Laparoscopic cholecystectomy for xanthogranulomatous cholecystitis: 18 years of experience

doi:10.21203/rs.3.rs-2706579/v2

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Laparoscopic cholecystectomy for xanthogranulomatous cholecystitis: 18 years of experience

https://doi.org/10.21203/rs.3.rs-2706579/v2

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Background Xanthogranulomatous cholecystitis (XG) is a rare inflammatory disease of the gallbladder (GB), macroscopic appearance may be confused with gallbladder cancer (GC) making the diagnosis challenging. Laparoscopic cholecystectomy (LC) is considerate the gold standard for the management of benign gallbladder disease however LC in XGC is associated with a high conversion rate to open cholecystectomy with a rate of 10.6 to 80%. The aim of this study was to determinate the rate of laparoscopic cholecystectomy on patients with histopathological diagnosis of CXG and the associated morbidity to the procedure.

Material and methods This study is an observational, retrospective, and cross-sectional study carried out over a period of 18 years in a single institution. Patients underwent to laparoscopic cholecystectomy with histopathological diagnosis of xanthogranulomatous cholecystitis were included. The primary outcome was the rate of conversion to open surgery; secondary outcomes were the morbidity and mortality. The data were reported on percentages and averages. Statistical Package for the Social Sciences (SPSS, version 26) was used to analyze the data. The study was approved by the board of ethical committee in our institution in 2018.

Results We registered 142 patients operated from cholecystectomy with histopathologic results of XGC and 106 surgeries were performed laparoscopically (74.6%); 52 were emergency surgeries (49%) and 54 elective (51%). The conversion rate to open cholecystectomy was 3.7% (4 patients). There were 5 post-surgical complications (4.7%) one biloma, one surgical site infection, and 3 pancreatitis.

Conclusions XGX represents a surgical challenge from diagnosis to surgical management and is associated to a higher number of perioperative complications; nevertheless, a laparoscopic approach is safe in high volume centers with experience in laparoscopy.

Xanthogranulomatous cholecystitis

Laparoscopic cholecystectomy

Surgical management

Gallbladder

pathology

Xanthogranulomatous cholecystitis is a rare inflammatory disease of the gallbladder with a prevalence of 0.7-11%. It is characterized by a severe proliferation of fibrotic tissue accompanied by the accumulation of lipid-laden macrophages and acute and chronic inflammatory cells[1,2]. Can be classified as a variant of chronic cholecystitis[2-5]. Macroscopic appearance may be confused with GC, even involving adjacent organs [2,3] and an association has been reported in up to 25%[6,10]. Laparoscopic approach in XGC is associated with a high rate of conversion to open surgery, reporting an increase from 10.6 to 32.4%[3], due to the difficulty caused by fibrosis, adhesions, and even abscesses, the use of laparoscopy has generated controversy[11,12].An increase in complications around this pathology is described both for open and laparoscopic procedures, reaching a high post-surgical morbidity of up to 33.3%.[11].

The aim of this study was to determinate the rate of laparoscopic cholecystectomy on patients with histopathological diagnosis of CXG and the associated morbidity to the procedure.

An observational, retrospective, and cross-sectional study was conducted. The study was approved by the board of ethical committee in our institution with the number 04-43-2018. This report adheres to the STROBE statement.

All the cholecystectomies performed was identified on a period from January 2000 to December 2017(18 years) at the general hospital "Dr Manuel Gea González”, Mexico City. The data of each patient were collected from the clinical expedients of our hospital and registered on a database. We included patients older than 16 years underwent cholecystectomy with laparoscopic approach and a histopathologic result of XGC.

Demographic information (age, sex, comorbidities) was collected; also, we achieved the clinical presentation and the preoperative diagnosis. About the surgery there were registered the surgical findings, conversion rate, time of surgery, bleeding intraoperative, complications and mortality.

The results were reported on percentages and averages. Statistical Package for the Social Sciences (SPSS, version V26) was used to analyze the data.

On the period from January 2000 to December 2017 a total of 4925 cholecystectomies were performed, of which 142 cases (0.85%) were diagnosed as XGC according to the histopathological report. In this study 106 patients were included with a laparoscopic approach: sixty women (55.6%) and 66 men (43.3%) with a mean of 48 years. Table 1. Eight patients (7.5%) had a history of cancer in various locations. 30 patients had a history of smoking (28.3%) and 17 alcoholism (16%).

