Study of morphology with assessment of expression of proliferation marker Ki67 antigen and P53 protein in lesions of gall bladder.

OBJECTIVE: To study the spectrum and distribution of histopathological changes and evaluate immunohistochemistry markers p53 protein and Ki67 antigen in various lesions of gall bladder. MATERIALS AND METHODS: A total of 804 consecutive gall bladder specimens were evaluated. Forty cases were selected for immunohistochemical analysis to evaluate expression of p53 and ki67 proliferation index, including 20 carcinoma gall bladder cases and 20 cases of inflammatory pathology associated with metaplasia, atypia, hyperplasia, dysplasia, and adenoma. p53 immunostaining was categorized as wild type and mutant type. ki67 of >20% was considered high expression. RESULTS: The majority of the gall bladder lesions were inflammatory in origin, most common being chronic cholecystitis. In the group of 20 gall bladder carcinoma cases, 65% were p53 mutant and the remaining 35% cases had a p53 wild-type immunophenotype. 55% cases showed high expression for ki67 labeling. However, significant correlation ( P < 0.05) was seen with lympho-vascular invasion. Among non-malignant lesions, normal/wild-type p53 expression was seen with increasing intensity and positivity in lesions with atypia and intra-epithelial neoplasms. Ki67 index also showed the same trend in all cases. CONCLUSIONS: p53 and ki-67 expression increases in inflammation, and further increment occurs in premalignant and malignant lesions of the gall bladder epithelium and can be used as a marker of aggression of histopathological lesions. The results emphasize the potential of Ki-67 and p53 as biomarkers of carcinogenesis in gall bladder carcinoma.

Histological examination of the gallbladder following routine cholecystectomy? A selective analysis is justified.

BACKGROUND: It was hitherto common practice to analyse each removed gallbladder for the presence of gall bladder cancer (GBC) although this approach may be questioned. The aim of this study was to determine whether a policy of selective histopathological analysis (Sel-HPA) is oncologically safe and cost effective. METHODS: This retrospective study was conducted in a single Dutch teaching hospital. Immediately following cholecystectomy, the surgeon decided on the basis of inspection and palpation whether histological examination was indicated. The Dutch Comprehensive Cancer Organisation (IKNL) registry was used to identify the number of GBC during this time period. RESULTS: Of 2271 patients who underwent a cholecystectomy in our institution between January 2012 and December 2017, 1083 (47.7%) were deemed indicated for histopathological analysis. Sixteen pathological gallbladders (1.5%) were identified in that period (intestinal metaplasia, n = 3; low grade dysplasia n = 7; carcinoma n = 6). During follow-up, no patient was found to have GBC recurrence in the population whose gallbladder was not sent for pathology (52.3%, n = 1188, median 49 months of follow up). The percentage of gallbladders that were analysed decreased over the six years of observation from 83% to 38%. Our policy of Sel-HP saved over €65 000. CONCLUSIONS: A policy of selective histopathology after cholecystectomy is oncologically safe and reduces costs.

Ultrasound Measurement of the Gallbladder Wall Thickness in the Assessment of the Risk of Conversion from Elective Laparoscopic Cholecystectomy to Open Surgery - Olkusz County Experience.

The aim of the study was to assess the risk of intraoperative difficulties, conversion and biliary-intestinal fistula during laparoscopic cholecystectomy on the basis of an ultrasound-measured gall-bladder wall thickness. MATERIAL AND METHODS: A prospective study was conducted in 50 patients undergoing laparoscopic cholecystectomy for chronic gallstone-induced cholecystitis. To calculate the relationships between categorical variables, a chi-square (χ2) independence test was used, and the results were interpreted for the significance threshold of α = 0.05. RESULTS: The relationship between the gall-bladder wall thickness and the occurrence of intraoperative difficulties in the analysed set is deterministic (AUC = 1), and the wall thickness of ≥ 5 mm allows to predict their occurrence as soon as at the stage of diagnostic evaluation (p < 0.001). In addition, the ultrasound-measured GB wall thickness is a good predictor of conversion (AUC = 0.976; 95% CI 0.444-0.975; p < 0.001) and biliary-intestinal fistula (AUC = 0.935; 95% CI 0.121-0.738; p = 0.001). CONCLUSIONS: The results allow prediction of technically difficult laparoscopic cholecystectomies in patients with CCh, and selection of the right surgical team helps to reduce the number of conversions and possible complications. In addition, bearing in mind the above results in everyday practice should facilitate planning and increase effectiveness in the operating room.

