Utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis in children.

BACKGROUND: Ultrasound is an integral part of evaluating for acute cholecystitis and choledocholithiasis in pediatric patients. Finding the common bile duct (CBD), a structure which is normally <4 mm in children, can be very challenging. OBJECTIVE: The primary objective of this study was to determine the prevalence of isolated sonographic CBD dilation in pediatric patients with acute cholecystitis and/or choledocholithiasis without laboratory abnormalities or pathologic findings on radiology based biliary ultrasound, apart from cholelithiasis. METHODS: We conducted a retrospective chart review of patients ≤21-years-old, at a single free-standing tertiary care children's hospital, who received a biliary ultrasound in the radiology department (RADUS) from September 2005 to February 2020. We identified patients who had a diagnosis of acute cholecystitis and/or choledocholithiasis on RADUS. Based on prior studies, a positive ultrasound was defined as having gallbladder wall thickening (GWT), pericholecystic fluid (PCF), or sonographic Murphy's sign (SMS). The final diagnosis was confirmed using the gold standard, cholecystectomy pathology diagnosis for patients with cholecystitis and endoscopic retrograde cholangiopancreatography (ERCP) diagnosis for patients with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. RESULTS: 180 patients met inclusion criteria. For the study population, 97 (53.9%) had a positive ultrasound, 127 patients (70.6%) had a dilated CBD, and 170 (94.4%) had at least one abnormal laboratory finding. Within the study population there were 76 patients (42.3%) with acute cholecystitis, 55 patients (30.5%) with choledocholithiasis, and 49 patients (27.2%) with acute cholecystitis and choledocholithiasis. Of the 127 patients with a dilated CBD, 80 (62.9%) had a normal ultrasound, apart from cholelithiasis. In this group of 80, 78 patients (97.5%) had at least one abnormal laboratory finding. Thus, for the entire study population, isolated CBD dilation without a positive ultrasound or laboratory abnormalities occurred in 2 patients (1.1%). Of note, these 2 patients had an ultrasound diagnosis of choledocholithiasis. CONCLUSION: The prevalence of isolated sonographic CBD dilation in pediatric patients with cholecystitis and/or choledocholithiasis was 1.1%. Thus, biliary ultrasound without CBD measurement is unlikely to result in missed cholecystitis and/or choledocholithiasis if the biliary ultrasound does not demonstrate GWT, PCF, SMS, or choledocholithiasis, and the patient has normal laboratory values.

Xanthogranulomatous cholecystitis with histologic features suggestive of IgG4 related cholecystitis - A morphologic overlap with IgG4 related disease.

AIMS: Both xanthogranulomatous cholecystitis (XGC) and IgG4-related cholecystitis (IgG4-CC) are rare chronic fibroinflammatory tumefactive diseases of the gallbladder, which cause a strong confusion with resectable malignancy in view of their mass forming tendency with extension into the liver. We aim to study the histopathologic features of xanthogranulomatous cholecystitis with regard to IgG4-related cholecystitis in extended cholecystectomy specimens. METHODS AND RESULTS: Sixty cases of extended cholecystectomy with liver wedge resection, diagnosed as XGC on histopathology from January 2018 to December 2021 were retrieved from the archives. Representative sections were reviewed by two pathologists independently. Immunohistochemistry was performed for IgG4 and IgG4/IgG was derived. The cases were dichotomized in two groups on the basis of IgG4 positive plasma cells. Six cases with >50 IgG4 positive plasma cells had storiform fibrosis, IgG4/IgG ratio >0.40 and extra-cholecystic extension. Of these, 50 % had obliterative phlebitis and 66.7 % had perineural plasma cell wrapping. CONCLUSIONS: A small subset of XGC cases (~10 %) had morphologic overlap with IgG4-CC, but should not be overcalled as the diagnosis of IgG4-RD requires an integrative approach based on clinical, serologic and imaging criteria and not solely on histopathology.

Sequential histologic evolution of gallbladder inflammation in acute cholecystitis over the first 10 days after onset of symptoms.

