Chronic cholecystitis

Gallbladder metastases are rare and the clinical presentations are often nonspecific. Intra-operative gross and frozen section diagnosis can be particularly challenging. Here we present three cases and reviewed the patients' clinical, gross, frozen, and final pathology findings. Patient one is a 59-year-old male with a history of clear cell renal cell carcinoma status post partial nephrectomy seven years ago. Surveillance imaging showed two small gallbladder polyps. Intra-operative gross examination showed gallbladder with a firm, polypoid area and two detached nodules. Frozen sections of the polypoid area showed histiocytic appearing inflammation and was interpreted as chronic cholecystitis. Permanent sections showed similar morphology, but positive pancytokeratin and PAX8 immunostaining confirmed metastatic renal cell carcinoma. Interestingly, sections of the detached nodules showed better tumor morphology. Patient two is an 81-year-old male with a history of urothelial carcinoma status post transurethral resection two years ago. He presented with right upper quadrant pain, and imaging showed emphysematous cholecystitis. The gallbladder was unremarkable grossly; however, histologic sections showed metastatic urothelial carcinoma. Patient three is a 55-year-old female with a history of metastatic melanoma three years ago. PET/CT showed a stable FDG-avid gallbladder lesion. Grossly the gallbladder wall showed pigmented areas and histologic sections showed metastatic melanoma. Our study shows that the clinical, gross, and frozen section diagnosis of gallbladder metastases can be challenging. Avoiding a diagnostic error will likely entail an integrated approach, inclusive of a thorough review of clinical history, a detailed gross inspection and adequate tissue sampling.

Gallstone ileus is an uncommon complication of chronic cholecystitis, characterized by mechanical small bowel obstruction due to gallstone migration through a biliodigestive fistula. The occurrence of double biliary-enteric fistulas (e.g., cholecysto-duodenal and cholecysto-colic) is infrequent and presents additional diagnostic and surgical challenges.

A 41-year-old woman with no significant past medical history presented with progressive abdominal pain, distension, and cessation of bowel movements. Laboratory findings indicated a severe inflammatory response (CRP: 312 mg/L; leukocytosis: 13,000/mm³). CT imaging revealed jejuno-ileal distention with a calcified intraluminal mass suggestive of gallstone ileus and evidence of a cholecysto-duodenal fistula. Emergency laparotomy confirmed a large obstructing gallstone 30 cm from the ileocecal valve. Surgical exploration revealed two fistulas: cholecysto-duodenal and cholecysto-colic. The stone was removed via enterotomy; both fistulas were sutured, and a partial cholecystectomy was performed. The postoperative course was uneventful.

Gallstone ileus typically affects older individuals, and its occurrence in a young patient is unusual. The presence of a double fistula is a rare complication that complicates surgical management. Early diagnosis via imaging and timely intervention are critical. In this case, a one-stage procedure involving enterotomy, fistula closure, and partial cholecystectomy was successfully performed.

This case underscores the diagnostic and surgical complexity of gallstone ileus, especially when associated with double biliary-enteric fistulas. It emphasizes the importance of individualized surgical planning and the utility of CT imaging in diagnosis.

To investigate the impact of antithrombotic therapy on the clinical outcomes of emergency laparoscopic cholecystectomy for acute cholecystitis.

A single-center retrospective surgical database included 550 patients who underwent emergency cholecystectomy between 2005 and 2025, and the current study population included 329 patients who underwent emergency laparoscopic cholecystectomy, excluding open cholecystectomy and chronic cholecystitis. Patients were divided into two groups: patients receiving antithrombotic therapy (ATT, n = 143) and those not receiving antithrombotic therapy (non-ATT, n = 186). The ATT group was divided into aspirin monotherapy (aspirin, n = 62) and multiple antithrombotic therapy (mATT, n = 21) groups. Outcome variables were compared between the groups, and risk factors for intraoperative blood loss were assessed using logistic multivariate analysis.

The overall rate of severe postoperative complications was 2.7% and the surgical mortality was zero in the entire cohort. Intraoperative blood loss was significantly larger in the ATT group. A multivariate analysis showed that dialysis (odds ratio: 5.210, P = 0.019) and severe acute cholecystitis (odds ratio: 2.630, P < 0.001) were significant risk factors for increased intraoperative blood loss. There were no significant differences in the perioperative outcomes between the aspirin and mATT groups.

Although dialysis and severe acute cholecystitis contribute to increased intraoperative blood loss, emergency laparoscopic cholecystectomy may be performed safely, even in patients receiving multiple antithrombotic therapies.