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Kobe University Repository : Kernel
タイトルTit le
Gallbladder Adenocarcinoma Found at the Time of Cholecystectomyfor Lithiasis in an Aged Pat ient : Operat ive Indicat ion for Cholelithiasis
著者Author(s)
Tabuchi, Yoshiki / Kotani, Yoichi / Yoshida, Hiroshi / Ajiki, Tetsuo /Onoyama, Hiroshi / Nakayama, Takeshi
掲載誌・巻号・ページCitat ion Bullet in of allied medical sciences Kobe : BAMS (Kobe),11:133-139
刊行日Issue date 1996-01-31
資源タイプResource Type Departmental Bullet in Paper / 紀要論文
版区分Resource Version publisher
権利Rights
DOI
JaLCDOI
URL http://www.lib.kobe-u.ac.jp/handle_kernel/00182505
PDF issue: 2021-08-15
Gallbladder Adenocarcinoma Found at the Time of Cholecys
tectomy for Lithiasis in an Aged Patient: Operative Indication for
Cholelithiasis
Yoshiki Tabuchil, Kotani Yoichi 2, Hiroshi Yoshida 2
, Tetsuo Ajiki 3,
Hiroshi Onoyama3 and Takeshi N akayama3
A 91-year-old male with adenocarcinoma of the gallbladder found at the time of cholecystectomy for the lithiasis was reported. Preoperative examinations including ultrasonograpghy, computed tomograpy, cholecystography and tumor· markers revealed actute cholecystitis due to the incarceration of cholelithiasis in the Hartmann's pouch and no evidence of adenocarcinoma, but an adenocarcinoma appearing as stage III was found at the time of cholecystectomy. The indication of cholecystectomy for the lithiasis has been discussed, because gallbladder carcinoma coexists occasionally with cholelithiasis in the aged patients and because it is very difficult to diagnose the carcinoma in the presence of cholelithiasis prior to cholecystectomy.
Key Words Cholelithiasis, Gallbladder carcinoma, Aged patient, Operative indication.
INTRODUCTION
Recently, the average life span of the Japanese people has been prolonged, and'the aged people increases in the population. On the other hand, the cholesterol type of cholelithiasis probably due to the change of dietary habit increases in the population (1-4). In parallel, the gallbladder
Faculty of Health Science!, Kobe University School of Medicine, Department of Surgery2, Yoshida Ardent Hospital and First Department of Surgery], Kobe University School of Medicine, Kobe, Japan.
carcinoma increases in Japan, because cholelithiasis is generally believed to. be a risk factor for the carcinoma (1-9) . Therefore, the carcinoma is occasionlly found in the aged patients in whom cholecystectomy for cholelithiasis is performed (1- 3, 8, 9) . However, it is very difficult to diagnose gallbladder carcinoma under the presence of cholelithiasis prior to cholecystectomy (1-3, 8, 9).
We treated recently an aged patient with adenocarcinoma of the gallbladder which was found at the time of cholecystectomy and choledochotomy for the lithiasis. In this patient, any preoperative examinations revealed no information about the presence of the carcinoma. Thus, the case was herein reported and the operative indication for cholelithiasis was discussed.
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Y. Tabuchi et al.
CASE REPORT
N.T., a 91-year-old male had been pointed out to have a combination stone in the gallbladder at the time of health examination about 10 years ago but rejected any treatments for the lithiasis, because none of the symptoms was noticed. On November 5, 1994, he noticed epigastric discomfort, general fatigue and appetite loss and consulted us because of exacerbation of the symptoms 4 days later.
Alt'hough his temperature was within normal limits, physical examination revealed the swelling gallbladder with tenderness and rebound tenderness in the right hypochondorium. The bowel sound also weakened. A oval stone shadow measuring 1.3 X 0.8 em
in the right upper abdomen was found by the plain X -ray film and ultrasonography (US, Fig. 1). Under a clinical dgagnosis of acute cholecystitis due to the incarceration of the stone in the Hartmann's pouch of the gallbladder, he admitted to the Department of Surgery, Yoshida Ardent Hos~ pital (Kobe, Japan) .
