shown an overall incidence of gallbladder carcinoma of 1-2% in patients with cholelithiasis. 7 ETIOLOGYNo single known factor has been identified to cause CaGB. Associations, predisposing and probable etiologic factors include cholelithiasis, polypoidal lesions of the gallbladder, genetic predisposition, chemical carcinogens, anatomical variations of pancreatico-biliary ductal system, infected bile, typhoid carrier-state and ulcerative colitis etc.The cause-and-effect relationship between gallstones and CaGB is not clear. Cholesterol stones, particularly of a large size (> 3 cm), are said to be intimately associated with CaGB. Chronic mechanical damage to the mucosa is believed to be a major promoting factor for this neoplastic transformation. 8 However, as the majority of CaGB are not squamous cell carcinomas, but are adenocarcinomas, malignant transformation in the gall- INTRODUCTIONThe prevalence of carcinoma in the gallbladder (CaGB) is greatly variable in different parts of the world. 1 In the United States Of America, Singapore and Nigeria, it is an uncommon cancer with an incidence of 2.5 per 100 000 population. In contrast, Chile has a much higher incidence of 7.5 per 100 000 population, especially in American Indian females. 2 The Indian Council of Medical Research Cancer Registry has recorded an incidence of 4.5 per 100 000 population in males and 10.1 per 100 000 population in females of northern parts of India, and 1.2 per 100 000 population in females of the southern parts of India. 3 The highest incidence of CaGB in India has been seen along the Ganges delta. 4 Gallstones associated with gallbladder carcinoma have been reported in 70-90% of patients with CaGB. Approximately 0.4% of all patients with gallstones have CaGB. 5 The risk of developing cancer among patients with untreated cholelithiasis has been estimated to be 0.2-0.5% over a 20-year period. 6 An autopsy study has REVIEW Current perspectives in gallbladder carcinoma SATYENDRA P KAUSHIK Department of General Surgery, Government Medical College and Hospital, Chandigarh, IndiaAbstract Carcinoma gallbladder (CaGB) is not a common malignancy in a large number of countries in the world, except Chile, Japan, some parts of India, and a few other regions. Lacunae exist even today in terms of understanding of its epidemiology, aetiopathogenesis, and in the early pick up of malignanacy, as well as in choosing the most appropriate treatment option for a given case. While Japanese surgeons have advocated radical resections for CaGB and have shown good outcome resulting in longterm survival, others have not felt convinced about the desirability of undertaking such morbid surgical procedures in all patients. Also, radical resections have not always resulted in a tumor-free state and a cure in a large percentage of cases. Under the circumstances, the clinician's mind is often confused as to the most beneficial option for that patient once curative resection is not possible. Palliation of the jaundice and/or gastric outlet obstruction relieves the sympto...

Fourteen cases of Mirizzi's syndrome are presented here. Clinical presentation was pain (14), jaundice (14), fever (10) and peritonitis (1). A clinical diagnosis of choledocholithiasis was considered in all the patients. Pre‐operative diagnosis of Mirizzi's syndrome was made in five patients on the basis of cholangiogram and the remaining cases were diagnosed at surgery. The stage (type) of Mirizzi's syndrome was based on the extent of erosion of the common bile duct. Four patients had type I, seven type II and three type III lesions. Associated choledocholithiasis was present in five and acute free perforation of the gall‐bladder in one. The operative procedures performed were partial cholecystectomy for type I, partial cholecystectomy, choledochoplasty and T‐tube choledochostomy for type II and bilioenteric anastomosis for type III lesions. Two patients had retained common bile duct stones. Mean follow up was 14 months (range 1–27 months). One patient with secondary biliary cirrhosis continues to have persistently elevated serum alkaline phosphatase levels without any demonstrable biliary obstruction. Diagnostic and operative strategies are discussed and a follow up protocol for such patients is suggested.

The possibility of conversion to open cholecystectomy (OC) always exists while performing a laparoscopic cholecystectomy (LC). This study has been performed with the aim of identifying factors predicting conversion to OC. From October 1992-April 1994, LC was attempted in 150 patients and conversion to OC was required in 29 (19%) patients. Ten preoperative factors were analyzed retrospectively to identify parameters significantly correlating with conversion to OC. Preoperative factors analyzed were age, sex, duration of symptoms, BMI (Body Mass Index), past history of jaundice, previous abdominal surgery, associated medical risk factors, palpable lump on clinical examination, USG, and OCG findings. Univariate and multiple stepwise regression analysis identified male sex, USG finding of contracted/thick-walled gall bladder, and a palpable gall bladder lump on examination as significant preoperative factors predicting conversion to OC.

The pain in GBS has a dual origin, and we recommend CBZ as an adjuvant to treat pain in GBS patients, during the recovery phase in the ICU, to reduce the narcotic requirement.

Background. The role of resectional surgery in patients with advanced stages of gallbladder carcinoma has not been fully defined. It is generally believed that the survival depends on the stage of the disease, rather than on the treatment option. Methods. Seventeen selected risk factors were analyzed using univariate and multivariate analyses to predict survival in 87 patients with gallbladder carcinoma who had undergone some form of surgical treatment. Similarly, a subset of 55 patients with American Joint Committee on Cancer Stage IV disease also was analyzed separately. Results. Palpable mass, tumor (T) status, local infiltration, lymph node involvement, distant metastasis, TNM stage, and the type of surgical treatment (laparotomy alone, bypass, or resection) were significant risk factors by univariate analysis. In addition to palpable mass and the type of surgical treatment, age was also a significant predictor of survival by multivariate analysis. Multivariate analysis of patients with Stage IV disease revealed the same three factors to be significant. In this subset of patients, the median survival after resectional surgery was 16.3 months; after biliary and/or gastric bypass, 4.8 months; and after laparotomy alone, 1.6 months. Conclusions. The type of surgical treatment significantly influenced survival. Resectional surgery was associated with better survival compared with biliary and/or gastric bypass or laparotomy alone for patients with all stages of the disease, including those with advanced carcinoma of the gallbladder.