Gallbladder Wall Thickening Research Articles

Chronic calculus cholecystitis: A prospective clinico-pathological study with lab based evidence

Chronic calculous cholecystitis is an inflammatory disease which affects the gallbladder wall and causes dysfunction of the biliary system. It is the most common benign disease of the gall bladder. To study the pattern of age and sex distribution, diet and clinical feature of patients, the laboratory and radiological investigations of patients presenting with the associated pathology, the intraoperative pathological changes of the gall bladder. This study was conducted from July 2021 to June 2022 at Department of General Surgery, Santosh Medical College and Hospital, Ghaziabad. 100 patients were included in this study. The age, gender, symptomatology, laboratory and radiological findings, intraoperative findings, and histopathological changes where analysed and documented. In our study maximum patients were found in 31-40 years of age. It was found to be most common in females, who consumed mixed diet. The most common symptom was abdominal pain. In ultrasound whole abdomen gall bladder wall thickness was found in majority of the patients. 98% of the patient underwent laparoscopic cholecystectomy and intraoperatively gall bladder was found contracted in 51% of patients. On histopathological examination mild degree of inflammation was seen in 60%, gall bladder wall thickness seen in 50% and the most common type of gall stone was found to be mixed type in 58% patients. We observed the intraoperative pathological changes of the gall bladder, radiological investigations of patients, laboratory investigations of patients and the pattern of age and sex distribution, diet, and clinical feature of patients.

Practices in the Management of Incidental Gallbladder Cancer.

Peeyush VarshneyBackground Histopathology of gallbladder removed for stones may reveal incidental gallbladder cancer (iGBC). We conducted this online e-survey to document the knowledge and practices of management of iGBC among surgeons in India. Methods A 38-question online e-survey Results Two-hundred thirty responses were recorded. Ninety-eight out of two-hundred (49%) responses were general surgeons. Two-hundred ten out of two-hundred twenty-one (95%) saw at least one iGBC per year, but only 74/225 (32%) correctly defined true iGBC. One-hundred seventy-eight out of two hundred twenty-two (80%) did computed tomography/magnetic resonance imaging for thick-walled gallbladder (GB) detected on ultrasound, while 25/222 (11%) did laparoscopic cholecystectomy and 14/222 (6%) did open cholecystectomy. For GB mass on laparoscopy, 16/222 (7%) responses went ahead with simple cholecystectomy. Seventy-four out of two-hundred twenty-five (32%) responses routinely used bag while extracting GB. One-hundred ninety-one out of two-hundred twenty-five (86%) mentioned about stone/bile spill, 121/220 (55%) mentioned about use of bag for extraction while 137/220 62% mentioned port used for extraction of GB in operation notes. One-hundred sixty-six out of two-hundred twenty-seven (73%) always cut open GB after cholecystectomy. On encountering a mass/lesion on cut open GB, 111/225 (49%) sent it for frozen section, 89/225 (40%) sent for routine histopathology while 10% (22/225) directly proceeded for extended cholecystectomy. Ten out of two-hundred twenty-seven (4.4%) did not consider it important to send GB for histopathology. T stage on histopathology is most important factor for deciding reoperation by 205/223 (91%). Conclusion There are lacunae in understanding and deficiencies in management of iGBC in India-a high GBC incidence country. The situation is likely to be worse in low GBC incidence areas. There is need for more awareness and knowledge for proper management of iGBC among surgeons.

Ultrasonographic features of gallbladder wall thickening in dogs with hypoalbuminemia

