A Preliminary Study On The Value Of Endoscopic Gallbladder-preserving Cholecystolithotomy For Intramural Gallstones

ABSTRACTCholecystolithiasis is generally thought of intraluminal gallbladder stones, only very few people noticed that the stone in the wall of the gallbladder; The intramural gallstones were difficult to found with preoperative examinations, so even if the intramural gallstones were found in the specimens after cholecystectomy , the there was no apparent clinical significance . In recent years, with the development of endoscopy and improvement of Endoscopic, Gallbladder-preserving Cholecystolithotomy , not only intraluminal gallstones can be seen, but also the "submucosal calculus" of the gallbladder wall. The experts think highly of them, considering that they are the recurrence factors of the gallstones after the EGPCL. In order to ensure the effectiveness of treatment and reduce relapse rate, the experts stressed that not only the intraluminal gallstones have to be removed compeletely, but also the "submucosal calculus". The "submucosal calculus" was only a part of the intramural gallstones, how did these intramural gallstones form? What is the clinical significance of them? How it would be that f the patients with intramural gallstones underwent the EGPCL? Until now, there is no definite answer.The aim of this research is to investigate the pathological characteristics of intramural gallstones, and the effects on the gallbladder contraction function, and the value of Endoscopic Gallbladder-preserving Cholecystolithotomy (EGPCL) performed on the patients with the intramural gallstones, with the specimens from cholecystectomy and the clinical data of the patients with intramural gallstones underwent the EGPCL.ObjectiveObserve the distribution of the intramural gallstones and the pathological features of the gallbladder wall which surrounding the stones. Analyze the clinical data of the patients with intramural gallstones who underwent the EGPCL, summarize the effect of the intramural gallstones of the gallbladder construction function. Preliminary investigate the value of Endoscopic Gallbladder-preserving Cholecystolithotomy (EGPCL) performed on the patients with the intramural gallstones.Methods1. Review the 912 gallbladder specimens from cholecystectomy because of gallstones, the specimens with intramural gallstones were found; the pathological characteristics and the distribution of the intramural gallstones were studied under light microscopy. The focal point are the distribution of the intramural gallstones and the pathological chrematistics of the tissue of the gallbladder that surround the stones. Using the microscope camera to photo the images of the intramural gallstones. Using the Akemi Image processing software and the SPOT measure software to measure the size of the stones. To apply two-sample homogeneity of variance test and t test for quantitative data for statistical analysis, distinguish the statistical significance of differences of the intramural gallstones in different layers.2. 108 patients with gallstone underwent EGPCL. the clinical data of 10 cases with intramural gallstones were retrospectively analyzed.; The EGPCL effectiveness on the patients with the intramural gallstones and the relationship between gallbladder contraction function and intramural gallstones were studied. ResultIn 912 gallbladder specimens, 71 intramural gallstones were found in the pathological sections of 32 case(s32/912,3.51%),5 in the mucous laye(r5/71,7%),16 in the muscular layer(16/71,23%),50 in the placenta percreta(50/71,70%). the differences in average of the area and diameter between the stones in the placenta percreta ,as well as the mucous layer, and the mucous layer are with statistical significance. Intramural gallstones were located in the dilated Rokitansky-Aschoff sinuses, Most of the epithelium of the sinuses with the intramural gallstones in the muscular layer and the placenta percreta are mucous epithelium of the gallbladder. The tissue surrounded the intramural gallstones were identified as mucus epicilliary cells, epithelial cells were cubic or cylindrical, are arranged neatly, no atypia. In some specimens, the canal between the lumen to the Rokitansky-Aschoff sinuses could be observed. The muscle layer is hyperplasia and hypertrophy, and these could thicken the wall of the gallbladder.Among the 108 cases underwent EGPCL, 10 (9.26%) patients showed the mucus and intramural gallstones. In which, 8 (80%) had well functional gallbladder contraction, and 2 (20%) had poor contraction function before EGPCL,. All the patients demonstrated different mild, moderate and severe clinical symptoms; and their symptoms all have been improved after EGPCL. However, the 2 patients with poor contraction of gall bladder were found to have cholesterol crystal in the gallbladder wall and substance stasis in the gallbladder respectively.After the surgery the symptoms of the patients with intramural gallstones have improved. In the two patients who had a poor construction function of the gallbladder , the ultrasonic exam showed needle-like Cholesterol deposition of the wall of the gallbladder and the stasis in the lumen respectively. Conclusion1. The intramural gallstones were located in the Rokitansky-Aschoff sinuses, and the Rokitansky-Aschoff sinuses came from the mucous membrane of gallbladder,and the mucous membrane invade the muscle layer to form a hernia or diverticulum-like structure . The "yellow ribbon sign" of the gallbladder wall is from the bile in the dilated Rokitansky-Aschoff sinuses. Those bile in the sinuses might be one of the factor of the formation of the intramural gallstones.2. The intramural gallstones does not necessarily have gallstones in the lumen of the gallbladder.3. After the formation of the intramural gallstones, the wall of the gallbladder would be thicken, but the influence of the construction function of gallbladder is not necessarily significant.4. The majority of patients with gallbladder stone wall have clinical symptoms, but after removing the stones, the symptoms may disappear .5. With the endoscope, it is easy to discover the stones in the mucous layer, it is difficult to observe and remove all the intramural gallstones in the seromuscular layer with the wall of the gallbladder is thick.Therefore, the patients with intramural gallstones have clinical symptoms and a thicken gallbladder wall, even if well construction function of the gallbladder is proved, we still suggest to remove the gallbladder.The suggested indications of the patients with intramural gallstones for the EGPCL are:â‘ The thickness of the gallbladder wall is less or equal to 3mm.â‘¡With well performed construction function of the gallbladder.â‘¢Most of the intramural gallstones could be removed which were detected by preoperative ultrasonic or intraoperative endoscopy .