Metagenomic Analysis of Biliary Microbial Flora in Patients with Gallbladder Cancer or Gallstones-Associated Chronic Cholecystitis.

Biliary dysbiosis is associated with gallbladder cancer (GBC). We aimed to look for biliary bacteria specifically detected in GBC patients. We used 16S rRNA-based metagenomic analysis to elucidate biliary microbiota in 30 GBC and 30 gallstones-associated chronic cholecystitis patients. Relative abundance of five genera, Streptococcus, Enterococcus, Halomonas, Escherichia and Caulobacter was significantly associated with GBC. Of 15-species, 7 were detected significantly higher in GBC, Streptococcus anginosus, Streptococcus constellatus, Streptococcus intermedius, Actinomyces bowdenii, Actinomyces israelii, Actinomyces gerencseriae, and Escherichia fergusonii were biosafety level-2 infectious bacteria; other 8 species were biosafety level-1 bacteria. These bacterial species may be involved in pathogenesis of GBC.

Fascioliasis associated with chronic cholecystitis in a woman from Sistan and Baluchestan province, a non-endemic region in Southeastern Iran.

BACKGROUND: Fascioliasis, caused by Fasciola hepatica, is a neglected zoonotic food-borne trematodiasis. The Caspian littoral in northern Iran is endemic for the disease, and human fascioliasis is well-known in that region. In the present study, we report the diagnosis, identification, and clinical management of a human case of fascioliasis associated with common bile duct (CBD) obstruction from a non-endemic remote area in southeastern Iran. CASE PRESENTATION: A 42-year-old female was admitted to Afzalipour Medical Center hepatobiliary surgery ward in Kerman with abdominal pain for the past three months. Dilated biliary tract and an ill-defined mass in CBD were reported in abdominal ultrasonography and magnetic resonance cholangiopancreatography, respectively. During distal CBD operation, nine leaf-like motile flatworms were isolated. A morphological study confirmed all the isolates as Fasciola, and further molecular investigations, identified the flukes as F. hepatica using both pepck multiplex PCR and cox1 sequencing. CONCLUSION: Molecular and morphological findings of the study indicated the presence of human fascioliasis in the southeastern province of Sistan and Baluchestan in Iran. Fascioliasis is among the etiologies of chronic cholecystitis, and physicians should consider chronic cholecystitis associated with fascioliasis in the differential diagnosis. In the present report, endoscopic ultrasound was usefully applied for the accurate diagnosis of biliary fasciolosis.

A case of Vagococcus fluvialis isolated from the bile of a patient with calculous cholecystitis.

BACKGROUND: Chronic cholecystitis, characterized by persistent inflammation of the gallbladder, predominantly stems from the prolonged presence of gallstones. Calculous cholecystitis has demonstrated a consistent escalation in its incidence over time.Gallbladder stones have been recognized as a predisposing factor for the development of biliary tract infections.Concomitantly, there have been substantial shifts in the distribution and resistance profiles of pathogenic microorganisms responsible for biliary tract infections. The timely acquisition of bile samples for pathogen analysis is of paramount importance, given its critical role in guiding judicious clinical pharmacotherapy and enhancing patient prognosis. CASE PRESENTATION: We present a case involving a 66-year-old female patient who had previously undergone subtotal gastrectomy due to diffuse large B-cell lymphoma. The patient was admitted to our institution with complaints of abdominal pain. Subsequent diagnostic evaluation revealed concurrent choledocholithiasis and cholecystolithiasis. The patient underwent surgical cholecystectomy as the therapeutic approach. Histopathological examination of the excised gallbladder disclosed characteristic features indicative of chronic cholecystitis. Subsequent laboratory analysis of the patient's bile specimen yielded Gram-positive cocci, subsequently identified through biochemical assays, mass spectrometry, and 16 S rRNA analysis as Vagococcus fluvialis. Further in vitro antimicrobial susceptibility testing using disk diffusion and microfluidic dilution showed that this strain exhibited inhibition zone diameters ranging from 12.0 to 32.0 mm in response to 26 antibiotics, including ampicillin, cefazolin, cefuroxime, cefotaxime, ceftriaxone, cefepime, ampicillin/sulbactam, piperacillin, ciprofloxacin, cefoperazone/sulbactam, imipenem, meropenem, piperacillin/tazobarb, penicillin, erythromycin, chloramphenicol, vancomycin, methotrexate/sulfamethoxazole, teicoplanin, linezolid, tigecycline, cefoxitin, ceftazidime, levofloxacin, minocycline and tobramycin. However, the inhibition zone diameters were 6.0 mm for amikacin, oxacillin, clindamycin, and tetracycline. The patient received ceftazidime anti-infective therapy both preoperatively and within 24 h postoperatively and was discharged successfully one week after surgery. CONCLUSION: In this study, we present the inaugural isolation and identification of Vagococcus fluvialis from bile specimens of patients afflicted with calculous cholecystitis. This novel finding lays a substantial experimental groundwork for guiding clinically rational antimicrobial therapy and advancing the exploration of relevant pathogenic mechanisms pertaining to Vagococcus fluvialis infections.

