were measured using computed tomography at the first episode of AC.The areas were divided by height to obtain the psoas muscle mass index(PMI)and subcutaneous/visceral adipose tissue index(SATI/VATI).According to median VATI,SATI and PMI values by sex,patients were divided into the high and low PMI groups.We performed propensity score matching to eliminate the baseline differences between the high PMI and low PMI groups and analyzed the cumulative incidence and predictors of RAC.Results:The entire cohort was divided into the high PMI(n=81)and low PMI(n=80)groups.In the propensity score-matched cohort there were 57 patients in each group.In Kaplan-Meier analysis,the low PMI group and the high VATI group had a significantly higher cumulative incidence of RAC than their counterparts(log-rank P=0.001 and 0.015,respectively).In a multivariate Cox regression analysis,the hazard ratios of low PMI and low VATI for RAC were 5.250(95%confidence interval 1.083-25.450,P=0.039)and 0.158(95%confidence interval:0.026-0.937,P=0.042),respectively.Conclusions:Low skeletal muscle mass and high visceral adiposity were independent risk factors for RAC.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET

Recently, several reports have demonstrated that fluorine-18 fluorodeoxyglucose positron emission tomography （FDG-PET） is useful in differentiating between benign and malignant lesions in the gallbladder. However, there is a limitation in the ability of FDG-PET to differentiate between inflammatory and malignant lesions. We herein present a case of xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma by ultrasonography and computed tomography. FDG-PET also showed increased activity. In this case, FDG-PET findings resulted in a false-positive for the diagnosis of gallbladder carcinoma.

Xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma: retrospective analysis of 10 cases

Objective: To investigate the reasons for misdiagnosing xanthogranulomatous cholecystitis (XGC) as gallbladder carcinoma, and to provide differential points between these two diseases. Methods: Thirty-three patients with the final diag- nosis of XGC in our hospital over a period of 10 years (1996–2005) were reviewed, among which 10 (6 males and 4 females) were misdiagnosed as having gallbladder carcinoma either preoperatively or intraoperatively. Results: 10 misdiagnosed cases were examined preoperatively by B-ultrasound (BUS) and computed tomography (CT). BUS and CT revealed 5 cases of gallbladder carcinoma and 1 of chronic cholecystitis; 2 cases were diagnosed as gallbladder carcinoma on BUS but chronic cholecystitis on CT; other 2 cases were diagnosed as chronic cholecystitis on BUS but as gallbladder carcinoma on CT. Intra- operatively, thickening of the gallbladder wall was found in all of the patients; xanthogranulomatous tissue was found invading into other tissues including gallbladder bed and omentum majus. Intraoperative frozen section investigation was performed on 1 patient revealing that no tumor cell was found. Open cholecystectomy + partial hepatic wedge resection were performed on 3 patients; cholecystectomy + partial hepatic wedge resection + regional lymphadenectomy in the liver duodenum ligament on 6 patients; cholecystectomy + cholecystoenterostomy + colocolic anastomosis after partial resection of transverse colon on 1 patient. Postoperative pathological findings revealed XGC in all these patients. Conclusion: XGC is an uncommon variant of chronic cholecystitis of which clinical and imaging presentations closely resemble gallbladder carcinoma. Thus differentiation is essential by means of intraoperative frozen section investigation to ensure optimal surgical treatment since XGC has its pathological distinctions, which are not that of a precancerous change.

Xanthogranulomatous cholecystitis managed by laparotomy may go through troublesome clinical course: Reflection of severe inflammation

To the Editor: Xanthogranulomatous cholecystitis(XGC) is an uncommon inflammatory disease of the gallbladder, and its incidence is reported to be 1.3%-5.2% [1]. XGC is diagnosed by histopathological examination, characterized by severe inflammatory destruction followed by a granulomatous reaction, marked proliferative fibrosis, and infiltration of inflammatory cells [2].

Duplicated gallbladder with acute cholecystitis:a case of unusual presentation and diagnostic challenges

Anomalies in the gallbladder can lead to misidentifying anatomical structures,heightening the risk of complications in laparoscopic and open cholecystectomy procedures.Failure to recognize these variations increases the chances of iatrogenic bile duct injuries and other complications.

