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

BACKGROUND

Early diagnosis of cholecystolithiasis is significant for prevention of further development of situation. Ultrasound is the best choice for the diagnosis of cholecystolithiasis with a sensitivity of >95% and specificity of practically 100%. However, ultrasound is not perfect for it is not so clear sometimes. So, MRI is needed to assist the diagnosing of cholecystolithiasis. Some studies have been conducted to investigate the diagnostic value of ultrasound combined with MRI in cholecystolithiasis, however, the evidence was not enough.

METHODS

We will search the following sources for the identification of trials: The Cochrane Library, PubMed, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure Database (CNKI), Chinese Science and Technique Journals Database (VIP), and the Wanfang Database. The searches were limited to articles published before 1st, April, 2021, and the language were limited to Chinese and English. Statistical analyses will be conducted with Sata 14.0 software and the evaluation of the quality of the included studies will be performed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).

RESULTS

This study will provide a rational synthesis of current evidences for MRI combined with ultrasound for cholecystolithiasis.

CONCLUSION

The conclusion of this study will provide evidence for the diagnostic value of MRI combined with ultrasound for cholecystolithiasis.

ETHICS AND DISSEMINATION

This protocol will not evaluate individual patient information or affect patient rights and therefore does not require ethical approval. Results from this review will be disseminated through peer-reviewed journals and conference reports.

PROSPERO REGISTRATION NUMBER

INPLASY202130003.

Preoperative diagnoses and identification rates of unexpected gallbladder cancer

Background

Unexpected gallbladder cancer (UGBC) is sometimes found in the resected gallbladder of patients during or after surgery. Some reports have indicated UGBC identification rates for all gallbladder surgeries, but scarce data are available for the UGBC identification rates for specific gallbladder diseases. The present study was performed to clarify UGBC rates and the factors suspicious for UGBC categorized according to preoperative diagnoses, in patients undergoing laparoscopic cholecystectomy (LSC).

Methods

We recorded data for all LSC surgeries performed in the Department of Surgery, Sada Hospital, Japan since 1991, and analyzed the 28-year data. We used the chi-square test and Kaplan–Meier analysis for this retrospective case–control study.

Results

The UGBC identification rate was 0.69% (63/9186 patients). The UGBC identification rates categorized according to the preoperative diagnoses were 1.3% (13/969) for acute cholecystitis, 2.4% (16/655) for benign tumor, 2.0% (28/1383) for chronic cholecystitis or cholecystitis, and 0.054% (3/5585) for cholecystolithiasis. The percentage of older patients (≥ 60 years) was significantly higher in UGBCs compared with cases finally diagnosed as benign in each group categorized according to the preoperative diagnoses (p≤0.0014), except for cholecystolithiasis. In cases pre-diagnosed as benign tumor, UGBCs were associated with higher rates of thickened gallbladder wall compared with benign tumor (69.2% vs. 27.9%, respectively; p = 0.0011). UGBCs pre-diagnosed as acute cholecystitis had higher T2–T4 rates (100% vs. 64.3%, respectively; p<0.05) and lower survival rates (p = 0.0149) than UGBCs pre-diagnosed with chronic cholecystitis.

Conclusions

UGBC identification rates depend on the preoperative diagnosis and range from 0.054% to 2.4%. Older age (≥ 60 years) could be related to UGBC, and a pre-diagnosis of acute cholecystitis might indicate more advanced cancer compared with a pre-diagnosis of chronic cholecystitis.

Sarcomatous intrahepatic cholangiocarcinoma: Case report and literature review

RATIONALE

Sarcomatous intrahepatic cholangiocarcinoma is a rare histological variant of cholangiocarcinoma (ICC). Previous medical literature has not mentioned the prevalence of this kind of disease, but a poorer prognosis than that of ordinary ICC was indicated. The diagnosis of the sarcomatous ICC is established on histopathological and immunohistochemical examinations. In this article, we present a new case of a patient with sarcomatous ICC who had no radiographic sign of intrahepatic tumor preoperatively.

PATIENT CONCERNS

A 63-year-old man was noted with cholecystolithiasis and right upper abdominal pain. Liver function was within normal limits, although the gamma-glutamyl transpeptidase level was elevated. Serum carbohydrate antigen 19-9 level was elevated. Radiography showed atrophy of the left lobe of the liver, high-intensity signals on T1 weighted images, and low/high-intensity signals on T2 weighted images in hepatic ducts.

DIAGNOSES

The preoperative diagnoses were hepatolithiasis, choledocholithiasis, and cholecystolithiasis.