Utility of near infrared fluorescent cholangiography in detecting biliary structures during challenging minimally invasive cholecystectomy.

BACKGROUND: Surgeons can minimize the risk of bile duct injury (BDI) during challenging mini-invasive cholecystectomy through technical standardization by means of a precise anatomical landmark identification (Critical View of Safety) and advanced technology for biliary visualization. Among these systems, the adoption of magnified stereoscopic 3-dimensional view provided by robotic platforms and near infrared fluorescent cholangiography (NIRF-C) is the most promising. METHODS: In this prospective cohort study, we evaluated all consecutive minimally invasive cholecystectomies (laparoscopic and robotic) performed with NIRF-C between May 2022 and January 2023 at General Surgery Unit, Department of Health Sciences, University of Milan, San Paolo Hospital (Milan, Italy). Inclusions criteria were as follows: (1) acute cholecystitis (emergency group), (2) history of chronic cholecystitis or complicated cholelithiasis (deferred urgent group), (3) difficult cases (patients affected by cirrhosis, with scleroatrophic gallbladder or BMI > 35 kg/m2). For each group, the detection rate and visualization order of the main biliary structures were reported (cystic duct, CD; common hepatic duct, CHD; common bile duct, CBD; and CD-CHD junction). RESULTS: A total of 101 consecutive patients were enrolled, including 83 laparoscopic and 18 robotic cholecystectomies. All patients were stratified into three subgroups: (a) emergency group (n = 33, 32.7%), (b) deferred urgent group (n = 46, 45.5%), (c) difficult group (n = 22, 21.8%). Visualization of at least one biliary structure was possible in 94.1% of cases (95/101). Interestingly, all four main structures were detected in 43.6% of cases (44/101). The CD was the structure identified most frequently, being recognized in 91/101 patients (90.1%), followed by CBD (83.2%), CHD (62.4%), and CD-CHD junction (52.5%). In the subset of patients that underwent emergency surgery for AC, the CD-CHD confluence was identified in only 45.5% of cases. However, early and precise identification of CBD (75.8%) and CD (87.9%) allowed safe isolation, clipping, and transection of the cystic duct. In the deferred urgent group, the CBD and the CD were easily identified as first structure in a high percentage of cases (65.2% and 41.3% respectively), whereas the CD-CHD junction was the third structure to be identified in 67.4% of cases, the highest value among the three subgroups. In the difficult group, NIRF-C did not prove to be a useful tool for biliary visualization. The rates of failure of visualization were elevated: CBD (27.3%), CD (18.2%), CHD (54.5%), and CD-CHD (68.2%). CONCLUSIONS: NIRF-C is a powerful real-time diagnostic tool to detect CBD and CD during minimally invasive cholecystectomy, especially when inflammation due to acute or chronic cholecystitis subverted the anatomy of the hepatoduodenal ligament.