[TREATMENT OF ACUTE CALCULOUS CHOLECYSTITIS: "EARLY" OR "PLANNED" LAPAROSCOPIC CHOLECYSTECTMIVY].

The comparative analysis of results of surgical treatment of 82 patients with acute cholecystitis, which made "early" (ELCE) or "planned" (PLCE) laparoscopic cholecystectomy (LCE) in the surgical department for the period from 2012 to 2014. The analysis showed that LCE can be set in any time from the beginning of acute cholecystitis. However, priority should be given ELCE, providing significant reduction in duration of treatment of patients in hospitals and is more cost effective.

[Structural state of the pancreas and coprogram parameters for assessment patients with chronic pancreatitis after cholecystectomy].

Reviewed by a structural condition of the pancreas by ultrasound and scores from the Marseille-Cambridge classification in patients with chronic biliary pancreatitis, including those who had a history of cholecystectomy. Found that after cholecystectomy gland size decreased slightly, but significantly fibrosis is increased. Chronic inflammation and fibrosis of the gland leads to inhibition of both acinar and ductal secretory function, leads to its external and internal secretion deficiency. In assessing coprogram found that most patients with CP present with signs of exocrine insufficiency, including steatorrhea and kreatorrhea that are most pronounced in patients with CP after open cholecystectomy.

Routine histological analysis of a macroscopically normal gallbladder--a review of the literature.

BACKGROUND: 70,000 cholecystectomies were performed in the United Kingdom in 2011-2012. Currently it is standard practice to submit all gallbladder specimens for routine histology to exclude malignancy. The aim of this systematic review was to establish whether a normal macroscopic appearance to the gallbladder at the time of cholecystectomy is sufficient to rule out malignancy and therefore negate the need for routine histology. METHODS: Relevant articles that were published between 1966 and January 2013 were identified through electronic databases. RESULTS: 21 studies reported on 34,499 histologically analysed specimens. 172/187 (92%) of gallbladder cancers demonstrated intra-operative macroscopic abnormality. Studies that opened the specimens intra-operatively identified all cancers, whereas gross macroscopic visualization resulted in 15 potentially missed cancers (p = 0.10). In patients of European ethnicity, gallbladder cancer in a macroscopically normal looking gallbladder was identified in only one study; however all of these patients were above the age of 60. The incidence of gallbladder cancer was significantly raised in ethnic groups from high risk areas (p = 0.0001). CONCLUSIONS: A macroscopically normal gallbladder in patients of European ethnicity under the age of 60 may not require formal histopathology. The best method for intra-operative examination may involve opening the specimen to allow inspection of the mucosa and wall, however this needs further investigation. In the context of the volume of gallbladder surgery being performed there is the potential for significant cost and time savings.

Percutaneous cryoablation of hepatic tumors adjacent to the gallbladder: assessment of safety and effectiveness.