Evaluating effectiveness and safety of combined percutaneous transhepatic gallbladder drainage and laparoscopic cholecystectomy in acute cholecystitis patients:Meta-analysis

BACKGROUND Acute cholecystitis(AC)is a common disease in general surgery.Laparoscopic cholecystectomy(LC)is widely recognized as the"gold standard"surgical procedure for treating AC.For low-risk patients without complications,LC is the recommended treatment plan,but there is still controversy regarding the treatment strategy for moderate AC patients,which relies more on the surgeon's experience and the medical platform of the visiting unit.Percutaneous transhepatic gallbladder puncture drainage(PTGBD)can effectively alleviate gallbladder inflammation,reduce gallbladder wall edema and adhesion around the gallbladder,and create a"time window"for elective surgery.AIM To compare the clinical efficacy and safety of LC or PTGBD combined with LC for treating AC patients,providing a theoretical basis for choosing reasonable surgical methods for AC patients.METHODS In this study,we conducted a clinical investigation regarding the combined use of PTGBD tubes for the treatment of gastric cancer patients with AC.We performed searches in the following databases:PubMed,Web of Science,EMBASE,Cochrane Library,China National Knowledge Infrastructure,and Wanfang Database.The search encompassed literature published from the inception of these databases to the present.Subsequently,relevant data were extracted,and a meta-analysis was conducted using RevMan 5.3 software.RESULTS A comprehensive analysis was conducted,encompassing 24 studies involving a total of 2564 patients.These patients were categorized into two groups:1371 in the LC group and 1193 in the PTGBD+LC group.The outcomes of the meta-analysis revealed noteworthy disparities between the PTGBD+LC group and the LC group in multiple dimensions:(1)Operative time:Mean difference(MD)=17.51,95%CI:9.53-25.49,P<0.01;(2)Conversion to open surgery rate:Odds ratio(OR)=2.95,95%CI:1.90-4.58,P<0.01;(3)Intraoperative bleeding loss:MD=32.27,95%CI:23.03-41.50,P<0.01;(4)Postoperative hospital stay:MD=1.44,95%CI:0.14-2.73,P=0.03;(5)Overall postoperative compli-cation rate:OR=1.88,95%CI:1.45-2.43,P<0.01;(6)Bile duct injury:OR=2.17,95%CI:1.30-3.64,P=0.003;(7)Intra-abdominal hemorrhage:OR=2.45,95%CI:1.06-5.64,P=0.004;and(8)Wound infection:OR=0.These find-ings consistently favored the PTGBD+LC group over the LC group.There were no significant differences in the total duration of hospitalization[MD=-1.85,95%CI:-4.86-1.16,P=0.23]or bile leakage[OR=1.33,95%CI:0.81-2.18,P=0.26]between the two groups.CONCLUSION The combination of PTGBD tubes with LC for AC treatment demonstrated superior clinical efficacy and enhanced safety,suggesting its broader application value in clinical practice.

Necrotizing Fasciitis Secondary to Emphysematous Cholecystitis and Cholecystocutaneous Fistula: A Rare Case Report Presentation

Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.

Strategies for diagnosis of xanthogranulomatous cholecystitis masquerading as gallbladder cancer

Background Patients with xanthogranulomatous cholecystitis sometimes exhibit imaging and intraoperative findings that are similar to those of advanced gallbladder cancer,thus these patients are easily misdiagnosed.The present study aimed to investigate the characteristics of xanthogranulomatous cholecystitis masquerading as gallbladder cancer that could potentially aid in the correct diagnosis of this condition.Methods The clinical,serological,radiological and operative features of twelve patients with obviously wall-thickening or mass-forming xanthogranulomatous cholecystitis were retrospectively analyzed.Additionally,the patient preoperative features were compared to those of 36 patients with advanced gallbladder cancers.Results Twelve patients with xanthogranulomatous cholecystitis exhibited one to three episodes of acute cholecystitis within 0.5 to 7 months prior to admission to the hospital.Five of these patients exhibited concomitant choledocholithiasis,whereas no concomitant choledocholithiasis was identified in patients with advanced gallbladder cancer.The incidence of abdominal pain （x2=6.588,P=0.010）,acute cholecystitis （x2=29.176,P=0.000）,acute cholangitis （x2=6.349,P=0.012）,choledocholithiasis （x2=16.744,P=0.000）,carcinoembryonic antigen test （P=0.007）,CA125 （P=0.001）,and diffuse gallbladder wall thickening （x2=6.031,P=0.014）,continued mucosal line （x2=15.745,P=0.000）,homogeneous enhancement of mucosal line （x2=19.947,P=0.000）,submucosal hypoattenuated nodules or band （x2=18.607,P=0.000） in computed tomography demonstrated statistically significant differences between cases of xanthogranulomatous cholecystitis and gallbladder cancer.Furthermore,all the twelve patients with xanthogranulomatous cholecystitis exhibited at least one positive computed tomography imaging feature aside from past acute cholecystitis episode,and no patient with advanced gallbladder cancer simultaneously exhibited past acute cholecystitis episode and at least one positive computed tomography imaging feature.Conclusions The accurate preoperative diagnosis of xanthogranulomatous cholecystitis includes an integrated review of past acute cholecystitis episode,choledocholithiasis,and positive computed tomography imaging features.Besides,we present an algorithm for intraoperative diagnosis.