Prognostic clinical indexes for prediction of acute gangrenous cholecystitis and acute purulent cholecystitis.

BACKGROUND: Preoperative prediction of severe cholecystitis (SC), including acute gangrenous cholecystitis (AGC) and acute purulent cholecystitis (APC), as opposed to acute exacerbation of chronic cholecystitis (ACC), is of great significance, as SC is associated with high mortality rate. METHODS: In this study, we retrospectively investigated medical records of 114 cholecystitis patients, treated in Shanghai No. 6 People's Hospital from February 2009 to July 2020. Gallbladder wall thickness (GBWT), indexes of blood routine examination, including white blood cell (WBC), alkaline phosphatase (ALP), the percentage of neutrophil, alanine transaminase (ALT), aspartate aminotransferase (AST), fibrinogen (FIB), gamma-glutamyl transferase, prothrombin time and total bilirubin were evaluated. One-way analysis of variance (ANOVA) was used to evaluate significant differences between a certain kind of SC and ACC to select a prediction index for each kind of SC. Receiver operating characteristic (ROC) curve analysis was conducted to identify the prediction effectiveness of these indexes and their optimal cut-off values. RESULTS: Higher WBC and lower ALP were associated with AGC diagnosis (P < 0.05). Higher percentage of neutrophils was indicative of APC and AGC, while higher GBWT was significantly associated with APC diagnosis (P < 0.05) The optimal cut-off values for these indexes were established at 11.1*109/L (OR: 5.333, 95% CI 2.576-10.68, P < 0.0001, sensitivity: 72.73%, specificity: 66.67%), 79.75% (OR: 5.735, 95% CI 2.749-12.05, P < 0.0001, sensitivity: 77.92%, specificity: 61.9%) and 5.5 mm (OR: 22, 95% CI 4.757-83.42, P < 0.0001, sensitivity: 78.57%, specificity: 85.71%), respectively. CONCLUSION: We established a predictive model for the differentiations of APC and AGC from ACC using clinical indexes, such as GBWT, the percentage of neutrophil and WBC, and determined cut-off values for these indexes based on ROC curves. Index values exceeding these cut-off values will allow to diagnose patients as APC and AGC, as opposed to a diagnosis of ACC.

Outcome of routine histopathological examination of gallbladder specimen following elective laparoscopic cholecystectomy.

BACKGROUND: Gallstone disease is one of the commonest surgical ailments encountered in our setup. Its prevalence in India varies from 2% to 29%. Although cholelithiasis accounts for more than 95% of gall bladder related disease, routine histopathological examination (HPE) is vital. It reveals a myriad of benign as well as the malignant surgical pathology of the gallbladder (GB). This part of the world is considered as an endemic region for GB carcinoma as well as gallstone disease. This study intends to evaluate the outcome of the routine HPE of laparoscopic cholecystectomy specimens. METHODS: This retrospective observational study evaluated the results of the routine HPE of elective laparoscopic cholecystectomy specimens of single tertiary care center. Patients suspected or diagnosed with carcinoma gall bladder were excluded. Demographic data such as age, sex, and pathology results were recorded. RESULTS: From January 2017 to December 2019, HPEs of 921 patients who had undergone laparoscopic cholecystectomy specimens were analyzed. 97.6% specimens had benign lesion of which chronic calculus cholecystitis was predominantly high (95.01%) followed by cholesterosis (9.9%) and xanthogranulomatous cholecystitis (6.51%). Incidental carcinoma gall bladder was observed in 17 specimens accounting for 1.85%. Mean age of patients who underwent cholecystectomy was 43.10 ± 13.90 with female to male ratio of 3.23:1. CONCLUSION: Chronic calculus cholecystitis was the most common gall bladder disease with high female preponderance to all GB pathologies. This study affirms the importance of routine HPE after cholecystectomy as early incidental detection of carcinoma gall bladder alters the postoperative management approach and patients are expected to have a better outcome with it.

