Gallbladder Carcinoma (GBC) is relatively rare worldwide, accounting for 0.6-1.2% of all cancers. GBC is the most common hepatobiliary malignancy with aggressive biological behaviour. Adenocarcinoma is the predominant histological variant, while Squamous Cell Carcinoma (SCC) of the gallbladder comprises <1% of GBC. It is most commonly found in elderly females and rarely found in young adult females. It is common in smokers and alcoholics. It is usually present in an advanced T staging or diagnosed only after a cholecystectomy done for a presumed benign condition. Therefore, SCC of the gallbladder has a poor prognosis. This case report discusses a rare case of SCC of the gallbladder in a 32-year-old young adult female presenting with abdominal pain and fever mimicking features of acute cholecystitis. Initial blood investigations show leucocytosis, and elevated serum Chorio Embryonic Antigen (CEA) and increased Cancer Antigen (CA) 19.9. Radiological evaluation suggested growth in the gallbladder, and she underwent open cholecystectomy, with fragments of the left and right lobes of the liver being removed to look for metastasis. Postoperative histopathology shows moderately differentiated SCC with infiltration into the serosa, fragments from both lobes of liver are free from infiltration and Immunohistochemistry (IHC) P63 shows moderate to strong nuclear positivity,confirming SCC. The final Impression was given as moderately differentiated SCC of the gallbladder- pT3NxMx. This case presents an unusual instance of SCC of the gallbladder in a young adult female.

Acute cholecystitis complicated with hepatic abscess caused by rare heterogeneous mucoid Salmonella Enteritidis: case report and literature review.

Abstract Background: Abdominal ultrasound is the first-line imaging modality for diagnosing acute cholecystitis. While sonographic criteria for acute cholecystitis are well established, their temporal dynamics and correlation with disease severity remain poorly understood. This study aimed to explore the time course of ultrasound findings in acute cholecystitis. Methods: Between November 2017 and October 2018, patients admitted with acute cholecystitis fulfilling the Tokyo Guidelines were prospectively enrolled. All patients received standard care and underwent an initial abdominal ultrasound at admission. Daily follow-up scans were planned until cholecystectomy or discharge. Patients with at least two ultrasound exams were included in the final analysis. Parameters assessed included gallbladder wall thickness and volume, as well as mural and pericholecystic edema. All exams followed a standardized protocol and were performed by certified ultrasound specialists. Results: A total of 120 patients were enrolled. Of these, 88 underwent at least one ultrasound examination, and 37 received two or more scans and were included in the final analysis. Gallbladder wall edema was present in all but one case and remained stable over time. Mean gallbladder wall thickness and volume showed minimal changes, with a slight reduction in volume during the 1 st days. Substantial intraindividual variability in gallbladder volume and wall thickness was observed, independent of disease severity. Conclusion: Sonographic criteria for acute cholecystitis remain stable over time, suggesting that the timing of ultrasound does not affect diagnostic accuracy. However, substantial individual variability limits their use for risk scoring or severity grading, highlighting the need for complementary diagnostic approaches.

Managing Acute Cholecystitis in a Patient Who Is Not a Surgical Candidate.

This study aimed to see the percentage of achievability of Critical View of Safety (CVS), using a doublet photograph technique in a tertiary care center, and identify factors beyond the surgeon in terms of the gender, age, socioeconomic status, and pathology of the disease. This prospective observational study analyzed 356 laparoscopic cholecystectomy cases performed by 2 experienced surgeons (>500 cases). A validated scoring system assessed three CVS criteria: identification of two structures connected to the gallbladder, the cystic plate, and hepatocytic triangle clearance. CVS was deemed satisfactory with a mean score ≥5.0, evaluated intraoperatively by the surgeon and independently scored by another. Patients' socioeconomic status was measured by the modified Kuppuswamy scale, and intraoperative findings were correlated with CVS attainment. The CVS was attained in 56.64% of cases. Socioeconomic status showed a weak association with CVS achievement (Cramér's V = 0.155, P = .073), with lower-class patients disproportionately represented in the "No CVS" group (residual = 1.73). Intraoperative factors significantly impacted CVS attainment, with short cystic ducts, large stones at the neck, and severe adhesions reducing success rates. Acute cholecystitis (β = -1.40, P < .001) and empyema (β = -1.66, P < .001) negatively impacted CVS, while blue/dull gallbladder (β = + 1.10) improved it. The attainability of the CVS using the doublet photograph technique is low, with satisfactory CVS achieved in only slightly more than half of cases. Despite experienced surgeons, patient-related factors and intraoperative difficulties-particularly acute cholecystitis, empyema, and severe adhesions-significantly limited CVS attainment. These findings indicate that the doublet photograph technique alone is insufficient to reliably ensure CVS, emphasizing the need for early intervention and adjunctive safety strategies during difficult cholecystectomies.

