Single-Institution Case Series of Patients Undergoing Cholecystectomy for Gallbladder Torsion

Gallbladder torsion was first reported in the clinical literature in 1898,¹ and more than 500 cases of gallbladder torsion have been reported to date.² The frequency of this condition increases with age, with the peak incidence observed in elderly women. However, it remains a rare event. Possible causal factors include anatomic variation of the gallbladder mesentery, loss of visceral fat, liver atrophy, and presence of elongated mesentery with cystic artery and duct, which is known as “floating gallbladder.”^3–7

Torsion of the gallbladder presents as one subtype of acute cholecystitis. In the 2013 Revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis,⁸ it is stated that gallbladder torsion is one of the local complications of biliary peritonitis, pericholecystic abscess, liver abscess, emphysematous cholecystitis, gangrenous cholecystitis, and purulent cholecystitis, and torsion is graded as “moderate severity.”⁹ An urgent cholecystectomy should be performed in cases where torsion of the gallbladder is suspected because any more conservative treatment will not resolve this emergency condition. The preoperative diagnosis of gallbladder torsion is considered to be difficult. A systematic review conducted in 2012 found that a preoperative diagnosis of the condition was made in only 26% of patients.¹⁰

Until now, numerous individual case reports have been published worldwide, but because of the very low incidence of the condition, there are few reports analyzing multiple cases of gallbladder torsion. Recently we experienced 6 consecutive cases of gallbladder torsion. In this report, we highlight the clinical and radiologic findings that facilitated the preoperative diagnosis of 6 cases of gallbladder torsion. All of the patients received the emergency operation, and we also discuss the surgical outcome.

Case Presentation

Between January 2005 and November 2011, a total of 172 patients received a diagnosis of acute cholecystitis in the surgical department at Toyonaka Municipal Hospital (Osaka, Japan). Each of the patients was assessed according to clinical findings, blood test results, and computed tomography (CT) findings. The diagnosis of acute cholecystitis followed the diagnostic criteria of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis. Of 172 patients, 5 patients received a diagnosis of gallbladder torsion or suspected gallbladder torsion preoperatively, and 1 additional patient was diagnosed intraoperatively. A total of 4 patients underwent laparoscopic cholecystectomy, and the remaining 2 patients underwent open cholecystectomy. The reasons to choose the open surgery were that the time delay being more than 3 days between the onset of symptoms and the operation was observed in patient 2, and biliary peritonitis was suspected in patient 3. Clinical, laboratory, and radiologic findings for these 6 patients were collected (age, sex, presence or absence of severe right upper quadrant abdominal pain, fever, white blood cell count, C-reactive protein, and CT findings).

Laparoscopic cholecystectomy was performed with a standard 4-port technique. After insertion of the first trocar, carbon dioxide was used for peritoneal insufflation, and abdominal pressure was maintained between 8 and 12 mmHg. Laparoscopic detorsion of the gallbladder was performed, and the cystic artery and cystic duct were freed from the surrounding tissue at the Calot triangle An effort was made to create the “critical view of safety” established by Strasberg and Brunt.¹¹ Intraoperative cholangiography was not routinely performed. The cystic artery was sealed and dissected using a laparoscopic Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio), and the cystic duct was intra-abdominally ligated and dissected.

The clinical characteristics, laboratory data, and radiologic findings pertaining to 6 patients who received a diagnosis of gallbladder torsion at our institute are shown in Table 1. The age of the patients ranged from 33 to 89 years. Half of the patients were older than 80 years. Median age was 76.5 years. A total of 4 patients were female and 2 were male. Upon presentation, each of the patients complained of sudden severe right upper quadrant abdominal pain. None displayed fever. Elevation of white blood cell count was not observed in 4 patients. In radiologic findings, ischemia of the gallbladder wall was frequently observed but was not specific to gallbladder torsion. The rotation of the gallbladder fundus, revealing an abnormal anatomic position, was observed in 5 patients. Moreover, these 5 patients showing the rotation of the gallbladder fundus had accompanying findings of excessive swelling of the gallbladder. Figure 1a and 1b show the CT findings, revealing both excessive swelling of gallbladder and the rotation of the fundus in patients 4 and 6. Both findings appear to be a useful preoperative indication of suspected gallbladder torsion. In 2 patients (patients 5 and 6), a multidetector CT study showed a twisted pedicle inferior to the liver, as well as a twisting of the cystic duct and cystic artery that could be observed as a “whirl sign” on contrast scans. Patient 1 revealed only ischemic change of the gallbladder wall, but this was not accompanied by any findings of excessive swelling of the gallbladder, rotation of the fundus, or torsion of the cystic duct, and was diagnosed as acute cholecystitis preoperatively. Laparoscopic cholecystectomy was performed. The cystic duct was twisted less than 180°, and the diagnosis of gallbladder torsion was done intraoperatively.