Association of Microbial Dysbiosis with Gallbladder Diseases Identified by Bile Microbiome Profiling.

BACKGROUND: Cholecystitis is an important risk factor for gallbladder cancer, but the bile microbiome and its association with gallbladder disease has not been investigated fully. We aimed to analyze the bile microbiome in normal conditions, chronic cholecystitis, and gallbladder cancer, and to identify candidate bacteria that play an important role in gallbladder carcinogenesis. METHODS: We performed metagenome sequencing on bile samples of 10 healthy individuals, 10 patients with chronic cholecystitis, and 5 patients with gallbladder cancer, and compared the clinical, radiological, and pathological characteristics of the participants. RESULTS: No significant bacterial signal was identified in the normal bile. The predominant dysbiotic bacteria in both chronic cholecystitis and gallbladder cancer were those belonging to the Enterobacteriaceae family. Klebsiella increased significantly in the order of normal, chronic cholecystitis, and gallbladder cancer. Patients with chronic cholecystitis and dysbiotic microbiome patterns had larger gallstones and showed marked epithelial atypia, which are considered as precancerous conditions. CONCLUSION: We investigated the bile microbiome in normal, chronic cholecystitis, and gallbladder cancer. We suggest possible roles of Enterobacteriaceae, including Klebsiella, in gallbladder carcinogenesis. Our findings reveal a possible link between a dysbiotic bile microbiome and the development of chronic calculous cholecystitis and gallbladder cancer.

Gender as a predictive factor in cholecystectomy - is it true or false?

INTRODUCTION: Cholecystolithiasis is one of the most frequent disorders of the human digestive system in a present population. It is common to point out that male gender is one of strong risk factors for complications during cholecystectomy, however the debate about that seems to be still open. AIM OF THE STUDY: The aim of this study was to compare the values related to the course and treatment effects between gender in patients undergoing cholecystectomy, based on own material. MATERIALS AND METHODS: The study encompassed 504 patients who were admitted to General Surgery And Polytraumatic Injury Department of University Hospital in Kraków, Poland between 2013 and 2018, with the initial diagnosis of cholecystolithiasis (scheduled cases) and acute cholecystitis (emergency cases). The patients underwent surgical gallbladder removal. In this group there were 326 (64.7%) female and 178 (35.3%) male patients. RESULTS: Statistically significant differences between both genders were found containing age, type of admission, numeric rating scale of pain during admission, results in American Society of Anesthesiologists physical status classification system, outcomes in Acute Physiology And Chronic Health Evaluation II severity-of-disease classification system, percentage of conversions, mortality, period of time from admission to surgical procedure, mean duration of the procedure, blood tests and histopathological results. CONCLUSIONS: Subgroups of the cases where determining factor is gender are strongly heterogeneous. Although treatment results were different for both subgroups and these differences were partly statistically significant, it cannot be clearly determined on the basis of a study with such selection of patients, that gender is an independent risk factor for surgical gallbladder removal.

Is hyperkinetic gallbladder an indication for cholecystectomy?

BACKGROUND: The (99m) technetium-labelled hepato imino diacetic acid (HIDA) scan is widely used to evaluate patients with biliary colic with a normal trans-abdominal ultrasound scan. Most studies recommend cholecystectomy for patients with biliary dyskinesia, defined by gallbladder ejection fraction (GBEF) of less than 35-40% on HIDA scan. There are no recommendations regarding management of hyperkinetic gallbladder defined by GBEF of greater than 80% on HIDA scan. The aim of our study was to evaluate the outcomes following cholecystectomy on patients with biliary colic associated with hyperkinetic gallbladder. METHODS: We performed a retrospective chart review of all patients with biliary colic associated with hyperkinetic gallbladder that underwent cholecystectomy in our practice from July 2014 to February 2018. Data collection included age, gender, body mass index, preoperative symptoms, comorbidities, additional tests, ejection fraction, surgery, and histopathology of the gallbladder. Symptomatic improvement was assessed during routine 2-week postoperative visit and a follow-up phone interview. RESULTS: Thirty-two patients had undergone laparoscopic cholecystectomy during the study period for symptomatic hyperkinetic gallbladder. All the patients had abdominal pain related to food intake and 17 (53%) patients had worsening of symptoms with CCK infusion. The average GBEF was 92%. Chronic cholecystitis was seen in 29 (90%) patients on pathology. 23 (74%) patients had complete resolution of biliary symptoms, 5 (16%) had improved symptoms, and 3 (10%) had no change in symptoms. CONCLUSION: Patients with biliary colic and hyperkinetic gallbladder respond favorably to laparoscopic cholecystectomy. Our results suggest that patients with biliary colic in the setting of hyperkinetic gallbladder have symptomatic improvement following cholecystectomy.