BACKGROUND: The timing of cholecystectomy during acute cholecystitis (AC) is controversial, especially whether it is advisable to perform in patients with duration of symptoms between 3 and 10 days. The purpose of this study is to define clearly the sequential evolution of histological changes following symptoms onset to guide recommendations regarding timing of cholecystectomy. METHODS: We identified patients with AC (2005-2018) who had cholecystectomy within 10 days of symptom onset of a first attack of AC. Histologic features of gallbladder injury including cellular and exudative inflammatory response to injury were determined on blinded pathologic slides. RESULTS: One hundred and forty-nine patients were divided into three groups; early-who underwent cholecystectomy 1-3 days after symptom-onset, intermediate-4-6 days, and late-7-10 days. Key features of injury were necrosis and hemorrhage. A subgroup of patients in the early phase developed severe necrosis and hemorrhage of an extent associated with difficult cholecystectomy. Large spikes in extent of necrosis and hemorrhage occurred at 7-10 days. Major inflammatory responses to injury were eosinophilic and lymphocytic infiltration and early fibrosis. CONCLUSIONS: Severe necrosis may develop rapidly and be present in the early period after symptom onset of AC. Cholecystectomy may be reasonable in some patients but by day 7-10, severe necrosis and hemorrhage may be expected to be present in most patients.

PARAMETERS OF CENTRAL AND INTRACARDIAC HAEMODYNAMICS IN WOMEN WITH THYROID HYPERPLASIA AND ACALCULOUS CHOLECYSTITIS.

OBJECTIVE: Aim: The study aimed to investigate some parameters of functional status of central and intracardiac haemodynamics in women with thyroid hyperplasia and acalculous cholecystitis. PATIENTS AND METHODS: Materials and Methods: Functional changes of haemodynamic status in women with thyroid hyperplasia and acalculous cholecystitis were investigated. All data are obtained through general and special clinical methods, standard and special laboratory methods of examination, physiological, biochemical and statistical methods. Parameters of central and intracardiac haemodynamics have been recorded by the method of two-dimensional M-mode echocardiography in the echo chamber "Toshiba-140" (Japan) at the resting state. RESULTS: Results: An increase in heart rate (by 45.6%) was observed in patients, which led to decreased duration of cardiac cycle and ejection time. Statistically significant (p<0.05, 11.7% on average) increase in total peripheral vascular resistance was indicated. Dynamics of changes of parameters of central and intracardiac haemodynamics indicates different parallel existing pathways of secondary disturbances in the part of cardiovascular system. A significant increase in peripheral vascular resistance associated with decreased elasticity (increased vascular rigidity) of the arteries is the element of concentric type of left ventricular hypertrophy. The increase in volume in the absence of vasospastic reactions and increasing venous tone is an element of eccentric hypertrophy. CONCLUSION: Conclusions: It is possible to talk about the presence of systolic dysfunction in patients, which, however, is predominantly of functional character. The revealed specific changes in homeostatic haemodynamic characteristics in the women's body with thyroid hyperplasia and acalculous cholecystitis require the development of new, more effective and preferably drug-free (due to liver pathology and detoxification dysfunction) approaches to medical treatment of such patients.

High frequency of cholecystitis in dogs with gallbladder mucocoele in Hong Kong.

The aims of this retrospective study were to characterise the epidemiological, clinical, histopathological, and microbiological findings as well as surgical outcomes in dogs admitted to a specialist veterinary hospital in Hong Kong for surgical management of gallbladder mucocoele (GBM). Inclusion criteria were cases with histopathological diagnosis of GBM and accompanying abdominal imaging, serum biochemistry, bile culture, and liver biopsy histology results. Fifty-six cases met the inclusion criteria. The median age at diagnosis was 12 years (range, 5-16 years). Miniature or toy pure-breed dogs were most commonly affected, including Poodles, Pomeranians, Schnauzers, Bichon frises and Chihuahuas. However, no breed was over-represented compared with their expected proportions among annual hospital admissions. Histological evidence of cholecystitis was present in 84% of cases, including acute cholecystitis in 18%, chronic cholecystitis in 37.5%, acute on chronic cholecystitis in 28% and acute with necrosis in 6%. The most common liver lesions were cholestasis in 64%, along with portal fibrosis in 55%, oedema in 50% and bile duct hyperplasia in 50%. Bile culture was positive in 29.6% of cases. Escherichia coli and Enterobacter species were most commonly isolated. Stentrophomonas maltophili was cultured from one case. Of the 16 cases where bacteria were isolated from bile culture, 94% had evidence of chronic cholecystitis and 81% had evidence of cholangiohepatitis. Fifty dogs (89.3%) survived to discharge including 5/5 dogs with ruptured gallbladders. Of 34 dogs with follow-up data, 21/34 (61.8%) were still alive 12 months later. Gallbladder mucocoeles were frequently associated with both acute and chronic inflammation. High survival rates to discharge were achieved.