PURPOSE: To assess safety and effectiveness of percutaneous image-guided cryoablation of hepatic tumors adjacent to the gallbladder. MATERIALS AND METHODS: Twenty-one cryoablation procedures were performed to treat 19 hepatic tumors (mean size, 2.7 cm; range, 1.0-5.0 cm) adjacent to the gallbladder in 17 patients (11 male; mean age, 59.2 y; range, 40-82 y) under computed tomography (n = 15) or magnetic resonance imaging (n = 6) guidance in a retrospective study. All tumors (mean size, 2.67 cm; range, 1.0-5.0 cm) were within 1 cm (mean, 0.4 cm) of the gallbladder; seven (33%) were contiguous with the gallbladder. Primary outcomes included complication rate and severity and postprocedure gallbladder imaging findings. Secondary outcomes included technical success and technique effectiveness at 6 months. RESULTS: Complications occurred in six of 21 procedures (29%); one (5%) was severe. Ice balls extended into the gallbladder lumen in 20 of 21 procedures (95%); no gallbladder-related complications occurred. The most common gallbladder imaging finding was mild, asymptomatic focal wall thickening after nine of 21 procedures (42%), which resolved on follow-up. Technical success was achieved in 19 of 21 sessions (90%). Six-month follow-up was available for 16 tumors; of these, all but two (87%) had no imaging evidence of local tumor progression. CONCLUSIONS: Percutaneous cryoablation of hepatic tumors adjacent to the gallbladder can be performed safely and successfully. Although postprocedural gallbladder changes are common, they are self-limited and clinically inconsequential, even when the ice ball extends into the gallbladder lumen.

Non-invasive assessment of fibrosis using color Doppler ultrasound in patients with hepatitis C virus in the Amazon rainforest, Brazil.

The purpose of this study was to correlate morphologic and hemodynamic Doppler ultrasound findings as indicators of the degree of inflammation and fibrosis and to diagnose chronic vital hepatitis complications and progression. A prospective, descriptive study of a case series was conducted that analyzed Doppler ultrasound images of the liver and portal system and used the portal vein congestion index, hepatic and splenic artery impedance indices, and the liver vascular index. Of 50 patients positive for antibodies against hepatitis C virus, morphologic changes highlighted increased hepatic parenchyma echogenicity in 24%, and increased gall blander echogenicity and wall thickness in 4%. The most common hemodynamic changes observed were reduced flow velocity in the portal vein trunk in 26%, congestion index changes in 12%, liver vascular index changes in 16%, and splenic and hepatic artery impedance index changes in 14%. These indices were shown to be associated with alanine aminotransferase levels, which suggested that they are important liver damage indicators in the early phase of infection with hepatitis C virus.

Ultrasonography assessment of hepatobiliary abnormalities in 3359 subjects with Opisthorchis viverrini infection in endemic areas of Thailand.

A cross sectional study on hepatobiliary abnormalities in opisthorchiasis was performed in 8936 males and females aged from 20 to 60 years from 90 villages of Khon Kaen province, Northeast Thailand. All were stool-examined for Opisthorchis viverrini infection by standard quantitative formalin/ethyl acetate concentration technique. Of these, 3359 participants with stool egg positive underwent ultrasonography of the upper abdomen. The hepatobiliary abnormalities detected by ultrasound are described here. This study found a significantly higher frequency of advanced periductal fibrosis in persons with chronic opisthorchiasis (23.6%), particularly in males. Risks of the fibrosis included intensity of infection, and age younger than 30 years. Height of left lobe of the liver, cross-section of the gallbladder dimensions post fatty meal, sludge, and, interestingly, intrahepatic duct stones were significantly associated with the advanced periductal fibrosis. Eleven suspected cholangiocarcinoma (CCA) cases were observed. This study emphasizes the current status of high O. viverrini infection rate and the existence of hepatobiliary abnormalities including suspected CCA in opisthorchiasis endemic areas of Thailand.

Accurate staging for gallbladder cancer: implications for surgical therapy and pathological assessment.