C-reactive protein as a predicting factor for difficult laparoscopic cholecystectomy or its conversion to open cholecystectomy in acute calculous cholecystitis: an observational study.

This study aimed to determine the incidence of anatomical variations of the biliary and pancreatic ducts using Magnetic Resonance Cholangiopancreatography (MRCP) and to evaluate their associations with inflammatory and malignant conditions. In this retrospective study, MRCP examinations performed between April 2022 and December 2023 were reviewed through the Picture Archiving and Communication System (PACS) regardless of clinical data. Biliary and pancreatic duct variations; the presence of gallbladder or biliary sludge/stones; findings of acute cholecystitis or pancreatitis; and masses or cysts in the pancreas and biliary tract were assessed. Categorical variables were analyzed using the Chi-square or Fisher's exact test, with p < 0.05 considered statistically significant. Of the 973 patients, 560 (58%) were female and 413 (42%) were male, with a mean age of 60.47 ± 17.33 years. Biliary tract variations were identified in 522 patients (53.6%), most frequently type II (27.78%), type D (26.25%), and type IIIa (15.52%). Pancreatic duct variations were found in 26 patients (2.67%), predominantly pancreas divisum (53.85%), pancreatobiliary junction anomaly (34.62%), and ansa pancreatica (11.54%). Gallstones were present in 474 patients (48.7%), masses in 93 (9.55%), acute cholecystitis in 177 (17.9%), and acute pancreatitis in 78 (8%). Biliary tract variation was significantly associated with gallstones (p < 0.05), while no significant associations were observed for other conditions or for pancreatic duct variations (p > 0.05). MRCP effectively identifies biliary and pancreatic ductal variations, which have important clinical implications. Accurate recognition of these variations may help prevent complications during diagnostic and surgical procedures and improve treatment planning.

Acute cholecystitis in high-risk surgical candidates is frequently managed with gallbladder drainage as a bridge to interval cholecystectomy. Each drainage modality-percutaneous transhepatic (PTGBD), EUS-guided (EUS-GBD), and endoscopic transpapillary (ETGBD)-has distinct anatomical effects that may influence subsequent cholecystectomy. While multiple meta-analyses have established drainage efficacy, comparative evidence regarding operative outcomes of interval surgery remains limited. We performed a systematic review and meta-analysis following PRISMA 2020 (PROSPERO: CRD420251232718). Five databases were searched (January 2000-December 2025) for comparative studies reporting operative outcomes of interval cholecystectomy after gallbladder drainage. Primary outcomes were conversion to open cholecystectomy and subtotal cholecystectomy. Random-effects models with Hartung-Knapp adjusted confidence intervals were used. Certainty of evidence was assessed using the GRADE approach. Ten comparative studies (2019-2025) were included. Meta-analysis of EUS-GBD versus PTGBD (3 studies, n = 215) showed no statistically significant difference in conversion to open cholecystectomy (6.4% vs. 16.5%; RR 0.51, 95% CI 0.23-1.13; P = 0.07; I²=0%). Meta-analysis of EGBS versus PTGBD (6 studies, n = 416) found no statistically significant difference in conversion (18.9% vs. 17.6%; RR 1.14, 95% CI 0.25-5.23; P = 0.83; I²=77%) or subtotal cholecystectomy (RR 1.16, 95% CI 0.61-2.18; P = 0.52; I²=0%). One RCT comparing ENGBD versus PTGBD (n = 22) was synthesized descriptively. Certainty of evidence was low to very low. No statistically significant differences in operative outcomes of interval cholecystectomy were found between endoscopic and percutaneous gallbladder drainage modalities (low to very low certainty of evidence). Given comparable operative outcomes, drainage modality selection may be guided by drainage efficacy, patient anatomy, and institutional expertise. CRD420251232718.

