Gallbladder Fossa Research Articles

Necrotizing Soft Tissue Infection Caused by Spilled Gallstones

We report a case of a 57-year-old woman who presented with a necrotizing soft tissue infection of the right anterior abdominal wall, 1 year after open cholecystectomy for gallbladder perforation. Surgical exploration revealed pigmented gallstones along with pus in the abdominal wall and gallbladder fossa. Intraoperative spillage of gallstones is common during both open and laparoscopic cholecystectomy, but, in rare cases, can lead to serious complications including necrotizing infection of the abdominal wall.

Early results of liver resection using laparoscopic technique.

The aim of the study was to present early outcomes of liver resection using laparoscopic technique. Retrospective analysis of patients who underwent liver resection using laparoscopic method was conducted. The analyzed group included 23 patients (11 women and 12 men). An average patient age was 61.3 years (37 - 83 years). Metastases of the colorectal cancer to the liver were the cause for qualification to the procedure of 15 patients, metastasis of breast cancer in 1 patient and primary liver malignancy in 5 patients. The other 2 patients were qualified to the liver resection to widen the surgical margins due to gall-bladder cancer diagnosed in the pathological assessment of the specimen resected during laparoscopic cholecystectomy, initially performed for other than oncology indications. Hemihepatectomy was performed in 11 patients (9 right and 2 left), while the other 12 patients underwent minor resection procedures (5 metastasectomies, 4 nonanatomical liver resections, 1 bisegmentectomy, 2 resections of the gall-bladder fossa). An average duration of the surgical procedure was 275 minutes 65 - 600). An average size of the resected tumors was 28 mm (7 - 55 mm). In three cases conversion to laparotomy occurred, caused by excessive bleeding from the liver parenchyma. Postoperative complications were found in 4 patients (17.4%). Median hospitalization duration was 6 days (2 - 130 days). One patient (4.3%) was rehospitalized due to subhepatic abscess and required reoperation. Histopathology assessment confirmed radical resection (R0) in all patients in our group. Laparoscopic liver resections seem to be an interesting alternative in the treatment of focal lesions in the liver.

Analysis of wedge resection of gallbladder bed and lymphadenectomy on adequate oncologic clearance for gallbladder cancer.

Surgery (R0 resection) is the mainstay of treatment of gallbladder cancer (GBC) as GBC is relatively resistant to currently known chemotherapy and radiotherapy regimens. to assess if wedge resection of the gallbladder bed achieves an adequate oncological clearance in GBC (namely T1 and T2) and some T3 GBC with minimal liver infiltration. Patients with GBC who underwent radical cholecystectomy (en bloc cholecystectomy, wedge resection of the gallbladder fossa with a ≥2 cm rim of nonneoplastic liver tissue, and regional lymph node dissection) between October 2012 and June 2015 after obtaining informed consent. Of thirty patients, mean age of 52 years, 5 had T1b, 13 T2, and 12 T3 GBC. R0 resection was achieved in all thirty GBC patients. Hepatic invasion was found in seven patients. The depth of hepatic invasion ranged from 0 to 9 mm. Follow-up ranged from a minimum of 12 to 43 months. Nineteen (63%) patients had N0 and 11 (37%) had N1 GBC. Total lymph node (TLND) count ranged from 1 to 12/patient with a median of 3. There was no local recurrence or systemic relapse of the disease. Wedge resection of the gallbladder bed achieves an adequate oncological clearance in early GBC. TLND counts remain poor even after a thorough standard lymph node dissection for resectable GBC.