Among the clinical presentations, 31 (29.2%) patients presented jaundice, 22(20.7%) patients had choluria, 18 patients (16.9%) developed acholia, nausea and emesis were present on 56 (52%) and 48 patients (45.2%) respectability. On the physical examination the most common presentation was pain on the right upper quadrant on 79 patients (74.5%), positive Murphy´s sign presented on 23 patients (21%), none of the patients had evidence of an upper quadrant mass. The time since the first signs and symptoms to hospital admission were more than twelve months in 32 patients (30.1%), 6 months to 12 months in 12 (11.3%), 15 days to 6 months in 25 (23.5%), from 4 to 14 days in 19 patients (17.9%) and less than 3 days in 18 patients (16.9%). All patients had an ultrasonography previous to the surgical procedure.

The total of preoperative diagnosis are described on table 1, none of the cases was XGC suspected.; on 32 patients endoscopic retrograde cholangiopancreatography (ERCP) was performed; 73% had choledocholithiasis which was solved during the procedure and 13 patients (12%) were diagnosed with cholangitis.

All patients included were underwent laparoscopic approach; with the median operating time was 97 minutes (30 to 243 minutes), with a mean of 103 ml of blood loss. The conversion rate to open cholecystectomy was 3.7% (4 patients). Table 2 . There were 5 complications (4.7%): two bilioma, two biliar leake and one surgical site infection. Table 3

XGC is a rare inflammatory disease; with an incidence reported from 0.6 to 11%, in our study we found an incidence of 0.85%, equal to the literature; it affects men and women equally, can be presents with presence of gallstones (91%-100%) [6,8]. On the review published by Hale at 2013[10], he found a higher incidence of XGC in Indian patients (8.8%), compared to European, American, or far Eastern cohorts (1.3%, 1.5% and 1.9%, respectively) [18]. Gilberto Guzman-Valdivia registered an incidence of 1.46% in a single center on Mexico City on 2004 [14].

The development of XGC is thought to start as biliary obstruction, causing acute or chronic cholecystitis and increasing gallbladder pressure, followed by a granulomatous reaction. Although the pathogenesis of this granulomatous reaction is not well understood, it has been postulated that obstruction of the GB outflow leads to extravasation of bile into the GB wall, with involvement of the Rokitansky-Aschoff sinuses, or extravasation through a small ulceration in the mucosa. This causes a granulomatous reaction that leads to the formation of intramural nodes. This inflammatory process may often extend to adjacent organs, such as the liver, duodenum, and transverse colon. Dense adhesions with a large mass of inflammatory tissue surrounding the GB are then formed[1].

Until today, there are no clinical or imaging characteristics that indicate a diagnosis with certainty[1-5, 16]. Clinical symptoms of XGC can be presented like an acute or chronic cholecystitis; this is equal to our series, with multiple clinical manifestations, that explain the challenging of obtain a perioperative diagnosis[1, 10-17]; most of our patients developed chronic symptoms.

The differential diagnosis between XGC and malignant neoplasm is difficult, especially in patients with severe proliferative fibrosis involving the GB and surrounding organs[1]. We did not perform any partial cholecystectomy in our series, in contrast to other authors that have reported a rate of 16 to 64%[6,19]. It has been described, the importance of performance a total cholecystectomy; and some series had suggested make an intraoperative biopsy or fine needle aspiration cytology[8]. XGC does not only mimic carcinoma of the gallbladder but may also coexist with gallbladder malignancy and has a stronger association with XGC from 2–15%[8,10,16], in contrast with our results GC was not detected in the definitive pathology results in any of the patients.

In the last 20 years, many authors described their experience with the laparoscopic approach for XCG Table 4, the controversy still about the laparoscopic approach and we can identify very different results, Guzmán et al [14] registered a conversion rate of 80% on 2004; Alotaibi et al[25] reported a 10% of conversion rate on 2022, we can resalt the time between both series are almost two decades. We found a lower conversion rate 3.7% that the other series, that can be relate with in our hospital the minimal invasive approach is performance in a several procedures, however some cases can be safe with conversion, and is relate with the experience of the center. The 4.7% (N=5) of cases in our center developed adverse events, these findings are similar to other series, with rates of 0–33% [11,14,19].

Our study had several limitations, including the retrospective in nature conducted at a single center; however, we believe the results can be replicable on other centers with experience at minimally invasive approach.

In conclusion XGC represents a challenging pathology including diagnosis and treatment. Experience in the laparoscopic approach for GB disease is crucial to minimize the risk of complications and conversion rates; the laparoscopic approach for XGC is feasible in high volume centers without increasing morbidity.

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No competing interests reported.

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Laparoscopic cholecystectomy for xanthogranulomatous cholecystitis: 18 years of experience

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