All of the following patients should be referred to for cholecystectomy EXCEPT:
Patients older than 70 years presenting with bile duct stones should have their ductal stones cleared endoscopically. Studies comparing surgery to endoscopic treatment have documented less morbidity and mortality for endoscopic treatment in this group of patients. They do not need to be submitted for a cholecystectomy, as only about 15% will become symptomatic from their gallbladder stones, and such patients can be treated as the need arises by a cholecystectomy.
Over a 10-year period, what percentage of patients with asymptomatic gallstones will remain symptom-free?
Gallstones in patients without biliary symptoms are commonly diagnosed incidentally on US, CT scans, or abdominal radiography or at laparotomy. Several studies have examined the likelihood of developing biliary colic or developing significant complications of gallstone disease. Approximately 3% of asymptomatic individuals become symptomatic per year (ie, develop biliary colic). Once symptomatic, patients tend to have recurring bouts of biliary colic. Complicated gallstone disease develops in 3 to 5% of symptomatic patients per year. Over a 20-year period, about two-thirds of asymptomatic patients with gallstones remain symptom-free.
All of the following increase risk for the development of gallbladder cancer EXCEPT:
Cholelithiasis is the most important risk factor for gallbladder carcinoma, and up to 95% of patients with carcinoma of the gallbladder have gallstones. However, the 20-year risk of developing cancer for patients with gallstones is <0.5% for the overall population and 1.5% for high-risk groups. The pathogenesis has not been defined but is probably related to chronic inflammation. Larger stones (>3 cm) are associated with a 10-fold increased risk of cancer. The risk of developing cancer of the gallbladder is higher in patients with symptomatic than asymptomatic gallstones. Polypoid lesions of the gallbladder are associated with increased risk of cancer, particularly in polyps >10 mm. The calcified "porcelain" gallbladder is associated with >20% incidence of gallbladder carcinoma. These gallbladders should be removed, even if the patients are asymptomatic. Patients with choledochal cysts have an increased risk of developing cancer anywhere in the biliary tree, but the incidence is highest in the gallbladder.
The most common type of gallbladder cancer is:
Between 80 and 90% of the gallbladder tumors are adenocarcinomas. Squamous cell, adenosquamous, oat cell, and other anaplastic lesions occur rarely. The histologic subtypes of gallbladder adenocarcinomas include papillary, nodular, and tubular. Less than 10% are of the papillary type, but these are associated with an overall better outcome, as they are most commonly diagnosed while localized to the gallbladder.
The gallbladder lymphatics drain into which of the following liver segments?
Lymphatic flow from the gallbladder drains first to the cystic duct node (Calot), then the pericholedochal and hilar nodes, and finally the peripancreatic, duodenal, periportal, celiac, and superior mesenteric artery nodes. The gallbladder veins drain directly into the adjacent liver, usually segments IV and V, where tumor invasion is common.