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Xanthogranulomatous cholecystitis is a rare, unusual and destructive form of chronic cholecystitis. It is clinically indistinguishable from other forms of cholecystitis and hence difficult to diagnose. Due to its propensity to form dense adhesions with stuctures surrounding the gall bladder and mimic malignancy of gall bladder intra-operatively, it's difficult to manage. This retrospective study was conducted with the aim to review the clinico-pathologic presentation of XGC and the possibility of its laparoscopic management. Patient and methods: All cases of histo-pathologically diagnosed XGC from January 2008 to December 2012 at Sharda Hospital, School of Medical Sciences & Research, Greater Noida were analyzed retrospectively. Results: Sixty two cases of biopsy proved XGC were studied.The mean age at presentation was 56.4 Â± 14.3 years (range 30 - 72 years), with a male: female ratio of 1.6:1. Gall bladder wall thickening on ultrasonography was seen in 91.9% cases and all (100%) had cholelithiasis. Laparoscopic cholecystectomy was possible in 18 (29%) cases, with a high conversion rate of 71% to open surgery. Two cases of carcinoma gall bladder accompanying XGC were documented. Both the mean operative time and hospital stay for laparoscopic surgery were longer for cases with XGC (105 minutes & 4.2 days respectively). No mortality occurred during the study period. Conclusion: XGC is difficult to diagnose preoperatively due to lack of distinguishing clinical features and imaging study results. Due to dense peri-cholecystic adhesions laparoscopic surgery though feasible in some cases is difficult to perform with a high conversion rate. Overall morbidity is also increased due to same reasons.
Keywords: Cholecystitis, Cholecystectomy, Malignancy, Xanthogranulomatous
Xanthogranulomatouscholecystitis(XGC) is a rare, more severe &destructive form of cholecystitis1,2. It is characterized by thickening of the gall bladder (GB) wall, with dense peri cholecysticadhesions and fistula formation3. The
preoperative clinical picture resembles that of acute or chronic cholecystitis and on imaging studies it may mimic GB cancer4, 5. It has been associated with increased chances of peri-operative complications and a difficult cholecystectomy6.
This study analyzed the clinical aspects of XGC, to assess laparoscopic cholecystectomy as a modality for treatment& identify causes for difficult cholecystectomy in XGC.
MATERIALS AND METHODS
All cases of histo-pathologically diagnosed XGC from January 2008 to December 2012 at Sharda Hospital, School of Medical Sciences & Research, Greater Noida were included.
Pathological diagnosis of XGC was made by following criteria: focal or diffuse mural affection with histiocyte infiltration, presence of cholesterol deposits, multinucleated foreign body giant cells, macrophages phagocytizing lipids and bile pigments to form xanthoma cells, non-specific acute/chronic inflammatory infiltrate.
Case records were analyzed retrospectively for clinical characteristics, comorbidities, imaging study findings, surgical findings, nature and duration of surgery, need and cause of conversion, additional procedures done, histo-pathological characteristics, and postoperative course & complications.
Of the 2670 patients who underwent cholecystectomy during the study period, 62 had pathologically proven XGC (2.32 %). The mean age at presentation was 56.4 Â± 14.3 years (range 30 - 72 years), with a male: female ratio of 1.6:1 (Table.1). Altered liver enzymes were seen in 28 (45.2%) cases. Associated co-morbidities included Type-2 diabetes mellitus in 14 (22.6 %), hypertension in 10 (16.1 %) and ischemic heart disease in 4 (6.5 %) cases.
Laparoscopic cholecystectomy was performed in 18 (29 %) cases rest 44 (71 %) cases required open cholecystectomy, 1 (1.6 %) patient had a cholecysto-colonic fistula that was treated with primary closure with omental patch, partial wedge resection of the liver was done in one (1.6 %) case due to doubt of carcinoma.
Of the 44 cases who underwent open cholecystectomy, fundus-first cholecystectomy was needed in 36 (81.8 %) cases, 8 (22.2 %) cases underwent duct-first cholecystectomy. Of the 36 cases who underwent fundus-first cholecystectomy, only a partial cholecystectomy with stump closure was possible in 18 (50 %) of cases, in 8 (22.2%) cases the posterior GB wall could not be dissected of the fossa bed and was left as such. Common bile duct exploration with T-tube drainage was done in 4 (6.5 %) cases. The mean operative time for open surgery was 125 Â± 102 minutes (range 55-175 minutes) & for laparoscopic cholecystectomy was 105 Â± 60 minutes (range 75-160 minutes).
Mean hospital stay for open surgery was 7.6 Â± 5.4 days (range 6 -14 days), and that for laparoscopic cholecystectomy was 4.2 Â± 2.8 days (range 3 -8 days).
Table.1: Patient profile
No. of cases (%)
Right hypochondrium pain
Nausea & vomiting
+ Murphys's sign
Table 2: Preoperative Ultrasound findings.