A study on relationship of nitric oxide,oxidation,peroxidation,lipoperoxidation with chronic cholecystitis

AIM:To study relationship of injury induced by nitric oxide, oxidation, peroxidation,lipoperoxidation with chronic cholecystitis.METHODS:The values of plasma nitric oxide (P-NO), plasma vitamin C (P-VC), plasma vitamin E (P-VE), plasma beta-carotene (P-beta-CAR), plasma lipoperoxides (P-LPO), erythrocyte superoxide dismutase (E-SOD), erythrocyte catalase (E-CAT), erythrocyte glutathione peroxidase (E-GSH-Px) activities and erythrocyte lipoperoxides (E-LPO) level in 77 patients with chronic cholecystitis and 80 healthy control subjects were determined, differences of the above average values between the patient group and the control group and differences of the average values between preoperative and postoperative patients were analyzed and compared, linear regression and correlation of the disease course with the above determination values as well as the stepwise regression and correlation of the course with the values were analyzed.RESULTS:Compared with the control group, the average values of P-NO, P-LPO, E-LPO were significantly increased (P【0.01), and of P-VC, P-VE, P-beta-CAR, E-SOD, E-CAT and E-GSH-Px decreased (P 【0.01) in the patient group. The analysis of the linear regression and correlation showed that with prolonging of the course, the values of P-NO, P-LPO and E-LPO in the patients were gradually ascended and the values of P-VC,P-VE, P-beta-CAR, E-SOD, E-CAT and E-GSH-Px descended (P【0.01). The analysis of the stepwise regression and correlation indicated that the correlation of the course with P-NO, P-VE and P-beta-CAR values was the closest. Compared with the preoperative patients, the average values of P-NO, P-LPO and E-LPO were significantly decreased (P 【0.01) and the average values of P-VC, E-SOD, E-CAT and E-GSH-Px in postoperative patients increased (P 【0.01) in postoperative patients. But there was no significant difference in the average values of P-VE, P-beta-CAR preoperative and postoperative patients.CONCLUSION:Chronic cholecystitis could induce the increase of nitric oxide, oxidation, peroxidation and lipoperoxidation.

Single-incision vs three-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis

AIM:To compare the clinical outcome of single-incision laparoscopic cholecystectomy(SILC)and three-incision laparoscopic cholecystectomy(3ILC)for acute cholecystitis.METHODS:From July 2009 to September 2012,136patients underwent SILC or 3ILC for acute cholecystitis at a tertiary referral hospital.One experienced surgeon performed every procedure using 5 or 10 mm 30-degree laparoscopes,straight instruments,and conventional ports.Five patients with perforated gallbladder and diffuse peritonitis and 23 patients with mild acute cholecystitis were excluded.The remaining 108 patients were divided into complicated and uncomplicated groups according to pathologic findings.Patient demography,clinical data,operative results and complications were recorded and analyzed.RESULTS:Fifty patients with gangrenous cholecystitis,gallbladder empyema,or hydrops were classified as the complicated group,and 58 patients with acute cholecystitis were classified as the uncomplicated group.Twenty-three(46.0%)of the patients in the complicated group(n=50)and 39(67.2%)of the patients in the uncomplicated group(n=58)underwent SILC;all others underwent 3ILC.The postoperative length of hospital stay(PLOS)was significantly shorter in the SILC subgroups than the 3ILC subgroups(3.5±1.1 d vs 4.6±1.3 d,P<0.01 in the complicated group;2.9±1.1 d vs 3.7±1.4 d,P<0.05 in the uncomplicated group).The maximum body temperature recorded at day 1 and at day 2 following the procedure was lower in the SILC subgroups,but the difference reached statistical significance only in the uncomplicated group(37.41±0.56℃vs 37.80±0.72℃,P<0.05 on postoperative day 1;37.10±0.43℃vs 37.57±0.54℃,P<0.01 on postoperative day 2).The operative time,estimated blood loss,postoperative narcotic use,total length of hospital stay,conversion rates,and complication rates were similar in both SILC and 3ILC subgroups.The complicated group had longer operative time(122.2±35.0 min vs 106.6±43.6 min,P<0.05),longer PLOS(4.1±1.3 d vs 3.2±1.2 d,P<0.001),and higher conversion rates(36.0%vs 19.0%,P<0.05)compared with the uncomplicated group.CONCLUSION:SILC is safe and efficacious for patients with acute cholecystitis.The main benefit is a faster recovery than that achieved with 3ILC.