Gallbladder Disease Rebecca Kowalski MD October 18 2017 Overview A brief history of gallbladder surgery Anatomy Anatomical variations Physiology Pathophysiology Diagnosti ID: 955749
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The Spectrum of Gallbladder Disease Rebecca Kowalski, M.D. October 18, 2017 Overview ï½ A (brief) history of gallbladder surgery ï½ Anatomy ï½ Anatomical variations ï½ Physiology ï½ Pathophysiology ï½ Diagnostic imaging of the gallbladder ï½ Natural history of cholelithiasis ï
½ Case presentations of the spectrum of gallstone disease ï½ Summary History of Gallbladder Surgery Gallbladder Surgery: A Relatively Recent Change ï½ Prior to the late 1800s, doctors treated gallbladder disease with a cholecystostomy, due to the fear that removing the organ woul
d kill patients ï½ Carl Johann August Langenbuch (director of the Lazarus Hospital in Berlin, Germany) practiced on a cadaver to remove the gallbladder, and in 1882, performed a cholecystectomy on a patient. He was discharged after 6 weeks in the hospital ï½ By 1897 over 100
cholecystectomies had been performed https://en.wikipedia.org/wiki/Carl_Langenbuch Gallbladder Surgery: A Relatively Recent Change ï½ In 1985, Erich Mühe removed a patientâs gallbladder laparoscopically in Germany ï½ In 1987, Philippe Mouret (a French gynecologic surgeon)
performed a laparoscopic cholecystectomy ï½ In 1992, the National Institutes of Health (NIH) created guidelines for laparoscopic cholecystectomy in the United States, essentially transforming surgical practice Erich Muhe https:// openi.nlm.ni h.gov/detailedresult. php?img=PMC3
0152 44_jsls - 2 - 4 - 341 - g01&req=4 Philippe Mouret https://www.pinterest.com /pin/58195020154734720/ Anatomy and Abnormal Anatomy http://accesssurgery.mhmedical.com/content.aspx?bookid=1202§ionid=71521210 http://www.slideshare.net/pryce27/rsna - final - 2 http://www.slideshare
.net/pryce27/rsna - final - 2 http://www.slideshare.net/pryce27/rsna - final - 2 Physiology http://www.nature.com/nrm/journal/v2/n9/fig_tab/nrm0901_657a_F3.html a Simplified overview of the bile acid biosynthesis pathway derived from cholesterol Lisa D. Beilke et al. Drug Metab Dispo
s 2009;37:1035 - 1045 http://dmd.aspetjournals.org/content/37/5/1035 http://clinicalgate.com/liver - biliary - tract - and - pancreatic - disease/ http://clinicalgate.com/liver - biliary - tract - and - pancreatic - disease/ Gallbladder Function: Absorption and Secretion ï½ Main func
tion of the gallbladder is to concentrate and store hepatic bile and to deliver bile into the duodenum in response to a meal ï½ In the fasting state, approximately 80% of the bile secreted by the liver is stored in the gallbladder Gallbladder Function: Absorption and Secretio
n (continued) ï½ The gallbladder mucosa has the greatest absorptive power per unit area of any structure in the body ï½ Epithelial cells of the gallbladder secrete at least two important products into the gallbladder lumen: glycoproteins and hydrogen ions https://www.barnardhe
alth.us/action - potential/bile - secretion - and - gall - bladder - function.html https:// courses.washington.edu/conj/bess/bile/bile.html http://www.austincc.edu/apreview/PhysText/Digestive.html Source: Gallbladder and the Extrahepatic Biliary System, Schwartz's Principles of Surger
y, 10e Citation: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE . Schwartz's Principles of Surgery, 10e ; 2014 Available at: http://accesssurgery.mhmedical.com/content.aspx?sectionid=59610874&bookid=980&jumpsectionID=100401453&Resultclick=2 Acces
sed: Ma rch 28, 2017 Copyright © 2017 McGraw - Hill Education. All rights reserved A. Fasting 1. Sphincter of Oddi contracted 2. Gallbladder filling B. Response to a meal 1. Sphincter of Oddi relaxed 2. Gallbladder emptying Pathophysiology Gallstone Types ï½ Gallstones form as
a result of solids settling out of solution ï½ Major organic solutes in bile are bilirubin, bile salts, phospholipids, and cholesterol ï½ Gallstones are classified by their cholesterol content ï½ Cholesterol stones ï½ Western countries: approximately 80% of gallstones ï½
