A contemporary analysis of xanthogranulomatous cholecystitis in a Western cohort

Xanthogranulomatous cholecystitis is a particularly destructive variant of cholecystitis marked by unique inflammatory changes evident in pathologic specimens. Multiple case series have evaluated this process. However, these often focus on differentiating it from malignancy and have largely been conducted in Asia, where the disease may differ from that seen in the Western hemisphere. This study evaluated surgical outcomes after cholecystectomy for xanthogranulomatous cholecystitis at a high-volume tertiary care institution in the United States. The goal was to determine whether the process can be identified preoperatively and whether modifications should be made to the operative approach in this setting.

Patients with histopathological confirmation of xanthogranulomatous cholecystitis who underwent cholecystectomy between 2002 and 2019 were identified from an updated institutional database. Data regarding demographics, imaging findings, surgical procedures, and perioperative complications were reviewed retrospectively. A cohort of patients undergoing cholecystectomy for more typical diagnoses was also identified for comparison.

Twenty-seven patients with a histopathologic diagnosis of xanthogranulomatous cholecystitis were identified. The median age was 64, and 17/27 (63.0%) were male. The majority of cases were done electively on patients admitted that day (17/27). Seventeen patients were evaluated with diagnostic ultrasonography, 21 with computed tomography scan, and 8 with magnetic resonance imaging; 21/27 patients had multiple modality studies. The most common singular finding was gallbladder wall thickening, but the radiographic findings were otherwise inconsistent. Twenty-five patients had planned laparoscopic cholecystectomies, but only 10 were completed. Only 8 of the 15 converted procedures were completed as simple cholecystectomies. Five patients required subtotal cholecystectomy. Median estimated blood loss was 250 cm³, and the median time of procedure was nearly 3 hours. Eight patients had complications, including 6 severe complications such as intraoperative bile duct injury.

Xanthogranulomatous cholecystitis unfortunately has a nonspecific presentation, which can make it difficult to recognize preoperatively. It is to be suspected in cases featuring a distended, severely inflamed gallbladder that does not match the benign appearance of the patient. When the diagnosis is suspected, an open approach is justified and patients should be counseled as to the increased likelihood of atypical approaches and elevated risk of complication. Referral to a hepatobiliary specialist is to be considered.