Gallbladder Serosa Research Articles

Ectopic liver tissue adherent to the gallbladder serosa: two cases report from Syria.

Case 1 involved a 52-year-old man who was admitted to the hospital due to an abdominal grip in the right hypochondrium and epigastrium for 1 month. The patient underwent laparoscopic cholecystectomy. During the gross examination, a well-circumscribed brownish nodule with a smooth outer surface, located at the fundus region was found. Case 2 involved a 40-year-old man with 2 months history of epigastric pain radiating to the right shoulder. Calculus chronic cholecystitis was diagnosed by ultrasound. The patient undergoes elective laparoscopic cholecystectomy. A gross inspection showed a small nodule attached to the serosa of the gallbladder. Microscopically, both cases revealed ectopic liver tissue. Ectopic liver tissue is an uncommon entity that occurs during the embryological development of the liver and can be found below and above the diaphragm, especially the gallbladder. Histologically, it usually has the normal architecture of the liver. Although ectopic liver tissue is an exceptional finding, pathologists should be aware of it because it has a high risk of transformation into malignancy. Hepatic choristoma is a rare failure of embryological liver development. It should be removed when recognized and examined histologically to rule out malignancy.

Emergency laparoscopic cholecystectomy for intraabdominal hemorrhage in a patient with a left ventricular assist device: a case report

BackgroundContinuous-flow left ventricular assist devices (LVADs), called “second generation LVADs,” have significantly improved the survival and quality of life outcomes. Accordingly, non-cardiac surgery in a patient with LVADs has required for conditions not directly related to their LVADs. And the management of bleeding in non-cardiac site remains one of long-term critical topics. Laparoscopic approach is useful in a patient with LVADs; however, there have been only few clinical reports. This report describes the first case of laparoscopic cholecystectomy (LC) for intraabdominal hemorrhage from the gallbladder serosa in a patient with LVADs.Case presentationA 56-year-old man with an LVAD had undergone LVAD (Jarvik 2000™; Jarvik Heart, Inc., New York, NY, USA) implantation at 53 years of age. He was in shock, and contrast-enhanced computed tomography revealed abdominal hemorrhage from the gallbladder serosa. Emergency laparoscopic cholecystectomy was performed. We could avoid injury of the LVADs driveline, which was located across the upper abdominal midline, near the right hypochondriac region, by laparoscopic approach. LVADs (Jarvik 2000) did not disturb the operating field because of its smaller size. There were no intra- and postoperative complications.ConclusionsLaparoscopic approach is useful and safe in a patient with LVADs for abdominal surgery. We could perform LC for intraabdominal hemorrhage from gallbladder serosa safety.

Mo1310 CHOLECYSTOENTEROSTOMY AS AN ALTERNATIVE TO CONVENTIONAL TREATMENT FOR CHOELCYSTITIS AND THE ROLE OF SEROTROPIC STENTS

Laparoscopic cholecystectomy for cholecystitis is the standard of care . Percutaneous cholecystostomy is used in patients deemed unfit for surgery . Endoscopic interventions include natural orifice trans-luminal endoscopic surgery (NOTES), per-oral endoscopic trans-papillary drainage and endoscopic ultrasound- guided endoluminal gallbladder drainage. There are a few EUS- specific stents that have shown promise through decreased tissue ingrowth, leakage and migration yet ensure drainage through apposition of lumens. Our index case highlights one stent but autopsy findings did not demonstrate apposition. A 26-year-old female presented with decompensated alcoholic cirrhosis with ascites, abdominal pain and hyperbilirubinemia. After a negative serologic evaluation, we requested a magnetic resonance cholangiopancreatography (MRCP) which demonstrated multiple gallstones and a mildly thickened gallbladder wall. We performed an endoscopic ultrasound which confirmed cholelithiasis, gallbladder distention and estimated the gall bladder wall thickness to be 2.4 mm. We then performed a cholecystoduodenostomy using the AXIOS™ stent and electrocautery enhanced delivery system (AXIOS, Boston Scientific, Natick, MA). Within 24 hours, the patient showed significant improvement in her abdominal pain. Second-look esophagogastroduodenoscopy 48 hours after the initial procedure to evaluate post procedural anemia was unrevealing. Two weeks after gallbladder drainage her hepatic status worsened and she expired. We participated in a limited autopsy to evaluate the effect of the stent invivo and reviewed the histological properties of the lumen. There was evidence of focal adherence of the gallbladder to the duodenum at the site of stent deployment with circumferential serosal formation. Figure 1. The diameter of the tract was 15 mm which was the diameter of the stent used. Histology demonstrated gallbladder serosa continuous with the neo-serosa of the tract and there was no evidence of significant adhesions. Figure 2. The AXIOS™ stent is FDA approved for trans-enteric drainage of pancreatic pseudocysts but recently has been used successfully for gallbladder drainage. Data describing adherence of the gallbladder to the duodenal wall in human subjects using the AXIOS™ stent is limited. Animal model studies have shown serosal adhesion of the stomach to gallbladder at 4 weeks. We observed serosal formation rather than adhesion after two weeks. Studies indicate that adhesions occur after disruption of serosal surfaces and tissue apposition. If tissue apposition does not occur, a new serosal surface will be formed similar to cutaneous wound healing. Trans-luminal stents likely decompress and drain but also are a conduit for serosal formation without direct tissue apposition. We refer to this process as “serotropism.”Figure 2. Histology showing continuation of gallbladder serosa with neo-serosa of the drainage tract created by the stent.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Case Report of Ectopic Liver on Gallbladder Serosa with a Brief Review of the Literature.

