Feasibility of transgastric endoscopic gallbladder-preserving surgery for benign gallbladder diseases (with video)

Endoscopic retrograde cholangiopancreatography combined with extracorporeal shock wave lithotripsy for the removal of large gallbladder stones: a pilot study

BACKGROUND

Endoscopic gallbladder-preserving cholecystolithotomy (EGPC) has become an alternative option for treating cholecystolithiasis. However, developing a new method of EGPC in which the gallbladder wall is not damaged remains a challenge. This study introduced a new EGPC method called endoscopic retrograde cholangiopancreatography (ERCP) combined with extracorporeal shock wave lithotripsy (ESWL), which preserves the integrity of the gallbladder wall in the treatment of cholecystolithiasis complicated with choledocholithiasis.

METHODS

In total, six patients (aged 23-72 years, 3 males and 3 females, Han ethnicity) who had large gallbladder stones (diameter ≥ 1 cm) complicated with common bile duct (CBD) stones and who underwent ERCP combined with ESWL at the First Affiliated Hospital of Nanchang University from July 2022 to December 2022 were enrolled. The patients' clinical characteristics, endoscopic treatment and follow-up data were analyzed. A paired t test was performed to compare the differences in the main serological indicators before and after EGPC.

RESULTS

Of the six patients, five completed EGPC, and one failed due to intolerable abdominal pain during ESWL and was subsequently transferred to surgery. With respect to post-EGPC adverse events, one patient developed mild post-ERCP pancreatitis, and no other adverse events occurred. Both the technical success rate and clinical success rate of ERCP combined with ESWL were 83.3% and the incidence of adverse events was 16.7%. The six patients were followed up for an average of 24 months, during which only one patient experienced a recurrence of gallbladder stones at the 3-month follow-up, but no gallbladder stones were found at the 6-month follow-up after oral administration of ursodeoxycholic acid.

CONCLUSIONS

ERCP combined with ESWL is a potentially safe and effective treatment for large gallbladder stones.

TRIAL REGISTRATION

This study was registered at the Chinese Clinical Trial Registry site. [Registration number: ChiCTR2200060927 ( http://www.chictr.org.cn/ ); registration date: June 14, 2022].

Safety and Efficacy of Ultrasound-Guided Radiofrequency Ablation in the Treatment of Gallbladder Polyps

RATIONALE AND OBJECTIVES

To investigate the safety and efficacy of ultrasound-guided radiofrequency ablation (RFA) in the treatment of gallbladder polyps.

MATERIALS AND METHODS

A retrospective analysis was conducted on the medical records of 296 patients diagnosed with gallbladder polyps. The study observed the changes in lesions post-procedure within the ablation group, and compared whether there was a difference in the gallbladder contraction rate in patients before and after ablation. It also compared the liver function indicators before and after surgery, some indicators during the periprocedural period, and the incidence of complications in two groups of patients.

RESULTS

In the ablation group, all lesions (84/84) were completely ablated, and the absorption effect of the ablation lesions was good after the ablation. No significant differences were observed in the gallbladder contraction rate before ablation compared to 1 month and 3 months post-ablation (p > 0.05). After the operation, statistically significant differences were observed in ALT and TP between the two groups (all p < 0.05). Significant differences were observed between the two groups in terms of hospital stay, procedural time, postprocedural mobilization time, postprocedural exhaust time, postprocedural eating time, and VAS score on postprocedural day 3 (all p < 0.05). There was no significant difference in the incidence of complications between the two groups (x2=0.477，p = 0.490).

CONCLUSION

Our findings demonstrate that ultrasound-guided RFA is a safe, effective, and feasible treatment for gallbladder polyps, as it not only effectively eliminates the polyps but also preserves the physiological functions of the gallbladder.

Gallbladder polypoid lesions: Current practices and future prospects

ABSTRACT

Gallbladder polypoid lesions (GPLs) refer to any elevated lesion of the mucosal surface of the gallbladder wall, and the prevalence is estimated to be between 0.9% and 12.1%. GPLs include benign polyps and malignant polyps. Benign polyps are further classified as non-neoplastic polyps and neoplastic polyps. Cholesterol polyps are the most common benign polyps and adenocarcinoma is the main type of malignant polyp. Hepatitis B virus infection, liver function abnormalities, dyslipidemia, and obesity are the main risk factors for GPLs. Studies of biological mechanisms have focused on malignant gallbladder polyps, the development of which is regulated by hormone levels in vivo , gut microbiota, inflammation, oxidative stress, Salmonella typhimurium , and related molecules. Diagnostic modalities include chemical examination and imaging examination, with imaging examination currently being the mainstay. Treatment of patients with GPLs is based on the presence or absence of symptoms, age, size of the polyps, tendency of the polyp to increase, and risk factors for symptomatic malignancy to determine whether surgery should be performed.