Incidentally Detected Gallbladder Adenocarcinoma Presenting as Acute Calculous Cholecystitis: A Case Report and Management Considerations

Gallbladder inflammation comprises distinct pathological entities, including acute, neutrophil-dominated injury and chronic, fibrotic remodeling. This study aimed to define the cellular and structural programs that characterize these two inflammatory states and link epithelial, immune, and stromal alterations. Tissue and blood samples from forty-one patients, including twelve with acute cholecystitis and twenty-nine with chronic cholelithiasis, were analyzed using histopathology, immunohistochemistry, transmission electron microscopy, targeted cytokine expression analysis, and single-cell RNA sequencing of immune-enriched suspensions. Acute cholecystitis showed epithelial disruption, edema, and dense infiltration by neutrophils and macrophages, including an increased density of CD163+ macrophages, accompanied by elevated systemic inflammation. Chronic cholelithiasis displayed preserved epithelial continuity, fibrosis, glandular remodeling, and reduced immune-cell density. Ultrastructural analysis revealed abundant mucin granules and intact junctions in acute inflammation, contrasting with mucin depletion and dense-body accumulation in chronic disease. Single-cell transcriptomic analysis identified twelve immune and stromal populations, showing contrasting immune-stromal configurations: pro-inflammatory myeloid and cytotoxic T cells dominated in acute inflammation, whereas macrophage-B-cell-fibroblast networks were enriched in chronic cholelithiasis, reflecting adaptive and fibrotic remodeling rather than a temporal transition. This study defines distinct but coordinated immune-stromal programs underlying human gallbladder inflammation and provides a cellular framework for understanding condition-specific mechanisms of acute and chronic disease.

Pediatric cholecystitis and cholelithiasis management is heterogeneous. We surveyed European centers to map current practices, training exposure, and outcomes of pediatric biliary cholecystectomy. A 24-item cross-sectional international survey was developed by the European Union of Medical Specialists (UEMS) Section of Paediatric Surgery and distributed to centers in 31 UEMS member states. Items covered institutional resources, indications and timing, surgical approach and adjuncts (ERCP, ICG), training exposure, and center-level outcomes; results are reported as n (%), median (IQR). Outcomes were reported at the center level and were self-reported by participating institutions. Thirty-two centers from 23/31 states responded (74.2%). Pediatric surgeons were primary operators in 84% (shared with adult surgeons in 16%); ERCP access was 66%. Trainee operator share was 22.5% (IQR 5-50) and simulator access 56%. ICG cholangiography was routine in 12.5% and selective in 31%. Acute calculous cholecystitis: 6% always index-admission and 59.4% interval (29-41 days) cholecystectomy; post-ERCP choledocholithiasis: 16% always index-admission cholecystectomy. In 2023, 185 cases were reported: 98.9% laparoscopic with 1.6% conversion; median age 14 years (IQR 12.25-15), operative time 90min (IQR 60-110), length of stay 2 days (IQR 1-2); 10 complications (5.4%). Substantial heterogeneity persists in both care pathways and training exposure; most centers lack formal pediatric-specific guidelines, and trainee-led operating remains limited, supporting the need for evidence-based protocols and structured training pathways.

Gallbladder perforation (GBP) is a life-threatening complication of acute cholecystitis (AC). Sarcopenia and visceral adiposity have been associated with adverse outcomes in AC and other surgical or emergency settings, but their relationship with GBP subtype and management remains unclear. To evaluate the association of sarcopenia and visceral adiposity with GBP type, treatment preferences, and overall mortality. This retrospective study analyzed patients diagnosed with GBP between 2019 and 2024. Body composition parameters including skeletal muscle index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous fat ratio (VSR) were measured from computed tomography (CT) images at L3 vertebral level. Logistic regression and Kaplan-Meier analyses were used to assess associations with clinical outcomes. The study included 89 adult GBP patients: 22 (24.7%) type 1 and 67 (75.3%) type 2. The mean age was 68.4 (± 14.5) years, with 62.9% male and 37.1% female. 37.1% had low-SMI, 51.7% had high-IMAC, and 31.5% had high-VSR. Urgent surgery was a treatment option in 58.4% patients, followed by percutaneous cholecystostomy catheter drainage (PCCD) in 31.5% patients. Low-SMI was independently associated with type 2 GBP (adjusted OR: 6.842, 95%CI: 1.4-34.1 p = 0.019). PCCD was more frequently preferred in patients with low-SMI, whereas urgent surgery was more commonly performed in those with normal SMI (p = 0.001). Total mortality was higher in low-SMI group in univariate analysis (p = 0.015), though not significant in multivariate analysis. Sarcopenia was linked to subacute (type 2) perforation and lower rates of surgical intervention, and its early detection on CT may support risk stratification and clinical management of GBP.