This case describes an intraoperative incidental finding and surgical removal of ectopic liver tissue attached to the gallbladder during a standard laparoscopic cholecystectomy for acute cholecystitis. These anomalies are rare, with interesting associations and possible clinically relevant complications. The details of the case, along with a brief literature review of embryology, common ectopic sites, and associations/complications, are presented in this paper. Since laparoscopic cholecystectomy is a very common procedure, it is important to increase vigilance of ectopic liver tissues during surgeries to minimize complications and provide optimal management.

Giant chylous cyst of liver: A case report

We present here a case of chylous cyst of liver with multiple cysts in mesentry, in a 14-year-old. A 14-year-old female presented in surgical outpatient unit with gradual swelling of abdomen for five months without any history of fever, jaundice, trauma or previous operation. Ultrasound and contrast enhanced computed tomography scan suggested a large multiseptate space occupying hypodense lesion. On laparotomy, a huge lobulated cyst containing clear fluid was found arising from left lobe of liver extending up to pelvis. Multiple small cysts were present in mesentery, mesoappendix and serosa of gallbladder. The giant cyst was excised completely with cystic left lobe of liver. Histopathology suggested chylous cyst of liver. There is no recurrence after two years of follow-up. We conclude that patient had chylous cysts at multiple places with largest from liver.

Hyperplastic Luschka Ducts

Ducts of Luschka are a developmental abnormality found within the gallbladder fossa in up to 10% of cholecystectomy specimens. They are most often encountered by surgeons when injured during laparoscopic or open cholecystectomy, leading to bile leakage and subsequent peritonitis. Histologically, they are typically composed of lobular aggregates of small ductules lined by bland, cuboidal-to-columnar biliary-type epithelium, associated with centrally located, larger ductules surrounded by concentric fibrosis. We have identified 6 cases of florid Luschka duct proliferation in which the ductules demonstrated irregular growth pattern, loss of characteristic concentric fibrosis, and epithelial atypia that strongly suggested the diagnosis of invasive pancreatobiliary adenocarcinoma or metastatic adenocarcinoma involving the gallbladder serosa. Two of the cases were initially diagnosed as invasive adenocarcinoma, whereas the other 4 were sent for consultation to rule out adenocarcinoma. All cases were associated with marked acute and chronic cholecystitis with mucosal ulceration, cholelithiasis, and thickening of the gallbladder wall. The ducts of Luschka were located within the rim of adherent liver in all 6 cases and the gallbladder serosa in 5 cases. Limited follow-up information was available for all patients with no documentation of progressive disease. Awareness and proper recognition of the anatomic location and histologic features are imperative in distinguishing florid ducts of Luschka from both non-neoplastic conditions and most importantly adenocarcinoma.