INTERVENTIONS

Exploratory laparotomy, adhesion release, cholecystectomy, choledocholithotomy, and T tube drainage were performed. During the surgery, an ill-defined tumor was detected on the atrophic left lateral lobe of the liver. Hepatic left lateral lobectomy was performed to remove the mass.

OUTCOMES

The final diagnosis of sarcomatous ICC was made by histopathology after surgery. No evidence of local recurrence or distant metastasis was noted on imaging during follow-up.

LESSONS

Although rare, sarcomatous ICC does exist in patients presented with cholecystolithiasis and liver atrophy. Surgeons should be aware of the existence of sarcomatous ICC due to the poor prognosis. We recommend that multidisciplinary approaches may be key to improve prognosis, including adjuvant chemotherapy or radiotherapy.

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

OBJECTIVE

To discuss the hazards of cholecystolithiasis recrudesce after cholecystolithotomy with gallbladder reservation; To provide a theoretical basis for reducing the recurrence rate of gallstone.

PATIENTS AND METHODS

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

RESULTS AND CONCLUSIONS

The main hazards of cholecystolithiasis recurrence were BMI, family history of gallstone disease, and emptying function of gallbladder.

[Clinical and laboratory diagnosis of an acute biliary pancreatitis]

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

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

AIM: To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) for patients with gall bladder stones (GS) and common bile duct stones (CBDS).

METHODS: Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram (TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS.

RESULTS: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed stones in 6 cases (7.9%); short lower end stricture with small stones present in two cases (2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case (1.3%) which was treated by open hepaticojejunostomy; and one case (1.3%) was proved to be ampullary carcinoma and whipple’s operation was scheduled.

CONCLUSION: The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.

Effect of Dexamethasone and Pheniramine Maleate in Patients Undergoing Elective Laparoscopic Cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (LC) is elective surgical procedure for uncomplicated gallstone disease and gallbladder polyp. The objective of this study was to assess the efficacy of Dexamethasone and Pheniramine hydrogen maleate on reducing stress response and pain after surgery in patients undergoing laparoscopic cholecystectomy.

METHODS

After obtaining approval from the institutional ethics committee and written informed consent, 120 patients undergoing elective laparoscopic cholecystectomy were enrolled in the study from Sep 2103 to Aug 2014 at Department of Surgery, Manipal College of Medical Sciences, Pokhara, Nepal. Patients were randomized to receive either 8mg/2ml of Dexamethasone + 45.5/2ml Pheniramine hydrogen maleate (treatment group, n= 60) or 5 ml of normal saline (control group, n=60) 90 minutes before skin incision.

RESULTS

There was a reduction of total bilirubin, C-reactive protein (CRP) value and Visual Analogue Score (VAS) in treatment group as compared to control group (p <0.05).

CONCLUSIONS

Use of Dexamethasone and Pheniramine hydrogen maleate prior to surgical skin incision helps to reduce both postoperative pain and acute physiological stress.

Biliary dyskinesia and symptomatic gallstone disease in children: two sides of the same coin?

BACKGROUND

Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis.

AIMS

We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH).

METHODS

Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh.

RESULTS

Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy.

CONCLUSIONS

A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.

Prehepatocholedochal proper hepatic artery. Rare anatomical variant. Surgical considerations. Case report

In classical anatomic variants, the proper hepatic artery (PHA)continues the common hepatic artery (CHA) after the gastroduodenal artery (GDA) detaches itself and divides into the right hepatic artery (RHA) and left hepatic artery (LHA), the proper hepatic artery being located to the left of the hepatocholedochal duct (HCD). This paper presents an abnormal positioning of the PHA placed before the HCD with an increased diameter of about 5-7 mm, which could be confused with the HCD. We present the case of a 57 year-old woman diagnosed with acute lithiasic cholecystitis, associated with hypersplenism and hypertension. The literature mentions manifold anatomical variants of arterial liver vascularization,including PHA. For this reason, this paper presents an overview of similar cases that can be found in medical literature. The aforementioned case is a rare topographic anatomy for the PHA that can easily pass for HCD especially during celioscopy, therefore it is crucial for this to be acknowledged by all surgeons.

One-step laparoscopic and endoscopic treatment of gallbladder and common bile duct stones: our experience of the last 9 years in a retrospective study

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.

Minimally invasive treatment of cholecysto-choledochal lithiasis - "Rendez-vous" technique

INTRODUCTION

In our paper we present the results of a study that was meant to provide a complex answer to the question:"Which is the most appropriate, most correct and least expensive treatment for mixt cholecysto-choledochal lithiasis(MCCL)?"