Hypoalbuminemia has been considered as a cause of gallbladder wall thickening in humans and dogs. Recent study revealed that gallbladder wall thickening in dogs with hypoalbuminemia may not be associated with serum albumin/plasma levels within 48 h of ultrasound study. However, gallbladder wall edema may change within 48 h, and the ultrasonographic features of gallbladder wall thickening in dogs with hypoalbuminemia have not been reported. The purpose of this study is to describe the relationship between serum albumin levels within 24 h of ultrasound and gallbladder wall thickening, and to describe the ultrasonographic features of thickened gallbladder walls in dogs with hypoalbuminemia. 37 hypoalbuminemic dogs with gallbladder ultrasound images were retrospectively included. Ultrasound studies were reviewed, and gallbladder wall thickness, layering appearance, echogenicity, echotexture, distribution, evidence of gallbladder mucocele, and presence of peritoneal effusion were recorded. Additionally, serum albumin levels within 24 h of ultrasound study and the administerd sedation were recorded. The prevalence of gallbladder wall thickening in dogs with hypoalbuminemia was 13.5%. The 3-layer appearance of the gallbladder wall was observed in 4 dogs, and a single-layer gallbladder wall thickening in one dog. Diffuse thickening was observed in all 5 dogs. The serum albumin level of dogs with gallbladder wall thickening was not different (p = 0.14) from dogs without thickening. Gallbladder wall thickening was not common, occurring only with mild hypoalbuminemia, and was commonly associated with a 3-layer appearance and considered as gallbladder wall subserosal edema. Causes other than hypoalbuminemia may be responsible for thickening of the gallbladder wall in dogs with hypoalbuminemia.

Analysis of risk factors for complications after laparoscopic cholecystectomy

ObjectiveTo analyze the risk factors of complications after laparoscopic cholecystectomy in 478 patients in our hospital. Methods: The clinical data of 478 patients who underwent laparoscopic cholecystectomy in our hospital from March 2018 to September 2022 were collected, and the occurrence of postoperative complications and related risk factors were analyzed. Results: A total of 36 patients (7.53%) had complications, including 9 cases (1.88%) of abdominal hemorrhage, 8 cases (1.67%) of bile duct injury, and 19 cases (3.97%) of biliary fistula. Univariate analysis showed that adhesions of Calot triangle, anatomical variation and gallbladder wall thickness greater than 5 mm were associated with postoperative complications (all P < 0.05). Multivariate analysis showed that: Calot triangle adhesion (OR = 3.041, 95%CI = 1.422–6.507), anatomical variation (OR = 4.368, 95%CI = 1.764–10.813) and gallbladder wall thickening (OR = 2.827, 95%CI = 1.422–6.507). 95%CI = 1.274–6.275) were independent risk factors for complications after laparoscopic cholecystectomy (all P < 0.05). Conclusion: In order to reduce the occurrence of postoperative complications, the risk factors of LC should be well understood and the preoperative preparation should be made.

Eosinophilic Cholecystitis and Eosinophils in Gallbladder Injuries: A Clinicopathological Analysis of 1050 Cholecystectomies.

"Eosinophilic cholecystitis" has been an elusive concept. Around 1050 consecutive cholecystectomies with chronic (CC, n = 895), subacute (SAC, n = 100), and acute cholecystitis (AC, n = 55) were reviewed for eosinophilic infiltration. Eosinophilic hot spots (>40 eosinophils/HPF) were seen in 63% of SAC and 35% of AC (vs. 6% of CC, p < 0.001). Eosinophils were mostly encountered in areas of wall thickening, revealing edema with early collagenization and young tissue-culture-type fibroblasts. However, in ten chronic cholecystitis patients (<1%), prominent eosinophilia with eosinophil-rich foci (>100 eosinophils/HPF) was noted. These ten cases, classified as "eosinophilic cholecystitis", were analyzed further: The patients were relatively young (mean age = 43 years), with a 9:1 female:male ratio. None had blood eosinophilia/eosinophilia syndromes. Although one had ulcerative colitis, others did not have any autoimmune diseases. The mean gallbladder wall thickness was 3.5 mm (vs. 4.2 mm in ordinary CC). In conclusion, eosinophils are a part of especially subacute injuries in the gallbladder. They are typically condensed in the areas of healing and appear to signify a distinctive state of injury in which there are erosions leading to slow/sustained exposure of the mural tissues to the bile contents that induce chemical injury/recruit eosinophils. Eosinophilic cholecystitis is a very uncommon occurrence and appears to be an exaggerated response in allergic patients who are prone to recruit eosinophils in reaction to injury.

Usefulness of contrast-enhanced ultrasonography for biliary tract disease.