Post Cholecystectomy Bile Leak From the Duct of Luschka in a Patient With Marfanʼs Syndrome

Marfan's syndrome is a rare connective tissue disorder and has been associated with poor post-surgical wound healing. It has been associated with increased incidence of Cholelithiasis as compared to the general population. There is no literature regarding post-cholecystectomy complications in patients with Marfan's syndrome. We present a 29 year old female with Marfan's syndrome and a history of aortic dissection with aortic valve rupture and replacement with prosthesis. She was diagnosed with gallstone pancreatitis and Choledocholithiasis. Endoscopic retrograde cholangiogram showed a 20 mm stone in the common bile duct. Multiple endoscopic procedures were needed to accomplish removal of the large stone and these included papillotomy, stenting and mechanical lithotripsy. Laparoscopic cholecystectomy was attempted which had to be converted to laparotomy due to extensive scarring around the gallbladder. Intraoperatively, a bile leak was noted which on cholangiogram was found to be from a severed accessory Duct of Luschka. The leak was closed with suturing. Two weeks post-surgery, the patient developed right upper quadrant abdominal pain. Imaging showed a fluid collection in the gallbladder fossa. Nuclear hepatobiliary (HIDA) scan did not show a bile leak. Percutaneous drainage of the fluid collection was performed and 40 cc of green colored fluid was aspirated, analysis of which did not reveal any evidence of infection. After two weeks, she presented with severe chest pain radiating to the back. Her WBC count was increased at 21,000 and CT imaging at this time showed a larger fluid collection in the gallbladder fossa. Repeat HIDA scan did not show a bile leak. She underwent repeat percutaneous drainage and 20 cc of purulent material was aspirated. She was treated with antibiotics and discharged from the hospital. Follow up CT showed significant reduction in the size of the fluid collection. To our knowledge, this is the first reported case of post cholecystectomy bile leak in a patient with Marfan's syndrome which was from injury to the Duct of Luschka. Intraoperative ligation of the duct with suturing failed to control the leak leading to a Biloma and subsequent abscess. This may have been a result of poor wound healing around the suture. In patients with connective tissue disorders such as Marfan's syndrome, Endoscopic therapy of post-cholecystectomy bile leaks with trans-papillary biliary stenting may be considered.Figure 1Figure 2

Asymptomatic true gallbladder duplication

A 32-year-old male presented for routine check-up. Abdominal ultrasound was normal except for two well-defined pear-shaped structures in the gallbladder fossa, each having separate cystic ducts which were uniting together before joining the common bile duct (Fig. 1). Gallbladders were normal in thickness, there was no stone/sludge or peri-cholecystic fluid and biliary ducts were normal. Magnetic resonance cholangio-pancreatography (Fig. 2, video file) was performed to better characterise anatomy.

Small bowel obstruction due to phytobezoar and adhesions following laparoscopic cholecystectomy

We report a case of 51 –year-old female with history of laparoscopic cholecystectomy presented with abdominal pain and diagnosed as small bowel obstruction caused by adhesions. The initial presentation was periumbilical pain with nausea and vomiting. Plain abdominal radiograph showed dilated small bowel loops and multiple air fluid levels. Due to failure of conservative treatment, laparotomy was performed. An open metallic clip was adhering the bowel to the gallbladder fossa causing sharp angulation. A phytobezoar proximal to this angulation was exteriorized through enterotomy. The patient was recovered smoothly and discharged from our hospital.

Gallbladder Fossa Abscess Masquerading as Cholecystitis After Cholecystectomy

We present a case of a 59-y-old woman who had undergone cholecystectomy and was subsequently found to have an abscess within the gallbladder fossa. A hepatobiliary scan using (99m)Tc-diisopropyliminodiacetic acid demonstrated the characteristic rim sign, a photopenic defect surrounded by a rim of mildly increased activity immediately adjacent to the gallbladder fossa. The rim sign was thought to be the result of reactive inflammation in the hepatic tissue adjacent to a postoperative abscess within the gallbladder fossa.