MATERIAL AND METHODS

Based on a five year experience (2008-2012), analysed retrospectively, during which 143 patients with MCCL were treated, we are trying to find answers to some of the questions that we have asked ourselves from the very beginning of this period. The answers were guided by alternative therapeutic options, for a pathology that does not have a "gold standard", with respect to the solutions available.

RESULTS

Given the fact that the period during which the study was conducted was chosen randomly and that the patients were included consecutively, the representativeness of the results is ensured for any other patient diagnosed with this pathology and admitted to a clinic with the same specialty, dimensions and equipment as the one presented.

CONCLUSIONS

This paper compares the results of our study to those of others, in terms of different or similar approach therapeutic options, developed in other minimally invasive surgery centres in the world, the final conclusions being encouraging for the therapeutic sequence that we practice.

[Detection of Clonorchis sinensis eggs in the ground gallbladder stones by microscopy]

Sera, feces, bile and gallbladder stones were collected from 179 patients who accepted gallbladder-preserving cholelithotomy during the period of January to June 2010 at the general surgery department in the Second People's Hospital of Panyu District in Guangzhou. Rapid colloidal gold immunochromatography was used to detect IgG against Clonorchis sinensis. C. sinensis eggs were examined by fecal direct smear, and in bile sediments and ground gallbladder stones. The results showed that the positive rate of rapid colloidal gold immunochromatographic assay for IgG was 51.4%, and the egg positive rate in feces, bile sediments and gallbladder stones was 30.7%, 44.7% and 69.8%, respectively. The detection rate of fecal direct smear was the lowest, while that of the gallbladder stone examination was the highest (P < 0.05). Those patients with egg-positive feces and/or bile sediments were all with egg-positive gallbladder stones.

[Two-stage clinical management of cholecystcholedocholithiasis]

This study aimed to evaluate the safety and short-term outcomes after two-stage medical tactics for 115 patients with gallstones and ductal calculi. The use of two-stage method of treatment has proved effective in 110 (95.7%) patients. There were 5 (4.3%) conversion in our series.

[Ultrasonography in the diagnosis of cholelithiasis and its complications]

The author presents the results of ultrasound investigation (USI) of 419 patients with cholecystocholedocholithiasis. The diagnostic accuracy of USI methods in patients with calculous cholecystitis was 98.8%. Direct signs of visualization of concrements in the common bile duct (CBD) were found but in 68.5% of patients. On the basis of USI results the common bile stones were found in 287 (68.5%) patients. The concrements omitted in transabdominal USI were diagnosed using endoscopic retrograde cholangiopancreaticography, magnetic resonance cholangio-pancreaticography, endoscopic ultrasonography as well as in operative intervention.

Multidetector computed tomography diagnosis of ileal and antropyloric gallstone ileus

Gallstone-induced ileus is a rare complication of cholelithiasis, and gastric outlet obstruction is even rarer. We describe the multidetector computed tomographic diagnosis of small bowel obstruction resulting from a gallstone impacted in the distal ileum and of gastric outlet obstruction from a gallstone impacted in the pyloric antrum (Bouveret syndrome).

[Endoscopic treatment at cholangioscopic cholangiolitiasis]

The article shows a retrospective analysis of endoscopic cholangioscopic conducted as an independent intervention after endoscopic retrograde cholangiopancreatography, and as an auxiliary manipulation during open and laparoscopic surgery. Was demonstrated that cholangioscopic manipulation can be an effective tool both in diagnosis and in prevention and treatment of recurrent and residual cholangiolitiasis, particularly in difficult-to-standard endoscopic techniques of cases. Were refined indications for manipulation and evaluated the diagnostic value and therapeutic effectiveness of the cholangioscopic manipulations. Based on our experience, were refined features and advantages of the methodology and limitations were analyzed and the reasons for the failures and suggests ways to overcome them.

[Spontaneous bilio-cutaneous fistula in cholecystolithiasis]

Spontaneous cholecystocutanea fistula is very rare disorder. The occurrence is very frequent in women above 60 years old. The symptoms of this disorder are nonspecific. The diagnosis is not made when the symptoms are not search actively. The first type of examination is fistulography. Laparotomic scheduled chelocystectomy is preferred in therapy. Conservative approach is suitable therapy only for polymorbid patients.

[Laparoscopic cholecystectomy in a patient with situs inversus totalis]

OBJECTIVE

To report a case with situs inversus totalis (SIT) and chronic cholelithiasis solved by laparoscopic surgery, outlining the utility of minimal invasive surgery and specific considerations in patients with anatomic variations.