BACKGROUND: This study evaluates the significance of tumor involvement of the liver in early T-stage tumors and lymph node (LN) metastases on outcome after R0 resection of gallbladder cancer (GBCA). METHODS: A prospectively maintained database, supplemented with review of the medical record, was used to identify patients who underwent a complete (R0) resection for GBCA. All patients underwent definitive surgical treatment at the initial operation (1 stage) or after initial noncurative cholecystectomy (incidental tumors, 2 stage), including partial hepatectomy and portal LN dissection, with or without bile duct and/or adjacent organ resection. Clinicopathological variables, including TNM stage, histologic tumor involvement of liver (residual or direct extension in the GB fossa or discontiguous disease), and the total number of regional LNs assessed were analyzed for their association with outcome. RESULTS: One hundred twenty-two patients were identified and analyzed. The median follow up period was 23 months. Liver and nodal involvement by GBCA were observed in 61 (50%) and 41(34%) patients, respectively. Among patients with T2 tumors (n = 53), 48 (91%) were incidental. Liver involvement was present in 26%, and this factor was associated with decreased recurrence-free (RFS) and disease-specific survival (DSS) compared with patients with T2 tumors without liver involvement (median RFS, 12 months vs. not reached, P = 0.004, median DSS 25 months versus not reached, P = 0.003); T1b tumors (n = 10) were not associated with liver involvement. The median total lymph node count (TLNC) was 3 (range 0-20). For the entire cohort, survival of patients classified as N0 based on TLNC < 6 was significantly worse than that of N0 patients based on TLNC ≥ 6 (median RFS, 22 months versus not reached, P < 0.001, median DSS 41 months versus not reached, P < 0.001). Liver involvement and TLNC remained significant prognostic factors in a multivariate model that included TNM stage. CONCLUSION: Resection and histologic evaluation of at least 6 lymph nodes improves risk-stratification after resection of GBCA. Incidental T2 tumors are often associated with residual liver disease and should be reclassified to reflect the adverse outcome. The data suggests a need for standardized minimum requirements for adequate surgical treatment and pathological examination.

Colecistectomía laparoscópica ambulatoria: una realidad aplicable a los hospitales públicos venezolanos / Ambulatory laparoscopic cholecystectomy: implementation in venezuelan public hospitals

Determinar la seguridad y factibilidad de la colecistectomía laparoscópica ambulatoria. Se aplicó un protocolo de selección para manejo ambulatorio a los pacientes ingresados por litiasis vesicular para colecistectomía laparoscópica electiva entre noviembre 2006 y diciembre 2007, a la Clínica Popular Paraíso, Hospital tipo III, en Caracas. Los datos se registraron prospectivamente en una base de datos y los resultados se expresaron en valores absolutos, porcentaje y media ± DE. 85 pacientes calificaron para manejo ambulatorio, siendo suspendidos 12 por dificultades técnicas intraoperatorias, quedando 73 pacientes para su estudio. La mayoría fueron femeninos, con edad promedio de 41 ± 12 años, sin comórbidos el 87,05 por ciento. Todos se operaron durante el turno matutino y egresaron a las 6 pm. Se presentaron complicaciones menores en 03 pacientes (3.53 por ciento), no hubo muertes. Tampoco se presentaron reingresos. La aceptación por parte del paciente fue 100 por ciento. Aplicando criterios de selección adecuados, la mayoría de los pacientes sometidos a colecistectomía laparoscópica electiva pueden ser egresados con seguridad el mismo día de la intervención. Esto lleva a una disminución considerable de costos, y aumenta la disponibilidad de camas hospitalarias.

[Assessment of severity assessment and prognosis of pyodestructive abdominal diseases (with editor's comment)].

Leukocytic index of intoxication (LII), number of leukocytes and lymphocytes in blood were compared with clinical symptoms and histological examination of removed organs in patients with acute pyodestructive diseases of abdominal organs. Correlation between LII and inflammation severity was revealed. It is also demonstrated that high LII with low level of lymphocytes is a negative prognostic sign.

Bile duct strictures after hepatobiliary surgery: assessment with MR cholangiography.