Conventional ultrasonography (US) for biliary tract disease shows high time and spatial resolution. In addition, it is simple and minimally invasive, and is selected as a first-choice examination procedure for biliary tract disease. Currently, contrast-enhanced US (CEUS), which facilitates the more accurate assessment of lesion blood flow in comparison with color and power Doppler US, is performed using a second-generation ultrasonic contrast agent. Such agents are stable and provide a timeline for CEUS diagnosis. Gallbladder lesions are classified into three types: gallbladder biliary lesion (GBL), gallbladder polypoid lesion (GPL), and gallbladder wall thickening (GWT). Bile duct lesions can also be classified into three types: bile duct biliary lesion (BBL), bile duct polypoid lesion (BDPL), and bile duct wall thickening (BDWT). CEUS facilitates the differentiation of GBL/BBL from tumorous lesions based on the presence or absence of blood vessels. In the case of GPL, it is important to identify a vascular stalk attached to the lesion. In the case of GWT, the presence or absence of a non-contrast-enhanced area, the Rokitansky-Aschoff sinus, and continuity of a contrast-enhanced gallbladder wall layer are important for differentiation from gallbladder cancer. In the case of BDWT, it is useful to evaluate the contour of the contrast-enhanced medial layer of the bile duct wall for differentiating IgG4-related sclerosing cholangitis from primary sclerosing cholangitis. CEUS for ampullary carcinoma accurately reflects histopathological findings of the lesion. Evaluating blood flow in the lesion, continuity of the gallbladder wall, and contour of the bile duct wall via CEUS provides useful information for the diagnosis of biliary tract disease.

Risk factors for pancreatitis occurrence after gallstone treatment using endoscopic retrograde cholangiopancreatography.

Patients with gallstones are prone to pancreatitis after treatment using endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to explore the risk factors for pancreatitis occurrence after gallstone treatment using ERCP. A total of 193 patients treated from October 2017 to October 2020 were assigned into pancreatitis group (n=55) and non-pancreatitis group (n=138). Multivariate logistic regression analysis was utilized to analyse the risk factors for post-ERCP pancreatitis. The discrimination and accuracy of an established nomogram model were evaluated using receiver operating characteristic and calibration curves, respectively. The incidence rate of pancreatitis was 28.50% (55/193). Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, number of intubation ≥2 and absence of pancreatic duct stenting were risk factors for post-ERCP pancreatitis (P<0.05). The established model had high discrimination and accuracy. The incidence rates of pancreatitis in patients with and without pancreatic duct stenting were 11.84% (9/76) and 39.31% (46/117), respectively. The patients undergoing pancreatic duct stenting had lower serum amylase levels 6, 12 and 24 h after ERCP than those of patients who did not. Patients with gallstones have a higher risk of developing pancreatitis. Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, pancreatic duct visualization and number of intubation ≥2 are risk factors for post-ERCP pancreatitis.

Billiary Tract Obstruction due to Gallbladder Carcinoma at Prof. Dr. R. D. Kandou General Hospital: Two Case Reports

Abstract: Gallbladder cancer is the fifth most common gastrointestinal malignancy with a high mortality rate. Detection of gallbladder carcinoma in early stages can be difficult, despite improvements in ultrasound and CT-Scan imaging. It is possible to cure gallbladder cancer surgically at an early stage. We reported two cases of gall bladder carcinoma, 65-year-old and 52-year-old females, with the chief complaints of abdominal pain in the right upper quadrant (RUQ) and obstructive jaundice in both cases. The abdominal CT-scans showed circumferentially irregular focal thickening of gallbladder wall, and severe intra and extrahepatic cholestasis. Endoscopic preoperative biliary drainage using biliary stent was performed in one case. Open cholecystectomy with in toto common bile duct resection and portal lymphadenectomy followed by roux en-y hepaticojejunostomy reconstruction were performed for both cases. Both patients are still well with no cancer recurrences over two-year follow-up. The symptoms of gall bladder cancer were non-specific, and commonly included RUQ abdominal pain, weight loss, anorexia, nausea or vomiting, jaundice, and pruritus. Imaging with ultrasound and CT-Scan had improved preoperative diagnosis of gallbladder cancer. Outcomes of patient with incidental finding of gallbladder cancer had better prognosis since it provided the patient to be staged and managed appropriately with resection. In conclusion, early detection of gallbladder cancer results in better surgical outcome and less patient morbidity and mortality which shows its importance. Keywords: gallbladder carcinoma; early-stage detection; common bile duct resection