Endoscopic transgastric pure NOTES cholecystectomy with naso‐gallbladder drainage tube placement and injection of a hyaluronic acid mixture (with Video)

Endoscopic transgastric pure natural orifice translumenal endoscopic surgery (NOTES) cholecystectomy is a difficult procedure, and most human female cases are performed as hybrid NOTES, using a transvaginal route. We tried a transgastric pure NOTES procedure without laparoscopic procedure in an animal study after placing an endoscopic naso-gallbladder drainage (ENGBD) tube and injecting a hyaluronic acid (HA) mixture. We performed the method in four pigs, using a standard single-channel endoscope. The ENGBD tube was placed first and the HA mixture was injected between the gallbladder (GB) serosa and liver bed. We determined the gastrotomy site using an ENGBD tube, which made the GB approach easy under fluoroscopic guidance. The scope was not retroflexed, but was rotated at the stomach fornix. The connecting tissues between the GB serosa and liver bed expanded following the injection of the HA mixture, facilitating GB removal with a Hook knife. The GB wall, liver, and vessels were observed clearly during the procedure, and there were no incorrect cuts. We successfully performed a transgastric pure NOTES cholecystectomy in pigs. An ENGBD tube was useful as a guide to the GB, and for recognizing the cystic duct, and injecting the HA mixture facilitated the GB dissection.

Laparoscopic colorectal resection in octogenarians.

The number and proportion of patients aged ?80 years are increasing. These patients often require surgical care and suffer subsequent high rates of morbidity and mortality. However, the surgical outcomes of laparoscopic colorectal resection in octogenarians are not well documented. Octogenarians were identified from a large prospective database comprising 507 consecutive laparoscopic colorectal resections performed between 1991 and 1999 in a university setting. Preoperative comorbidity and surgical outcomes were analyzed. Sixty-two patients (30 men, 32 women) aged ?80 years were identified. Their mean age and weight were 85 years and 63 kg, respectively. Seven patients (11%) were converted to an open procedure. Four (6%) intraoperative complications occurred in four patients (one colon perforation, one small bowel perforation, one burned gallbladder serosa, and one missed lesion), necessitating two conversions. Twenty -four postoperative complications occurred in 19 patients (31%) (six ileus [10%], five wound infections [8%], five cardiac problems [8%], two urinary retentions [3%], two hemorrhages [3%], one abscess [2%], one pneumonia [2%], and two other [3%]). Intraoperative complications did not increase postoperative morbidity. Three patients (5%) died within 30 days of surgery. When the procedure was completed laparoscopically, the overall median postoperative hospital stay was 10.0 days; occurrence of a postoperative complication increased the median length of stay to 15.0 days. These results are superior to published historical controls involving open colorectal resection in octogenarians. Overall mortality, lung, and urinary tract complications were decreased, and there were no reoperations for small bowel obstruction. Laparoscopic colorectal resection is technically feasible and can be done safely in elderly patients. Results require randomization against those for open surgery to elucida te the real advantages of this technique.

Anatomic Rationale for Arterial Bleeding from the Liver Bed During and/or after Laparoscopic Cholecystectomy: A Postmortem Study

The aim of this study was to establish an anatomic rationale for liver bed arterial bleeding during laparoscopic cholecystectomy. Fifty consecutive human cadavers were dissected. A corrosion cast method was used. Six anastomotic branches (12%) of the cystic artery to the right or left hepatic artery ran underneath the gallbladder serosa surface and entered liver parenchyma after crossing the medial or lateral edge of the liver fossa without passing through the areolar tissue of the liver bed. Their mean length was 18.3 mm (range 4-60), and the mean diameter was 0.38 mm (range 0.2-0.8). Two cystic arteries that ascended in the midline between the gallbladder and liver bed were identified in 50 (4%) casts. Their lengths were 16 and 18 mm, and their diameters were 1.9 and 2.2 mm. Five and seven branches encircling the gallbladder arose radially. These two arterial branching patterns can cause arterial bleeding from the liver bed during and/or after laparoscopic cholecystectomy.

Electrocholecystogram: a study of the electromechanical activity of the gall bladder in a canine model.