Table 1  Clinical, laboratory, and radiologic findings

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Details, including the type of operation performed and the clinical outcomes of the 6 cases, are shown in Table 2. The laparoscopic approach was chosen for 4 patients, and conversion to open cholecystectomy was not necessary. Figure 2 shows that the necrotic gallbladder was observed with an anticlockwise torsion of more than 360° in its mesentery in patient 6. In all patients, the gallbladder was attached to the liver only by the cystic duct and artery; this condition is described as a “floating gallbladder.” Torsion can be classified as “incomplete,” in which rotation is less than 180°, or “complete,” in which rotation is more than 180°. A total of 3 cases represented complete torsion, and 3 represented incomplete torsion. The operation duration ranged from 26 to 77 minutes. The durations of the open cholecystectomy procedures were shorter than those of the laparoscopic cholecystectomy procedures, and all fell within an acceptable range. All of the patients were discharged without any postoperative complications. The periods of postoperative hospital stay ranged from 2 to 16 days. The average length of hospital stay for patients receiving laparoscopic cholecystectomy is supposed to be shorter than that for patients receiving open cholecystectomy, indicating earlier recovery in the patients treated with laparoscopic procedures.

Table 2  Type of operation performed and clinical outcomes observed

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Discussion

Gallbladder torsion, or volvulus, was first reported in 1898 by Wendel.¹ It remains a relatively uncommon event, occurring primarily in elderly women. Gallbladder torsion is defined as a rotation of the gallbladder on the mesentery along the axis of the cystic duct and cystic artery. The consequent obstruction of bile and blood flow leads to empyema formation and the development of necrosis of the gallbladder wall. Clinically, gallbladder torsion is an emergency surgical situation, and prompt cholecystectomy is necessary to avoid the morbidity and mortality associated with necrosis and perforation of gallbladder.

The correct preoperative diagnosis of gallbladder torsion is challenging. In 2012, Reilly et al¹⁰ conducted a systematic review of cases of gallbladder torsion, and the data of 324 patients with gallbladder torsion since 1898 were collected. The authors reported that a preoperative diagnosis of gallbladder torsion was made in only 26% of cases within the last 20 years (32 cases out of 125 patients).¹⁰ The symptoms of gallbladder torsion comprise acute onset of severe right upper quadrant abdominal pain, nausea and vomiting, and a tender palpable mass. These symptoms are mainly nonspecific, and their presentation varies with the type of torsion, which may be either complete or incomplete.^12–15 In this study, we assessed CT findings that were most helpful in the differential diagnosis of gallbladder torsion. CT can play an important role in the diagnosis of gallbladder torsion. The observation of a distended gallbladder outside the normal anatomic fossa indicates the condition called a “free-floating gallbladder,” which is one of the risk factors for gallbladder torsion. Multidetector CT scan was reported to be useful to diagnose gallbladder torsion before surgery.¹⁶ Observation of a twisted pedicle of the cystic duct and cystic artery with a “whirl sign” appearance may be considered definitive findings in the diagnosis of gallbladder torsion.^2,10,17–19 In the series presented in this study, contrast-enhanced CT imaging was quite helpful in the process of diagnosis of gallbladder torsion. A preoperative diagnosis of gallbladder torsion was made in 83% of the cases. From our series, CT findings of both excessive gallbladder swelling and rotation of the gallbladder fundus were believed to be key findings indicative of gallbladder torsion. The CT image showing torsion of the cystic duct named a “whirl sign” was a definitive diagnostic finding for gallbladder torsion, and this sign was observed in 2 patients. Multidetector CT scan is widely used now, and more patients can receive a preoperative diagnosis of gallbladder torsion.

The treatment for gallbladder torsion is emergency cholecystectomy, which must be performed immediately to prevent the potential complications of gallbladder perforation and biliary peritonitis. Cholecystectomy can be performed using either a laparoscopic approach or an open approach.²⁰ In previously published case reports, the gallbladder was minimally adherent to the liver bed, allowing the laparoscopic procedure to be performed easily.^21–23 The laparoscopic cholecystectomy has been recommended because it is less invasive and patients have a more rapid recovery after the operation. In this series of gallbladder torsion patients, all patients underwent emergency cholecystectomy; 2 patients underwent an open cholecystectomy procedure and 4 underwent a laparoscopic cholecystectomy procedure. The operative duration of open cholecystectomy was shorter than that of laparoscopic cholecystectomy. Two patients treated with open cholecystectomy were very lean, and the twisted gallbladder was easily resected. This resulted in a shorter operative duration in the patients with open cholecystectomy. All of the patients were discharged from the hospital without any complications. The patients treated using a laparoscopic approach showed more rapid recovery and shorter postoperative hospital stay before discharge. The laparoscopic approach could be considered the recommended first choice for patients with a diagnosis of or suspected to have gallbladder torsion.

Conclusion

The diagnosis of this rare emergency condition can be facilitated by the observation that CT findings showing both excessive gallbladder swelling and rotation of the gallbladder fundus are indicative of gallbladder torsion. The laparoscopic cholecystectomy approach could be considered the first choice for patients with gallbladder torsion.