68% of patients. In 55% of the patients, complete fistula closure was noted. The main side effects reported in clinical trials included infusion reactions, delayed hypersensitivity reactions, human antichimeric antibodies, drug-induced lu- pus, and one case of lymphoma in Crohn’s disease. When infliximab was approved by the FDA for clinical use in 1998, there were concerns among patients and phy- sicians including the short and long term safety of the medication, the place that it would have in the therapeutic armamentarium in Crohn’s disease patients, and indications and safety of re-infusions. Such concerns were based at least partly, on the limited number of patients with Crohn’s disease that had been treated in clinical trials. The experi- ence at the Mayo Clinic is welcomed and timely. Until controlled information is available, it expands the informa- tion available as to the safety of infliximab, and also opens the door for newer indications. The safety, tolerability and effectiveness in the first 100 patients treated at the Mayo Clinic, parallels the observations gathered from clinical trials. It is remarkable that in only two patients the drug had to be discontinued because of side effects. It also shows that the main side effects appear to be infectious complications, rather than neoplasia. Medicine has come a long way in the past 3 decades: Burril Crohn once wrote of Crohn’s disease in a textbook published in 1969 (5) that “a specific conservative or med- ical approach does not exist; the long, slowly downward course cannot be interfered with or changed by any method now known.” We have come a long way since then. Cer- tainly these are exciting and hopeful times for patients, researchers and clinicians caring for IBD patients. With better understanding of the disease process, closer collabo- ration with basic scientist and pharmaceutical industry, and the development of new treatment modalities, the future is brighter for patients with Crohn’s disease. Aaron Brzezinski, M.D. Center for Inflammatory Bowel Disease The Cleveland Clinic Foundation Cleveland, Ohio REFERENCES 1. Truelove SC, Witts LJ. Cortisone and corticotrophin in ulcer- ative colitis. BMJ 1959;1:387–94. 2. Present DH, Wisch N, Glass JL, et al. The efficacy of immu- nosuppressive therapy in Crohn’s disease. A randomized long term double blind study. Gastroenterology 1977;93:1114. 3. Targan SR, Hanauer SB, van Derventer SJH, et al. A short-term study of chimeric monoclonal antibody cA2 to tumor necrosis factor alpha for Crohn’s disease. N Engl J Med 1997;337:1029 – 35. 4. Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999;340:1398 – 405. 5. Paulson M, ed. Gastroenterological medicine. Philadelphia: Lea and Febiger, 1969. Reprint requests and correspondence: Aaron Brzezinski, M.D., Cleveland Clinic, Ctr. for Inflammatory Bowel Disease, Desk S-40, 9500 Euclid Avenue, Cleveland, OH 44195. Received Nov. 9, 2000; accepted Dec. 6, 2000. Incidental Gallbladder Cancer Gallstone disease (GSD) is prevalent all over the world. Cholecystectomy is one of the most common operations performed by a general surgeon. Most cholecystectomies are performed laparoscopically, and the patients are dis- charged on the first or second postoperative day. Gallblad- der cancer (GBC) is the most common biliary tract malig- nancy. The characteristic clinical features of GBC include dull continuous right upper abdominal pain, loss of appetite and weight, jaundice and vomiting (caused by biliary and gastric outlet obstruction), and a hard gallbladder mass (1). These are, however, features of advanced GBC; early GBC may be asymptomatic, have nonspecific symptoms, or symptoms indistinguishable from GSD (2). A 40-yr-old woman had an attack of biliary colic— ultra- sonography revealed gallstones. She underwent an unevent- ful laparoscopic cholecystectomy and was discharged on the second postoperative day. Histopathology of the gall- bladder revealed adenocarcinoma. What should be done? Incidental (also called occult, subclinical, inapparent, or unexpected) GBC is defined as one unrecognized before or at operation and detected for the first time on histological examination of gallbladder removed for presumed (clinical, ultrasound, and operative) diagnosis of GSD. At the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Luc- know, India, a total of about 2600 cholecystectomies were performed between 1989 and 1999 for presumed GSD; of these, 25 (1%) had an incidental GBC. These formed 7% of 358 patients with GBC operated during the same period. The management of GBC depends upon the stage of the disease. The stage in incidental GBC is primarily decided by the depth of invasion (T) because information about nodal involvement (N) may not be available. If the cystic lymph node is not included in the specimen or, even if it is, and is negative for metastasis, other nodes may still be involved. There is, however, a correlation between T and N. For disease beyond muscularis propria (T2 and T3), ex- tended cholecystectomy is recommended as lymph nodes are involved in about 60% and 80% of patients, respectively (3). Shirai et al. (4) reported that 23 of 41 patients with T2 and T3 disease had local recurrence after simple cholecys- tectomy; 5-yr survival in T2 lesions was 90% after extended cholecystectomy as compared with only 40% after simple cholecystectomy. In another report, 13 of 25 patients with involvement of the entire thickness of the gallbladder wall (T2 and T3) had local recurrence after simple cholecystec- tomy (5). Three-year survival in patients with T2 and T3 GBC was 91% after extended cholecystectomy versus only 28% after simple cholecystectomy (6). 627 AJG – March, 2001 Editorials