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

Endoscopic Transpapillary Gallbladder Drainage for Recurrent Cholecystitis after Covered Self-expandable Metal Stent Placement for Unresectable Malignant Biliary Obstruction

A 76-year-old woman with advanced pancreatic cancer developed recurrent cholecystitis after covered self-expandable metal stent (CSEMS) placement. The cholecystitis was refractory to repeated percutaneous transhepatic gallbladder drainage (PTGBD). Cholecystography showed a patent cystic duct with right and cranial side bifurcation, which is indicative of an increased likelihood of success of endoscopic transpapillary gallbladder drainage (ETGBD). We were able to manage the cholecystitis by ETGBD without further recurrence. ETGBD is considered an effective internal drainage method for the management of acute cholecystitis after CSEMS placement, and its indication may be decided on the basis of the findings of cholecystography through the PTGBD route.

Current status of endoscopic management of cholecystitis

Laparoscopic cholecystectomy remains the standard treatment for acute cholecystitis (AC) although it is always not suitable for patients who are poor candidates for surgery. Recently, endoscopic gallbladder (GB) drainage was found to be a potentially revolutionary alternative for cholecystectomy for the control of symptoms, definitive treatment, or bridging therapy until surgery is possible. Two endoscopic methods have been established using either the trans-mural or trans-papillary drainage approach. Endoscopic ultrasound-guided GB drainage (EUS-GBD; trans-mural approach) is a novel technique that allows stent placement between the GB and duodenum or stomach via fistula track, effectively enabling GB drainage. For endoscopic trans-papillary GB drainage (ETGBD; trans-papillary approach), attempts of selective cannulation to the cystic duct should be made to place the stent in the same manner as an endoscopic retrograde cholangiopancreatography. In comparison, EUS-GBD has higher clinical success and lower recurrence rates than ETGBD due to the use of larger-caliber stents, which allow for effective drainage when performed by skilled practitioners at high-volume centers. Advantages of ETGBD over EUS-GBD include more affordable costs and physiologic drainage, which preserves naive anatomy for possible future cholecystectomy. Although the field of endoscopic treatment for AC is rapidly advancing, important questions regarding which method improves clinical outcomes and safety more effectively remain unaddressed. Herein, the current status of endoscopic treatment for AC, including a technical review on clinical outcomes, adverse events, and advantages and disadvantages of each technique are reviewed, as well as other future prospects.

Factors influencing failure to undergo interval cholecystectomy after percutaneous cholecystostomy among patients with acute cholecystitis: a retrospective study

Background

Percutaneous cholecystostomy (PC) with interval cholecystectomy is an effective treatment modality in high-risk patients with acute cholecystitis. However, some patients still fail to undergo interval cholecystectomy after PC, with the reasons rarely reported. Hence, this study aimed to explore the factors that prevent a patient from undergoing interval cholecystectomy.

Methods

Data from patients with acute cholecystitis who had undergone PC from January 1, 2017 to December 31, 2019 in our hospital were retrospectively collected. The follow-up endpoint was the patient undergoing cholecystectomy. Patients who failed to undergo cholecystectomy were followed up every three months until death. Univariate and multivariate analyses were performed to analyze the factors influencing failure to undergo interval cholecystectomy. A nomogram was used to predict the numerical probability of non-interval cholecystectomy.

Results

Overall, 205 participants were identified, and 67 (32.7%) did not undergo cholecystectomy during the follow-up period. Multivariate analysis revealed that having a Tokyo Guidelines 2018 (TG18) grade III status (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.27–11.49; p = 0.017), acalculous cholecystitis (OR: 4.55; 95% CI: 1.59–12.50; p = 0.005), an albumin level < 28 g/L (OR: 4.15; 95% CI: 1.09–15.81; p = 0.037), and a history of malignancy (OR: 4.65; 95% CI: 1.62–13.37; p = 0.004) were independent risk factors for a patient’s failure to undergo interval cholecystectomy. Among them, the presence of a history of malignancy exhibited the highest influence in the nomogram for predicting non-interval cholecystectomy.

Conclusions

Having a TG18 grade III status, acalculous cholecystitis, severe hypoproteinemia, and a history of malignancy influence the failure to undergo cholecystectomy after PC in patients with acute cholecystitis.

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.