The patient was treated with conservative therapy consisting of antibiotics, continuous drip infusion and fasting for 3 days after hospitalization, because he was a extremely aged patient and because he had undergone the medical treatment for angina pectoris and brain infarction for about six years prior to this hospitalization. Although the symptoms and abdominal signs progressed favorably by the conservative therapy, the liver func-
Figure 1. Ultrasonography. The gallbladder is distended and one stone is found in the Hartmann's pouch. The bladder wall is edematously thickened and the bile is not homogeneous. The tumor is not demonstrated in any of the other slices ..
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Gallbladder cancer found at the time of cholecystectomy
Table 1. Changes of liver function during the pre- and post-operative period from November 9,1994 to June 30, 1995.
Blood examination day 11/9 11/13 11/24 12/8 1/12 3/14 6/30
OOT (5-40 IU/I)· 66 372 31 35 17 18 22
OPT (5-35 IU/I)· 166 284 65 49 18 16 18
ALP (96-284 IU/I)· 497 707 677 371 296 192 194
Bilirubin (0.2-1.0 mg/dl)· 2.2 4.1 1.0 1.5 0.5 0.7 0.6
. ( ) indicates blood levels within normal limits .
tion became worse and jaundice was also disclosed by the blood examination (Table 1). The blood 'levels of CAI9-9(10), CEA (11), and KMO-l (12) were 12U/ml, 1.5ng/ml and 280U/ml respectively, and all of these tumor markers were within normal limits.
Morphologic examinations including US (Fig. 1) and computed tomography (CT, Fig. 2) revealed cholelithiasis and acute cholecystitis but no findings of gallbladder' carcinoma and choledocholi thiasis.
In the drip infusion cholecystography (DIe) undertaken after the improvement of liver function, the choledochus was one cm in diameter and dilated slightly, but stricture of the choledochus, choledocholithiasis and/or gall bladder . carcinoma were not suggested. However, choledocholithiasis was strongly suspected by the increase of COT, CPT, ALP and bilirubin in the blood (Table 1).
Under the tentative diagnoses of cholelithiasis and choledocholith'iasis, laparotmy through right subcostal incision was performed on November
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30, 1994, when liver function improved (Table 1).
The gallbladder was diffusely thickened, and tumor with serosal invasion measuring about 3 cm was found in the peritoneal side of the boundary region between the fundus and body, and multiple stones in the gallbladder were also palpable. The liver and
Figure 2. Computed Tomography. ,One stone is confirmed in the swelling gallbladder. : The wall is diffusely thickened. No tumor is found in this slice and every slice of the gallbladder. No'space occupying lesion in the liver is also found in '~my of the other slices.
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Y. Tabuchi et al.
Figure.3. Intraoperative choledochography after resection of the gallbladder. Three radiolucent shadows are clearly demonstrated.
peritoneal metastases and invasion into the liver were not found. The choledochus was carefully examined after Kocher's mobilization of the duodenum but choledocholithiasis could not be confirmed. Thus, the cholecystectomy with regional lymph node dissection was performed after ligation of the cystic duct for the prevention of stone entry into the choledochus. Because of preoperative suspection of choledocholithiasis, choledochography was performed via the cut-end of the cystic duct. Three floating stones were visualized clearly (Fig. 3). Therefore, the stones were removed by means of choledochotomy and T -tube was inserted into the choledochus for the drainage of bile.
