|
Porcelain gallbladder complicated with pancreas divisum.J
Hepatobiliary Pancreat Surg.
2006;13(6):580-3. Epub 2006 Nov 30.
We report a rare
case of porcelain gallbladder associated with pancreas divisum (PD). A
60-year-old woman suffered from discomfort in the back of the right
side. An abdominal radiograph revealed a calcified spherical mass in
the right upper quadrant. Ultrasonography revealed a scattered echo
with a posterior acoustic shadow in the gallbladder wall. A plain
computed tomography (CT) scan showed flecks of intramural
calcification in the wall of the gallbladder. Endoscopic retrograde
cholangiopancreatography (ERCP) and magnetic resonance
cholangiopancreatography (MRCP) showed separate openings for the
Santorini and Wirsung ducts. The patient underwent cholecystectomy
after porcelain gallbladder and pancreas divisum had been diagnosed.
The porcelain gallbladder resulted from a stone impacted in the neck
of the gallbladder. Patients with PD should be followed carefully,
because gallstones often accompany PD, and porcelain gallbladder may
result, as in this patient.
Eosinophilic
dysplasia of the gallbladder: a hitherto undescribed variant
identified in association with a "porcelain" gallbladder.Diagn
Pathol. 2006 Jul 31;1:15.
Non-mass
forming, neoplastic intraepithelial proliferations (dysplasia)
represent the most well-accepted precursor lesions to gallbladder
adenocarcinomas. They are typically small, localized, grossly
unrecognizable lesions that have been identified in the epithelium
adjacent to up to 79% of gallbladder adenocarcinomas. Morphologic
variants that have been reported include flat, micropapillary,
papillary and cribriform. We have recently encountered a
morphologically distinctive, previously unreported lesion to which we
have applied the designation eosinophilic dysplasia. This lesion was
identified in a gallbladder with diffuse mural fibrosis and
calcification (porcelain gallbladder). The dysplastic focus was
confined to one tissue section, and was comprised of a localized true
papilla [i.e with a fibrovascular core], measuring approximately 1.2
mm in greatest dimension and an adjacent, flat, 7-cell epithelial
segment. These foci were lined by cells displaying significant nuclear
enlargement [1.5-4 times the adjacent benign cells], nuclear
pleomorphism, occasional multinucleation, hyperchromasia and nuclear
membrane irregularities. Nucleoli were present but inconspicuous.
These cells also showed voluminous eosinophilic to granular cytoplasm,
such that the overall nuclear-to-cytoplasmic ratio was generally not
increased. The cells displayed diffuse and marked nuclear
immunoreactivity for p53, and approximately 70% of the cells showed
nuclear positivity for Ki-67. The cells were also positive for
cytokeratin 7 and were entirely negative for carcinoembryonic antigen
(CEA) and chromogranin A. The cells of the adjacent normal epithelium
were positive for cytokeratin 7 and CEA, negative for p53 and
chromogranin A and showed a Ki-67 labeling index of <10%. Marked
overexpression of the p53 protein as well as its high proliferative
index are strong arguments in favor of the dysplastic nature of this
lesion. However, further studies are required to elucidate its true
clinical significance and to determine whether or not its association
with a porcelain gallbladder, as noted herein, is entirely fortuitous.
However, such studies can only be performed with an increased
recognition by practitioners of this distinctive variant.
Porcelain
gallbladder with extrahepatic bile duct obstruction in a child.Pediatr
Surg Int. 2006 Mar;22(3):293-6. Epub 2005
Dec 1.
An
extrahepatic bile duct obstruction was diagnosed in a 13-year-old boy
presenting with pruritus, abdominal pain and jaundice. Several weeks
after sphincterotomy and biliary stenting via endoscopic retrograde
cholangiopancreaticography which relieved the obstruction, the patient
was operated on. Severe fibrosis encased the extrahepatic biliary
tract, so only cholecystectomy was performed because planned
hepaticojejunoanastomosis could jeopardize the vascular supply to the
liver. Histopathology showed calcification of the gallbladder wall and
chronic fibroproliferative changes in the surrounding tissue. The
stricture of extrahepatic biliary duct resolved after 3 years of
repeated replacement of stents. The stenting was thereafter
terminated. In the following 3 years no dilation of intrahepatic bile
ducts and no laboratory signs of cholestasis recurred and the now
19-year-old boy is doing well. Neither a case of porcelain gallbladder
with extrahepatic bile duct obstruction in a child nor a successful
treatment of the obstruction by long-term stenting has been described
in the literature yet.
Laparoscopic
cholecystectomy in patients with porcelain gallbladder based on the
preoperative ultrasound findings.Hepatogastroenterology.
