Chemical ablation of the gallbladder

Palliative Measures with Ethanol Gallbladder Ablation and Endobiliary Radiofrequency Ablation Followed by Endoscopic Biliary Stent Placement in an Advanced Case of Common Bile Duct Cancer: A Case Report

Endobiliary radiofrequency ablation (RFA) is a procedure performed widely to induce locoregional tumor control by the transfer of thermal energy to the lesion and subsequent tumor necrosis. A 72-year-old male with a prior history of acute calculous cholangitis and perforated cholecystitis was admitted to the Kyungpook National University Hospital complaining of fever and nausea. He had an indwelling percutaneous transhepatic gallbladder drainage (PTGBD) catheter from the previous episode of perforated cholecystitis. An abdominal CT scan showed marked dilation of both the intrahepatic and extrahepatic bile ducts. Common bile duct cancer was confirmed histologically after an endobiliary biopsy. A surgical resection was considered to be the initial treatment option. During open surgery, multiple metastatic nodules were present in the small bowel mesentery and anterior abdominal wall. Resection of the tumor was not feasible, so endobiliary RFA was performed prior to biliary stenting. Cholecystectomy was required for the removal of the PTGBD catheter, but the surgical procedure could not be performed due to a cystic ductal invasion of the tumor. Instead, chemical ablation of the gallbladder (GB) with pure ethanol was performed to breakdown the GB mucosa. Palliative treatment for a biliary obstruction was achieved successfully using these procedures. In addition, a PTGBD catheter was removed successfully without significant side effects. As a result, an improvement in the patient's quality of life was accomplished.

Internal biliary drainage for isolated posterior segmental biliary obstruction: a case report

Background

Biliary system anatomical abnormalities can be preoperatively detected on magnetic resonance imaging; therefore, some presume that the number of bile duct injuries should decline. However, once a bile duct injury occurs, repair may be difficult. There are various ways to repair bile duct injuries, but successful repair may be exceptionally difficult.

Case presentation

A 72-year-old Japanese man underwent a pancreaticoduodenectomy due to a diagnosis of middle bile duct cancer. We had a complication of an isolated posterior segmental biliary obstruction when pancreaticoduodenectomy was performed. We conducted a drip infusion cholecystocholangiography-computed tomography test to determine the positional relationship between his bile duct and elevated jejunum. To secure the bile duct we punctured the bile duct under computed tomography guidance, and the hepaticojejunal anastomosis site was visualized by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle and verified the vibrations with the endoscope. We observed a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion. We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum. We removed all drains after percutaneously inserting an uncovered metallic stent. Our patient’s subsequent clinical course was unremarkable. He visits our institution as an out-patient and has had no stent occlusion even after 6 months.

Conclusions

When repairing bile duct injuries, it is important to accurately determine the positional relationships between the injured bile duct and the surrounding organs.

A Review of Therapeutic Ablation Modalities

Understanding basic science and technical aspects is essential for scientists and engineers to develop and enhance ablative modalities, and for clinicians to effectively apply therapeutic ablative techniques. An overview of ablative modalities, anatomical locations, and indications for which ablations are performed is presented. Specifically, basic concepts, parameter selection, and underlying biophysics of tissue injury of five currently used therapeutic ablative modalities are reviewed: radiofrequency ablation (RFA), cryoablation (CRA), microwave ablation (MWA), high-intensity focused ultrasound (HIFU), and chemical ablation (CHA) (ablative agents: acetic acid, ethanol, hypertonic sodium chloride, and urea). Each ablative modality could be refined for expanding applications, either independently or in combination, for future therapeutic use.

Applying chemical bile duct embolization to achieve chemical hepatectomy in hepatolithiasis: a further experimental study

BACKGROUND

Hepatolithiasis is the presence of calculi within the bile ducts of the liver. It represents a significant problem for hepatobiliary surgery because of its high recurrence rate and the associated risk for partial hepatectomy. This study was designed to explore the long-term efficacy of chemical biliary duct embolization (CBDE) to treat recurrent hepatolithiasis.