Transcription factor 4 expression and correlation with tumor progression in gallbladder cancer.

Background: Dysregulation in Wnt/ß-catenin signaling has been associated with the initiation and metastasis of cancer cells. Transcription factor 4 (TCF4) (also named as transcription factor 7-like 2) is a key transcriptional factor of the Wnt signaling pathway, which, when interact with ß-catenin activates Wnt genes which plays an essential role in tumor development. The expression pattern and clinical significance of TCF4 in gallbladder cancer (GBC) are not yet established. Aims: This study was performed to assess the expression pattern of TCF4 in GBC tissue and attempted to correlate its expression with different clinicopathological parameters. Materials and Methods: The study was conducted on 33 surgically resected specimens of gallbladder carcinoma (GBC) and 12 cases of chronic cholecystitis (CC) as control, which had been confirmed from histology. The expression of TCF4 was performed by the reverse transcription polymerase chain reaction and immunohistochemistry. Results: Relative mRNA expression levels of ß-catenin and TCF4 in GBC tissues were significantly (P < 0.05) higher than in CC samples. TCF4 protein expression was observed in 81.82% (27/33) GBC cases. Specifically, among GBC samples, 21.21% (7/33) was graded as strongly positive, 60.61% (20/33) graded as moderately positive, whereas 18.18% (6/33) graded as negative. All 12 CC samples graded as negative. Overall, TCF4 expression in GBC tissues was statistically significant over CC samples (P < 0.05). Moreover, we observed that TCF4 expression was significantly higher (P < 0.05) in high tumor grades than low grade, higher (P < 0.05) in Stage 2 and Stage 3 than Stage 1. Conclusion: The present study suggests that TCF4 may exert an oncogenic role in the progression of GBC and may serve as a new potential candidate biomarker for tumor progression, and it might be a potential therapeutic target against GBC.

Value of Multislice Spiral CT in Differential Diagnosis of Thick-Wall Gallbladder Carcinoma and Chronic Cholecystitis.

To summarize the value of multislice spiral CT (MSCT) in the differential diagnosis of thick-wall gallbladder carcinoma (TWGC) and chronic cholecystitis (CC), the clinical data of 36 patients with TWGC and 60 patients with chronic cholecystitis who were treated in our hospital from January 2017 to May 2021 were retrospectively analyzed, and the CT image features and diagnostic accuracy of the patients were summarized. Compared with the CC group, the proportions of disruption of gallbladder mucosa line, blurred gallbladder outline, high obstruction of biliary tract, lymphomegaly, adjacent invasion, peritoneal effusion, wall nodules, and the gallbladder wall thickness in the TWGC group were higher, with statistical significance (P < 0.05). Thirty-four patients with TWGC and 62 patients with chronic cholecystitis were diagnosed by MSCT. The sensitivity and specificity of MSCT in diagnosing TWGC were 86.11% and 95.00%, respectively. The positive likelihood ratio was 17.222 and the negative likelihood ratio was 0.1462. The positive prediction rate was 91.18%, the negative prediction rate was 91.94%, and the correct rate was 91.67%. MSCT can show the characteristic difference between TWGC and chronic cholecystitis, which can be used for differential diagnosis.

Cholecystitis: association between ultrasound findings and surgical outcomes.

AIM: To identify sonographic signs of cholecystitis that correlate with surgical outcomes. MATERIALS AND METHODS: Three hundred and thirty-three consecutive patients who underwent cholecystectomy between 22/06/2014 and 1/3/2016 and underwent abdominal ultrasound (US) within 7 days of surgery were included. Individual US signs, including gallstones, gallbladder distention, wall thickening, pericholecystic fluid, and abscess, were graded by two radiologists, 1 and 2. Outcomes included operative duration (OD), drain placement, partial cholecystectomy, conversion from laparoscopic to open cholecystectomy, surgical pathology, bile leak, infection, and 30-day readmission. US signs and outcomes were analysed using analysis of variance, chi-square test, or odds ratios (OR). RESULTS: Radiologist 1 reported 141/333 and radiologist 2 reported 128/333 patients showed gallbladder distention. For the subset with OD, radiologist 1 reported 140/320 and radiologist 2 reported 126/320 patients showed gallbladder distention. Distention was predictive of increased OD (radiologist 1, +23.2 minutes, p<0.0001; radiologist 2, +19.4 minutes, p=0.0003). Cases with gallbladder distention were more likely to have surgical drain placement (OR= 2.60; 95% confidence interval [CI]: 1.12-6.08, p=0.027 radiologist 1; OR=2.59; 95% CI: 1.13-5.95, p=0.025 radiologist 2). Wall thickening was present in 126/333 patients reported by radiologist 1 and 120/333 by radiologist 2. Cases with wall thickening were more likely to have drain placement (OR=2.66; 95% CI: 1.16-6.13, p=0.021 radiologist 1; OR=3.49; 95% CI: 1.49-8.16, p=0.004 radiologist 2). For the subset with OD, wall thickening was present for 121/320 reported by radiologist 1 and 116/320 by radiologist 2 and predicted longer OD (radiologist 1, +15.9 minutes, p=0.0033; radiologist 2, +13.3 minutes, p=0.0143). CONCLUSION: Gallbladder distention and wall thickening on US correlate with prolonged OD and surgical drain placement in patients with cholecystitis.

