Endoscopic ultrasound in the evaluation of radiologic abnormalities of the liver and biliary tree

Histopathological changes in gall bladder mucosa in relation to the number, and size of gallstones, and analysis of the findings in the context of age distribution of the patients: A perspective

Backgrounds/Aims

To study histopathological changes in gall bladder mucosa in cholelithiasis patients, and analyse their relation to the number and size of gallstones. These findings were evaluated in the context of age distribution of the study population.

Methods

One hundred cases of cholecystectomy were part of the study, which was conducted in collaboration with the pathology department. The time period of the study was January 2020 to June 2021.

Results

Maximum cases had multiple stones (69.0%), while one third cases (31.0%) had solitary stones. While initial univariate analysis showed age (odds ratio [OR], 6.882; p = 0.043), gallstone number (OR, 9.1; p = 0.050), gallstone size (OR, 17.111; p = 0.013), and duration of symptom (OR, 34.125; p = 0.001) to be significant risk factors associated with gallbladder carcinoma, multivariate analysis found none of these variables to be significant. However, conditional multivariate analysis for the duration of symptom (p = 0.008; OR, 21.118) yielded significant p- value. With histopathological diagnoses, 5% of cases had gallbladder cancer.

Conclusions

This study shed light on the rising incidence of cholelithiasis in the young population and the high rate of gallbladder carcinoma in Punjab, India. Although gall stone characteristics (size, number) and patient age appeared to be significant risk factors when their individual relation with gallbladder carcinoma was studied, multivariate analysis, could not prove that. Conditional multivariate analysis showed the duration of symptom to be the only significant risk factor associated with gallbladder carcinoma. Further research with larger sample size is needed to study the rising incidence of gallbladder carcinoma, and the risk factors associated with it.

Endoscopic Evaluation of Biliary Strictures: Current and Emerging Techniques

The diagnosis of biliary strictures in clinical practice can be challenging. Discriminating between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Missing a malignant biliary stricture may delay surgery, resulting in poor prognostic outcomes. Conversely, it has been demonstrated that approximately 20% of patients who undergo surgery for suspected biliary malignancies have a benign etiology on histopathology. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures.

Quantitative contrast-enhanced US helps differentiating neoplastic vs non-neoplastic gallbladder polyps

OBJECTIVES

To differentiate between large (≥ 1 cm in diameter) gallbladder (GB) non-neoplastic and neoplastic polyps using quantitative analysis of contrast-enhanced ultrasound (CEUS) findings.

METHODS

From September 2017 to May 2018, 29 patients (10 males; median age, 63 years) with GB polyps of ≥ 1 cm in diameter who were undergoing cholecystectomy were consecutively enrolled. All patients underwent preoperative conventional US and CEUS examinations. Quantitative analysis of CEUS findings using time-intensity curves between the two groups was independently performed by two radiologists. The interobserver agreement for the quantitative analysis of the CEUS results was measured using the intraclass correlation coefficient. Receiver operating characteristic analysis was performed to evaluate the diagnostic performance of CEUS examination.

RESULTS

After the cholecystectomy, the patients were classified into the non-neoplastic polyp group (n = 12) and the neoplastic polyp group (n = 17) according to the pathological results. The interobserver agreement for quantitative assessment between the two radiologists was near perfect to substantial. Quantitative assessment of the CEUS findings revealed that the rise time, mean transit time, time to peak, and fall time of non-neoplastic GB polyps were significantly shorter than those of neoplastic polyps (p < 0.001, p = 0.008, p = 0.013, and p = 0.002, respectively). The sensitivity and specificity of the quantitative CEUS parameters for the differentiation between the two groups were 76.5-100% and 75%, respectively, with an area under the curve of 0.765-0.887.

CONCLUSIONS

Quantitative analysis of CEUS findings could be valuable in differentiating GB neoplastic polyps from non-neoplastic polyps.

KEY POINTS

• Quantitative analysis of CEUS findings could be valuable in differentiating gallbladder neoplastic polyps from non-neoplastic polyps. • Quantitative analysis of CEUS findings in gallbladder polyps provides cut-off values for differentiation between neoplastic polyps and non-neoplastic polyps with near-perfect to substantial interobserver agreement.

Post cholecystectomy syndrome need to redo laparoscopic completion surgery: A case report

INTRODUCTION

Cholecystectomy is the standard treatment for symptomatic gallbladder stone disease. However, symptoms such as abdominal pain and dyspepsia may persist even after surgery, if the gallbladder is incompletely removed known as postcholecystectomy syndrome.

