Percutaneous ablation of gallstones

A new experimental model of calculous cholecystitis suitable for the evaluation and training of minimally invasive approaches to cholecystectomy

BACKGROUND

Novel, less invasive approaches such as single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery require preclinical evaluation and training. Therefore, there is a need for an experimental model closely mimicking the clinical situation. The aim of our study was to create an experimental model of calculous cholecystitis in a large laboratory animal and test its feasibility for the evaluation of different techniques of cholecystectomy.

METHODS

In 11 laboratory pigs, gallstones were placed inside the gallbladder laparoscopically. Levels of inflammatory markers-leucocytes (WBC), C-reactive protein (CRP) and interleukin 6 (IL-6)-were monitored on the postoperative days (POD) 1, 2, 3, 7 and 30. Abdominal ultrasound was performed 2 and 4 weeks after the operation. Four weeks after the lithiasis induction, laparoscopic cholecystectomy was performed. The control group consisted of ten healthy animals in which a cholecystectomy was performed. The pigs were monitored for 30 days after surgery. All removed gallbladders were assessed histologically.

RESULTS

The induction of lithiasis took 42 (35-52) min with no morbidity and mortality. The values of WBC, CRP and IL-6 increased significantly (vs. baseline) on POD 1, 2 and 3 (p < 0.05) and then normalised. Ultrasonography confirmed the presence of chronic calculous cholecystitis in all cases after 4 weeks. Laparoscopic cholecystectomy was significantly longer in animals with lithiasis, 63 (42-91) versus 46 (31-62) min (p = 0.018). Perioperative gallbladder wall perforation was significantly more frequent in the model group (8/11 vs. 1/10; p = 0.04). In contrast to healthy animals, all gallbladders with stones showed histological signs of chronic inflammation.

CONCLUSIONS

A new animal model of calculous cholecystitis was created. Laparoscopic cholecystectomy was more technically difficult compared to operating on a healthy gallbladder. This model may be a suitable tool for effective preclinical training and also for the evaluation of different techniques of cholecystectomy.

The percutaneous rotary lithotrite: a new approach to the treatment of symptomatic cholecystolithiasis

This report evaluates the use of a new device for destruction of gall stones, the Kensey-Nash Lithotrite (Baxter Corporation, California, USA). The principle of the instrument is that of a liquidiser with an impeller that emulsifies stones. Twenty five patients were treated; 13 patients were considered unfit for conventional treatment (complex group) and 12 elected to have the procedure (non-complex group). In the complex group nine patients were treated under local anaesthesia. Only six of the 13 patients had a clear gall bladder at the end of the first procedure, but after further treatments that included cholecystoscopy, endoscopic sphincterotomy, and percutaneous cholecystolithotomy 11 patients had a gall bladder free of stones. The morbidity was high, mainly due to pain and bile leaks, causing prolonged stays in hospital (median 18 days). In the non-complex group six patients had the procedure performed under local anaesthesia. Ten patients had a successful clearance of the gall bladder, and the remaining two patients had the stones removed at cholecystoscopy. Despite good clearance, the morbidity was high, with eight emergency admissions on account of complications and a prolonged duration of stay (median 13 days). In conclusion the technique is effective, but the morbidity is high. Further development is required if this technique is to be included in the alternative treatments for the management of gall stones.