PREDICTION OF DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY BASED ON ULTRASONOGRAPHIC FINDINGS

Objectives: The objective of the study is to the role of pre-operative ultrasonography (USG) abdomen to find difficulty in laparoscopic cholecystectomy. Methods: It was a prospective observational study conducted in the Department of General Surgery, Government Medical College, Kottayam, for a period of 12 months after obtaining approval from the Institutional Review Board and Ethical Committee. A total of 94 patients who underwent elective laparoscopic cholecystectomy were randomly allotted and their pre-operative ultrasound was assessed. Pre-operative predictability of difficult laparoscopic cholecystectomy based on USG was studied. Results: Out of 78 difficult laparoscopic cholecystectomies, 71 cases were predicted to have intra-operative difficulty with pre-operative ultrasound as per total time taken for surgery. Out of these 78 difficult cases, 68 cases were able to predict as per difficulty in dissecting GB from GB fossa. This gives a positive predictive value of 91%, which is in agreement with earlier studies. Conversion rate in our study was 9.6% of total and 11.5% of difficult cases. Those cases that were predicted pre-operatively with ultrasound to be easy were never converted to open. Conclusion: Pre-operative USG can be used as a screening method for laparoscopic cholecystectomy as this is a valuable predictor of difficulty in laparoscopic cholecystectomy in most of the cases. It will help the surgeon to make an idea of potential difficulty that he/she can face during the intra-operative period. The most valuable assessment using the ultrasound is the gall bladder wall thickness, gall bladder contracted or not, common bile duct diameter, and stones impacted in the neck of GB.

Assessing the Role of Gallbladder Wall Thickness in Cholecystectomy: Surgical Considerations and Patient Outcomes - A Prospective Study

Assessing the Role of Gallbladder Wall Thickness in Cholecystectomy: Surgical Considerations and Patient Outcomes - A Prospective Study

Computed tomography findings of hepatobiliary systems in patients with immune checkpoint inhibitor-induced liver injury.

The incidence of immune checkpoint inhibitor (ICI)-induced liver injury has increased recently; however, its imaging characteristics remain unclear. This study aimed to characterize the computed tomography (CT) findings of ICI-induced liver injury. This was a single-center retrospective study of patients with ICI-induced liver injury who underwent CT between January 2020 and December 2021. Two board-certified radiologists independently evaluated the CT findings of the patients before the start of ICI therapy (pre-CT)and at the onset of ICI-induced liver injury (post-CT) to determine the presence or absence of imaging findings suggestive of hepatitis and cholangitis. ICI-induced liver injury was classified into three categories based on the CT findings: hepatitis alone, cholangitis alone, and overlapped (cholangitis plus hepatitis). A total of 19 patients were included in this study. Bile duct dilatation, bile duct wall thickening, non-edematous gallbladder wall thickening, hepatomegaly, periportal edema, and gallbladder wall edema were observed in the post-CT images of 12 (63.2%), 9 (60%), 11 (57.9%), 8 (42.1%), 6 (31.6%), and 2 (10.5%) patients, respectively. Wall thickening in the perihilar, distal, intrapancreatic bile duct and the cystic duct were observed in 53.3%, 60%, 46.7%, and 26.7% of the study population, respectively. Regarding the classification of ICI-induced liver injury, cholangitis alone was most common (36.8%), followed by overlapped (26.3%) and hepatitis alone (26.3%). Patients with ICI-induced liver injury demonstrated a higher incidence of biliary abnormalities than hepatic abnormalities on CT images; nonetheless, future studies with larger sample sizes are needed to validate these findings.

Sonographic “Cervix Sign”: A New Ancillary Sign of Gallbladder Neck Malignancy

The differentiation of benign and malignant gallbladder wall thickening is challenging. The purpose of this study is to evaluate a new sonographic sign, "cervix sign" for differentiation of benign and malignant gallbladder neck thickening. This retrospective study comprised consecutive patients with gallbladder neck thickening who underwent sonography between August 2019 and December 2021. The presence of "cervix sign" was assessed by two radiologists independently. Sixty-five patients had gallbladder neck thickening (28 malignant and 37 benign). The sonographic "cervix sign" was present in 18 (64%) patients with malignant thickening and in only one (2.7%) patient with benign thickening (P= 0.0001). The mean wall thickness was greater, and symmetric wall thickening and liver metastases were more common in malignant thickening with "cervix sign" (without reaching statistical significance). There was substantial agreement (kappa=0.78) between the two observers for the cervix sign. Sonographic "cervix sign" is a useful ancillary feature of gallbladder neck cancer.

