Gallbladder Cryoablation: Clinical and Technical Considerations

As many as 500,000 cholecystectomies are performed per year in the United States. Frail patients are at higher risk from cholecystectomy, with reported postoperative complication and mortality rates as high as 31 and 5% in patients older than 75 years. Percutaneous cholecystostomy drainage is commonly employed in high-risk patients with cholecystitis, with over 12,000 cases performed annually. Cholecystostomy, however, is not a definitive treatment, with up to 30% of patients having a recurrent episode of cholecystitis within 4 months after tube removal. Gallbladder cryoablation has emerged as a minimally invasive procedure that achieves transmural gallbladder wall necrosis in a single session resulting in gallbladder fibrosis and involution. Early clinical data have been promising, with reported technical success of 86% and clinical success of 100% at up to 500 days of follow-up. Several challenges and unknowns remain, however, including optimal patient selection and procedural technique, the potential need for adjunct procedures to occlude the cystic duct, the implications of the immunostimulatory effects of cryoablation, and the impact of the presence of gallstones on outcomes. This article reviews the rationale behind gallbladder cryoablation, updates early clinical outcomes, and discusses the challenges that remain for the adoption of the technique for the treatment of benign gallbladder disease.

The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Cholecystoduodenal Fistula

Large gallstones could erode through gallbladder wall to nearby structures, causing fistulas, gastric outlet obstruction and gallstone ileus. They typically occur in elderly patients with comorbidities carrying therapeutic challenges. We present a case of a middle-aged woman who was thought to have symptomatic cholelithiasis. Extensive adhesions precluded safe cholecystectomy. While hepatobiliary iminodiacetic acid scan and magnetic resonance imaging with cholangiopancreatography (MRI-MRCP) failed to visualize the gallbladder, computed tomography (CT) was consistent with cholecystoduodenal fistula. A very large gallstone was seen endoscopically in the duodenum, which was broken down into pieces using a large stiff snare.

Risk Factors for Early Recurrence of Gallstones in Patients Undergoing Laparoscopy Combined With Choledochoscopic Lithotomy: A Single-Center Prospective Study

Objective: For patients with gallstones, laparoscopy combined with choledochoscopic lithotomy is a therapeutic surgical option for preservation rather than the removal of the gallbladder. However, postoperative recurrence of gallstones is a key concern for both patients and surgeons. This prospective study was performed to investigate the risk factors for early postoperative recurrence of gallstones.Methods: The clinical data of 466 patients were collected. Each patient was followed up for up to 2 years. The first follow-up visit occurred 4 months after the operation, and a follow-up visit was carried out every 6 months thereafter. The main goal of each visit was to confirm the presence or absence of gallbladder stones. The factors associated with gallstone recurrence were analyzed by univariate analysis and Cox regression.Results: In total, 466 eligible patients were included in the study, and 438 patients (180 men and 258 women) completed the 2-year postoperative follow-up. The follow-up rate was 94.0%. Recurrence of gallstones was detected in 5.71% (25/438) of the patients. Univariate analysis revealed five risk factors for the recurrence of gallstones. Multivariate Cox regression analysis showed that multiple gallstones, a gallbladder wall thickness of ≥4 mm, and a family history of gallbladder stones were the three predictive factors for postoperative recurrence of gallstones (P < 0.05).Conclusion: The overall 2-year recurrence rate of gallstones after the operation was 5.71%. Multiple gallstones, a gallbladder wall thickness of ≥4 mm, and a family history of gallstones were the three risk factors associated with early postoperative recurrence of gallstones.

Xanthogranulomatous Cholecystitis: Our Clinical Experience

Background: Xanthogranulomatous cholecystitis is a rarely encountered chronic inflammatory condition presenting with severely proliferated fibrotic tissue. It usually spreads the neighboring organs, imitates gallbladder cancer and may lead to difficulty in cholecystectomy. Objectives: The present study was directed towards reviewing the results of medical examinations and surgery for xan-thogranulomatous cholecystitis and providing proper surgical treatment for patients with xanthogranulomatous cholecystitis. Methods: This is an observational study in which clinical features of thirty six patients with diagnosis of cholecystitis who were operated in our institute between 2012 and 2019 and found as xanthogranulomatous cholecystitis on pathology were analyzed. Results: The rate of xanthogranulomatous cholecystitis in cholecystectomy patients was found to be 0.6 % (36/5999) in the hospital where this study was performed over 7 years. Xanthogranu-lomatous cholecystitis was not accompanied by gallbladder carcinoma in any of these cases. Xanthogranulomatous cholecystitis could not be diagnosed in any of the patients prior to surgery. Radiological imaging performed before surgery demonstrated cholelithiasis in 29 patients (80.6 %), thickening of the gallbladder wall in 28 patients (77.8%), and suspicious cancer in two patients (5.6%). However, none of the cases of xanthogranulomatous cholecystitis had concomitant gallbladder cancer. Nine (25%) patients underwent open cholecystectomy and Twenty seven patients (75 %) were scheduled to have laparoscopic cholecystectomy, but six of these patients (16,8%) were converted to open cholecystectomy. Conclusion: To conclude, it is still difficult to distinguish xanthogranulomatous cholecystitis from other gallbladder diseases both before and during surgery. The gallbladder commonly adheres to the neighboring organs and tissues and make surgical treatment difficult. A challenging laparoscopy is commonly converted to open surgery, which results in higher rates of complications as compared with standard open or laparoscopic cholecystectomy.