CASE REPORT

A case of a 46 year-old female who presented with a six-month history of abdominal colic pain at the left hypochondrium, accompanied with nausea and vomiting, is presented. On examination she had epigastric tenderness. Blood tests, including liver function tests, were normal. Electrocardiogram showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia. Chest-X-Ray confirmed the diagnosis of dextrocardia. An ultrasound scan of the upper abdomen identified the gallbladder containing stones in the left upper quadrant. A CT scan visualized the spleen and the gastric camera in the right upper quadrant. Barium gastrointestinal transit, barium enema and abdominal-X-Ray were used as complementary diagnostic studies. A magnetic resonance cholangiography was not performed because the patient suffered from claustrophobia. Cholecystectomy and transcystic cholangiography were performed by laparoscopic route, taking care to set-up the operating theatre in the mirror image of the normal set-up for cholecystectomy. The patient completed a successful procedure without complications and was discharged 48 hours after the procedure. Histological exam diagnosed a chronic lithiasic cholecystitis.

CONCLUSIONS

Laparoscopic cholecystectomy is an adequate surgical procedure for patients with total situs inversus and cholelithiasis, having a high security range. Detailed clinical examination is important for the diagnosis of previously unknown anatomic variations. Transcystic cholangiography is mandatory when a magnetic resonance cholangiography can not be performed. Furthermore, perhaps in this situation a left-handed surgeon is better prepared than a right-handed one to comfortably carry out the procedure.

[Quality of life of patients with cholecystolithiasis in the remote period after cholecystectomy]

The aim of the study was to evaluate the quality of life in patients with gallstone disease (GSD) in the remote period after cholecystectomy for various forms of surgical intervention and the disease (latent or symptomatic). Also we compared them with the indicators of quality of life of patients with cholecystolithiasis.

MATERIALS AND METHODS

In an open clinical study were surveyed 170 patients with gallstone disease, of which 60 people were operated for gallstone disease, 110 patients had cholecystolithiasis. At 1/3 of patients with gallstone disease was asymptomatic, in 2/3--with clinical manifestations. To assess the quality of life using were validated specific questionnaire for patients with gallstone disease--Gallstone Impact Checklist.

RESULTS

Among all patients with cholelithiasis who underwent cholecystectomy that asked for gastroenterologists help patients the quality of life was significantly worse on the scale of power (26.0 +/- 2.8 points) and the joint account (89.0 +/- 9.6 points) than in patients with stones in the gallbladder (16.5 +/- 2.2 and 61.0 the mini-access (total score 83.6 +/- 13.7 points), did not differed from those after laparoscopic cholecystectomy (85.0 +/- 10.9 points, p > 0.05). For those patients with cholelithiasis in which the disease before surgery were no symptoms quality of life (general account) decreased more significantly (to 29.8%) compared to patients with cholelithiasis who have this disease before the operation proceeded with clinical manifestations (4.1%), when compared with the total score of all examined patients with CL.

CONCLUSIONS

Quality of life in patients with gallstone disease in the postoperative period after cholecystectomy was significantly worse than the individual scales of the questionnaire GIC compared to patients with stones in the gallbladder, regardless of the type of operation (from the mini-access or laparoscopic). In this patient with a latent course of gallstone disease before the operation quality of life significantly worse on all scales than patients with clinical symptoms before surgery.

Diagnosis and laparoscopic approach to gallbladder torsion and cholelithiasis

Torsion of the gallbladder is common in elderly women. Different causes have been proposed for this rare condition. The presence of a long mesentery and loss of visceral fat are the main causes for the development of torsion. Patients present with a sudden, acute pain in the right upper quadrant, suggesting cholecystitis. Different imaging methods have shown particular findings, but the diagnosis is still complex. Today, just a few cases have been reported in the literature. The treatment for this condition consists of surgical detorsion and cholecystectomy. Gallbladder torsion is a very rare entity and should be suspected when these clinical findings are present.

Laparoscopic treatment of stone recurrence in a gallbladder remnant: report of an additional case and literature review

Cholecystectomy is an effective treatment of gallstones. Nevertheless, recurrence of biliary symptoms following cholecystectomy, either laparotomic or laparoscopic, is quite common. Causes are either biliary or extrabiliary. Symptoms of biliary origin chiefly depend on bile duct residual stones or strictures. Rarely, they depend on stone recurrence in a gallbladder remnant. Diagnosis of gallstone recurrence in gallbladder remnant is difficult, mainly arising from ultrasonography, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography.Incomplete gallbladder removal may be either voluntary or inadvertent: in the first case, it is performed to remove gallstones without dissecting a difficult Calot's triangle or an excessively bleeding posterior wall of gallbladder caused by liver cirrhosis. Available data do not support the hypothesis that laparoscopic cholecystectomy entails an increased incidence of this condition, in spite of some opposite opinions. Treatment of lithiasis in gallbladder remnants is chiefly surgical. Although technically demanding, completion cholecystectomy can be safely performed in a laparoscopic way. We report a case of stone relapse in a gallbladder remnant, discovered 16 years following laparoscopic cholecystectomy and successfully treated by laparoscopic completion cholecystectomy. We furthermore review literature data in order to ascertain whether recent large diffusion of laparoscopic surgery causes an increase of such cases.