Utility of the Parkland Grading Scale to determine intraoperative challenges during laparoscopic cholecystectomy: a validation study on 206 patients at an academic medical center in Nepal

BackgroundMost of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy.MethodThis was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale.ResultsOut of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19–75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5.ConclusionParkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery.

Candida albicans cholecystitis in a dog with diabetes mellitus

AbstractA 10‐year‐old, 8.9‐kg, spayed, female Jack Russell Terrier, with previously well‐controlled diabetes mellitus, presented with hyporexia of 2‐day duration. Cranial abdominal pain and weight loss were detected on clinical examination. Blood tests, urinalysis, urine protein:creatinine ratio, blood pressure, abdominal ultrasound and liver aspirate cytology revealed hyperglycaemia, elevated serum liver enzyme activities, glucosuria, proteinuria, hypertension, rounded liver edges, irregular hyperechoic gall bladder wall thickening, irregular hyperechoic gall bladder content and vacuolar hepatopathy. Bile cytological examination demonstrated fungal organisms, which were identified as Candida albicans on bile fungal culture. No bacteria were detected on bile cytological examination or bile bacterial aerobic and anaerobic culture. The dog was diagnosed with Candida albicans cholecystitis and recovered after a 12‐week course of oral ketoconazole. This case report highlights the value of performing bile cytology in suspect canine cholecystitis cases and is the first to describe Candida albicans fungal cholecystitis without bacterial coinfection in dogs.

A Study of the Degree of Gall Bladder Wall Thickness and Its Impact on Patients Undergoing Laparoscopic Cholecystectomy.

Background The gold standard management for symptomatic gallstone disease is elective laparoscopic cholecystectomy, which has replaced open cholecystectomy. The wall thickness of the gallbladder is an indicator of cholecystitis in patients who have presented with symptoms of gallstone disease. The aim of this study was to evaluate preoperative gall bladder wall thickness by ultrasonography and assess its impact on the outcome of laparoscopic cholecystectomy, including conversion rate, complications, operative time, and postoperative hospital stay. Method This prospective study was conducted on 350 patients with symptomatic gallstone disease, those who had undergone laparoscopic cholecystectomy in Dr. Sampurnanand Medical College, Jodhpur, and attached hospitals from July 2019 to November 2021. On the basis of ultrasonography findings of gallbladder wall thickness, patients were divided into four groups: normal thickness - up to 2 mm, mild thickness - 3-4mm, moderate thickness - 5-6mm, and severe wall thickness - more than 6mm). Up to 2 millimeters thickness was considered as normal. Results The incidence of conversion rate, as well as intra or postoperative complications, were higher in moderate and severe wall thickness groups. The maximum incidence of complication rate is seen in moderately thickened group (33.33%). In severely thickened group, complication was seen in 100% of patients. Operative time, as well as postoperative hospital stay, were more in higher thickness groups. There was a statistically significant correlation between gallbladder wall thickness and conversion rate, complications operative time, and postoperative length of stay. Conclusion Increased gallbladder wall thickness causes increased intra as well as postoperative complications, more conversion to open procedure rate, increased operative time, and enhanced postoperative hospital stay. Among the total study population, 29.71% of patients had increased gallbladder wall thickness. In our study, a positive correlation was seen among gallbladder wall thickness, complication rate, conversion rate, intraoperative time, and postoperative hospital stay.

A novel approach to distinguish complicated and non-complicated acute cholecystitis: Decision tree method.