2004 Jul-Aug;51(58):950-3.
BACKGROUND/AIMS: Porcelain gallbladder is considered a relative
contraindication to laparoscopic cholecystectomy, because of a high
incidence of gallbladder cancer or gastrointestinal cancer. We
examined the management of laparoscopic cholecystectomy in patients
with porcelain gallbladder. METHODOLOGY: 1,608 patients underwent
cholecystectomy and 13 (0.81%) patients had porcelain gallbladder. All
patients underwent preoperative spiral computed tomography after
intravenous infusion cholangiography and intraoperative
cholangiography. Patients with porcelain gallbladder were classified
as Type I to III according to preoperative ultrasound findings. The
Type I porcelain gallbladder was indicated for laparoscopic
cholecystectomy and Type II porcelain gallbladder was selected for
open cholecystectomy. RESULTS: The laparoscopic cholecystectomy was
completed in 10 patients with Type I porcelain gallbladder and the
microscopie diagnosis demonstrated no cancer in the calcified wall of
the gallbladder. In one patient with a non-transected injury to the
right hepatic duct, a T-drainage tube was inserted at the site of the
injury using the laparoscopic technique. Three patients with Type II
porcelain gallbladder underwent open cholecystectomy and one patient
had gallbladder cancer, therefore additional hepatectomy and
lymphadenectomy was performed. CONCLUSIONS: We conclude that patients
with a Type I porcelain gallbladder should be considered for
laparoscopic cholecystectomy using a preoperative selection based on
the ultrasound findings.
Case of mucinous adenocarcinoma with porcelain gallbladder.
J Gastroenterol Hepatol. 2003
Aug;18(8):995-8.
Histologically,
the majority of gallbladder cancers are adenocarcinomas. Among the
adenocarcinomas, the mucinous adenocarcinoma is relatively uncommon.
Porcelain gallbladder is a rare finding and the risk of gallbladder
cancer is significantly increased in porcelain gallbladder. We
describe a rare case of mucinous adenocarcinoma with porcelain
gallbladder. A 46-year-old man was admitted to Chonnam National
University Hospital with a 2-week history of right upper quadrant
pain. Three and 2 years previously, he had two episodes of
cholecystitis with gallstones. An abdominal computed tomography
revealed a contracted gallbladder with circumferential mural
calcification, and the possibility of gallbladder cancer and porcelain
gallbladder were considered. At laparotomy, cholecystectomy, liver
wedge resection, and radical lymph node dissection were performed. The
resected gallbladder showed thickened wall, luminal narrowing and
mucosal irregularity. A histological examination of the resected
gallbladder showed a mucinous adenocarcinoma composed of poorly
differentiated glandular cells with mucin lakes. Porcelain gallbladder
may be an end result of a chronic inflammatory reaction, and this
change is associated with the development of gallbladder cancer.
Is the
laparoscopic approach appropriate for porcelain gallbladder?
J Chir
(Paris). 2003 Apr;140(2):115-9.
Contrary to
the fears raised in surgical publications of the 1950's and 60's, the
prognosis of porcelain gallbladder is not automatically associated
with an increased risk of gallbladder carcinoma. Two recent cohort
studies have allowed a better definition of the appropriate
therapeutic attitude for a patient with a calcified gallbladder. In
cases of "true" porcelain gallbladder, i.e., the presence of complete
transmural calcification of the entire gallbladder wall, indications
for cholecystectomy are based on biliary symptoms, all the more so
since choledocholithiasis is often associated with porcelain
gallbladder. In the case of partial calcification of the gallbladder,
i.e., focal plaques of calcification involving the mucosa, prophylatic
operative treatment is indicated. In these cases, the incidence of
malignancy is markedly increased (14 times that of a control
population). Cholecystectomy can still be performed laparascopically
as long as the rules for prevention of peritoneal dissemination of
tumor cells are scrupulously observed--the gallbladder should not be
opened nor bile spilled, the specimen should be placed in a bag for
removal through the abdominal wall, the pneumoperitoneum should be
evacuated with the trocars still in place and the specimen should be
opened and examined after removal with immediate frozen section
pathologic exam if there is any question of tumor.
Cholecystoduodenal fistula in a porcelain gallbladder.Eur
Radiol. 2002 Sep;12(9):2284-6. Epub 2002
Feb 2.
Calcification
of the gallbladder wall (porcelain gallbladder) is rare. Its
appearance is quite characteristic on plain films, ultrasonography and
computed tomography. Sporadic cases of cholecystitis have been
described in porcelain gallbladders. Enterobiliary fistula may
complicate acute or chronic cholecystitis in non-calcified
gallbladder. We report a unusual case of acute cholecystitis with
cholecystoduodenal fistula in a porcelain gallbladder.
Pre- and
intraoperative evaluation of biliary system for successful
laparoscopic cholecystectomy in porcelain gallbladder patients.Hepatogastroenterology.