[Laparoscopic cholecystectomy in situs viscerum inversus totalis: technical note]

The Authors report the case of a patient admitted in Emergency Room for biliary colic. She knew her dextrocardia. ECG and chest X-ray confirmed the dextrocardia. Ultrasonography and CT scan discovered a situs viscerum inversus totalis and cholecystolithiasis responsible of the abdominal colic. Laparoscopic cholecystectomy was performed. The Authors discuss the clinical case and the particular technique used.

[Clinical epidemiologic study of 277 patients with gallstones, treated at the Gastroenterology Unit of the Emergency Hospital of Bacau County, in 2006-2008]

A sample of 277 cases admitted for gallstones was studied between September 2006 and August 2008. The purpose of the study was the investigation of gallstones with or without other pathologies, which have a connection with gallbladder diseases. Paraclinical investigations were necessary to monitor the diagnosis and complications.

[Improved minilaparotomical choledochoscopy and litoextraction in cholecystocholedocholithiasis]

An analysis of results of surgical treatment of 55 patients with an cholecystocholedocholithiasis who had undergone minilaparotomic fibrocholedochoscopia and lithoextraction. In conclusion it is staled, that this method can be provided in most of patients and guarantees good postoperative results.

[Primary hyperparathyroidism associated with chronic pancreatitis, cholecysto- and nephrolithiasis]

The case of primary hyperparathyroidism in a combination to a chronic pancreatitis, bilious--and urolithic disease is exposed in this article. Difficulties of diagnostics and differential diagnostics of hyperparathyroidism are described there. You can find literatures, concerning this problem. Also here were made some recommendations to practising doctors.

Diagnostic value of MRCP and indications for ERCP

BACKGROUND/AIMS

To assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) and examine the indications for endoscopic retrograde cholangiopancreatography (ERCP).

METHODOLOGY

MRCP was performed in 185 patients with hepatobiliary disease in whom abdominal ultrasonography (US) had not been of diagnostic value. These patients were selected for MRCP in view of their abdominal symptoms, high levels of hepatobiliary enzymes, and pancreatic/bile duct dilatation found by abdominal US. Based on MRCP findings, 75 patients were selected for ERCP.

RESULTS

ERCP provided new findings in 14 (18.%) patients. In 110 patients subjected to only MRCP and follow-up as well as in 75 patients with MRCP followed by ERCP, MRCP-based diagnosis corresponded with the final diagnosis. In our study, patients who would have conventionally required ERCP, such as those with natural passed choledocholithiasis and postoperative bile duct dilatation, could be followed up without ERCP. These results the importance of considering indications for ERCP.

CONCLUSIONS

MRCP can be an alternative to ERCP at least for diagnosis.

Gastric heterotopia together with squamous metaplasia in the gallbladder

Heterotopic gastric mucosa in the gallbladder is extremely unusual. In this study, we aimed to report a case of gastric heterotopia together with squamous metaplasia in the gallbladder of a 47-year-old female patient who experienced an intensive abdominal pain. He was admitted to the hospital for clinical treatment without any improvement. Ultrasonography showed a stone located in the gallbladder neck and dilatation of intrahepatic bile ducts, both hepatic ducts and common hepatic duct. Laparoscopic cholecystectomy was performed. In the microscopical examination, the epithelium of the gallbladder revealed an unspecified chronic cholecystitis. Besides, at the level of the gallbladder body, a heterotopic gastric mucosa contain chief, parietal and mucosal cells with cystic glands and squamous metaplasia was found. Actually the patient is in long-time follow-up, asymptomatic. We also review 96 other reports of HGM in the gallbladder in the international medical literature from 1934. As heterotopic tissue may promote carcinogenesis of the gallbladder, close attention should be paid to any occurrence of such lesions in this anatomical region. It appears that laparoscopic cholecystectomy may be unavoidable for patients affected by heterotopic gastric mucosa at the present time and care must be taken when a diagnosis is made based on intraoperative frozen sections.

[Diagnosis and treatment of gallbladder and common bile duct stones: our experience]

AIM

The aim of this study was to verify the possibility to identify and treat common bile duct (CBD) stones by means of preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) with a reduction of postoperative complications.