CASE PRESENTATION

A 55-year-old man with a history of open cholecystectomy presented with a complaint of recurrent pain on his upper abdomen. Abdominal ultrasonography and magnetic resonance cholangiopancreatography revealed a cystic structure in the gallbladder fossa, with a filling defect at the midpoint of the cystic duct, suggesting a retained stone in the cystic duct and residual gallbladder. Therefore, he underwent completion laparoscopic cholecystectomy. He had an uneventful postoperative period with relief of the recurrent pain.

DISCUSSION

Proper dissection and identification of the gallbladder and cystic duct junction is necessary for complete removal of the gallbladder and preventing postcholecystectomy syndrome. Patients with a retained stone in the residual gallbladder should undergo surgery, and the laparoscopic method can be performed by a surgeon with expertise in this revision surgery.

CONCLUSION

In post-cholecystectomy syndrome, symptomatic Patients with retained stone in partially removed gall bladder by open method needs laparoscopic cholecystectomy by an expert surgeon to relieve their symptoms.

Is it necessary to perform prophylactic cholecystectomy for all symptomatic gallbladder polyps diagnosed with ultrasound?

OBJECTIVE

The main aim of this study is to determine the necessity of cholecystectomy in patients with ultrasound diagnosed symptomatic polypoid lesions of the gallbladder.

MATERIAL AND METHODS

The data of 82 patients with polypoid lesions of the gallbladder who had cholecystectomy between 2000 and 2012 were analyzed retrospectively with preoperative ultrasound and histopathology results.

RESULTS

The mean age was 48.05±11.18 years (range 25-74 years). All patients underwent preoperative ultrasound examination. Eighteen (22%) of the 82 patients were asymptomatic; their polypoid lesions of the gallbladder were detected with ultrasound during a check-up or other reasons. In 45 (55%) of cases pathology reported no polypoid lesions of the gallbladder. Right upper quadrant or epigastric pain was the most common symptom (41.46%) that led to hepatobiliary ultrasound, the other symptom was dyspepsia (36.59%). On preoperative ultrasound evaluation, 22 patients had multiple polyps, and 9 of these 22 patients had at least 3 polyps.

CONCLUSION

There is an inaccuracy of ultrasound to detect polypoid lesions of the gallbladder. After diagnosing polypoid lesions of the gallbladder by using standard ultrasound, further pre-operative diagnostic tests are needed to help discriminating benign lesions from malignant ones, which may prevent unnecessary surgery regardless of symptoms.

Assessment for diagnosis of lymph node metastasis in esophageal cancer using endoscopic ultrasound elastography

BACKGROUND

We performed endoscopic ultrasound real-time tissue elastography to more accurately diagnose lymph node metastasis of esophageal cancer. The aim of this study was to evaluate the ability of EUS elastography to distinguish benign from malignant lymph nodes in esophageal cancer patients.

METHODS

The present study had two steps. As the first step (study 1), we developed diagnostic criteria for metastatic lymph nodes using elastography and verified the validity of the criteria. Three hundred and twenty-two lymph nodes from 35 patients treated by surgical resection were included in the study. As the second step (study 2), we preoperatively examined the lymph nodes of esophageal cancer patients with EUS elastography and compared its diagnostic performance with that of the conventional B-mode EUS images. A total of 115 lymph nodes from 31 patients were included.

RESULTS

In study 1, lymph nodes were considered malignant if 50 % or more of the node appeared blue, or if the peripheral part of the lesion was blue and the central part was red/yellow/green. The sensitivity and specificity of the elastography were 79.7 and 97.6 % with an accuracy of 93.8 %, which was significantly higher than the values for conventional B-mode imaging. In study 2, the sensitivity and specificity of the EUS elastography were 91.2 and 94.5 % with an accuracy of 93.9 %, which was also significantly higher than the values for conventional B-mode EUS imaging.

CONCLUSIONS

The present study demonstrated that EUS elastography is useful for diagnosing lymph node metastasis of esophageal cancer.

Residual gallbladder stones after cholecystectomy: A literature review

BACKGROUND

Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy.

MATERIALS AND METHODS

Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up.

RESULTS

Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct.

CONCLUSION

Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.

Gallbladder cancer: can newer insights improve the outcome?