The postoperative course was almost uneventful, although the patient showed a slight degree of delu-
,. I
<H'd~''''H),>1 -I" ~> .f' <0 ,H' ,
j ~ t ~ \
"-C 10 '-'--'-,-- 15 _._-:-
Figure 4. Resected gallbladder and removed stones. A nodular infiltrative tumor measuring 3.5 X 2.8 cm is found in the boundary region between the body and fundus. Three stones representing at the left side and the other stones shows the stones in the choledochus and gallbladder, respectively. The bladder wall is diffusely thickened.
sive condition and bronchopneumonia for 10 days after operation. The complications improved gradually by the conservative therapy, and he was discharged 5 weeks after operation. Liver and peritoneal recurrence of the tumor has not been found morphologically and serologically, and all items of the liver function test became within normal limits 7 months, on June 30, 1995, after operation (Table 1).
The resected gall bladder and remove stones were shown in Fig. 4. The cholelithiasis was consisted of 1 combination stone and 10 mixed stones, and the choledocholithiasis consisted of 3 mixed stones (Fig. 4). The gallbladder was diffusely thickened for the chronic cholecystitis and was erosive sporadically. The cystic duct was dilated up to 0.5 cm in diameter and the spiral structure dis-
136 Bulletin of Allied Medical Sciences, Kobe
Gallbladder cancer found at the time of cholecystt~ctomy
appeared. The tumor measuring 3.5 X 2.8 cmwas nodular infiltrative type (13) without node metastasis (Fig. 4). Microscopically, it was well differentiated tubular adenocarcinoma (Fig. 5) with serosal invasion. Finally, the carcinoma was concluded to be an ad vanced carcinoma of stage ill according to "the General Rules for Surgical Studies on Cancer of Biliary Tract" (13).
DISCUSSION
Recently, cholesterol type of cholelithiasis probably due to the changes of dietary habit increases in the Japanese population (1-4). In parallel, gallbladder carCIlloma with poor prognosIs Illcreases III the population (1-4), because cholelithiasis is generally believed to be a risk factor for the carcinoma (1 - 3, 5-9). Therefore, the carcinoma is occationally found in the patients in whom cholecystectomy for cholelithiasis is recently performed (1-3, 8,9). In fact, gallbladder carcinoma has been reported to occur in 2 ~ 10% of patients with cholelithiasis and 0.5 ~ 1.0% in patients without cholelithiasis (1-3, 8, 9). Furthermore, incidence of the carcinoma has been reported to be 6 ~ 10 times more in cholelithiasis patients over 60 ~ 65 years of age than in the patients under 60 years of age (1-4) . On the other hand, cholelithiasis has been reported to be found in 70 ~ 90% of patients with gall bladder carCIlloma (1-3,8,9).
In general, it is very diffcult to diagnose preoperatively gall bladder carcinoma in the presence of cholelithiasis. Therefore, the carcinoma is
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Figure 5. Microscopy of the tumor. The microscopy reveals a well differentiated tubular adenocarcinoma. Hematoxylin and eosin, original magnification X 40.
occasionally diagnosed at the' time of cholecystectomy for symptomatic cholelithiasis as in this case (1-3, 8, 9) . The main causes of diagnostic difficul ty have been reported to be based on the inflammatory thickness, collapse of gallbladder lumen due to the incarceration of stone in the cystic duct and poor presentation of the carcinoma due to the dominant stone shadow (1, 8, 9). The high frequency of superficial and/or infiltrative types of carcinoma coexlstlllg with cholelithiasis (1, 8, 9) seems to be one of the diagnostic difficulty, because these types of carcinoma are morphologically demonstrated only by the partial thickness of gallbladder wall. In our case, morphologic examinations including US, CT and DIC revealed only cholelithiasis but no evidence of gallbladder carcinoma, because inflammatory thickness and stone shadow were prominent and because the carcinoma was an infiltrative type. The presence of carcinoma did not suggested also by the determination of tumor
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Y. Tabuchi et al.
markers in the bllod, even though the carcinom·a was the advanced one.