English

CONTEXT: Variations in the peritoneal reflections of the gallbladder are encountered during surgery and post-mortem examinations mainly form of mesentery and often have significant clinical implications, which can be life threatening at times. AIM: In this study, the manner of the peritoneal reflection over the gall bladder, its relative adherence to the gall bladder fossa and the relation of the fundus to the inferior margin of liver was examined. SETTINGS AND DESIGN: This cadaveric gross anatomical study was undertaken in the Department of Anatomy, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India and Subharti Medical College, Meerut, Uttar Pradesh, India, in the course a four year period i.e. 2008 to 2012, after obtaining necessary permission from the Institutional Ethical Committees. METHODS AND MATERIAL: It was carried out on one hundred gall bladders specimens, obtained from 10% formalin fixed cadavers during routine undergraduate students dissection The liver along with the gall bladder was retrieved from the abdominal cavity during undergraduate dissection of the abdomen and the peritoneal reflection over it was studied. RESULTS: Differential peritoneal reflections were observed in seven out of hundred specimens and formation of mesentery over the whole organ was found in two. In two there was mesentery over the neck and upper part of body. One the gall bladder was found floating in the gall bladder fossa but without the formation of mesentery. CONCLUSIONS: Differential peritoneal reflections of gall bladder were seen in seven specimens and mesentery formation to various degrees was seen in four. It was observed that peritoneal attachment of the gall bladder and the relative adherences of the viscus to the gall bladder fossa were closely associated.

Comparative study between the conventional laparoscopic cholecystectomy and clipless cholecystectomy using a harmonic scalpel

Objective This was a comparative study between laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel. Background This study aimed to compare the laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel in terms of the duration of the operation, intraoperative blood loss, postoperative complications, postoperative pain, and hospital stay. Patients and methods This study included 80 patients who were classified into two groups: group A (40 patients) was subjected to laparoscopic cholecystectomy by clipping of the cystic duct and cystic artery and dissection of the gall bladder from the gall bladder fossa by electrocautery and group B (40 patients) was subjected to laparoscopic cholecystectomy by a harmonic scalpel, closure and division of both the cystic duct and artery and dissection of the gall bladder from the liver bed by a harmonic scalpel. The intraoperative and postoperative parameters were determined including duration of operation, intraoperative blood loss, postoperative drainage, postoperative pain, complications, and hospital stay. Results The harmonic scalpel provided a shorter operative duration than the conventional method (34.21 ± 9.6 vs. 41.7 ± 13.79, respectively, P = 0.006), and the difference was statistically significant. A statistically significantly lower volume of intraoperative blood loss was observed in group B than group A (64.20 ± 44.01 vs. 96.62 ± 53.33, respectively, P = 0.004) and fewer incidences of gall bladder perforation in group B (7.5 vs. 17%, respectively, P = 0.176), but this was not statistically insignificance, and a lower rate of conversion to open cholecystectomy in group B than group A (0 vs. 5%, respectively, P = 0.246), but this was not statistically significant. The amount of postoperative drainage was significantly less in group B than group A (60.30 ± 11.48 vs. 79.0 ± 36.95, respectively, P = 0.004). Three patients in group B with dilated cystic duct discovered intraoperative and clip technique used for closure; otherwise, no postoperative bile leak was encountered in group B, but it occurred in 5% of patients in group A as a minor biliary leak. In terms of postoperative pain, it was less in group B than group A at 12 and 24 h (45 vs. 70%, P = 0.024, and 37.5 vs. 60%, P = 0.044, respectively), which was statistically significant and insignificant at 48 h and 1 week. Visual analogue scale in group B was lower than that in group A at 12 and 24 h (3.12 ± 0.33 vs. 3.49 ± 0.49, P = 0.01, and 2.5 ± 0.34 vs. 3.34 ± 0.47, P = 0.01, respectively) and statistically significant and insignificant at 48 h and 1 week; the hospital stay was shorter in group B than in group A (20.15 ± 5.65 vs. 24.65 ± 6.22, P = 0.006) and the difference was statistically significant. Conclusion The harmonic scalpel can be used safely for sealing of the cystic artery and cystic duct less than 6 mm in size in laparoscopic cholecystectomy without a risk of major injuries or leak; if the diameter is more than 6 mm, the clips technique should be used. It is better than electrocautery in terms of not just a faster and safer surgery, but also less intraoperative blood loss and less postoperative drainage, with decreased associated morbidity and pain and early return home; however, it is very costly.