Gallbladder cancer (GBC) is the leading cause of cancer related mortality in certain geographic areas. Most of the patients with GBC have advanced disease at presentation, precluding curative resection resulting in a dismal prognosis. However, recent advances in the understanding of its epidemiology and pathogenesis coupled with development of newer diagnostic tools and therapeutic options, has resulted in enhanced optimism towards the management of the disease. The leading risk factors are gallstones, advancing age, female gender, anomalous pancreaticobiliary ductal junction, certain ethnic groups and geographic populations. Advances in radiological imaging and the advent of endoscopic ultrasound have facilitated early detection and accurate staging of the tumor. A high index of suspicion in high risk groups is necessary to pick up incidental and early GBC, as surgical resection is curative. In patients with suspected GBC, an open surgical resection that is appropriate for that stage is advocated. Adjuvant combination chemotherapy and molecular targeted therapy are emerging as effective therapeutic options in those with advanced GBC. Endoscopic palliation of biliary and gastric outlet obstruction with metallic stents has improved their quality of life. Prevention remains the hitherto less explored option to reduce GBC related mortality. Prophylactic cholecystectomy in high risk groups is a cost-effective option. A multi-disciplinary systematic global approach to initiate collaborative ventures to understand epidemiology, standardize management strategies, conduct multi-centric trials with newer therapeutic agents and initiate preventive measures, would pave way for the future conquest of the disease.

The clinical utility and limitations of serum carbohydrate antigen (CA19-9) as a diagnostic tool for pancreatic cancer and cholangiocarcinoma

BACKGROUND

CA19-9 is a tumor marker for pancreatic cancer, cholangiocarcinoma, and other malignancies. However, its sensitivity and specificity is suboptimal in clinical practice, which we hypothesized limits its clinical utility.

AIMS

To evaluate the clinical utility and limitations of CA19-9 as a tumor marker.

METHODS

We performed a retrospective review of CA19-9 levels (U/ml) in 483 consecutive patients between 2006 and 2008 at two university hospitals. We abstracted clinical, radiographic, and pathological data and final diagnoses. Descriptive and non-parametric analyses were performed.

RESULTS

Patients presenting with jaundice had the highest CA19-9 (420) compared to other complaints (<20) (p<0.01). The indications with the highest CA19-9 had evidence of biliary obstruction (71), liver mass (54), and pancreatic head mass (27) compared to other indications (<15) (p<0.01). The diagnoses with the highest CA19-9 (p<0.01) were cholangiocarcinoma (476), pancreatic cancer (161), and choledocholithiasis (138). Using a receiver operator curve to evaluate CA19-9, the area under the curve was 0.7 when evaluating all patients for pancreatic cancer or cholangiocarcinoma or patients with pancreatic head mass for pancreatic cancer.

CONCLUSIONS

This study found that for pancreatic cancer and cholangiocarcinoma, CA19-9 had poor clinical utility as a tumor marker and did not change patient management. Elevations in CA19-9 were associated with biliary obstruction based on clinical history, laboratory data, and diagnoses.

Residual gallstone disease - Laparoscopic management

BACKGROUND

A few patients who continue to suffer antecedent symptoms following laparoscopic cholecystectomy (LC) may harbor residual gallstones. The incidence of residual gallstones following cholecystectomy is <2.5%. Many of these patients require a completion cholecystectomy to ameliorate their symptoms.

MATERIALS AND METHODS

We reviewed our experience of laparoscopic re-intervention for residual gallstones over a period of 10 years from January 1998 to December 2007. Twenty six patients underwent Laparoscopic completion cholecystectomy (LCC) for residual gallstone disease. Twelve patients had a previous LC (2 patients - subtotal cholecystectomy) and 9 patients had a previous open cholecystectomy (7 patients - subtotal cholecystectomy). Five patients had previously undergone a cholecystostomy. Diagnostic investigations included abdominal ultrasound, endoscopic ultrasound (EUS), magnetic resonance cholangio-pancreatography (MRCP) and endoscopic retrograde cholangio-pancreatography (ERCP).

RESULTS

Findings included a remnant gallbladder in 3 patients, long cystic duct stump with impacted stone in 18 patients and a contracted gallbladder in 5 patients. All procedures were successfully completed laparoscopically. The mean operative time was 62 minutes and mean blood loss 50cc. Ten patient required abdominal drains postoperatively. Two patients had bilious drainage lasting 9 days and 11 days respectively. One patient died a week following surgery of acute myocardial infarction. Another patient died 6 months later of unrelated causes. The remaining patients have remained symptom free at a mean follow up of 3.2 years (range 7 months to 9 years).

CONCLUSION

The possibility of residual gallstones increases with subtotal cholecystectomy and inadequate dissection of the Calot's triangle in the presence of acute inflammation. Laparoscopic re-intervention for treating residual gallstone disease is feasible and can be safely performed in centers of expertise.

Diagnosis and management of gallbladder polyps

Gallbladder polyps are frequently encountered on cross-sectional imaging, often in asymptomatic patients. Most are benign and of little clinical importance. However, some polyps do have a malignant potential. This article discusses the clinical presentation, diagnosis, and natural history of gallbladder polyps and risk factors for malignant polyps and indications for cholecystectomy.