METHODS

We have carried out a retrospective monocenter analysis of 104 consecutive patients who underwent a laparoscopic or open cholecystectomy performed by a single surgeon at the VII Division of General Surgery, Second University of Naples, between 2002 and 2006. Before the operation, we have performed highly selective studies like MRCP and ERCP to identify and treat CBD stones in patients affected by pancreatitis, jaundice, high liver function tests or in case of common bile duct dilation at the US examination, without intraoperative cholangiography.

RESULTS

Of 104 patients with indication for a cholecystectomy, 22 patients (21.2%) presented high levels of cholestasis tests; 13 patients (12.5%) presented common bile duct dilation at the US examination (>6 mm diameter). Both groups underwent a MRCP which was positive in 8 patients (7.7%), confirming the diagnosis of common bile duct stones. For these reasons we removed CBD stones using preoperative ERCP.

CONCLUSION

Preoperative ERCP and RMCP, without intraoperative cholangiography, is not associated with a significant increase in morbility/mortality associated with CBD stones before surgical treatment.

[Cholecysto-gastric fistulas: case report and literature revision]

Authors report a recent case of cholecysto-gastric fistula. On the basis of their own experience and of the literature, authors discuss the pathogenesis of the cholecysto-enteric fistulas and underline the relative non frequent of fistulas with the stomach. Authors stress the available diagnostic and therapeutic features and believe that this disease deserves, whenever possible, a surgical correction.

Porcelain gallbladder complicated with pancreas divisum

We report a rare case of porcelain gallbladder associated with pancreas divisum (PD). A 60-year-old woman suffered from discomfort in the back of the right side. An abdominal radiograph revealed a calcified spherical mass in the right upper quadrant. Ultrasonography revealed a scattered echo with a posterior acoustic shadow in the gallbladder wall. A plain computed tomography (CT) scan showed flecks of intramural calcification in the wall of the gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) showed separate openings for the Santorini and Wirsung ducts. The patient underwent cholecystectomy after porcelain gallbladder and pancreas divisum had been diagnosed. The porcelain gallbladder resulted from a stone impacted in the neck of the gallbladder. Patients with PD should be followed carefully, because gallstones often accompany PD, and porcelain gallbladder may result, as in this patient.

Gallbladder management during laparoscopic Roux-en-Y gastric bypass surgery: routine preoperative screening for gallstones and postoperative prophylactic medical treatment are not necessary

In the bariatric surgery literature, the optimum approach to the gallbladder is controversial. Recommendations range from concomitant cholecystectomy to selective screening and postoperative medical prophylaxis. At our institution, we have taken a highly selective approach where patients are not routinely screened for gallstones, nor are they medically treated postoperatively with bile salts. We have reviewed our experience with this approach. From January 2003 to January 2005, 407 laparoscopic Roux en Y gastric bypasses were performed at UCLA and postoperative outcomes were collected into a prospective database. Exclusion criteria included previous cholecystectomy, a follow-up period less than 6 months, or incomplete records. One hundred ninety-nine patients were included in the study. With a mean follow up period of 17.8 months, 12 (6%) patients required cholecystectomy for gallstone-induced pathology. Laparoscopic removal was performed in 11 (92%) patients. Indications for surgery included acute cholecystitis in five (2.5%) patients, gallstone pancreatitis in two (1%) patients, and biliary colic alone in another five (2.5%) patients. The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low. These results are similar to those from institutions where routine preoperative screening and prophylactic postoperative medical therapy is used. Routine preoperative screening or medical prophylaxis may not be necessary.

[Gallstone ileus and cholecystoduodenal fistula. Case report]

OBJECTIVE

We report on a patient with gallstone ileus and cholecystoduodenal fistula at the Hospital de Especialidades, Centro Medico Nacional Siglo XXI (IMSS) Mexico City, Mexico.

CLINICAL CASE

A 54-year-old male patient was admitted to the hospital with a diagnosis of acute cholecystitis. He had undergone an appendectomy at 34 years of age. There was no history of biliary disease. He was afebrile, with moderate abdominal distention and right upper quadrant pain, Murphy (+). His white blood cell count was 8,900/mm(3) with 40% bands. His liver function tests, amylase and lipase, were all within normal limits. Ultrasound revealed edema and thickening of the gallbladder wall with calculi. He underwent exploratory surgery, which provided the following findings: sclerotrophic gallbladder with intense surrounding inflammation. We therefore decided to perform a cholecystostomy. Two days postoperatively the patient presented abdominal distention and vomiting as well as the presence of intestinal material through the cholecystostomy catheter. Plain abdominal film showed the bowel to be dilated and an aberrantly located gallstone. Cholecystography was performed and showed a cholecystoduodenal fistula. Computed tomography was carried out and disclosed the bowel to be slightly dilated and with an intraluminal gallstone. A laparotomy with enterolithotomy was performed. Sized of the gallstone found was approximately 3 cm. Presently the patient is asymptomatic.