MATERIALS AND METHODS

A rabbit model of hepatolithiasis was established, and CBDE was achieved using oxybenzene and N-butyl-cyanoacrylate. The short-term (6 wk) and long-term (12 wk) efficacy of CBDE treatment was compared by observing the degree of atrophy, fibrosis, proliferation of collagen fibers, and apoptosis of hepatocytes and hepatic stellate cells in the embolized hepatic lobe. Biochemical measurement of β-glucuronidase was also evaluated to determine the effect of CBDE on stone formation.

RESULTS

Six weeks after CBDE, there was liver cell destruction, collagen accumulation, and bile duct proliferation only in the peripheral part of the target lobe. Twelve weeks after CBDE, "self-cut" chemical hepatectomy was achieved, as manifested by the destruction of almost all the hepatocytes in the target lobe, bile duct proliferation, and collagen fiber accumulation. The β-glucuronidase activity was markedly lower in the embolized lobe than in the nonembolized lobe. In contrast, bax, caspase-3, caspase-9, and α-smooth muscle actin expression was substantially higher in the embolized lobe than in the sham-operation group at 6 wk, but was lower at 12 wk.

CONCLUSIONS

CBDE is a potentially effective therapeutic approach for treating and preventing the recurrence of hepatolithiasis.

[Gallbladder ablation with a laser in an animal model]

INTRODUCTION

Attempts to remove the gallbladder by non-surgical means began in the 1980's, by applying chemicals, heat or laser to remove its mucosa and reduce it to an innocuous scar. The aim of this work is to determine whether complete ablation of this organ is possible using total ablation by applying a diode laser.

MATERIAL AND METHODS

Thirty rabbits were divided into 3 groups of 10 animals. The gallbladder was surgically accessed and a 980 nm diode laser was applied endoluminally using fibre optics until it shrunk. Ethanol was used as a sclerosing agent plus a fibrin tail to seal the gallbladder lumen in one of the control groups, and a physiological solution was used in the rest. The animals were slaughtered at 65 days and the results of the procedure were observed macroscopically and histologically, evaluating the remains of the gallbladder lumen, fibrosis, and areas of re-epithelialisation. Statistical analysis was made using the Fisher test.

RESULTS

Eight of the gallbladders treated by laser disappeared leaving a small sub-hepatic scar. There were no complications during or after surgery. The results were successful in only case in the ethanol group, and there was no ablation with physiological solution. The comparison of the results showed a significant positive difference in the group treated with laser compared to those with ethanol plus fibrin tail (P<.0055) and the physiological solution (P<.0007).

CONCLUSIONS

Ablation of the gallbladder using a diode laser was possible in this experimental model.

Chemical ablation of the gallbladder using alcohol in cholecystitis after palliative biliary stenting

Chemical ablation of the gallbladder is effective in patients at high risk of complications after surgery. Percutaneous gallbladder drainage is an effective treatment for cholecystitis; however, when the drain tube cannot be removed because of recurrent symptoms, retaining it can cause problems. An 82-year-old woman presented with cholecystitis and cholangitis caused by biliary stent occlusion and suspected tumor invasion of the cystic duct. We present successful chemical ablation of the gallbladder using pure alcohol, through a percutaneous gallbladder drainage tube, in a patient who developed intractable cholecystitis with obstruction of the cystic duct after receiving a biliary stent. Our results suggest that chemical ablation therapy is an effective alternative to surgical therapy for intractable cholecystitis.