Cholecystectomy in patients with hematologic malignancies.

BACKGROUND: Cholecystectomy in patients with hematologic malignancies remains poorly understood. METHODS: We retrospectively evaluated patients with hematologic malignancies who underwent cholecystectomy at a single institution. RESULTS: Of 313 patients who presented for evaluation of abdominal pain, 64 underwent cholecystectomy for acute cholecystitis (34.4%), gangrenous cholecystitis (21.9%), chronic cholecystitis (23.4%), and cholelithiasis (20%). Most had a history of hematopoietic cell transplantation (62.5%) and/or immunosuppressive medication within 30 days of consultation (82.8%). Ultrasound had a 39% false-negative rate for acute nongangrenous cholecystitis. Operative time was 92 ± 39 min, 7 were performed open, 10 had intraoperative transfusions, and 4 had grade 3+ complications. Intraoperative transfusion was associated with increased postoperative length of stay (p = 0.03). Open procedure, operative time, estimated blood loss, intraoperative transfusion, and complications were not associated with timing of surgery. CONCLUSIONS: Patients with hematologic malignancies can safely undergo cholecystectomy. Length of postoperative stay for inpatients is associated with intraoperative blood transfusion.

The inclusive use of effect size conversion and Bayes factor in digestive disease research.

An important article was published, whicht evaluated statistically significant associations (p < 0.05) using the odds ratio (OR), in the first issue of volume 113 of this journal. The study evaluated a relationship between C-reactive protein levels (CRP > 100) and the histological diagnosis of gangrenous acute cholecystitis in patients who underwent cholecystectomy (OR = 3.1).

Noninvasive preoperative differential diagnosis of gallbladder carcinoma and xanthogranulomatous cholecystitis: A retrospective cohort study of 240 patients.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is an extremely rare entity. Due to XGC's clinical and radiological resemblance to gallbladder carcinoma (GBC), intraoperative frozen section during cholecystectomy is often performed to exclude the diagnosis of GBC. Our study is aiming to find a noninvasive indicator of XGC. To our knowledge, this is the largest XGC cohort ever studied. METHODS: This study retrospectively collected clinical characteristics, serological tests, and imaging features of 150 GBC patients and 90 XGC patients. The diagnosis of these 150 GBC patients and 90 XGC patients was based on intraoperative frozen section histopathology. T-test was utilized to compare differences between XGC and GBC. Receiver operating characteristic (ROC) curve was conducted and the area under the curve (AUC) was managed to evaluate the validity. RESULTS: The carcinoembryonic antigen (CEA) level in blood tests was significantly elevated in GBC patients than in XGC patients (p = 0.007). The presence of submucosal hypo-attenuated nodules (80% in XGC, 16% in GBC, p < 0.001), low density border (60% in XGC, 21% in GBC, p = 0.001), and nodular thickening in the bottom of the gallbladder with calcification (70% in XGC, 37% in GBC, p = 0.004) is significantly associated with XGC patients, whereas massive hilar infiltration (0% in XGC, 21% in GBC, p < 0.001), multiple lymph nodes in the hilar area (10% in XGC, 72% in GBC, p = 0.001), and gallbladder mucosal line continuity (50% in XGC, 95% in GBC, p = 0.002) are highly associated with GBC patients. The ROC curve was performed and the gallbladder mucosal line continuity (AUC = 0.708) and the AUC of low density border around the occupation (AUC = 0.654) showed a good prediction of XGC. CONCLUSIONS: Gallbladder mucosal line continuity and low density border around the occupation presented good indication value for the diagnosis of XGC. Our study proposed a noninvasive differential diagnosis method for XGC and GBC.