Pigment stones ï½ Black ⢠Western countries: approximately 15 - 20% ï½ Brown ⢠Only a small percentage of stones in Western countries Cholesterol Stones ï½ Pure cholesterol stones are uncommon and account for less than 10 % of all stones ï½ Typically occur as single large s
tones with smooth surfaces ï½ Most other cholesterol stones contain variable amounts of bile pigments and calcium, but are always greater than 70 % cholesterol by weight ï½ Usually multiple stones of varying sizes ï½ May be hard and faceted, or irregular, mulberry - shaped,
and soft ï½ Colors range from whitish yellow and green to black ï½ Less than 10 % of cholesterol stones are radiopaque Source: Gallbladder and the Extrahepatic Biliary System, Schwartz's Principles of Surgery, 10e Citation: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunt
er JG, Matthews JB, Pollock RE . Schwartz's Principles of Surgery, 10e ; 2014 Available at: http://accesssurgery.mhmedical.com/ViewLarge.aspx?figid=100401457&gbosContainerID=0&gbosid=0 Accessed: March 28, 2017 Copyright © 2017 McGraw - Hill Education. All rights reserved Cholesterol
Supersaturation ï½ The common primary event in the formation of cholesterol stones is supersaturation of bile with cholesterol ï½ H igh bile cholesterol levels and cholesterol gallstones are considered as one disease ï½ Cholesterol is highly nonpolar and insoluble in water
and bile ï½ Cholesterol solubility depends on the relative concentration of cholesterol, bile salts, and lecithin (the main phospholipid in bile ) ï½ Supersaturation is caused by cholesterol hypersecretion rather than by a reduced secretion of phospholipid or bile salts Source
: Gallbladder and the Extrahepatic Biliary System, Schwartz's Principles of Surgery, 10e Citation: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE . Schwartz's Principles of Surgery, 10e ; 2014 Available at: http://accesssurgery.mhmedical.com/Vie
wLarge.aspx?figid=100401457&gbosContainerID=0&gbosid=0 Accessed: March 28, 2017 Copyright © 2017 McGraw - Hill Education. All rights reserved Pigment Stones ï½ Pigment stones contain less than 20 % cholesterol and are dark because of the presence of calcium bilirubinate ï½ Black s
tones and brown stones have very little in common aside from cholesterol content and should be considered separate entities https://www.flickr.com/photos/jian - hua_qiao_md/3953725382 Black Pigment Stones ï½ Typically small , brittle, black, and sometimes spiculated ï½ Formed by
supersaturation of calcium bilirubinate , carbonate , and phosphate ï½ Most often secondary to hemolytic disorders such as hereditary spherocytosis and sickle cell disease, and in those with cirrhosis ï½ Almost always form in the gallbladder ï½ In Asian countries such as J
apan, black stones account for a much higher percentage of gallstones than in the Western hemisphere Brown Pigment Stones ï½ Typically less than 1 cm in diameter, brownish - yellow, soft, and often mushy ï½ Can form either in the gallbladder or in the bile ducts ï½ Typically
secondary to bacterial infection caused by bile stasis ï½ Precipitated calcium bilirubinate and bacterial cell bodies compose the major part of the stone ï½ Typically found in the biliary tree of Asian populations and are associated with stasis secondary to parasite infectio
n ï½ In Western populations, brown stones occur as primary bile duct stones in patients with biliary strictures or other common bile duct stones that cause stasis and bacterial contamination Diagnostic Imaging of the Gallbladder Plain Abdominal X - Ray ï½ X - ray ï½ 10 - 15% of
gallstones seen on X - ray ï½ Air in the biliary tree http://www.slideshare.net/shaffar75/ultrasound - of - the - gallbladder http://medlibes.com/entry/porcelain - gallbladder Porcelain gallbladder Ultrasound ï½ Gold standard for diagnosis of cholelithiasis ï½ ~85% sensitive for ga