La douleur biliaire : comment la reconnaître ? Comment l’explorer ?

Biliary colic is the most common clinical presentation of symptomatic gallstone disease, whatever its localisation (cholelithiasis or choledocolithiasis). The pain of biliary colic is unfortunately called "colic", a word suggesting paroxystic bouts and usually described as localised in the right upper quadrant. In fact, biliary pain is most frequently epigastric in location, usually starts abruptly to generally persists without fluctuation and resolve gradually over two to four hours. Biliary lithiasis has a high prevalence in the population, especially in elderly women but only 20% of the patients are symptomatic and among them, only 10 to 20% experience severe pain. Misdiagnosis is frequent with potential disastrous implications, especially with other causes of epigastric pain (atypical myocardial ischemia, perforated ulcer, etc.). Non invasive imaging of the biliary tract is now generally easy to obtain; abdominal ultrasound for gallbladder stones and magnetic resonance cholangiography for the main bile duct and the intrahepatic bile ducts. But, for gallbladder stones, the greatest care must be taken by the radiologist to link up the symptomatology and the cholelithiasis. Precise description of the abdominal pain (nature, intensity, location, duration, irradiation...) is needed and must be searched by the radiologist to prevent misdiagnosis.

Acute biliary pancreatitis and cholecystolithiasis in a child: One time treatment with laparoendoscopic “Rendez-vous” procedure

Acute biliary pancreatitis (ABP) is rare in childhood and endoscopic sphincterotomy should be avoided in the child due to the risk of both early and late complications but, when necessary, the optimal timing between endoscopic procedure and cholecystectomy is still uncertain. A nine years old child with acute biliary pancreatitis underwent successfull laparo-endoscopic “Rendez-Vous” procedure in which endoscopic drainage of the common bile duct and laparoscopic cholecystectomy were performed simultaneously. This is the first case reported of laparo-endoscopic Rendez-Vous in a child. The excellent outcome of this patient and the review of the literature concerning other available options for the treatment of such cases suggest that this procedure offers great advantages, especially in children, of reducing the required number of treatments, the risk of ineffectiveness, the number of anaesthesia, the length of hospital stay and the risk of iatrogenic morbidity.

[Causes of failure in choledochoscopic diagnosis and removal of gallstone]

OBJECTIVE

To discuss the causes for failure in diagnosis and removal of gallstone using choledochoscope.

METHOD

A retrospective analysis was conducted in 714 cases of gallstone treated with choledochoscopic operations.

RESULTS

Residual stones in the bile duct were found in 132 (18.5%) cases after the operation. In 54 cases the bile duct stones failed to be completely removed even before the closure. By T-tube cholangiography and choledochoscopy after the operation, 78 cases were found to have residual bile duct stones, among them 29 were complicated with intrahepatic bile duct and bile duct opening stenosis, 37 with intrahepatic bile stone and bile duct variation, and 12 with choledochus inferior segment stenosis and stone formation.

CONCLUSION

Due attention should be paid during the choledochoscopic operation to bile duct variation, bile duct opening stenosis or choledochus inferior segment stenosis, which should be carefully inspected by segments in succession to minimize the possibility of residual stones.

[Diagnostics for diseases of the gallbladder and biliary tract from the viewpoint of the internist and surgeon. Demands made on radiological diagnostics]

Jaundice and colic pain of the right upper quadrant are the main symptoms of biliary diseases. Gallstone-related diseases often lead to hospital admission. The evaluation of a patient with biliary symptoms requires a combination of history taking, physical examination, laboratory analysis, and imaging modalities. A high-quality magnetic resonance imaging (MRI) or computed tomography (CT) scan is usually sufficient to evaluate a patient with painless jaundice. Ultrasonography is helpful as an initial screening test to guide the diagnostic work-up. Invasive methods (e.g., ERCP) are mainly used for palliation of patients with incurable disease.

Vergleich von 2D- und 3D-Sequenzen für die MRCP

Magnetic resonance cholangio-pancreaticograpy (MRCP) is a non-invasive imaging modality of the pancreatico-biliary system which plays an increasingly important role in the clinical and diagnostic workup of patients with biliary or pancreatic diseases. The present review is designed to give an overview of the currently available and appropriate sequences, their technical background, as well as new developments and their relevance to the various clinical issues and challenges. The impact of the latest technical innovations, such as integrated parallel imaging techniques and navigator-based respiratory triggering, on the diagnostic capacities of MRCP is discussed. In this context, the individual value of RARE, T2w single shot turbo/fast spin echo (SSFSE) and the recently introduced 3D T2w turbo/fast spin echo sequences (T2w 3D-T/FSE) is reviewed. RARE imaging may be preferred in severely ill patients with limitations in cooperation, SSFSE is particularly effective in differentiating benign and malignant stenosis, and 3D-FSE offers additional advantages in the detection of small biliary concrements.