Clinical outcome for laparoscopic cholecystectomy in extremely elderly patients.

PurposeExtremely elderly patients who present with complicated gallstone disease are less likely to undergo definitive treatment. The use of laparoscopic cholecystectomy (LC) in older patients is complicated by comorbid conditions that are concomitant with advanced age and may increase postoperative complications and the frequency of conversion to open surgery. We aimed to evaluate the results of LC in patients (older than 80 years).MethodsWe retrospectively analyzed 302 patients who underwent LC for acute cholecystitis between January 2011 and December 2013. Total patients were divided into three groups: group 1 patients were younger than 65 years, group 2 patients were between 65 and 79 years, and group 3 patients were older than 80 years. Patient characteristics were compared between the different groups.ResultsThe conversion rate was significantly higher in group 3 compared to that in the other groups. Hematoma in gallbladder fossa and intraoperative bleeding were higher in group 3, the difference was not significant. Wound infection was not different between the three groups. Operating time and postoperative hospital stay were significantly higher in group 3 compared to those in the other groups. There was no reported bile leakage and operative mortality. Preoperative percutaneous transhepatic gallbladder drainage and endoscopic retrograde cholangiopancreatography were performed more frequently in group 3 than in the other groups.ConclusionLC is safe and feasible. It should be the gold-standard approach for extremely elderly patients with acute cholecystitis.

Choledochal cyst or gallbladder duplication? Diagnostic laparoscopy for chronic abdominal pain in a 10 year old boy

Structural abnormalities in close proximity with the gallbladder fossa such as gallbladder duplications could be misrepresented as choledochal cysts, duodenal duplication cysts or gallbladder adenomyomas on sonography. We present a case of a ten year old boy who presented with a chronic abdominal pain of a three month duration and nausea and vomiting. Ultrasound and magnetic resonance cholangiopancreaticoography (MRCP) was reported by radiology as a possible 2.7 x 1.7 x 1.6 cm choledochal cyst with high differential consideration for a gallbladder duplication. The patient underwent a diagnostic laparoscopy and a grossly normal gallbladder was visualized with no gross visualization of cystic biliary tree dilatation. The gallbladder was successfully resected laparoscopically following a meticulous dissection of the triangle of calot. Pathology showed evidence of a septate gallbladder with a common cystic duct and no evidence of cholelithiasis. The patient is two years post -laparoscopic cholecystectomy and remains symptom-free. Successful laparoscopic resection of a duplicate gallbladder requires a pre-operative diagnostic delineation of the biliary tree anatomy to rule out other possible differentials.

The gallbladder of human foetuses: A morphological and morphometric study

IntroductionThe study aims in analyzing the gross development of human gallbladder and its variations. Methods92 foetuses, 59 males and 33 females, of different age groups were dissected for morphological analysis of gallbladder. The length and weight of foetal gallbladder, its relationship with the gallbladder fossa of liver and inferior hepatic margin, its lumen and wall, detection of bile and congenital anomalies are looked into the present study. ResultsIn foetus, the gallbladder is short of inferior hepatic margin. A sudden increase in mean length and weight of the gallbladder is observed as foetal age advances from 26–30 weeks to 31–35 weeks. . Bile staining of the wall of gallbladder is observed from 17-week old foetuses onwards Double gallbladder with common cystic duct, intraparenchymal gallbladder, a gallbladder on the inferior surface of liver along the line of attachment of falciform ligament (which is attached on the anterior surface of liver), a gallbladder with dilated body and neck, Phrygian cap, an enlarged gallbladder with wide lumen, thin wall and absence of bile stain were the variations observed in the present study. DiscussionFrom this study, the gross development of the gallbladder can be analyzed. The knowledge of the variations in development of human gallbladder will be helpful for clinical studies.