It is difficult to differentiate between non-complicated acute cholecystitis (NCAC) and complicated acute cholecystitis (CAC) preoperatively, which are two separate pathologies with different management. The aim of this study was to create an algorithm that distinguishes between CAC and NCAC using the decision tree method, which includes simple examinations. In this retrospective study, the patients were divided into 2 groups: CAC (149 patients) and NCAC (885 patients). Parameters such as patient demographic data, American Society of Anesthesiologists (ASA) score, Tokyo grade, comorbidity findings, white blood cell (WBC) count, neutrophil/lymphocyte ratio, C-reactive protein (CRP) level, albumin level, CRP/albumin ratio (CAR), and gallbladder wall thickness (GBWT) were evaluated. In this algorithm, the CRP value became a very important parameter in the distinction between NCAC and CAC. Age was an important predictive factor in patients with CRP levels >57 mg/L, and the critical value for age was 42. After the age factor, the important parameters in the decision tree were WBC and GBWT. In patients with a CRP value of ≤57 mg/L, GBWT is decisive and the critical value is 4.85 mm. Age, neutrophil/lymphocyte ratio, and WBC count were among the other important factors after GBWT. Sex, ASA score, Tokyo grade, comorbidity, CAR, and albumin value did not have an effect on the distinction between NCAC and CAC. In statistical analysis, significant differences were found groups in terms of gender (34.8% vs 51.7% male), ASA score (P < .001), Tokyo grade (P < .001), comorbidity (P < .001), albumin (4 vs 3.4 g/dL), and CAR (2.4 vs 38.4). By means of this algorithm, which includes low-cost examinations, NCAC and CAC distinction can be made easily and quickly within limited possibilities. Preoperative prediction of pathologies that are difficult to manage, such as CAC, can minimize patient morbidity and mortality.

Validation of a Pre-Existing Scoring System for Preoperative Prediction of Difficulty in Laparoscopic Cholecystectomy

Background: One of the most commonly performed surgeries globally is Laparoscopic Cholecystectomy (LC) which is the gold standard surgical procedure for removal of gallbladder. It provides numerous benefits over open cholecystectomy but has also shown higher complication rates. Therefore, a system devised for pre operative assessment of intra operative difficulty level of Laparoscopic Cholecystectomy should be adopted to help with preparedness for complications and ensure an efficient course of surgery. Objective: The aim of this study was to validate a scoring system made by Randhawa Et al to assess intra operative difficulty level of Laparoscopic Cholecystectomy preoperatively. Study Design: This is a non randomized prospective observational study Methodology: This study was conducted in the department of general surgery unit 2 at Dow University Hospital, Karachi, Pakistan on 202 patients. Age, gender, BMI, history of previous hospitalization, examination finding of palpable gallbladder, previous abdominal surgery scars and sonographic findings including wall thickness of gallbladder, pericholecystic collection and impacted stone were considered to score a patient preoperatively. Results: Male gender and presence of pericholecystic fluid collection were found to be statistically significant in predicting intraoperative difficulty in patients undergoing laparoscopic cholecystectomy. Practical implications: Around 7 to 35% of laparoscopic cholecystectomy ends up getting converted into open cholecystectomy. This could be due to various reasons one of which is due to lack of preparedness for intraoperative difficulty in performing the surgery. For this reason, a scoring system that accurately predicts difficulty of surgery could help reducing this rate. Keeping this benefit in mind, a preformed scoring system was tested for its validity in assessing the intraoperative difficulty level of LC preoperatively. Keywords: Laparoscopic cholecystectomy, Scoring system, complications

Adenomyomas of the Gallbladder: An Analysis of Frequency, Clinicopathologic Associations, and Relationship to Carcinoma of a Malformative Lesion.