No of cases (%)
Gallbladder wall thickening
Common Bile Duct stones
Gall bladder + Common Bile Duct stones
Sub hepatic abscess
Sub phrenic collection
Table 3: Peroperative findings
No. of patients (%)
Common Bile Duct dialation
Common Bile Duct
Gall bladder + Common Bile Duct
Postoperative wound infection occurred in 9 (14.5 %) cases, wound gaped in 1 (1.6 %) case that was sutured secondarily, and there was no mortality. Grossly visible yellowish discoloration of the mucosal surface suggestive of xanthomatous change was seen in 38 (61.3 %) cases. Microscopically, foam cells, the hall mark of xanthomatous change were seen in all 62 (100%) cases, foreign body giant cells in 48 (77.4 %) cases, trans-mural inflammation and fibrosis in 54 (87.1 %) cases, micro-abscesses in 28 (45.2 %) cases. In 2 (3.2 %) cases XGC was co-existent with carcinoma.
Historically XGC, first described by McCoy et al is a rarer form of cholecystitis affecting the older population with an incidence varying from 0.7 -13.2 %7, 8. 9. Similar age distribution & incidence of 56.4 Â± 14.3 years, 2.32 % respectively was found in this study. The relatively low incidence and no specific pre-operative indicators (Tables 1 & 2) make it difficult to diagnose until surgery. All cases included in this series were suspected only during the course of surgery and confirmed later histo-pathologically. Male: Female ratio of 1.6:1 is opposite to normally greater incidence of cholecystitis in females and almost an equal distribution of XGC in both men & women as reported by others6. A regional or dietary factor could be the only plausible explanation for this, as is also proposed by Kansakar PBS et al who found the incidence of XGC and cholecystitis in general to be more in north India as compared to south10. A 100% association of XGC with cholelithiasis in our study is also in accordance with results reported by other authors' worldwide 11, 12, 13. A thickened GB on ultrasound seen in 91.9 % was the only pointing indicator preoperatively for XGC, which was significantly higher than 57.6%, as reported by others13&14. This by itself is not specific for XGC and hence is a cause of misdiagnosis by clinicians.
Two (3.2%) cases had co-existence of adenocarcinoma GB along with XGC. In one case malignancy was suspected per-operatively and the patient underwent extended cholecystectomy with wedge resection of liver. The other patient was found to be having carcinoma along with XGC on histo-pathology. This is comparable to data reported by others in literature11 & 14. Laparoscopic cholecystectomy was completed in 18(29%) cases, with a significant seventy one percent of cases requiring conversion to open cholecystectomy. This though lower than those reported by other authors (81.8 % & 80 %, byGilberto Guzman-ValdiviaandKansakar PBS et al and respectively), is still significantly high8, 10. The major reason for conversion was dense adhesions between the GB and surrounding structures and those at the Calot's triangle which prevented a safe completion of the procedure laparoscopically. This is evident from the fact that even in those cases who underwent an open procedure, there was a high number (81.8%) of fundus first cholecystectomies suggesting the Calot's had dense adhesions that prevented adequate dissection of cystic duct /artery directly. In half of these cases only partial removal of the GB could be achieved.
The above findings have two important implications. First is that these adhesions make the procedure, whether open or laparoscopic more challenging and hazardous with greater chances of severe peri-operative morbidity requiring additional and even secondary procedures. Secondly dense adhesions mimic malignancy and may lead to more radical procedures, than are required. Hence when XGC is encountered and malignancy is suspected, a frozen section biopsy may go a long way in deciding the appropriate procedure on a case to case basis. We did not have this facility, hence performed an extended cholecystectomy in one case where cancer was suspected but others have opined that frozen-sections are essential in patients, in whom differentiation of XGC from malignant lesions is difficult intra-operatively8,14.
In our study, the mean duration of operation was 125 minutes for open and 105 minutes for laparoscopic cholecystectomy, longer than that for their counterparts for routine cholecystectomy, illustrating that XGC creates difficulty in operation. Mean hospital stay for both open and laparoscopic surgery was also longer, 7.6 &4.2 days respectively, as compared to routine non XGC cases again pointing to the above stated fact.
We did not encounter any bleeding, bile leaks in any cases however post-operative wound infection occurred in 14.5% cases that required prolonged antibiotic administration.
XGC is a benign condition of the gallbladder with a low mortality rate. Clinically XGC is indistinguishable from chronic cholecystitis. It can mimic carcinoma of gall bladder intra operatively but carcinoma of gall bladder also appears to be more frequently associated with XGC. Frozen section is advisable in cases where malignancy is suspected as cholecystectomy alone is adequate treatment for XGC. Laparoscopic cholecystectomy is feasible but more challenging, hence one should have a low threshold for conversion to avoid significant post-operative complications.
We have not received any substantial contributions from non-authors.
Conflict of interest
The authors have none to declare.