Ovarian cancer: imaging in treatment selection and planning with FIGO update

The International Federation of Gynecologists and Obstetricians (FIGO) has recently revised the staging of ovarian cancer [1]. It includes a revision of the stage III patients and allotment to stage IIIA1 is based on spread to the retroperitoneal lymph nodes without intraperitoneal dissemination, because an analysis of these patients indicates that their survival is significantly better than those who have intraperitoneal dissemination [1]. The FIGO staging system for ovarian cancer is surgically based. It does not formally include imaging but the FIGO committee encourages the use of imaging techniques if available to assess the important prognostic factors such as disease resectability and lymph node status. The standard of care for patients with newly diagnosed advanced ovarian cancer has been comprehensive staging laparotomy and primary optimal surgical cytoreduction followed by adjuvant chemotherapy. However, the use of neoadjuvant chemotherapy followed by interval debulking surgery (IDS) as a suitable alternative is supported by multicenter randomized controlled trials [2]. Imaging is therefore of paramount importance in helping triage patients for appropriate management by accurately evaluating the extent and anatomical location of peritoneal spread, which in turn dictates the feasibility of cytoreductive surgery and predicts the likelihood of optimal primary cytoreduction. Optimal cytoreductive surgery (residual disease <1 cm) is a very strong predictor of survival, and even after the threshold for optimal cytoreduction has been reached, it is important to remove as much of the residual tumor as possible. CT is the primary imaging modality used to stage ovarian cancer. It is complimentary to surgical staging identifying possible sites of unsuspected disease such as pelvic peritoneum, paraaortic nodes, diaphragm and chest [3,4]. The thorax frequently harbors undiagnosed pleural disease at the time of the initial diagnosis which is likely to affect survival even in cases of optimal debulking [5,6]. Accurate imaging helps guide the surgeon to areas of disease that may be difficult to identify surgically. Relative criteria for non-optimally resectable disease have been developed [7]. They include lymph node enlargement above the renal hilum, presence of abdominal wall invasion, parenchymal liver and subcapsular liver metastases, peritoneal implants of >2 cm along the diaphragm, lesser sac, porta hepatis, intersegmental fissure, gall bladder fossa, gastrosplenic, gastrohepatic ligament and small bowel mesentery. However, it is important to realize that these criteria may vary and will depend on the aggressiveness of the surgical procedure and on the performance status of the patient. Therefore, they should only be used as a basis for a multidisciplinary consensus. It is important to note that upper abdominal disease and pleural metastases can be surgically resected, but this requires careful planning as it involves a team of surgeons (e.g. liver surgeons for hepatic resection). There has been a growing awareness of the potential of diffusion weighted magnetic resonance imaging (DW-MRI) in improving the mapping of the extent of ovarian cancer [8,9]. There is also growing evidence that FDG-PET/CT may play a role in pre-operative staging of patients with advance ovarian cancer [10].

Intra-Abdominal Xanthogranulomatosis Secondary to Postoperative Bile Leak

Introduction: Xanthogranuloma is a rare benign tumor, macroscopically characterized by golden yellow nodules and microscopically as multicentric, mass-like accumulation of non-Langerhans lipid-laden histiocytes. The etiopathogenesis is not fully understood, however granulomatous reaction of histiocytes to an unknown stimulus is postulated. When xanthogranuloma affects multiple organs, it is called Erdheim-Chester disease, which occurs more commonly in men than women, with a peak incidence in the sixth decade of life. Here, we discuss a rare presentation of intra-abdominal xanthogranulomatosis in a patient caused due to postoperative bile leak. Case Report: A 71-year-old female patient with past medical history of hypertension, hyperlipidemia, and hypothyroidism was referred to our facility for persistent abdominal pain for past 6 months. The pain was associated with poor appetite and progressive loss of weight. On further questioning, it was revealed that she had undergone laparoscopic cholecystectomy for acute cholecystitis prior to the onset of these symptoms. Postoperative course was complicated by bile leak which was diagnosed by HIDA scan. Subsequently, she underwent ERCP with sphincterotomy with resolution of bile leak. No stents were placed. For the persistent abdominal pain, the patient underwent a CT scan of abdomen that showed a 1.7-cm nodule in the omentum surrounding the gastric antrum. In addition, she also had multiple peritoneal nodules surrounding the liver. To further delineate these lesions, she underwent MRI of the abdomen, which showed similar lesions suspicious for peritoneal carcinomatosis. The patient underwent CT-guided biopsy of the lesions. Pathology revealed mixed inflammatory cell infiltrate composed of histiocytes, lymphocytes, plasma cells, eosinophils, and giant cells suggestive of xanthogranulomatous inflammation. The giant cells contained bile pigment, which suggested that the most likely etiology was postoperative bile leak. Further, a diagnostic laparoscopy was done. Intraoperative findings included yellowish 1-2 cm masses in omentum near the gallbladder fossa and greater curvature of stomach. Surgical pathology confirmed the diagnosis of xanthogranulomatous with bile pigment deposits. Conclusions: Intra-abdominal xanthogranulomatosis is an extremely uncommon condition, the etiopathogenesis of which is not yet known. Given the presence of bile pigments in the histology, postoperative bile leak was the inciting factor for this patient.