[The effectiveness of the application of medicinal mineral water from the 'Omonkhona' source in the patients presenting with the diseases of the hepatobiliary system]. / Éffektivnost' primeneniia lechebnoi mineral'noi vody iz istochnika 'Omonkhona' u patsientov s zabolevaniiami gepatobiliarnoi sistemy.

BACKGROUND: Investigations into the medicinal properties of 'Omonkhona' mineral water used for the treatment of hepatobiliary pathology make up the entirely new field of balneological research in Uzbekistan. AIM: The objective of the present study was to identify the hepatoprotective and choleretic components of the 'Omonkhona' mineral water and elucidate their action in the patients presenting with the diseases of the hepatobiliary system. MATERIAL AND METHODS: A total of 77 patients suffering from the diseases of the hepatobiliary system were available for the examination including 38 patients with chronic hepatitis (CH), 17 with chronic cholecystitis (CC), and 22 patients with liver cirrhosis (Cr). All the patient were prescribed drinking the mineral water (from 1.0 to 3.0 liters per day) during consequtive 12-14 days. The clinical, biochemical, and instrumental studies were carried before and after the treatment. RESULTS: The treatment with 'Omonkhona' water resulted either in the complete elimination or the significant alleviation of pain in the right hypochondrium. The patients presenting with CH and CC experienced normalization of ESR even though it remained high in the Cr patients. All the patients exhibited a decrease of specific gravity of the urine, probably due to the diuretic effect of the mineral water. The biochemical studies of blood and bile showed that the initially slightly enhanced bilirubin levels, alanine aminotransferase and alkaline phosphatase activities in the CH and CC patients normalized after a course of the treatment with 'Omonkhona' mineral water (p<0.05). No such changes were documented in the patients with liver cirrhosis. The patients with CH and CC experienced the two-fold reduction in the intensity of inflammation whereas the bilirubin and bile acid levels increased although the relative cholesterol content decreased and the cholate-cholesterol coefficient increased (p<0.05). The Cr patients demonstrated only insignificant changes of these parameters. The ultrasound examination showed that the CC patients treated with 'Omonkhona' mineral water had a decrease in the swelling of the gallbladder walls, the improvement of its motor function and the disappearance of the stagnation phenomenon. In the CH patients, there was a significant decrease in the cranio-caudal size of the right lobe of the liver, the cranio-caudal size of the left lobe, and the anteroposterior size of the left lobe (p<0.05). A decrease in the acoustic conductivity was noted that can probably be attributed to the reduced swelling of the liver parenchyma. The Cr patients had no significant changes of these parameters following the treatment. CONCLUSIONS: The results of this study give evidence that the treatment of the diseases of the hepatobiliary system with 'Omonkhona' mineral water exerts the well apparent positive influence on the patients presenting with CC and CH even though its beneficial effect was less pronounced in the patients with livre cirrhosis.

Helicobacter Pylori infection of the gallbladder and the risk of chronic cholecystitis and cholelithiasis: A systematic review and meta-analysis.