Robotic-assisted cholecystectomy has gained popularity due to its purported advantages over the traditional laparoscopic technique. However, studies to date have not consistently demonstrated improved patient outcomes. Concerns regarding increased costs, particularly when the platform's clinical benefit is unclear, have limited its adoption. To our knowledge, there has been no study focusing on the role of robotic technique in interval cholecystectomy, which may present greater technical challenges, and the advantages offered by robotic technology may lead to improved outcomes. In this retrospective study, we identified patients undergoing cholecystectomy at least one month after either percutaneous or endoscopic drainage of the gallbladder for acute cholecystitis at a single tertiary center between August 2018 and February 2025. Medical records were reviewed to collect patient outcomes for comparison between procedures initiated as robotic-assisted versus laparoscopic-assisted. A total of 215 patients, with a mean age of 67years (± 16), underwent interval cholecystectomy after a median of 102days (interquartile range (IQR): 85-148days). Initial therapy for acute cholecystitis was either percutaneous drainage (n = 135, 63%) or endoscopic transcystic duct drainage (n = 80, 37%) of the gallbladder. Interval cholecystectomy was initiated laparoscopically in 177 cases, while 38 surgeries were robotically assisted. Conversion to open cholecystectomy occurred significantly more frequently in the laparoscopic group (33 cases, 19%) compared to the robotic group (0 cases, p < 0.01). Estimated blood loss was also higher in the laparoscopic group (67 ± 74ml vs 30 ± 25ml, p < 0.01). Robotic surgeries lasted longer (185 ± 71 vs 155 ± 65min, p = 0.02). In our retrospective review, robotic-assisted interval cholecystectomy is associated with a lower risk of conversion to open surgery, reduced estimated blood loss, and longer operative times when compared to the laparoscopic approach.

ABSTRACT Aim Emergency cholecystectomy for acute cholecystitis remains controversial in patients classified as high risk by the Tokyo Guidelines 2018 (TG18), although surgery is often unavoidable in real‐world emergency settings. The perioperative risk profile of this TG18 non‐recommended population remains insufficiently defined. The objective of this study was to examine perioperative outcomes in patients undergoing emergency cholecystectomy against TG18 recommendations, while also exploring clinical factors associated with actual operative risk. Methods This retrospective cohort study included 252 consecutive patients who underwent emergency cholecystectomy for acute cholecystitis between 2018 and 2025. Patients were stratified into TG18 emergency‐surgery‐recommended and non‐recommended groups. Perioperative outcomes were compared, and independent risk factors of major postoperative complications, defined as Clavien‐Dindo grade≥III events, were evaluated. Results Major postoperative complications occurred in 11.9% of patients and were significantly more frequent in the TG18 non‐recommended group than in the recommended group (18.0% vs. 2.9%, p &lt; 0.001). In multivariable analysis, American Society of Anesthesiologists physical status classification ≥ 3 and preoperative shock status were independent predictors of major postoperative complications, whereas age and Charlson Comorbidity Index were not. Exploratory stratification of the non‐recommended cohort demonstrated substantial heterogeneity in risk, with comparatively low complication rates observed in patients without physiological instability. Conclusion Emergency cholecystectomy may be feasible in carefully selected TG18 non‐recommended patients. Perioperative risk appears to be driven by physiological instability rather than chronological age or comorbidity burden, supporting a more individualized approach to surgical decision‐making.

Multidimensional impacts of the Lebanese economic crisis on the management of acute cholecystitis.