Postoperative bile leakage managed successfully by intrahepatic biliary ablation with ethanol

We report a case of postoperative refractory bile leakage managed successfully by intrahepatic biliary ablation with ethanol. A 75-year-old man diagnosed with hepatocellular carcinoma underwent extended posterior segmentectomy including the caudate lobe and a part of the anterior segment. The hepatic tumor attached to the anterior branch of the bile duct was detached carefully and resected. Fluid drained from the liver surface postoperatively contained high concentrations of total bilirubin, at a constant volume of 150 mL per day. On d 32 after surgery, a fistulogram of the drainage tube demonstrated an enhancement of the anterior bile duct. Endoscopic retrograde cholangiography demonstrated complete obstruction of the proximal anterior bile duct and no enhancement of the peripheral anterior bile duct. On d 46 after surgery, a retrograde transhepatic biliary drainage (RTBD) tube was inserted into the anterior bile duct under open surgery. However, a contrast study of RTBD taken 7 mo post-surgery revealed that the fistula remained patent despite prolonged conservative management, so we decided to perform ethanol ablation of the isolated bile duct. Four mL pure ethanol was injected into the isolated anterior bile duct for ten minutes, the procedure being repeated five times a week. Following 23 attempts, the volume of bile juice reached less than 10 mL per day. The RTBD was clamped and removed two days later. After RTBD removal, the patient had no complaints or symptoms. Follow-up magnetic resonance imaging demonstrated atrophy of the ethanol-injected anterior segment without liver abscess formation.

Chemical ablation of the gallbladder: clinical application and long-term observations

BACKGROUND

We investigated whether minicholecystostomy followed by chemical ablation of the gallbladder could be used as a alternative to cholecystectomy in patients at high risk for complications of surgery.

METHODS

From January 1990 through January 2003, 34 patients at high risk underwent minicholecystostomy. Six weeks after the operation, microwave irradiation was provided to burn the mucosa of the cystic duct at locations at 3, 6, 9, and 12 o'clock around the orifice. Each location was treated eight times at 50 mA for 10 sec. Then chemical ablation of the gallbladder was performed by infusing 95% ethanol into the gallbladder cavity for 30 min. For each sclerosis course, the procedure was repeated every 4 h for a total of eight times. Approximately 2 weeks later, the drainage tube was removed from the gallbladder after cholecystography showed that no cavity other than the lumen of the tube remained in the gallbladder.

RESULTS

Patients tolerated the procedure well and were followed with ultrasonography for 2-14 years (mean, 9). Twenty-nine patients had no complications or side effects, and five patients developed a 1.5- to 3- cm mucocele in the gallbladder. The long-term success rate of sclerotherapy was 85.3% (29/34). No recurrent cholecystitis, new stone or formation, canceration were encountered at the site of the gallbladder.

CONCLUSIONS

Minicholecystostomy followed by chemical ablation of the gallbladder was a safe, effective, and simple procedure for treating high-risk patients with acute cholecystitis and/or cholelithiasis.

An experimental study of selective intrahepatic biliary ablation with ethanol

BACKGROUND

Few attempts have been made to investigate the feasibility of selective intrahepatic biliary ablation with absolute ethanol.

METHODS

Through a catheter cannulated into the bile duct of the left lateral and median lobes (70% of total liver weight), 0.2 mL of absolute ethanol was injected into rats.

RESULTS

The weight of the infused lobes decreased to less than 50% of the entire liver weight 14 days after treatment, while the weight of the noninfused lobes increased to 1.6-fold of the original value. This increase was associated with a markedly elevated Ki-67 labeling index. Both bile flow and bile acid excretion in the noninfused lobes significantly increased to more than twice the original values on Day 14. Histologically, the interlobular bile ducts of the infused lobes were destroyed. Ethanol also soaked through Glisson's capsule and destroyed hepatocytes, which were replaced by fibrous tissue and proliferating bile ductules without necrosis by Day 14. The portal veins and hepatic arteries supplying the infused lobes were structurally well preserved throughout the study period.

CONCLUSION

Selective biliary infusion of ethanol can be performed safely without serious complications, achieving lobar ablation with contralateral hypertrophy of the liver.