llstones ï½ False negative results in only 5% of patients (small stones or contracted gallbladder) ï½ Typically misses stones in the CBD Ultrasound of normal gallbladder http://www.derryimaging.com/body - map/ultrasound/ Ultrasound of gallbladder with gallstones https://commons.wiki
media.org/wiki/File:Ultrasound_image_of_gallbladder_stone_Gallstone_091937515.jpg Ultrasound of gallbladder âsludgeâ http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&s=2&t=80 Ultrasound of cholecystitis http://www.radiologyassistant.nl/en/p43a0746accc5d/gall
bladder - wall - thickening.html Ultrasound vs. CT of Cholecystitis http://www.radiologyassistant.nl/en/p43a0746accc5d/gallbladder - wall - thickening.html Radionuclide scan (HIDA) http://www.slideshare.net/shaffar75/ultrasound - of - the - gallbladder Magnetic Resonance Cholangiopanc
reatography (MRCP) https://mrimaster.com/anatomy/biliary%20system%20anatomy%20(mrcp)/ Percutaneous transhepatic cholangiography (PTC) "PTC" by J. Guntau at German Wikipedia - Transferred from de.wikipedia to Commons.(Original text: Endoskopiebilder.de). Licensed under Public Domain
via Endoscopic retrograde cholangiopancreatography (ERCP) https://www.ceessentials.net/article41.html Natural History of Cholelithiasis Spectrum of Gallbladder Disease Spectrum of Gallstone Disease ï½ Asymptomatic cholelithiasis ï½ Biliary colic (chronic cholecystitis or symptomati
c cholelithiasis) ï½ Acute cholecystitis ï½ Calculous cholecystitis ï½ Acalculous cholecystitis ï½ Mirizziâs syndrome ï½ Choledocholithiasis ï½ Ascending cholangitis ï½ Gallstone pancreatitis ï½ Gallstone ileus ï½ Biliary dyskinesia ï½ Benign gallbladder tumors ï½ Gallbl
adder carcinoma Case #1 ï½ 53 year old female presented for evaluation after she underwent an echocardiogram which incidentally identified a 3 - cm gallstone ï½ She denied abdominal pain, nausea, vomiting, diarrhea, or constipation ï½ RUQ US demonstrated cholelithiasis (a large g
allstone measuring 3 cm) without gallbladder wall thickening, pericholecystic fluid, or a sonographic Murphyâs sign Asymptomatic cholelithiasis ï½ Approximately 30% of people with cholelithiasis end up having surgery ï½ Symptoms of gallstone disease generally do not change in s
everity ï½ Each year, approximately 2% of patients with asymptomatic gallstones develop symptoms ï½ Presence of gallstones in a person with asymptomatic or mildly symptomatic disease is not an indication for cholecystectomy ï½ Reasons to recommend cholecystectomy in asymptomatic
cholelithiasis ï½ Larg�e stones ( 2 cm in diameter) â they produce acute cholecystitis more often than small stones ï½ Calcified gallbladder â often associated with carcinoma Case #2 ï½ 29 year old female presented complaining of episodic abdominal pain and abdominal
bloating approximately 1 hour after eating ï½ RUQ US demonstrated cholelithiasis with a 1.6 cm gallstone and diffuse gallbladder wall thickening without pericholecystic fluid, and a negative sonographic Murphyâs sign ï½ HIDA demonstrated chronic cholecystitis (non - filling of
the gallbladder at 45 minutes, but eventual filling at 4 hours) Biliary Colic (Chronic Cholecystitis) ï½ Most common form of symptomatic gallbladder disease ï½ Signs/symptoms ï½ Caused by transient gallstone obstruction of the cystic duct ï½ Right upper quadrant pain, but can be
epigastric or left abdominal pain ï½ Diagnosis ï½ RUQ ultrasound ï½ Gallstones can be demonstrated in about 95% of cases, and a positive reading for gallstones is almost never in error ï½ About 2% of patients with gallstone disease have normal ultrasound studies Biliary Colic (
Chronic Cholecystitis) (continued) ï½ Complications ï½ Predisposes to acute cholecystitis, common duct stones, and adenocarcinoma of the gallbladder ï½ Complications are infrequent ï½ Treatment ï½ Medical ï½ Avoiding fatty foods ï½ Dissolution of stones â ursodiol ( Actigall
) ï½ Surgical ï½ Cholecystectomy is indicated in most patients with symptoms Case #3 ï½ 31 year old male presented complaining of epigastric pain, nausea, and vomiting ï½ On admission to the emergency department, blood pressure was 180/107. WBC was 7.4 ï½ CT angio chest/abdom