BACKGROUND: Helicobacter pylori is coexisted with various diseases, including chronic gastritis, ulcer, and gastric cancer. Besides, chronic cholecystitis and cholelithiasis are extremely widespread over the world, which are considered as high health-care cost burdens of digestive diseases. Epidemiologic evidence on Helicobacter pylori infection in gallbladder increasing the risk of biliary diseases has been contradictory. AIM: Conduct a meta-analysis of overall studies and investigate an association between Helicobacter pylori infection of the gallbladder with chronic cholecystitis/cholelithiasis. METHODS: We used PubMed, EMBASE, and Cochrane library databases to identify all published studies before August 2017. Pooled odds ratios (OR) and corresponding 95% confidence intervals (CIs) were obtained using the random effects model. Heterogeneity, sensitivity, and stratified analyses were also performed. RESULTS: Eighteen studies involving 1544 participants and 1061 biliary cases with chronic cholecystitis/cholelithiasis were included. Helicobacter pylori infection of the gallbladder was significantly associated with an increased risk of chronic cholecystitis and cholecystitis (OR = 3.022; 95% CI, 1.897-4.815; I2  = 20.1%). In addition, country-based subgroup analysis also showed a positive association between Helicobacter pylori positivity and chronic cholecystitis/cholelithiasis risk. The ORs (95% CIs) for Asian and non-Asian region studies were 3.75 (1.83-7.71) and 2.25 (1.29-3.89), respectively. CONCLUSION: This meta-analysis suggests that infection of the gallbladder with Helicobacter pylori is closely related to an increased risk of chronic cholecystitis and cholelithiasis.

1H nuclear magnetic resonance (NMR)-based serum metabolomics of human gallbladder inflammation.

OBJECTIVE AND DESIGN: We present in this article 1H nuclear magnetic resonance (NMR)-based metabolic approach to screen the serum metabolic alterations in human gallbladder inflammation with chronic cholecystitis (CC). MATERIAL/METHODS: Total of 71 human serum samples was divided into two groups, (n = 41, CC) and (n = 30 control). 1H NMR metabolic profiling was carried out for investigation of metabolic alterations. Multivariate statistical analysis was applied for pattern recognition and identification of metabolites playing crucial role in gallbladder inflammation. Receiver operating curve (ROC) and pathway analysis on NMR data were also carried out to validate the findings. RESULTS: Serum metabolites such as glutamine, low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), alanine, branch chained amino acids (BCAA), histidine and tyrosine were found to be depleted whereas formate, lactate, 1,2-propanediol were found to be elevated in CC. Metabolic pathways associated with metabolite alteration have also been reported. CONCLUSIONS: NMR has been established for disease diagnosis along with identification of metabolic pattern recognition in biofluids. Gallstones cause inflammation of the gallbladder in the form of CC. Inflammation plays a major role in causation of gall bladder cancer and leads the way to malignancy. Metabolic analysis of CC may lead to early diagnosis of disease and its progression to gallbladder cancer.

[Chronorehabilitation of the patients suffering from chronic cholecystitis with concomitant gallbladder dysfunction and opisthorchiasis]. / Khronoreabilitatsiia bol'nykh khronicheskim kholetsistitom s disfunktsiei zhelchnogo puzyria i opistorkhozom.

The importance of the development of the effective rehabilitative measures for the patients suffering from chronic cholecystitis with concomitant gallbladder dysfunction and opisthorchiasis is beyond question. The adequate methods for the rehabilitation of the patients after an intensive de-worming remain to be developed. It is known that de-worming is not infrequently followed by the immediate amplification of the manifestations of the stagnation of bile in the gallbladder that become even more pronounced than before the de-worming procedure. With the purpose of improving the effectiveness of the spa and health resort-based rehabilitation and prevention of the complications, it is recommended to make use of the modern therapeutic physical factors to be prescribed taking into consideration the characteristics of the biological rhythms in the functional activity of the biliary system in the individual patients. The most effective rehabilitation methods for the treatment of the pathology in question include the application of the therapeutic physical factors known to produce the beneficial effect on the functional state of the biliary system and exert the normalizing influence on the structure of the biological rhythms of the functional activity of various organs and systems. We used a range of approaches for the treatment of 123 patients with chronic cholecystitis and concomitant gallbladder dysfunction plus opisthorchiasis including extremely high-frequency electromagnetic irradiation (EHF therapy) in the combination with the oral intake of the choleretic herbal remedies followed by the transverse galvanization of the epigastric region with due regard for the phase of the rhythm of the functional activity of the gallbladder. The results of such treatment gave evidence of the positive dynamics of all the studied indicators of the functional activity of the biliary system and the organism as a whole which suggests the highest therapeutic effect (87.9%) of the proposed treatment that was maintained during 6 to 12 months.