Neutrophilic inflammation in gallbladder carcinoma correlates with patient survival: A case-control study.

Gallbladder carcinoma is an uncommon malignancy with an overall 5-year survival of less than 5%. Gallbladder carcinoma has been strongly linked with cholelithiasis and chronic inflammation. Case reports and series have described cholecystitis with acute (neutrophilic) inflammation in association with gallbladder carcinoma, although a clear relationship to patient outcome has not been established. Our series included 8 cases of gallbladder carcinoma with high tumor-associated neutrophils (>25 per high power field) that were associated with shorter patient survival (Cox regression coefficient 6.2, p = 0.004) than age- and stage-matched controls. High tumor-associated neutrophils were not associated with gallbladder rupture/perforation or increased bacterial load measured by 16S PCR. Neutrophilic inflammation with gallbladder carcinoma correlates to shorter survival, independent of patient age and stage of carcinoma. The findings suggest that the degree of neutrophilic inflammation may have prognostic significance in specimens from patients with gallbladder carcinoma after cholecystectomy. Further studies with larger case numbers are needed to confirm and generalize these findings.

The SARS-CoV-2 first wave impact in the acute inflammatory surgical pathologies.

Anecdotal evidence suggests that community infection control measures during the COVID-19 outbreak have modified the number and natural history of acute surgical inflammatory processes (ASIP-appendicitis, cholecystitis, diverticulitis and perianal abscesses) admissions. This study aims to evaluate the impact of the COVID-19 pandemic on the presentation and treatment ASIP and quantify the effect of COVID-19 infection on the outcomes of ASIP patients. This was a multicentre, comparative study, whereby ASIP cases from 2019, 2020 and 2021 (March 14th to May 2nd) were analyzed. Data regarding patient and disease characteristics as well as outcomes, were collected from sixteen centres in Madrid, and one in Seville (Spain). The number of patients treated for ASIP in 2019 was 822 compared to 521 in 2020 and 835 in 2021. This 1/3rd reduction occurs mainly in patients with mild cases, while the number of severe cases was similar. Surgical standards suffered a step back during the first wave: Lower laparoscopic approach and longer length of stay. We also found a more conservative approach to the patients this year, non-justified by clinical circumstances. Luckily these standards improved again in 2021. The positive COVID-19 status itself did not have a direct impact on mortality. Strikingly, none of the 33 surgically treated COVID positive patients during both years died postoperatively. This is an interesting finding which, if confirmed through future research with a larger sample size of COVID-19 positive patients, can expedite the recovery phase of acute surgical services.

Diagnostic Value of Inflammatory Factors in Patients with Gallbladder Cancer, Dysplasia, and Cholecystitis.

BACKGROUND: Involving pre-sampled patients with cholecystitis, dysplasia, and adenocarcinoma, the present study aimed to compare the neutrophil/lymphocyte (NLR), monocyte/lymphocyte (MLR), platelet/lymphocyte (PLR) ratios, and plateletcrit (PCT), mean platelet volume (MPV), and platelet distribution width (PDW) values and to determine their prognostic importance. METHODS: The present study involved 187 cholecystectomy specimens that were diagnosed as cholecystitis, dysplasia, and adenocarcinoma. Preoperative neutrophil, monocyte, lymphocyte, and platelet counts, NLR, MLR, and PLR ratios, and PCT, MPV, and PDW levels of the same patient groups were retrospectively recorded. RESULTS: In the present study, the cut-off values for dysplasia of NLR, PLR, and MLR were found as 1.61, 81.45, and .19, whereas those for cancer of NLR, PLR, and MLR were 2.65, 182.69, and .35, respectively. The NLR, PLR, and MLR values of the chronic cholecystitis and chronic calculous cholecystitis groups were statistically significantly lower than those of the chronic active calculous cholecystitis group (P < .01). The NLR and MLR values of the non-cancer and non-dysplasia groups were statistically lower than those of the cancer and dysplasia groups (P < .05). CONCLUSION: According to the results of the present study, using additional imaging methods, acute-phase cholecystitis can be distinguished using preoperative neutrophil and monocyte counts, and NLR, PLR, and MLR cut-off values can be used to distinguish dysplasia, which is the antecedent of gallbladder cancer. It is thought that this might provide patients with an advantage in terms of early treatment and survival.

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.

Xanthogranulomatous Cholecystitis: Is Surgery Difficult? Is Laparoscopic Surgery Recommended?