Safety and Efficacy of Percutaneous Gallstone Extraction in High-Risk Patients: An Alternative to Cholecystectomy or Long-Term Drainage?

BACKGROUND

Acute cholecystitis in nonsurgical candidates is often managed with cholecystostomy tube drainage. After symptom resolution, management options include cholecystectomy, long-term tube drainage, or tube removal. Percutaneous cholecystolithotomy (PCCL) can offer another therapeutic option for patients who are poor operative candidates.

STUDY DESIGN

A retrospective study of PCCL performed between December 2000 and September 2017 was conducted. Demographic characteristics, procedure details, gallstone-related complications, procedure-related complications, readmission, and mortality data were collected.

RESULTS

Seventy-five patients were identified (52.0% male, 48.0% female, mean ± SD age 75.6 ± 13.9 years). Mean ± SD follow-up time was 2.8 ± 3.7 years. Most of the patients (90.7%) had an American Society of Anesthesiologists physical status classification of 3 or 4. Eleven patients (14.7%) had failed earlier cholecystectomy. A total of 96 PCCL procedures were performed, and complete gallstone removal was achieved in 68 of 75 patients (90.7%), including all patients with previously aborted cholecystectomy. The 30-day and 90-day readmission rates were 4% and 8%, respectively. Three patients (3.9%) subsequently underwent cholecystectomy after PCCL. Ten (10.4%) procedure-related complications (Clavien-Dindo grade I and II) and 17 (22.7%) gallstone-related complications occurred during the follow-up period. Postprocedural choledocholithiasis occurred in 6 patients (8.0%). Recurrent gallstones developed in 5 patients (6.3%) (3 patients undergoing cholecystectomy and 2 patients treated with cholecystostomy tube).

CONCLUSIONS

PCCL is a viable option for management of symptomatic gallbladder stones in high-risk surgical patients. There is a high technical success rate, even in patients with earlier failed cholecystectomy. Most patients (77.3%) avoided gallstone-related complications after the procedure.

First in-Human Gallbladder Cryoablation in a Patient with Acute Calculous Cholecystitis Initially Treated with a Cholecystostomy Tube

A 71-year-old poor surgical candidate with acute calculous cholecystitis was initially managed with cholecystostomy tube drainage for 28 days. He subsequently underwent gallbladder cryoablation under moderate sedation with 3 cryoprobes and 2 separate 10-8-10 freeze-thaw cycles targeting the gallbladder neck/body and fundus followed by cholecystostomy tube removal. He was discharged 1 day after ablation. Magnetic resonance and hepatobiliary iminodiacetic acid scan 1 month postablation demonstrated a thick-walled, distended gallbladder and no filling of the cystic duct. Magnetic resonance 3 months postablation demonstrated retraction of the gallbladder wall with luminal collapse. The patient denied any pain after discharge and is asymptomatic 3 months after ablation.

Acalculous Cholecystitis in Burn Patients: Is There a Role for Percutaneous Cholecystostomy?

Although acute acalculous cholecystitis is uncommon in burn patients, this condition can be rapidly fatal due to delays in diagnosis and treatment and should always be considered in the differential diagnosis when burn patients become septic, develop abdominal pain, or have hemodynamic instability. This article reviews the use of percutaneous cholecystostomy in burn patients as both a diagnostic and therapeutic intervention.

Endoscopic Management of Gallbladder Stones: Can We Eliminate Cholecystectomy?

The gold standard for the management of acute cholecystitis is laparoscopic cholecystectomy. In patients that are not fit for surgery, percutaneous cholecystostomy is the standard treatment. However, the procedure is only a temporary measure for controlling gallbladder symptoms and it is frequently associated with morbidities. Recently, endoscopic options for management of acute cholecystitis have been developed. The approach avoids the need for a percutaneous drain and may allow endoscopic treatment of the gallstone. The aim of this article is to provide an overview on the current status of endoscopic management of acute cholecystitis.

Laparoscopic hepaticoplasty using gallbladder as a subcutaneous tunnel for hepatolithiasis

AIM: To investigate the feasibility, efficacy and safety of laparoscopic hepaticoplasty using gallbladder as subcutaneous tunnel and sphincter-of-Oddi preservation for hepatolithiasis.