en/pelvis demonstrated no evidence of an aortic dissection and no intraabdominal findings ï½ Discharged home ï½ Presented again 12 hours later with RUQ pain and WBC was 14.9 with a left shift of 80.4% neutrophils ï½ RUQ ultrasound demonstrated gallbladder wall thickening of 0.6
cm, cholelithiasis, trace pericholecystic fluid, and a positive sonographic Murphyâs sign Acute Cholecystitis ï½ In 80% of cases, acute cholecystitis results from obstruction of the cystic duct by a gallstone ï½ Pathologic changes in the gallbladder ï½ Gangrene and perforation m
ay occur as early as 3 days after onset, but most perforations occur during the second week ï½ In cases that resolve spontaneously, acute inflammation has largely cleared by 4 weeks ï½ About 20% of cases of acute cholecystitis occur in the absence of cholelithiasis (acalculous cho
lecystitis) ï½ Most cases occur in patients hospitalized with some other illness ï½ Common in trauma victims and patients receiving TPN Acute Cholecystitis (continued) ï½ Signs/symptoms ï½ RUQ pain and tenderness ï½ Murphyâs sign ï½ Inspiratory arrest with right subcostal regi
on palpation during inspiration ï½ Nausea and vomiting are present in about half of patients, but the vomiting is rarely severe ï½ Fever (usually 38 ° C to 38.5 ° C) ï½ High fever and chills are uncommon and should suggest the possibility of complications or an incorrect diagnosis
ï½ Labs ï½ WBC elevated ï½ LFTs should be normal ï½ Imaging ï½ US ï½ HIDA Acute Cholecystitis (continued) ï½ Complications ï½ Suppurative cholecystitis (empyema) ï½ Gangrene ï½ Emphysematous cholecystitis ï½ Perforation â total incidence about 10% ï½ Localized perforat
ion with pericholecystic abscess ï½ Free perforation with generalized peritonitis ï½ Perforation into an adjacent hollow viscus with formation of a fistula ( cholecystenteric fistula) Acute Cholecystitis (continued) ï½ Treatment ï½ IV fluids ï½ IV antibiotics ï½ Laparoscopic (o
pen) cholecystectomy ï½ Percutaneous cholecystostomy ï½ Prognosis ï½ Overall death rate of acute cholecystitis is about 5% Algorithm for Management of Acute Cholecystitis Adapted from: RUQ pain, tenderness, RUQ US positive Non - operative management If US equivocal, HIDA Late
cholecystectomy Good operative risk Advanced disease, toxic Early cholecystectomy (or cholecystostomy) No No Prompt improvement Yes No Diagnostic Yes Case #4 ï½ 46 year old female presented complaining of RUQ pain ï½ Labs ï½ WBC count 6.8 ï½ Total bilirubin 5.8 ï½ Al
kaline phosphatase 182 ï½ AST 237 ï½ ALT 516 ï½ RUQ US demonstrated cholelithiasis without gallbladder wall thickening or pericholecystic fluid, and a slightly dilated CBD ( 0.8 cm) without dilated intrahepatic bile ducts ï½ ERCP demonstrated a stone in the distal CBD, whic
h was removed Choledocholithiasis ï½ Approximately 15% of patients with cholelithiasis have stones in the bile ducts ï½ Common duct stones are usually accompanied by others in the gallbladder, but in 5% of cases, the gallbladder is empty ï½ Two possible origins for common duct st
ones ï½ Secondary common duct stones ï½ Stones develop within gallbladder and pass through cystic duct into CBD ï½ Cholesterol stones ï½ Primary common duct stones ï½ Stones develop within CBD ï½ Pigment stones Choledocholithiasis (continued) ï½ Symptoms ï½ RUQ, epigastric or
sub - sternal pain with referred pain to the right scapula ï½ Intermittent chills/fever ï½ Jaundice ï½ Transient darkening of urine ï½ Pruritis ï½ Labs ï½ AST/ALT, Alkaline phosphatase , and bilirubin all elevated ï½ WBC may be elevated or normal Choledocholithiasis (continue
d) ï½ Imaging ï½ X - ray ï½ US ï½ CT ï½ MRCP ï½ ERCP Choledocholithiasis (continued) ï½ Complications ï½ Intra - hepatic abscesses ï½ Hepatic failure or secondary biliary cirrhosis ï½ Acute pancreatitis ï½ Erosion of a CBD stone through the ampulla ï gallstone ileus ï½
Hemorrhage ( hemobilia ) ï½ Treatment ï½ Antibiotics if cholangitis is suspected ï½ ERCP ï½ Cholecystectomy with cholangiogram ï½ Common bile duct exploration Natural History of Choledocholithiasis Gallbladder stones 100 Cholangitis 3 Biliary colic 2 Pancreatitis 1 Suppurativ
