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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

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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

Vol. 11, 1995

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

Vol. 11, 1995

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.

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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

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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

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