Bile Leak After Cholecystectomy

Introduction: A 59-year-old male with history of hypertension, diabetes and arthritis was admitted with complaints of right upper quadrant abdominal pain, fatigue, jaundice and weight loss of almost 20 lbs. Initial work-up showed a thickened gall bladder on ultrasound and he underwent a cholecystectomy. Three weeks later, the patient presented to the ER with worsening abdominal distension. CT scan of the abdomen showed the patient had a 4.5x3.5 cm pancreatic head mass with large volume ascites concerning for malignant ascites. The tumor was abutting and penetrating into the superior mesenteric vein. Ascitic fluid studies showed an albumin of 1.0 g/dL, WBC -0 k/mm3, and RBC 15,000 k/mm3 and bilirubin of 7.9 mg/dL. Cytology of the peritoneal fluid was negative for malignant cells. Serum albumin was 3.2 g/dL, AST-19 U/L, ALT-27 U/L, alkaline phosphatase-1507 U/L, serum bilirubin-2 mg/dL. Patient was deemed a non-surgical candidate due to the SMV penetration and ascites. EUS was done to take a biopsy of the pancreas and ERCP due to suspected compression of the CBD from the head mass. ERCP showed a biliary stricture and a bile leak from a possible duct of Luschka. (Figure 1) The leak resolved after stenting of the biliary stricture. (Figure 2)Figure 1Figure 2Duct of Luschka or supravesicular ducts are small ducts that originate from the right hepatic lobe and course along the gall bladder fossa to drain directly in the gall bladder or extrahepatic ducts. Post surgical removal of the gall bladder these ducts may remain open and if the CBD gets obstructed due to stones or stricture, it may lead to leakage of bile in the peritoneal cavity due to the back flow. Physicians need to be aware of this complication in the appropriate setting to prevent any delays in starting necessary work-up and treatment.

English

Isolated agenesis of the gallbladder is a rare congenital anomaly that results from failure of the cystic bud to develop in utero. Patients are usually asymptomatic, and the diagnosis is commonly made as an incidental finding during abdominal surgery or at autopsy. OBJECTIVE: To aware about a rare case of Gall Bladder Agenesis in inconclusive USG findings. METHODOLOGY: Preoperative USG shows contracted gall bladder containing stone but intra-operatively GB was absent and postoperative MRCP shows absent gall bladder fossa with normal biliary radicals. RESULTS: Agenesis of the gallbladder is a rare but well-recognized congenital anomaly, the management of which is conservative. However, clinical and radiologic features mimic those of more common biliary conditions, and so patients frequently undergo unnecessary operative procedures. CONCLUSION: In conclusion, with the newer minimally invasive radiologic techniques, this situation can largely be avoided if awareness of this condition is improved. Pre-operative MRCP should be considered in cases in which ultrasound is inconclusive, and surgeons should maintain a low threshold for further investigation before any decision to operate.