e cholangitis Jaundice 3 Asymptomatic common duct stones 6 Common bile duct stones 15 Rare Adapted from: Case #5 ï½ 28 year old male presented complaining of severe epigastric abdominal pain, nausea, vomiting, and chills ï½ History of a laparoscopic cholecystectomy 3 weeks prio
r ï½ Febrile (101.4 ° F) ï½ Labs ï½ WBC 10.8 ï½ Total bilirubin 7.1 ï½ Alkaline phosphatase 199 ï½ AST 130 ï½ ALT 408 ï½ CT abdomen/pelvis demonstrated intra - and extra - hepatic biliary ductal dilatation ï½ ERCP demonstrated a stone in the CBD, which was extracted Ascendin
g cholangitis ï½ Bacterial infection of obstructed biliary ducts ï½ Causes ï½ Choledocholithiasis ï½ Biliary stricture ï½ Neoplasm ï½ Less common: ï½ Chronic pancreatitis, ampullary stenosis , pancreatic pseudocyst, duodenal diverticulum , congenital cyst, and parasitic invas
ion ï½ Iatrogenic cholangitis may complicate transhepatic or T - tube cholangiography ï½ Higher chance of ascending cholangitis once the duct is colonized with bacteria ï½ Predominant organisms (in decreasing frequency) are E. coli , Klebsiella , Pseudomonas , Enterococci , and
Proteus Ascending cholangitis (continued) ï½ Diagnosis is mostly clinical, although RUQ ultrasound can demonstrate dilated intra - and extra - hepatic ducts ï½ Charcotâs triad â present in only 70% of cases ï½ RUQ pain ï½ Fever ï½ Jaundice ï½ Reynoldsâ pentad ï½ Charc
otâs triad ï½ Altered mental status ï½ Hypotension Ascending cholangitis (continued) ï½ Treatment ï½ Antibiotics ï½ ERCP ï½ PTC ï½ Common bile duct exploration Case #6 ï½ 46 year old female presented complaining of two days of severe abdominal pain, which started in the epi
gastrium and became diffuse, associated with nausea and vomiting ï½ Labs ï½ WBC 21.2 ï½ Total bilirubin 2.3 ï½ Alkaline phosphatase 126 ï½ AST 99 ï½ ALT 170 ï½ Lipase 8059 ï½ RUQ US demonstrated a distended gallbladder with mild wall thickening, small pericholecystic flu
id, non - mobile stones, and a mildly dilated CBD (0.9 cm) ï½ MRCP demonstrated acute pancreatitis with extensive peripancreatic infiltration and acute peripancreatic fluid collections, cholelithiasis, choledocholithiasis, and mild biliary dilatation Gallstone Pancreatitis ï½ A
cute pancreatitis due to biliary obstruction ï½ Diagnosis is mostly clinical (history, physical exam, labs) ï½ RUQ ultrasound demonstrates cholelithiasis ï½ CT can be used to find necrotizing pancreatitis, fluid collections, or other complications but is not technically required to
make the diagnosis ï½ Treatment is supportive initially ï½ Cholecystectomy with cholangiogram prior to discharge from the hospital if the pancreatitis is mild or moderate to avoid a recurrent episode ï½ ~30% will recur within 6 weeks if CBD is not cleared prior to discharge Gal
lstone Ileus ï½ A mechanical intestinal obstruction caused by a large gallstone lodged in the lumen ï½ It occurs more often in women, and the average patient age is about 70 years ï½ Usually presents with obvious small bowel obstruction ï½ The obstructing gallstone enters the in
testine through a cholecystenteric fistula located in the duodenum, colon, or, rarely, the stomach or jejunum ï½ Stones that cause gallstone ileus are almost always 2.5 cm or more in diameter Gallstone Ileus (continued) ï½ Imaging ï½ Abdominal X - ray may show a radiopaque gal
lstone ï½ Pneumobilia will be seen in about 40% of cases http://radiopaedia.org/articles/gallstone - ileus Gallstone Ileus (continued) ï½ Treatment ï½ Emergency laparotomy and removal of the obstructing stone through a small proximal enterotomy ï½ Leave gallbladder alone at eme
rgency laparotomy ï½ The death rate from gallstone ileus remains about 20%, largely because of the poor general condition of elderly patients at the time of laparotomy Summary RUQ pain? Fever? Elevated WBC? Elevated LFTs? Diagnosis? Treatment? Biliary colic Yes (intermittent) No