The role of H. pylori infection in gall bladder cancer: clinicopathological study.

Recent work demonstrated the presence of Helicobacter pylori (H. pylori) in the bile and gallbladder of more than 75 % of patients with gallbladder cancer and more than 50 % of patients with chronic cholecystitis. The aim of the work was to determine the prevalence of H. pylori in the gallbladder of patients operated on for chronic cholecystitis and relating their presence to the precancerous histological changes. In our study, fifty patients were operated on for chronic cholecystitis. The patients were subdivided into two groups (each includes 25 patients): H. pylori-positive group, who had H. pylori in their gallbladder mucosa detected by Giemsa stain, and H. pylori-negative group. The histological findings (mucosal erosions, atrophy, metaplasia, dysplasia, lymphoid infiltration, musculosa hypertrophy, and fibrosis) were compared between the two groups. Comparing the histological findings of the H. pylori-infected gallbladders with the non-infected ones, the gallbladders with mucosal hyperplasia, metaplasia/dysplasia, and lymphoid infiltration showed statistically significant differences, with a P value of 0.028, 0.049, and 0.022, respectively. On the other hand, no statistically significant differences were detected between the two groups in the degree of mucosal erosions (P = 0.299), atrophy, musculosa hypertrophy (P = 1.000), and fibrosis (P = 1.000). These results highlight the role of H. pylori infection in aggravating the mucosal lesions (mucosal hyperplasia, metaplasia, and lymphoid infiltration) of the gallbladder that is considered potentially precancerous.

Xanthogranulomatous cholecystitis: Diagnostic dilemma and surgical solution in geriatric patients: A case report.

INTRODUCTION: Xanthogranulomatous Cholecystitis (XGC) is a rare inflammatory condition characterized by the presence of xanthogranulomas within the gallbladder wall, often mimicking gallbladder carcinoma (GBC). Diagnosis is challenging and may require biopsy. Once GBC is excluded, an open cholecystectomy is recommended, although laparoscopic cholecystectomy is increasingly being performed with great caution. This case report aims to evaluate clinical and radiological features, surgical outcomes, and treatment approaches for XGC. CASE PRESENTATION: A 70-year-old patient presented with right hypochondrial pain and a palpable gallbladder. A CT scan revealed a distended lithiasic gallbladder with a thickened irregular wall and hepatic nodules. A hepatic MRI suggested xanthogranulomatous cholecystitis. A CT-guided biopsy of the liver nodule showed no signs of malignancy. An open cholecystectomy with a trans-cystic drain was performed. Histological examination confirmed chronic xanthogranulomatous cholecystitis. The patient was discharged on postoperative day 10. A clinical and radiological follow-up at 6 months postoperatively showed no abnormalities. CLINICAL DISCUSSION: XGC presents diagnostic challenges due to its resemblance to GBC. Imaging aids in diagnosis, but biopsy may be necessary. Open cholecystectomy is the recommended surgical treatment due to excessive local inflammation and the risk of concomitant malignancy. CONCLUSION: Managing XGC demands a holistic approach that integrates all clinical insights and mandates close collaboration among a multidisciplinary team of surgeons, radiologists, and pathologists. Further research is needed to refine diagnostic and therapeutic strategies for this rare condition, especially in geriatric patients.

