Peroral cholecystoscopy with electrohydraulic lithotripsy for treatment of symptomatic cholelithiasis in end-stage liver disease (with videos)

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.

Gallstone Disease in Cirrhosis-Pathogenesis and Management

Gallstones are more common in patients with cirrhosis of the liver, and the incidence increases with severity of liver disease. Pigment stones are the most frequent type of gallstones (GSs) in cirrhotics, and majority remain asymptomatic. Hepatitis C virus infection and nonalcoholic fatty liver disease are the underlying etiologies of liver diseases that most often associated with GSs. Multiple altered mechanisms in cirrhosis such as chronic hemolysis due to hypersplenism, reduced bile acid synthesis and transport, decreased cholesterol secretion, decreased apolipoprotein A-I and A-II secretion, gallbladder hypo-motility, autonomic dysfunction, and portal hypertension collectively lead to increased risk of lithogenesis. Asymptomatic GSs should be followed up closely and offered laparoscopic cholecystectomy once symptomatic in Child-Pugh class A and B patients. The model for the end-stage liver disease score is the best predictor of the outcome after cholecystectomy. In patients of Child-Pugh class C, conservative or minimally invasive approaches should be used to treat complications of GSs.

Feasibility of per-oral cholecystoscopy and advanced gallbladder interventions after EUS-guided gallbladder stenting (with video)

BACKGROUND AND AIMS

The recent development of EUS-guided gallbladder drainage (EGBD) with a lumen-apposing stent has made endoscopic assessment and advanced gallbladder interventions via the stent possible. The aim of this study was to assess the feasibility and safety of per-oral cholecystoscopy and the types of gallbladder interventions that can be performed.

METHODS

This was a retrospective review conducted in the Prince of Wales Hospital from June 2012 to March 2016. All patients who had acute cholecystitis with EGBD were included. Cholecystoscopy was performed 1 to 3 months after stent insertion. Patients' demographic data, technical success, types of intervention, and adverse events were recorded.

RESULTS

Twenty-nine cholecystoscopies were performed in 25 patients. Twenty-seven of 29 cholecystoscopies were successful (93.1%). Magnifying endoscopy was performed in 10 patients, confocal endomicroscopy and EUS in 1 patient, and endocytoscopy in another patient. Fourteen patients (56%) had spontaneous stone passage. Eleven patients (44%) had residual gallstones on cholecystoscopy, and removed in 8. Overall stone clearance rate was 88% after a mean (standard deviation) number of 1.25 (0.46) sessions of cholecystoscopy.

CONCLUSIONS

Per-oral cholecystoscopy and advanced gallbladder interventions were feasible and safe. This opens up exciting possibilities for endoscopic treatment of gallbladder pathologies.

[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.