The nature and associations of gallbladder (GB) "adenomyoma" (AM) remain controversial. Some studies have attributed up to 26% of GB carcinoma to AMs. To examine the true frequency, clinicopathologic characteristics, and neoplastic changes in GB AM. Cholecystectomy cohorts analyzed were 1953 consecutive cases, prospectively with specific attention to AM; 2347 consecutive archival cases; 203 totally embedded GBs; 207 GBs with carcinoma; and archival search of institutions for all cases diagnosed as AM. Frequency of AM was 9.3% (19 of 203) in totally submitted cases but 3.3% (77 of 2347) in routinely sampled archival tissue. A total of 283 AMs were identified, with a female to male ratio = 1.9 (177:94) and mean size = 1.3 cm (range, 0.3-5.9). Most (96%, 203 of 210) were fundic, with formed nodular trabeculated submucosal thickening, and were difficult to appreciate from the mucosal surface. Four of 257 were multifocal (1.6%), and 3 of 257 (1.2%) were extensive ("adenomyomatosis"). Dilated glands (up to 14 mm), often radially converging to a point in the mucosa, were typical. Muscle was often minimal, confined to the upper segment. Nine of 225 (4%) revealed features of a duplication. No specific associations with inflammation, cholesterolosis, intestinal metaplasia, or thickening of the uninvolved GB wall were identified. Neoplastic change arising in AM was seen in 9.9% (28 of 283). Sixteen of 283 (5.6%) had mural intracholecystic neoplasm; 7 of 283 (2.5%) had flat-type high-grade dysplasia/carcinoma in situ. Thirteen of 283 cases had both AM and invasive carcinoma (4.6%), but in only 5 of 283 (1.8%), carcinoma arose from AM (invasion was confined to AM, and dysplasia was predominantly in AM). AMs have all the features of a malformative developmental lesion, and may not show a significant muscle component (ie, the name "adeno-myoma" is partly a misnomer). While most are innocuous, some pathologies may arise in AMs, including intracholecystic neoplasms, flat-type high-grade dysplasia or carcinoma in situ, and invasive carcinoma (1.8%, 5 of 283). It is recommended that gross examination of GBs include serial slicing of the fundus for AM detection and total submission if one is found.

Psychological and sociodemographic factors for delayed patient discharge after daycare laparoscopic cholecystectomy.

Objective: To estimate the psychological and sociodemographic correlates of delayed discharge of patients undergoing Elective Laparoscopic Cholecystectomy. Study Design: Retrospective Cross-sectional Descriptive study. Setting: Department of Surgery, Fauji Foundation Hospital. Period: July 2019 and June 2022. Material &amp; Methods: The study comprised reviewing medical records of 160 patients who underwent daycare cholecystectomy. It was noticed from patients’ medical records that patients were carefully selected for daycare surgery. Patients with comorbidities, previous upper intra-abdominal surgery, ultrasound findings of thickened gallbladder wall &gt; 5mm were not offered day care surgery. For data collection a Performa was designed based on literature review. To assess psychological state, we applied Hospital anxiety and depression scale in Urdu. Descriptive statistics were calculated for the sociodemographic variables, mean and standard deviation was found for continuous variables and frequency percentages for categorical variables. Results: One hundred and thirty-one 131 (81.8 percent) of the 160 cholecystectomies could be sent home within 24 hours, whereas 29 (18 percent) required a lengthier hospital stay. One hundred and thirty-one 131 (81.8 percent) of the 160 cholecystectomies could be sent home within 24 hours, whereas 29 (18 percent) required a lengthier hospital stay. In LS group, the postoperative stay range was 2 –19. Observation of postoperative fever (n = 3), surgery-related causes postoperative pain (n= 6), delayed oral diet = 1, retained abdominal drain = 4, and postoperative complications (n= 3). Bowel injury (n = 2) and septicemia (n = 1) were serious postoperative consequences resulting in more prolonged hospital stay. PONV (n = 2), medical causes (n = 3), and patient preference (n = 7) were among the reasons for the prolonged hospital stay. Conclusion: While our study has a few limitations; it is a retrospective review with nonrandomized patient selection and a smaller sample size, we have established safety of day case laparoscopic cholecystectomy in select group of patients. Patients’ personal satisfaction was the most common reason for their overnight admission after day case LC which was because of number of sociodemographic factors.

Exploring the imaging features and treatment options of Mirizzi syndrome

The patient is a 54-year-old female who presented to the emergency department for episodic right biliary colic with nausea and vomiting over the past year. The patient's symptoms warranted multiple emergency department visits, but were self-limiting. During the most recent visit, the patient had a low-grade fever of 99.8°F (96.8°F-99.5°F) and a borderline elevated total bilirubin of 1.2 (0.2-1.2 mg/dL). Abdominal ultrasound revealed cholelithiasis, gallbladder wall thickening, and biliary ductal dilatation. Subsequent MRCP revealed an impacted stone within the gallbladder neck and a prominent common hepatic duct, compatible with Mirizzi syndrome Type I. The obtained imaging combined with clinical correlation in the setting of jaundice and right upper quadrant pain guided the patient's management. A laparoscopic cholecystectomy was performed and the patient was safely discharged the following day.