PURPOSE: To establish the accuracy of magnetic resonance (MR) cholangiography for diagnosis of postsurgical bile duct strictures. MATERIALS AND METHODS: Sixty-seven patients suspected of having bile duct strictures after liver transplantation (n = 54), cholecystectomy (n = 8), hepatic resection (n = 4), or pancreaticoduodenectomy (n = 1) underwent MR cholangiography. Thick-slab single-shot fast spin-echo (repetition time msec/echo time msec, 4,500/940) imaging was performed in the coronal through sagittal planes with rotation in 10 degrees increments, and contiguous thin-section images were obtained in the transverse and the optimal coronal oblique planes by using half-Fourier rapid acquisition with relaxation enhancement (1,900/96). Three blinded observers independently reviewed the MR images and recorded diagnostic features including presence of biliary stricture by using a five-point confidence scale. Receiver operating characteristic analysis was used to measure the accuracy of MR cholangiography. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Final diagnosis was established at surgery (n = 29) and direct cholangiography (23 of 29) or at direct cholangiography, liver biopsy, and/or serial liver function tests (n = 38). RESULTS: Thirty-three of 67 patients had strictures confirmed with the reference standard. MR cholangiography enabled correct diagnosis and depicted the site of strictures in all cases. Findings of stricture at MR cholangiography were false-positive in five patients with moderate duct dilatation and caliber change at the level of the anastomosis. Mean accuracy, sensitivity, specificity, PPV, and NPV were 94%, 97%, 74%, 86%, and 96%, respectively. CONCLUSION: MR cholangiography is as sensitive as direct cholangiography for the assessment of bile duct strictures after hepatobiliary surgery but may lead to overestimation of the importance of duct dilatation and caliber change.

[Histological examination of the gallbladder after cholecystectomy]. / Histologisk undersøgelse af galdeblaeren ved kolecystektomi.

BACKGROUND AND OBJECTIVES: Normally, the gallbladder is sent routinely for histological examination after cholecystectomy. From a cost-benefit point of view this may not be optimal. METHODS: Computerised records were used to identify patients with gallbladder carcinoma over a 20-year period, from 1979 to 1999, and these patient records were evaluated manually. RESULTS: The estimated cost for one histological examination was $37. During the period, 4,614 cholecystectomies were performed and 33 patients had gallbladder carcinoma. In 29 of the 33 patients, there was evident preoperative and/or peroperative suspicion of cancer, but no such suspicion in four patients. These four patients had other peroperative macroscopic abnormal findings, besides gallbladder stones. CONCLUSION: This retrospective series indicates that in the case of normal preoperative and/or peroperative macroscopic conditions (except for gallbladder stones) there is no need for histological examination of the gallbladder.

Evolution of schistosomiasis-induced pathology after therapy and interruption of exposure to schistosomes: a review of ultrasonographic studies.