2002 May-Jun;49(45):621-4.
BACKGROUND/AIMS: A porcelain gallbladder is generally thought to be a
relative contraindication for laparoscopic cholecystectomy because of
the difficulties in grasping the calcified wall of the gallbladder
with forceps and making a retraction which would create a good
operation field. The aim of this study was to define the clinical
criteria for safe laparoscopic cholecystectomy in the treatment of
porcelain gallbladders. METHODOLOGY: Between January 1993 and December
2000, 4 patients with porcelain gallbladders underwent laparoscopic
cholecystectomy in our department. The significant features of the
biliary system which contributed to the surgical results were
investigated in these patients. RESULTS: All 4 patients were
successfully treated by means of laparoscopic cholecystectomy. The
confluence of the cystic duct was clearly demonstrated on the
preoperative cholangiogram in all patients. Furthermore, the neck
portion of the gallbladder wall, revealed no calcification on the CT
scans of 3 patients, although the whole wall of the gallbladder,
including the neck portion, showed a circumferential calcification in
the remaining patient. Laparoscopic exposure and dissection of the
Calot's triangle was relatively easy to perform in the former and was
difficult in the latter, and thus, an anterograde laparoscopic
cholecystectomy was the procedure of choice. Intraoperative
cholangiography clearly demonstrated the confluence of the cystic duct
in all of the patients. CONCLUSIONS: Porcelain gallbladder is an
indication for laparoscopic cholecystectomy, especially in cases of a
patent cystic duct and an uncalcified wall in the neck portion of the
gallbladder. Laparoscopic cholecystectomy might be an indication for
selected patients with porcelain gallbladder when an uncalcified and
patent cystic duct are evident in pre- and intraoperative
cholangiograms.
Carcinoma in
the porcelain gallbladder: a relationship revisited.Surgery.
2001 Jun;129(6):699-703.
BACKGROUND:
Gallbladder cancer is the most common biliary tract malignancy.
Calcification of the gallbladder wall is reported to be associated
with gallbladder cancer. In the literature, the incidence is quoted to
be between 12% and 61%. This study aims to clarify the risk of cancer
in a calcified gallbladder. METHODS: The charts and pathology reports
at the Massachusetts General Hospital were reviewed, and patients with
either gallbladder cancer or a calcified gallbladder were included in
the study. The Fisher exact test was used to test for the association
between cancer and gallbladder wall calcifications. RESULTS: From 1962
to 1999, there were approximately 25,900 gallbladder specimens
analyzed at the Massachusetts General Hospital. There were 150
patients with gallbladder cancer and 44 patients with calcified
gallbladders. Two types of calcified gallbladders were noted: those
with complete intramural calcification (n = 17) and those with
selective mucosal calcification (n = 27). The incidence of cancer
arising in a gallbladder with selective mucosal wall calcification was
approximately 7%. There was a significant association between
gallbladder cancer and selective mucosal calcification with an odds
ratio of 13.89 (P =.01). There were no patients with diffuse
intramural calcification and cancer. CONCLUSIONS: A calcified
gallbladder is associated with an increased risk of gallbladder
cancer, but at a much lower rate than previously estimated. The
incidence of cancer depends on the pattern of calcification; selective
mucosal calcification poses a significant risk of cancer whereas
diffuse intramural calcification does not.
Porcelain
gallbladder is not associated with gallbladder carcinoma.Am
Surg. 2001 Jan;67(1):7-10.
The surgical
management of porcelain gallbladder is based on studies performed in
1931 and 1962, which indicated a correlation between porcelain
gallbladder and carcinoma. We sought to evaluate the characteristics
of patients with porcelain gallbladder and the risk for gallbladder
carcinoma. The medical records of 10,741 cholecystectomies performed
between 1955 and 1998 were reviewed and recorded. The pathology slides
were evaluated for evidence of calcification and gallbladder
carcinoma. Fifteen (0.14%) of 10,741 specimens were porcelain
gallbladders. Ten patients (67%) had symptoms suggestive of biliary
colic or cholecystitis. Five (33%) were asymptomatic and diagnosed
incidentally. All specimens demonstrated chronic cholecystitis and
partial calcification of the gallbladder wall. Nine (60%) had
cholelithiasis. None had gallbladder carcinoma by recent review of
pathologic material. During this same period 88 (0.82%) patients had
gallbladder carcinoma, none of which showed calcification of the wall.
This report represents the largest modern review of porcelain
gallbladders. No carcinoma was identified among patients with
porcelain gallbladder. In addition no patient with gallbladder
carcinoma had calcified gallbladder. With a better understanding of
the natural history of the porcelain gallbladder the current
management of these patients may change.
|