Current considerations for the surgical management of gallbladder adenomas

Gallbladder adenomas are rare lesions (0.5%) associated with potential malignant transformation, particularly with gallbladder adenomas that are ≥ 1 cm in size. Early detection and management are crucial for preventing lethal carcinoma development. These polyps can often be distinguished from the more often nonneoplastic cholesterol pseudopolyps (5%-10%), which are benign. Ultrasonography is the first-line tool for initial diagnosis and follow-up when indicated. The question is whether cholecystectomy is always necessary for all adenomas. The management of gallbladder adenomas is determined according to the size of the tumor, the growth rate of the tumor, the patient's symptoms and whether risk factors for malignancy are present. Adenomas ≥ 1 cm in size, an age > 50 years and a familial history of gallbladder carcinoma are indications for immediate laparoscopic cholecystectomy. Otherwise, ultrasound follow-up is indicated. For adenomas 6-9 mm in size, the absence of ≥ 2 mm growth at 6 months, one year, and two years, as well as an adenoma sized < 5 mm without existing risk factors indicates that no further surveillance is required. However, it would be preferable to individualize the management in doubtful cases. Novel interventional modalities for preserving the gallbladder need further evaluation, especially to determine the long-term outcomes.

Advances in the management of gallbladder polyps: establishment of predictive models and the rise of gallbladder-preserving polypectomy procedures

Gallbladder polyps are a common biliary tract disease whose treatment options have yet to be fully established. The indication of "polyps ≥ 10 mm in diameter" for cholecystectomy increases the possibility of gallbladder excision due to benign polyps. Compared to enumeration of risk factors in clinical guidelines, predictive models based on statistical methods and artificial intelligence provide a more intuitive representation of the malignancy degree of gallbladder polyps. Minimally invasive gallbladder-preserving polypectomy procedures, as a combination of checking and therapeutic approaches that allow for eradication of lesions and preservation of a functional gallbladder at the same time, have been shown to maximize the benefits to patients with benign polyps. Despite the reported good outcomes of predictive models and gallbladder-preserving polypectomy procedures, the studies were associated with various limitations, including small sample sizes, insufficient data types, and unknown long-term efficacy, thereby enhancing the need for multicenter and large-scale clinical studies. In conclusion, the emergence of predictive models and minimally invasive gallbladder-preserving polypectomy procedures has signaled an ever increasing attention to the role of the gallbladder and clinical management of gallbladder polyps.

Update on the natural orifice transluminal endoscopic surgery for gallbladder preserving gallstones therapy: A review

Cholecystectomy remains the "gold standard" for the management of symptomatic gallstones. Minimally invasive laparoscopic cholecystectomy has been the treatment of choice for the past 3 decades. However, the technique of natural orifice transluminal endoscopic surgery cholecystolithotomy is evolving, with some experts advocating gallbladder stone removal without gallbladder excision in order to preserve gallbladder function and eliminate post-cholecystectomy syndromes, including complications of the surgical incision, bile duct injury, functional gastrointestinal, and psychological conditions, and possibly an increase in colon cancer. In addition, transluminal endoscopic cholecystolithotomy is an option for elderly patients who are not suitable candidates for open surgery and those who desire scar-free minimally invasive surgery with organ preservation. This article summarizes the established pure natural orifice transluminal endoscopic surgery gallbladder preserving gallstone removal techniques and highlights the pros and cons of different popular available endoscopic approaches to gallstone therapy and how flexible endoscopic surgery via the natural orifice is compared to the well-established cholecystectomy.

Gallbladder-preserving cholecystolithotomy

INTRODUCTION

Cholecystectomy is the preferred option for symptomatic gallstones. Gallbladder-preserving cholecystolithotomy (GPC) is proposed to satisfy the specific surgical patients with high-risks, biliary deformity and suffered from concomitant gallstone and choledocholithiasis.

AREAS COVERED

This review summarizes and compares the various GPC operations for cholelithiasis in some specific cases.

EXPERT OPINION

Transmural GPC mainly focuses on the gallstones, including endoscopic minimally invasive cholecystolithotomy (EMIC)-, natural orifice transluminal endoscopic surgery-, and endoscopic ultrasonography (EUS)-GPC. These GPC procedures potentially preserve gallbladder integrity and function after clearance of gallstones. Additionally, transmural GPC may overcome the disadvantages of cholecystectomy, including cosmetic considerations and postoperative complications. However, the stone recurrence rate of EMIC varies greatly from 4.92% to 40.0%, and based on limited studies, long-term adverse events due to gallbladder mucosa and natural lumen injury are largely unknown in transmural GPC. Thus, transmural GPC may be an alternative to cholecystectomy for surgical patients with high-risks and abnormal biliary anatomy. Endoscopic retrograde cholangiopancreatography-based transcystic GPC may be promising for some specific patients with concomitant gallstones and choledocholithiasis, since gallbladder integrity and function may be completely preserved as the gallbladder wall was hardly injured and the function of sphincter of Oddi was retained.