To characterize an 'electrocholecystogram' (EChG) for the normal gall bladder (GB) that might act as a standard for the evaluation of pathological electrocholecystograms of the diseased GB, ten mongrel dogs (14.4+/-3.2 kg) were studied. Under anaesthesia, the abdomen was opened and three silver-silver chloride electrodes were sutured to the GB serosa. The GB pressure was measured by a perfused catheter introduced through the fundus. The response of the myoelectrical activity of the GB to balloon distension was tested and the direction of electrical waves was defined by GB myotomies. Pacesetter potentials (PPs) were recorded exhibiting the same frequency, amplitude and velocity of conduction from the three electrodes of each dog on all test days. Action potentials (APs) followed the PPs randomly and were associated with a rise of the GB pressure. Balloon distension of the GB caused increased PP and AP frequency. The electrical waves showed proximally but not distally to GB myotomy, indicating that they propagate proximo-distally towards the cystic duct. To conclude, the GB possesses electrical waves which are probably initiated from a 'pacemaker' at the GB fundus. A normal EChG could be characterized in the canine model. It is suggested that this EChG might show changes in gall bladder diseases and might thus act as an investigative tool, provided it can be developed to be performed percutaneously.

A double-blinded evaluation of intraperitoneal bupivacaine vs saline for the reduction of postoperative pain and nausea after laparoscopic cholecystectomy

Intraperitoneal local anesthesia has been reported to reduce postoperative pain after laparoscopy for gynecologic procedures that do not require a great deal of dissection or manipulation of viscera. This study was performed to determine the efficacy of intraperitoneal bupivacaine in laparoscopic cholecystectomy (LC). Fifty-five patients were evaluable in this randomized, double-blind, placebo-controlled study. Twenty-six patients received bupivacaine (0.1%) and 29 patients received placebo (saline). Prior to any dissection of the gallbladder, the surgeon irrigated 100 ml of experimental solution under the right hemidiaphragm, over Glisson's capsule, over the gallbladder serosa, and into the subhepatic space. The operation was then performed as usual. Postoperatively, analgesic medication usage, nausea, vomiting, and pain scores were determined during hospitalization. A questionnaire was given to each patient upon discharge from the hospital in order to continue monitoring medications and pain for the first 48 h at home. Postoperative pain was reduced significantly (P < 0.05) in the patients who received bupivacaine, but the effect was modest and observable only during the first 6 h after surgery. Despite this difference, there was no significant reduction in the amount of analgesic medication used by the patients who received bupivacaine, nor was there any reduction in nausea, vomiting, or shoulder pain when queried specifically. Intraperitoneal bupivacaine offered a detectable, albeit subtle benefit to patients undergoing LC. However, the effect was transient and had little impact upon the patient's convalescence.

Intrinsic nerves affect gallbladder contraction in the guinea pig

Muscarinic antagonists block gallbladder contraction induced by cholecystokinin in vivo but have little effect on gallbladder muscle strips. This study examined the effect of neural blockade on cholecystokinin-octapeptide-induced contraction of the intact guinea pig gallbladder in vitro using cholecystokinin-octapeptide applied to the gallbladder serosa, the lumen, or both compartments simultaneously. Simultaneous cholecystokinin stimulation of both the lumen and serosa was the most potent stimulus to contraction, and the responses were significantly inhibited by atropine and tetrodotoxin. Cholecystokinin in the gallbladder lumen alone evoked contraction by a dose-dependent mechanism that was entirely blocked by atropine or tetrodotoxin. Serosal application of cholecystokinin was the least potent, resulting in contractile responses and low sensitivity to neural blockers comparable to effects reported in muscle strips. The results suggest that cholecystokinin can cause gallbladder contraction by stimulating muscle receptors, neural receptors, or both, and combined neural and muscular stimulation is the most potent contractile stimulus.

Persistence of sudanophilic lipid in sections of mummified tissue.

PARAFFIN sections of Egyptian mummy tissues made by various workers1–4 have shown the appearances of adipose tissue; examinations of mummy tissues by frozen section have been infrequent3,5. Shaw3 failed to detect fat globules in frozen sections of adipose tissue from eighteenth-dynasty canopic material, namely, mesentery and gall-bladder serosa. Lipids have been demonstrated by chemical methods in mummy tissue6,7 and proved to consist largely of fatty acids with traces of unaltered fat. These fatty acids have been thought to be derived not only from neutral fat but also from protein during the embalming process. Fatty acids and cholesterol have also been demonstrated by chemical methods in remnants of mummy brain8.