For the patients with symptomatic cholelithiasis, cholecystectomy is generally performed. For the patients with asymptomatic cholelithiasis' , however, two different modalities of treatments have been performed and discussed recently: conservative treatment including dissol ution therapy or extracorporal shockwave lithotripsy and cholecystectomy by laparoscopy or laparotomy are discussed about their short-term and long-term efficacies (1, 2, 8, 9). In the conservative treatment, some disadvantages and/or problems are pointed out (1,2,4,9): it is not indicated for all of the patients, cholelithiasis reccurs frequently and serious complications such as peritonitis, sepsis and cholangitis occur sometimes during the period of treatment. In contrast, cholecystectomy indicates for almost all of the patients not only with cholelithiasis but also with its complications and the efficacy is reliable, although the short-term
REFERENCES
therapeutic stress is accompanied by the treatment. Furthermore, cholecystectomy with and without choledochotomy is an already established safe treatment, and the mortality and morbidity rates are almost null in the patients without serious complications of the other systems who are not indicated for general anesthesia at the present time (1-3, 9) . In fact, cholecystectomy and choledochotomy with lymph node dissection were performed for a highly aged, 91-year-old, patient with angina pectoris and brain infarction, and the patient discharged 5 weeks after operation. In conclusion, cholecystectomy seems to be indicated and recommended for asymptomatic cholelithiasis patients over 60 ~ 65 years of age, because gallbladder carcinoma and the aforementioned serious complications may occasionally occur in these patients (1, 4, 8, 9) and because diagnosis of gall bladder carcinoma with poor prognosis is very difficult in the presence of cholelithiasis.
1. Matuno M, Hanyu F: Liver, gallbladder, extrahepatic biliary system and pancreas. In stan· dard textbook of surgery (6th edition). Edited by Muto T, Tanabe T. Tokyo, Igaku Syoinn, 1992, P.565-620 (in Japanese)
2. Kimura W, Shimada H, Kuroda A, Morioka Y: Carcinoma of the gallbladder and extrahepatic bile duct in autopsy cases of the aged, with special reference to its gallstone. Am J Gastroenterol 84: 386-390, 1989
3. Ishihara F, Kameda H: Specificity of cholelithiasis in the aged patients. Biliary Tract Pan· creas 3: 929-942, 1982
4. Tanaka S: Neoplasm. In standard textbook of surgery (6th edition). Edited by Muto T, Tanabe T. Tokyo, Igaku Syinn, 1992, P. 175-202 (in Japanese)
5. Piehler JM, Crichlow RW: Primary carcinoma of the gallbladder. Surg Gynecol Obstet 147: 929-942, 1978
6. Bismuth H, Malt RA: Carcinoma of biliary tract. N Engl J Med 301: 701-707, 1979 7. Polk HC: Carcinoma of the calcified gallbladder. Gastroenterol 50: 582-594, 1966 8. Wanebo HJ, Falkson G, Order SE: Cancer of the hepatobiliary system. In Cancer, principles
& practice of oncology (3rd edition). Edited by DeVita VTJr, Hellmann S, Rosenberg SA. Philadelphia, JB Lippincott, 1989, P.836-874
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Gallbladder cancer found at the time of cholecystectomy
9. Zinner MJ, Roslyn JJ: Gallbladder and extrahepatic biliary system. In Principles of surgery (6th edition). Edited by Schwartz SI, Shires GM, Spencer Fe. New York, McGraw-Hill Inc, 1994, P.1367-1400
10. Gold P, Freedman SO: Demonstration of tumor specific antigens in human colonic carcinoma by immunological tolerance and absorption technique. J Exp Med 121: 439-462,1965
11. Koprowski H, Stepleski Z, Michell K, et al: Colorectal carcinoma antigens detected by hybrydoma antibodies. Somat Cell Genet 5: 957-971, 1979
12. Ohyanagi H, Saitoh Y, Okumura T, et al: A new monoclonal antibody-defined tumor marker (KMO 1) for pancreatic carcinoma. Mount Sinai J Med 54: 393-400, 1987
13. Japanese Biliary Surgical Society: General rules for surgical studies on cancer of biliary tract. Kanehara Syuppan, Tokyo (in Japanese)
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