Liver pucker sign: predictor of difficult laparoscopic cholecystectomy: a case series.

Introduction: Pucker sign is the depression of the liver in the region of the gallbladder due to a high degree of chronic contractive inflammation of the gallbladder. It usually develops in patients who have a delayed cholecystectomy after acute cholecystitis due to a high degree of chronic contractive inflammation of the gallbladder and contraction of the cystic plate. It is an essential finding either preoperatively or intraoperatively as it can act as a stopping rule during cholecystectomy (act as a guide that cholecystectomy will be difficult). Case series: The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy. Discussion: Chronic cholecystitis is a prolonged, subacute condition caused by inflammation of the gallbladder, which mostly occurs in the setting of cholelithiasis. Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Hence, it would be beneficial to be aware of reliable signs that predict difficult Laparoscopic cholecystectomy. Pucker sign usually predicts increased operative difficulty as there is an operative danger of biliary or vascular injury. Conclusion: The pucker sign is a novel indicator of significant persistent inflammation and heightened difficulty during surgery. It might establish a halting rule that modifies the procedure's management and raises its level of safety.

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons.

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

Chyle and Bile Leak Following Open Cholecystectomy: A Rare Complication.

Gallstone disease is extremely common and frequently and safely treated by cholecystectomy. Chyle leak is a rare but significant side effect of many abdominal surgeries with rarely reported post-cholecystectomy. In this case, we report a 78-year-old lady with multiple comorbidities and symptomatic gallstones who underwent open cholecystectomy complicated by bile and chyle leak, which was successfully managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting for bile leak and conservative management for the chyle leak, which included drainage, low-fat diet, and octreotide.

A Rare Case of Duplicated Gallbladder in the United Arab Emirates.

Gallbladder duplication is a rare congenital aberration that requires special attention due to its clinical, diagnostic, and surgical complexity. Its symptoms are usually consistent with cholecystitis and other gallbladder etiologies. This is a case report of a 39-year-old male patient with a known case of chronic cholecystitis and cholelithiasis. He presented with mild epigastric abdominal pain over two months; as a result, he opted for elective cholecystectomy. Subsequently, a type I septate duplicated gallbladder was incidentally diagnosed following a histopathology report. This literature is the first report of a case of septate gallbladder duplication presenting with cholecystitis in the United Arab Emirates.

Sensitivity and predictive value of ultrasound in pediatric cholecystitis.

BACKGROUND: Ultrasonography has a high sensitivity and positive predictive value (PPV) for diagnosing cholecystitis in adults. The objective of this study was to determine the sensitivity and PPV of ultrasonography in the diagnosis of pediatric cholecystitis. METHODS: We performed a single-institution retrospective review of the records of all patients undergoing cholecystectomy with a preoperative ultrasound during 2005-2010. We calculated sensitivity, specificity, and PPV using pathologic findings as the standard for the diagnosis of cholecystitis. RESULTS: In the 223 included patients, the median (interquartile range) age was 14 y (11-16 y); and 64% were female. Preoperative symptoms of abdominal pain were reported in 98% of patients. A diagnosis of cholecystitis was reported in 10% (23 of 223) of ultrasound readings. Pathologic diagnosis of cholecystitis was present in 80% (179 of 223) of cholecystectomy specimens, with 8% (15 of 179) having acute cholecystitis, 83% (148 of 179) chronic cholecystitis, and 9% (16 of 179) both. Sensitivity of ultrasound findings ranged from 6% for Murphy's sign to 66% for cholelithiasis. Positive predictive values ranged from 67% for Murphy's sign to 87% for gallbladder sludge. Presence of any one ultrasound sign had a sensitivity of 82% and PPV of 80%. CONCLUSIONS: Ultrasound findings in pediatric cholecystitis have lower sensitivities and PPVs than reported in adults. These differences may be explained by the higher prevalence of chronic cholecystitis in children, which suggests that children may have milder episodes of self-limited gallbladder inflammation compared with adults, which may lead to a delay in treatment.