Biliobiliary fistulas manifested by worsening liver function--a case report

We report a case of cholecystolithiasis with biliobiliary fistulas from gallbladder to hepatic ducts, which were manifested by worsening liver dysfunction. Although it was not diagnosed preoperatively, it was successfully treated by cholecystectomy with closure of fistulas by the gallbladder wall. This case suggests that an internal biliary fistula may be possible, when the gallbladder wall is thickened and shrunken in the case of cholecystolithiasis, accompanied with liver dysfunction despite no dilatation of the common bile duct.

Short- versus long-sequence MRI cholangiography for the preoperative imaging of the common bile duct in patients with cholecystolithiasis

BACKGROUND

This study aimed to compare an 18-s fast spin echo magnetic resonance image sequence (coronal thick-section two-dimensional breathhold) with a three-dimensional axial and coronal thin-section sequence and its secondary reconstruction, and to assess its value in the diagnosis of bile duct pathologies, particularly common bile duct stones (CBDS) before laparoscopic cholecystectomy.

METHODS

This study prospectively included 72 patients. Because of protocol violations, 14 of these patients had to be excluded. Thus, 58 patients (29 Man and 29 women with a mean age of 51 years) who had cholecystolithiasis or suspected choledocholithiasis were evaluated. Magnetic resonance cholangiopancreatography (MRCP) was performed for all patients with a fast sequence (18 s) and a long sequence (coronal oblique and axial respiratory triggered; 16 min). Two radiologists, blinded with respect to diagnosis, evaluated all the radiographic images. The MRCP results were confirmed for all the patients: 20 by endoscopic retrograde cholangiopancreatography, 46 by intraoperative cholangiography, and 2 by percutaneous transhepatic cholangiography.

RESULTS

According to the findings, 16 patients (28%) had CBDS, 6 patients (10%) had common bile duct stenosis, and 36 patients (62%) had a clear bile duct. With regard to CBDS, the short sequence had 100% specificity, 94% sensitivity, and an overall accuracy of 98%. Its negative predictive value was 98%, and its positive predictive value was 100%. The long sequence had a specificity of 100% and a sensitivity of 100%.

CONCLUSION

Because of its high sensitivity and specifity, MRCP has the potential to be the diagnostic method of choice for CBD evaluation. The short sequence is not suitable for the diagnosis of all CBD pathologies, but in cases of suspected CBDS, more than 80% of the patients could be diagnosed correctly, and the complete sequence could be dropped.

Preoperative risk factors for common bile duct stones: defining the patient at high risk in the laparoscopic cholecystectomy era

BACKGROUND

Common bile duct stones (CBDS) are present in 3-20% of patients with cholelithiasis. Intraoperative cholangiography has high sensitivity in detecting CBDS but its routine use is associated with increased costs and operating room time. The aim of our study was to define an accurate and simple model for the prediction of CBDS using preoperative variables.

METHODS

The study consisted of a retrospective analysis followed by a prospective study. Multivariate analysis of the retrospective data was used to create a predictive model for the presence of concurrent CBDS in patients undergoing cholecystectomy. The predictive model was then validated in a prospective series of 160 patients undergoing laparoscopic cholecystectomy.

RESULTS

Among the 19 potentially predictive variables for CBDS, only four were found to be statistically significant and independent: X1-alkaline phosphatase levels (UI/L); X2-number of gallbladder stones; X3-total serum bilirubin (mg/dL); and X4-CBD diameter (mm). Using these four variables, the multivariate analysis created the equation: score = 0.002 x X1 + 0.485 x X2 + 0.232 x X3 + 0.220 x X4 - 4.167 to define the risk of CBDS in each patient. The predictive model, tested prospectively in 160 patients undergoing laparoscopic cholecystectomy (LC), showed an elevated index of correlation (r = 0.75) among the predicted and the observed frequencies (chi2 = 126.6; P < 0.0001). The predictive model sensitivity and specificity were 92.9% and 99.3%, respectively.

CONCLUSIONS

In patients undergoing cholecystectomy, accurate prediction of the risk for concurrent CBDS can be achieved using four preoperative variables. The use of this predictive model can contribute to reducing the number of unnecessary common bile duct explorations.