Prophylactic intravenous antibiotics are not routinely administered prior to direct peroral cholangiopancreatoscopy. The frequency of post-procedure bacteremia has not been well studied. To evaluate the risk of bacteremia following endoscopic retrograde cholangiopancreatography (ERCP) with cholangiopancreatoscopy. To assess the prevalence of other infectious complications and the effect of real-life practices regarding prophylactic antibiotic administration. We conducted a retrospective analysis on consecutive patients (2016-2022) who underwent cholangiopancreatoscopy using the single-operator SpyGlass System (Boston Scientific Corporation, USA). Prophylactic antibiotic treatment was administered based on clinical discretion. Demographic and clinical data, including procedure indication, procedure reports, blood culture results, pre- and post-procedure antibiotic treatment, hospital length, mortality, and infectious and non-infectious complications, were collected. Our single-center cohort included 75 patients who underwent ERCP with direct cholangiopancreatoscopy. We involved 63 patients in the analysis. In 17/63 patients (27%), post-procedural blood cultures were drawn based on clinical suspicion of infection. Positive cultures were found in 4/17 (23.5%) of all cultures and 4/63 (6.3%) of the entire cohort; 2/63 (3.2%) had clinically significant bacteremia. Antibiotic prophylaxis was administered to 35 patients (55.6%), with no evidence of significant reduction in bacteremia, cholangitis, hospitalization length, or mortality rates when compared to patients who did not receive prophylactic antibiotics (P > 0.05). Post-procedural cholangitis was observed in 5/63 patients (7.9%). There were no cases of acute cholecystitis or liver abscess. The prevalence of bacteremia and cholangitis following ERCP with direct cholangiopancreatoscopy was 6.3% and 7.9%, respectively. Prophylactic antibiotics did not reduce post-procedural infectious adverse events.

Background: Laparoscopic surgery (LS), also termed minimal access surgery, has brought a paradigm shift in the approach to modern surgical care. Port-site infection (PSI), although less frequently occurs, but it is one of the bothersome complications which may fade the benefits of Laparoscopic cholecystectomy (LC). The present study undertaken to find out the factors associated with it. Materials&amp; Methods: This prospective observational study was conducted in the Department of Surgery, Rajshahi Medical College Hospital, Rajshahi, Bangladesh, from July 2019 to January 2021. A total of 150 patients of any age and either sex who underwent laparoscopic cholecystectomy were consecutively included. Demographic characteristics, clinical conditions, and operative variables were considered independent variables, while PSI within 30 days after surgery was the outcome variable. Data were analyzed using descriptive and inferential statistical methods. Result: In the present study, over three-quarters (77%) of the patients were (31 – 40 years old) and female’s outnumbered males by 3:2. Majority (65%) of the patients had chronic cholecystitis and 35% had acute cholecystitis. Risk factors or co-morbidities present among the study subjects were smoking (29%), diabetes (20%), hypertension (12%), obesity 20% and malnutrition 5%. Among the co-morbidities diabetes mellitus was more significant factor to the development of PSI that is four patient was infected out of 11 patients. Acute cholecystitis, spillage of bile’s/stones act as significant determinants of PSI. The duration of operation was observed to be significantly longer in the patients that is more than 60 minutes who developed PSI than that in patients who did not develop. Swabs taken from the port-sites of every patients were subjected to culture; of them 11(7%) exhibited growth (4 Gram +ve and 7Gram -ve). Conclusion: The co-morbidities or risk factors (diabetes, hypertension, smoking, obesity and malnutrition) contributed to the development of PSI. Acute cholecystitis, spillage of bile’s/stones and duration of operation are the significant determinants of PSI.

Emphysematous cholecystitis is a rare but severe variant of acute cholecystitis characterized by gas-forming organisms within the gallbladder wall or lumen. It progresses rapidly and carries substantial mortality, making early and accurate recognition essential. Although its pathogenesis involves gallbladder wall ischemia with superimposed infection by gas-producing bacteria-most commonly Clostridium species-the clinical presentation is often nonspecific, particularly in patients with diabetes mellitus or immunosuppression. Imaging therefore serves as the cornerstone of diagnosis. Abdominal radiographs may demonstrate intraluminal or intramural gas, while ultrasound can reveal echogenic foci with reverberation artifacts, though overlying bowel gas and diagnostic mimics may limit sensitivity. Computed tomography remains the most accurate modality, precisely delineating gas within the gallbladder wall, lumen, or adjacent tissues and facilitating urgent surgical or percutaneous intervention. Magnetic resonance imaging offers complementary soft tissue characterization when computed tomography is contraindicated. This review synthesizes traditional imaging findings and emerging diagnostic innovations by critically comparing modality-specific strengths, limitations, and pitfalls. Dual-energy and photon-counting computed tomography enhance tissue contrast and gas conspicuity, while artificial intelligence-assisted image analysis enables earlier detection and expedited triage in emergency settings. By integrating evolving technologies with established radiologic principles, this article provides a forward-looking framework for improving diagnostic precision and ultimately enhancing outcomes for patients with emphysematous cholecystitis.