Ultrasonography (US) is suitable for diagnosing schistosomiasis-related organic pathology and is particularly useful to assess its evolution after therapy and/or interruption of exposure to the Schistosoma parasites. Evolution of pathology after treatment: Regression of hepatic abnormalities in Schistosma mansoni-infected children and adolescents has been observed already from 7 months post-therapy on. This does, however, not occur in all cases: individual differences are great ranging from spontaneous regression of pathology without treatment to persistence of pathology lasting for years after therapy even without re-infection. Intensity and duration of exposure, different parasite strains, patients' age and genetic background all influence the evolution of pathology. In communities at continuous exposure to S. mansoni infection, repeated re-treatment is required to control hepatosplenic morbidity. In Schistosoma japonicum infection, changes around the portal tree may regress, but characteristic diffuse abnormalities described as 'network pattern' abnormalities do not resolve. In Schistosoma haematobium infection bladder abnormalities and urinary tract obstruction frequently resolve after treatment. Clinically relevant pathology may resurge from 1 year after therapy on if exposure continues. Subjects with more advanced pathology before therapy, appear to be at higher risk of pathology re-appearance. Evolution of pathology after interruption of exposure to schistosomiasis: Knowledge on the evolution of pathology induced by S. mansoni is limited to some reports in emigrants and to the experience of ultrasonographists working in areas, where transmission has been partially interrupted. Due to the longevity of the parasite, infection may last for many years. Even after elimination of the parasites severe pathology may persist for long. In S. haematobium infection spontaneous healing after interruption of re-exposure may occur, but cases have been reported where urogenital lesions led to complications many years after exposure. Contrary to hepatosplenic and urinary pathology, knowlegde on the evolution of other organic abnormalities is very limited: studies on the evolution of biliary abnormalities or intestinal pathology have not been published. Genital pathology may be induced by all Schistosoma spp. Post-therapy evolution of genital schistosomiasis is largely ignored. In some European travellers partial regression of prostatic fibrosis has been described. Schistosomal adnexitis leading to infertility and/or ectopic pregnancy has been reported occurring many years after interruption of exposure. Ultrasonography (US) has never been used to study the influence of schistosomiasis on pregnancy. Concluding, current knowlegde on the evolution of pathology after treatment and/or interruption of exposure is still fragmentary. Frequently, fibrosis reverses after therapy, but advanced pathology may persist for long. Therefore, the possibility of severe clinical complications has to be taken into account, even if the infection is inactive since many years. In interventions aimed at controlling schistosomiasis-related morbidity, evolution of pathology must be monitored by US in representative patient cohorts. Further systematic US-studies are needed not only on the evolution of hepatosplenic and urinary pathology but also on that of intestinal, biliary and genital pathology induced by schistosomiasis, as well as on the influence of schistosomiasis on the outcome of pregnancy.

Constructing a local district telepathology network in Japan. Diagnosis of intraoperative frozen sections via telepathology over an integrated service digital network and the National Television Standard Committee System.

OBJECTIVE: To construct a local telepathology network between the Department of Pathology, Tohoku University Hospital, and Koritu Kesennuma Hospital, about 150 km away. STUDY DESIGN: Tohoku University Hospital is connected with Koritu Kesennuma Hospital by an integrated service digital network for telepathology using the National Television Standard Committee system. The cases submitted for telepathology were limited to those in which a rapid intraoperative diagnosis was made on frozen sections. RESULTS: At this writing, more than 200 cases were diagnosed during a period of 2.5 years. The cases submitted increased with time, amounting to 150 in 1996. In some cases the use of telepathology proved to be fairly advantageous. For example, in one case a radical operation was avoided because of a diagnosis on intraoperative frozen sections. DISCUSSION: There are problems to be solved before telepathology becomes available for practical use: (1) misdiagnosis due to poor quality of instruments, including the transmission cable and pictures; (2) cost-benefit ratio, (3) protection of patients' privacy, and (4) overwork for pathologists. The Japanese government will officially accept telepathology as a means of medical examination in the future. Despite some problems left, telepathology is a promising technology.

[Effect of diagnostic imaging on pre-mortem diagnostic reliability]. / Einfluss bildgebender Verfahren auf die prämortale Diagnosesicherheit.

BACKGROUND: Between 1972 and 1984 the diagnostic arsenal has much changed due to wide application of endoscopy, sonography and computed tomography. PATIENTS AND METHOD: Using the data from patients undergoing autopsy in the years 1972, 1977, 1981, and 1984, it was assessed how many of the diagnostic techniques had been used and to what extent the premortal diagnosis of abnormalities found at autopsy improved during this period. RESULT: While the number of autopsies declined from 113 in 1977 to 66 in 1984, the number of diagnostic techniques used increased continuously (94, 107, 118, and 140, amounting to 0.83, 1.34, 1.76 and 2.12 per patient). The premortal detection of abdominal abnormalities increased globally from 16.8 to 32.5%. This increase was largely due to better diagnosis of liver and gallbladder abnormalities which were in most cases of little relevance. CONCLUSION: Thus, the massive increase of the application of technical diagnostic tools leads only to a limited premortal diagnostic gain while costs are significant.