METHODS: From January 2010 to July 2013, six patients with hepatolithiasis were treated at our institution. All the patients underwent laparoscopic surgery. The procedures included common hepatic duct exploration, stone clearance by fiberoptic choledochoscopy, hilar bile duct hepaticoplasty with preservation of the sphincter of Oddi, anastomosis between the hilar bile duct and neck of the gallbladder, and establishment of a subcutaneous tunnel with the gallbladder. Two patients underwent left lateral hepatectomy simultaneously. Clinical data including operation time, intraoperative blood loss, operative morbidity, hospital mortality, stone clearance, and recurrence rate were analyzed.

RESULTS: All patients successfully completed laparoscopic surgery. The mean length of hospital stay was 4.5 ± 0.9 d (range: 3-6 d). The mean blood loss of the hepatectomy was 450 mL (range: 200-700 mL), and the blood loss of the other four was 137 ± 151 mL (range: 50-400 mL). The mean operative time was 318 ± 68 min (range: 236-450 min). The operative morbidity and hospital mortality were zero. The immediate stone clearance rate was 100%. All patients were followed up for an average of 17 mo (range: 7-36 mo). One of the six patients had abdominal mass with pain, and subcutaneous tunnel cholangiography showed severe gallbladder-biliary anastomotic stricture at 4 mo postoperatively. There was no stone recurrence and no cholangitis during follow-up.

CONCLUSION: Laparoscopic hepaticoplasty using gallbladder with a subcutaneous tunnel and preserving the sphincter of Oddi is feasible, safe and effective for hepatholithiasis.

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.

Feasibility and safety of functional cholecystectomy by pure NOTES: a pilot animal study

BACKGROUND

NOTES cholecystectomy has become one of the hottest areas of research. But most of the cases need the assistance of the laparoscope. This study is conducted to evaluate the feasibility and safety of a newly proposed operative method-functional cholecystectomy by pure NOTES.

MATERIALS AND METHODS

The functional cholecystectomy was performed on eight female miniature pigs. An incision was made on the vaginal wall, and an endoscope was inserted into the peritoneal cavity to create a pneumoperitoneum to expose the intra-abdominal viscera, gallbladder, and cystic duct. The cystic duct was isolated and closed with a clip. Then, an injection needle was inserted into the gallbladder to suck up the bile. After the gallbladder was washed with saline, an incision was made on the wall of the gallbladder, and the tip of the endoscope was inserted into the gallbladder cavity. After the endoscope was withdrawn, the gallbladder incision was closed with clips in four pigs and was suspended in the other four pigs. The vaginal incision was closed with clips. All the animals were closely monitored and euthanized 28 days after the procedure. Necropsy was performed.

RESULTS

The functional cholecystectomy was successfully completed in all eight pigs. No severe intraoperative complications occurred. The animals recovered well postoperatively. At necropsy, no macroscopic signs of intraperitoneal infection or bile leakage in the peritoneal cavity were observed, and the clips were still present on the cystic duct in a good position in all cases. The gallbladder incision healed, with no sign of bile leakage or injury to the adjacent organs.

CONCLUSIONS

We successfully performed the functional cholecystectomy by transvaginal approach on pigs, which appears to be feasible, safe, and convenient. Functional cholecystectomy provides a new fitting path to pure NOTES.

[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.

Multimodality imaging following 90Y radioembolization: a comprehensive review and pictorial essay

Radioembolization with yttrium 90 (90Y) microspheres represents an emerging transarterial therapy for the treatment of liver malignancies that continues to generate interest in the medical community. The classic indication of treatment response is a reduction in tumor size; however, parenchymal changes (eg, necrosis, lack of enhancement, specific findings at positron emission tomography and functional magnetic resonance imaging) and other benign findings (pleural effusions, perivascular edema, contralateral hypertrophy, ring enhancement, perihepatic fluid, fibrosis) may occur following treatment, requiring proper image interpretation. With classic imaging findings and surrogates (time to progression, duration of response, disease-free interval), response rates range from 20% to 80% in patients treated for hepatocellular carcinoma or metastatic disease to the liver. Complications of 90Y radioembolization include cholecystitis, abscess, and bilomas and should be recognized early in the imaging follow-up of these patients. Radiologists who are involved in the posttreatment assessment of patients undergoing 90Y radioembolization should be familiar with the imaging findings and potential imaging pitfalls associated with this therapy.