Transmural migration of surgical sponge into the stomach with outlet obstruction: Rare Case

To highlight the unusual postoperative clinical presentation of a retained sponge. Recognition of postoperatively retained foreign bodies is essential but often delayed, either because of medicolegal implications or because of a confusing clinical presentation and non-specific imaging features. In contrast to radio-opaque materials which are detected at follow-up imaging, radiolucent objects like sponges create problems in identification. A 30-year-old lady presented with intermittent non-bilious vomiting, epigastric pain and fever. Contrast-enhanced computed tomography of the abdomen showed a heterogeneous mass in the duodenum with multiple air pockets. Surgical exploration revealed a full-size surgical sponge with one end embedded in the gallbladder fossa and the other perforating the antrum of the stomach, thus causing an obstruction. The sponge was retrieved, and distal gastrectomy with Billroth II anastomosis was performed. The postoperative course was uneventful. A high degree of suspicion and awareness of non-specific symptomatology associated with retained sponges after surgery is essential for early diagnosis and correct treatment.

MRI features of plexiform neurofibromas involving the liver and pancreas in children with neurofibromatosis type 1

To describe magnetic resonance imaging (MRI) findings of plexiform neurofibromas (PNF) involving the liver and pancreas in paediatric patients with neurofibromatosis type 1 (NF1). A retrospective search of the hospital database was undertaken to find cases of PNF in the porta hepatis, hilar neurofibroma, and hepatic neurofibroma over a 12 year period. The images were analysed and a review of the charts was undertaken. Five paediatric patients were identified with extensive PNFs involving the liver. In all cases, the PNFs involved the liver along the intrahepatic portal distribution. Additionally, the gallbladder fossa was affected in 2/5 patients, the pancreatic head in 4/5 patients, the pancreatic neck in 2/5 patients, and the pancreatic tail in 1/5 patients. All tumours showed low signal intensity (SI) on T1-weighted images and high SI with a central target sign on water-sensitive sequences. No patient showed any signs or symptoms, nor required treatment or surgery related to hepatic or pancreatic involvement. Intrahepatic PNFs were stable over a median follow-up time of 3.6 years (range 3 months to 8.8 years). Intrahepatic and pancreatic involvement, although rare, does occur in paediatric NF1 patients. The MRI findings of the tumour are similar to the PNFs that occur more commonly elsewhere in this population. The hallmark of liver involvement is the periportal distribution.

Abstract No. 369 - Drug-eluting beads transarterial chemoembolization of the cystic artery: less scary than it sounds

To evaluate the safety and efficacy of performing drug-eluting beads transarterial chemoembolization (DEB-TACE) through the cystic artery to treat hepatic tumors adjacent to the gallbladder fossa supplied by this vessel.

Watch Out for the Unexpected: Sole Gallbladder Metastasis in a Patient with Malignant Melanoma Striked by FDG-PET

Metastatic gallbladder disease is a rare pathology. Gallbladder metastasis of malignant melanoma is especially rarer. Herein we present the solitary metastasis of a malignant melanoma to the gallbladder. 47-year old male having an ulcerated skin lesion at right toe was diagnosed as malignant melanoma with excisional biopsy. Thereon the patient without locoregional disease was treated with large surgical resection. A metastatic inguinal lymph node was excised 4 months later and interferon-alpha treatment was begun. FDG-PET imaging was requested to evaluate the extent of disease after 15 days and any metastatic focus was not detected. A control FDG-PET was performed for the evaluation of therapy 8 months later. There was only an unexpected, markedly increased focal FDG uptake arousing doubt in the gallbladder fossa on the whole-body images. This accumulation was proven histopathologically as malignant melanoma metastasis after exploratory cholecystectomy and the patient was treated by dacarbazine+cisplatin. Physicians interpreting FDG-PET scans of patients with malignant melanoma must be cautious about the significance of prominent unusual uptakes at unexpected localizations. It is mandatory to establish a certain histopathologic diagnosis if possible.