Introduction: Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder (GB). XGC surgery is a difficult process due to its clinical, radiological, and intraoperative findings. In this study, our aim is to show the difficulties of XGC surgery and to find out if laparoscopic surgery is a sufficient procedure. Materials and Methods: Histological findings of 3339 cholecystectomy patients, who were operated between January 2015 and January 2020, were retrospectively reviewed. Age, gender, radiological results, clinical features, intraoperative findings, and surgical management of the patients with XGC were recorded. Results: XGC was observed in 70 patients (2.09%). The average age was 53.75. M:F ratio was 1.2. In radiological examinations, gallstones were found in 94.2% of the patients and GB wall thickness (≥3 mm) was increased in 58.5% of the patients. Around 45.7% of the patients came to the clinic with chronic cholecystitis and 32.9% with acute cholecystitis. In the intraoperative period, adhesions were observed in 80% and increase in GB wall thickness was observed in 77.1% of the patients. The operation started laparoscopically in 66 patients. In 14 patients (21.2%), it was converted to open surgery usually due to insufficient dissection of Calot's triangle. Gallbladder carcinoma (GBC) was suspected in 6 patients, but none of them had malignancy in frozen sections or histology. Conclusions: XGC surgery is difficult due to its radiological, clinical, and intraoperative features and mimicking GBC. It can be converted to open cholecystectomy due to difficulties in laparoscopic dissection. However, since conversion cholecystectomy rates are reasonable, laparoscopic surgery is recommended in patients with suspected XGC.

Mast cell hyperplasia in Opisthorchis viverrini-associated cholecystitis.

Despite significant advances in understanding the role of the immune response in Opisthorchis viverrini-associated carcinogenesis, little is known about how infection induces gall bladder disease. This study investigated whether mast cells are activated in cholecystitis associated with O. viverrini, gall bladder specimens from ninety-two patients who had undergone cholecystectomy at the Khon Kaen Regional Hospital, Khon Kaen, Thailand. Two representative sections from the body of fresh gall bladder tissue were fixed in Carnoy's solution and embedded in paraffin wax. The paraffin sections were stained for mast cells and IgE plasma cells by the double histochemical and immunohistochemical method. The cells in the epithelium, lamina propria, muscular layer, and subserosa were counted and expressed as cells per square millimeter. The gall bladder bile was examined for the presence of O. viverrini eggs. Significantly higher mean mast cell numbers were found in the lamina propria (221.41 ± 16.01 vs 116.97 ± 14.61 cells per mm2; P < 0.005) of egg positive compared to egg negative groups, respectively. No comparable differences in mast cell number were observed in other layers. IgE plasma cells were rarely seen. The results suggest that mast cell hyperplasia occurs during cholecystitis in association with opisthorchiasis and may play a role in the pathogenesis of the disease.

Factors that Predict the Need for Subtotal Cholecystectomy.

BACKGROUND: Subtotal cholecystectomy is a "damage control" or "bailout procedure" that is used in difficult gallbladder cases when severe inflammation distorts the local anatomy resulting in increased risk in damage to surrounding structures. Subtotal cholecystectomy rates increased nationally over the past decade. We aimed to determine provider experience and patient factors associated with the performance of subtotal cholecystectomies. METHODS: All cholecystectomies from 2016 to 2019 were reviewed. Patient demographics, laboratory values, imaging, preoperative diagnosis, surgical technique (fenestrating vs. reconstituting), and years of attending and resident experience were collected. Multivariable regression analysis was performed to evaluate for factors that increase the likelihood of subtotal cholecystectomy. RESULTS: Of 916 cholecystectomies, 86 were subtotal. The likelihood of subtotal cholecystectomy did not increase based on attending experience of ≤5 vs. > 5 years (odds ratio (OR) .66, P = .09). Older age (adjusted odds ratio (aOR) 1.23, P = .03), male sex (aOR 2.59, P < .01), white blood cells (WBC) above 10.3 (aOR 2.02, P = .02), and preoperative diagnosis of acute on chronic cholecystitis (aOR 5.47, P < .01) were associated with increased likelihood of subtotal cholecystectomy. DISCUSSION: Older age, male sex, WBC above 10.3, and preoperative diagnosis of acute on chronic cholecystitis were associated with the increased likelihood of subtotal cholecystectomies. The performance of subtotal cholecystectomy was not impacted by attending years of experience. In cases of severe gallbladder pathology, this technique is being used as an operative strategy among all surgeon levels.