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Key Clinical Message Cholecystocolic fistula, a rare complication of long‐standing gallstone disease, is a diagnostic challenge owing to nonspecific clinical presentation and lack of accurate preprocedural diagnostic modalities. In case of incidental discovery of the fistula during the surgical procedure, excision of the fistula with repair of the colonic defect is imperative.

Introduction Throughout the world, laparoscopic cholecystectomy is a widely accepted surgical treatment for both acute and chronic cholecystitis. It provides total relief of pre-surgical symptoms in up to 85% of patients. However, about 5% of patients may experience severe episodes of upper abdominal pain similar to those that they had prior to cholecystectomy; this is known as post-cholecystectomy syndrome. Gallbladder remnant with calculi is one of the causative factors. However, there have been only a few case series related to this reported in literature to date. Herein, we present our experience with laparoscopic management of gallbladder remnant with calculi in 40 cases. Methods A retrospective study of 40 cases was carried out in our institution. All patients underwent open cholecystectomy at other centres, and their cases were managed by laparoscopic completion cholecystectomy. Results The mean operating time was 102.4 min (range, 60–120 min). The duration of hospital stay was 2–4 days. Two cases were converted to open surgery because of extensive dense adhesions. One case had minor a common bile duct injury, and another had port-site infection. There were no cases of mortality. Conclusion Gallbladder remnant containing stones may be the cause of otherwise unexplained postcholecystectomy pain. Completion cholecystectomy offers a definitive treatment for any residual gallbladder remnant and can be performed laparoscopically.

Clinical diagnosis of chronic cholecystitis is made based on diffuse hyperechoic thickening of the gallbladder wall as shown by ultrasonographic examination. We herein report three cases of chronic cholecystitis showing localized hypoechoic thickening of the gallbladder wall that mimicked gallbladder cancer by ultrasonography. Histologically, hypertrophy of the muscularis propria was a common characteristic finding in these three patients. A smooth surface of the inner hypoechoic layer of the thickened wall was considered to be a reliable finding in the differential diagnosis between this type of chronic cholecystitis and gallbladder cancer.

Background: High biliary calcium and trace elements (copper, zinc and iron) in patients with chronic cholelithiasis can be associated with gallstones. Methods: Estimations of calcium, copper, zinc and iron were done in the serum, gall bladder bile and gallstones of 48 patients with chronic cholelithiasis and in 20 age- and sex-matched controls. Biliary levels of calcium and trace elements and bile/serum ratio of calcium and trace elements were compared in the two groups. Results: Serum calcium was significantly less (P= 0.009) than controls, but biliary calcium was higher in the patients with chronic cholecystitis. All trace elements were found to be significantly higher (P≤ 0.036) in the bile of patients with chronic cholelithiasis. The bile/serum ratio of calcium, copper and zinc was significantly greater (P≤ 0.03) in patients of chronic cholelithiasis. Gall bladder bile in patients with chronic cholelithiasis was slightly more alkaline. Pigment stones contained significantly more calcium, copper and iron than cholesterol stones (P≤ 0.001). Conclusion: Higher biliary calcium and trace elements as well as a defective pH of gall bladder bile in patients with chronic cholelithiasis could be the underlying factor in the pathogenesis of gallstones.

Qualitative and quantitative (1) H NMR analysis of lipid extracts of gallbladder tissue in chronic cholecystitis (CC, benign) (n = 14), xanthogranulomatous cholecystitis (XGC, intermediate) (n = 9) and gallbladder cancer (GBC, malignant) (n = 8) was carried out to understand the mechanisms involved in the transformation of benign gallbladder tissue to intermediate and malignant tissue. The results revealed alterations in various tissue lipid components in gallbladder in CC, XGC and GBC. The difference in the nature of lipid components in benign and malignant disease may aid in the identification of the biological pathways involved in the etiopathogenesis of GBC. This is the first study on lipid profiling of gallbladder tissue by (1) H NMR spectroscopy, and has possible implications for the development of future diagnostic approaches.

The medium-term effect of cholecystectomy on common bile duct diameters (CBD) was investigated prospectively in 64 patients with gallstone disease examined by ultrasonography immediately before and 27 months to 39 months after the operation. In 32 patients with chronic cholecystitis and patent cystic ducts, CBD diameters increased slightly (median 4.6 mm pre- and 5.3 mm postoperatively; p less than 0.05). A group of 19 patients with acute cholecystitis or cystic duct occlusion showed a significant decrease (median 7.7 mm pre- and 5.5 mm postoperatively; p less than 0.05). In 13 patients with common bile duct stones, the CBD diameters also decreased significantly after surgical intervention (median 7.5 mm pre- and 5.0 mm postoperatively; p less than 0.05). The widest CBD diameter after cholecystectomy observed in this study was 10 mm. We conclude that either increases or decreases of the CBD diameters may occur after cholecystectomy in patients with calculous gallbladder disease, and that the postoperative evolution is governed by the exact nature of the underlying biliary disease at the time of the index operation.

This paper concerns with 17 cases of chronic cholecystitis with various granulomatous changes of the wall. All materials were obtained from patients who underwent cholecystectomy for various complications of gallstone disease. The only significant sign attributable to the granulomas was a palpable nodular induration in the wall at operation in several cases, and this led to a suspicion of neoplasm in one. Pathologically, these lesions were characterized principally by nodular proliferation (0.5-3.0 cm in size) of various forms of histiocytic cells, including lipid-containing histiocytes (foam cells), PAS positive brown pigmented cells, and multinucleated giant cells. Deposition of bile pigment and/or cholesterin crystals were found deeply in the areas of granulomatous reaction in about two-thirds of the cases. This finding supports a bile-induced granulomatous process of these lesions. The granuloma in one of our series contained typical Michaelis-Gutmann bodies seen in a case of malakoplakia. It is suggested that bile materials, which are capable of eliciting intense phagocytic reaction, may also act as an initiating factor in formation of malakoplakic lesions.

The value of gallbladder thickening in predicting the presence of acute cholecystitis was assessed by reviewing gallbladder sonograms for 150 normal patients, 15 fasting normal patients, 24 patients with proven acute cholecystitis, 24 patients with ascites or an alcoholic history, and 50 patients with surgically proven chronic cholecystitis and gallstones. Thickened gallbladder walls were found in all patients with ascites, 45 percent of patients with acute cholecystitis, and approximately 10 percent of those with chronic cholecystitis. The finding of gallbladder wall thickening is suggestive evidence of acute cholecystitis, but it is not a pathognomonic finding.