No No US Laparoscopic cholecystectomy Acute cholecystitis Yes (constant) Yes Yes No US HIDA 1) Antibiotics 2 ) Laparoscopic cholecystectomy 3) Percutaneous cholecystostomy Choledocholithiasis Yes No No Yes MRCP 1) ERCP 2) Laparoscopic cholecystectomy Ascending cholangitis Yes Y
es Yes Yes Clinical US 1) Antibiotics 2) ERCP 3) PTC 4) CBD exploration Gallstone pancreatitis Yes (Epigastric) Maybe Yes Yes Clinical US CT 1) Supportive 2) Laparoscopic cholecystectomy Post - Cholecystectomy Syndrome ï½ A heterogeneous group of disorders affecting patients who c
ontinue to complain of symptoms after cholecystectomy ï½ The usual reason for incomplete relief after cholecystectomy is that the preoperative diagnosis of chronic cholecystitis was incorrect ï½ An organic cause for the symptoms is more likely to be discovered in patients with se
vere episodic pain than in those with other complaints ï½ Abnormal liver function studies, jaundice, and cholangitis are other manifestations that indicate residual biliary disease ï½ Patients with suspicious findings should be studied by ERCP or PTC Benign Gallbladder Tumors ï½
The differentiation from gallstones is based upon observing whether a shift in position of the projections follows changes in posture of the patient, since stones are not fixed ï½ Cancer should be suspected in any polypoid lesion that exceeds 1 cm in diameter ï½ Polyps ï½ Adenom
yomatosis ï½ Adenomas Gallbladder Carcinoma ï½ An uncommon neoplasm that occurs in elderly patients ï½ Associated with gallstones in 70% of cases ï½ The risk of malignant degeneration correlates with the length of time gallstones have been present ï½ Prevalence in women compared
to men is approximately 2:1 ï½ Histology â adenocarcinoma is the most common ï½ Scirrhous (60%) ï½ Papillary (25%) ï½ Mucoid (15%) Gallbladder Carcinoma (continued) ï½ Early direct invasion of the liver and hilar structures and by metastases to the common duct lymph nodes, l
iver, and lungs ï½ Carcinoma can be incidentally found after cholecystectomy, where the tumor is confined to the gallbladder ï½ Symptoms ï½ Right upper quadrant pain ï½ Obstruction of the cystic duct by tumor sometimes initiates an attack of acute cholecystitis ï½ Other cases p
resent with obstructive jaundice and, occasionally, cholangitis due to secondary involvement of the common duct Gallbladder carcinoma â Imaging Gallbladder Carcinoma: Complications and Prevention ï½ Complications ï½ Intra - hepatic, pericholecystic or within the gallbladder absc
esses ï½ Prevention? ï½ Incidence of gallbladder cancer has decreased in recent years as the frequency of cholecystectomy has increased ï½ Estimated that one case of gallbladder cancer is prevented for every 100 cholecystectomies performed Gallbladder Carcinoma: Surgical Treatment
ï½ In the few cases when cancer has not penetrated the muscularis mucosae, cholecystectomy alone should suffice ï½ Small invasive carcinoma discovered by the pathologist ï½ Reoperation to perform a wedge resection of the liver bed plus regional lymphadenectomy ï½ Localized carci
noma ï½ Cholecystectomy along with en bloc wedge resection of an adjacent 3 - 5 cm of normal liver and dissection of the lymph nodes in the hepatoduodenal ligament ï½ More extensive hepatectomies (e.g., right lobectomy) are not worthwhile ï½ There is little that surgery can of
fer in cases with hepatic metastases or more distant spread Gallbladder Carcinoma: Prognosis ï½ Radiotherapy and chemotherapy are not effective palliative measures ï½ About 85% of patients are dead within a year after diagnosis ï½ The 10% of patients who survive more than 5 year
s: ï½ Carcinoma was an incidental finding during cholecystectomy for symptomatic gallstone disease ï½ An aggressive resection has removed all gross tumor References ï½ CURRENT Diagnosis & Treatment: Surgery, 14e Gerard M. Doherty ï½ Schwartzâs Principles of Surgery, 10e
F . Charles Brunicardi , Dana K. Andersen, Timothy R. Billiar , David L. Dunn, John G. Hunter, Jeffrey B. Matthews, Raphael E. Pollock ï½ The History of Medicine: The Galling Gallbladder. http://columbiasurgery.org/news/2015/06/11/history - medicine - gal