BACKGROUNDPercutaneous cholecystostomy (PCT) is widely used for high-risk acute cholecystitis as an alternative to emergent cholecystectomy. Despite its effectiveness, the optimal timing, catheter management, and long-term outcomes remain to be elucidated.AIMTo characterize timing, catheter management, survival, and follow-up outcomes after PCT in a high-risk cohort.METHODSThis single center retrospective cohort study included consecutive adult patients undergoing PCT placement for acute cholecystitis at a community hospital setting in New York between January 2012 and December 2024. The study population was grouped according to type of acute cholecystitis (calculous vs acalculous), according to the timing of PCT placement since diagnosis [early (≤ 4 days) vs late (> 4 days)], and according to level of care [intensive care unit (ICU) vs non-ICU patients]. Cox proportional hazards models were used to examine effects of PCT placement interval on mortality rates, after accounting for potential confounding factors (age, Charlson Comorbidity Index, cholecystitis type, ICU status, bile culture and blood culture data).RESULTSThe population consisted of 174 patients who underwent PCT placement for acute cholecystitis between 2012 and 2024 at a community hospital in New York. Median time to PCT was 2 days (interquartile range 1-4). Overall, mortality was 21% (36/174) and was higher with delayed PCT (> 4 days) vs early PCT [35% (17/49) vs 15% (19/125), P = 0.001]. Catheter removal occurred in 13% (23/174), 55% (96/174) remained catheter-dependent, and 32% (56/174) had interval cholecystectomy. ICU admission was associated with prolonged catheter duration but was not associated with mortality. Kaplan-Meier analysis demonstrated a significantly higher survival rate in the early group compared with the late group (log-rank P = 0.006). In both unadjusted models and models adjusted for selected covariates, patients who had catheters placed late (> 4 days) had 2.5-fold higher risk of death than patients with early placement.CONCLUSIONEarly PCT was associated with higher survival in high-risk acute cholecystitis. High rates of catheter dependency highlight the need for standardized protocols and reassessment for definitive surgery.

In patients with acute cholecystitis and choledocholithiasis undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by interval cholecystectomy (6 weeks-3 months), preoperative biliopancreatic events are reported in 18.3-41.8%. Endoscopic Transpapillary Gallbladder Drainage (ET-GBD) is indicated in this patient group if there are comorbidities preventing surgery. This study compared biliopancreatic events during the interval to cholecystectomy in patients who underwent ET-GBD despite being surgically fit versus those treated with ERCP alone. In this retrospective study conducted between 2018 and 2023, 121 patients with cholecystitis secondary to choledocholithiasis underwent ERCP. Surgical candidates expected to undergo delayed cholecystectomy were divided into two groups: those who received ET-GBD (study group) and those who did not (control group, from the first half of the study period). The ET-GBD group had a mean age of 54.54 (56.7% female), while the non-ET-GBD group had a mean age of 63.18 (50% female). During the waiting period, biliopancreatic events occurred in 1/34 (2.9%) of ET-GBD patients versus 18/34 (52.9%) of controls (absolute risk reduction 50.0%, 95% CI 21.8-68.0; relative risk 0.056, 95% CI 0.0079-0.39; p < 0.001). Specifically, biliary colic (2.9% vs. 47.1%; p < 0.001), cholecystitis (0% vs. 17.6%; p = 0.009), and choledocholithiasis (0% vs. 26.4%; p = 0.001) were significantly less frequent in the ET-GBD group. ET-GBD was associated with significantly lower biliopancreatic complications during the interval to surgery in operable patients with acute cholecystitis and choledocholithiasis.