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.

Laparoscopic cholecystectomy in the dog

Cholecystectomy is a procedure used to rectify severe gallbladder disease that is not amenable to medical management. It is most commonly performed in dogs with gallbladder mucocoele, a condition affecting mainly small breeds such as the Border Terrier, Cocker Spaniel and Shetland Sheepdog. Traditionally, this has been done by open laparotomy but, in the human field, where cholecystectomy is a common and routine procedure, laparoscopic cholecystectomy has almost completely superseded open laparotomy, as it has been shown to be safer and have lower rates of morbidity. This article describes a technique for laparoscopic cholecystectomy in the dog as a suitable alternative to open laparotomy.

Laparoscopic cholecystectomy during COVID-19 pandemic- Retrospective analysis of tertiary care centre

INTRODUCTION: Laparoscopic cholecystectomy is the most commonly performed general surgical procedure. During the COVID-19 pandemic, general recommendation worldwide is to postpone elective surgeries as far as possible to decrease the resource utilization and also aerosol-related transmission among hospital staff and patients. We conducted this study to see the burden of gallbladder disease, their management and outcomes of all patients who presented to our centre during first wave of COVID-19 pandemic. METHODS: We conducted a retrospective analysis of all patients who underwent laparoscopic cholecystectomy at the Hospital for Advanced Medicine and Surgery (HAMS) after the commencement of strict lockdown in the first wave of the COVID-19 pandemic. Ethical approval for the study was taken from Nepal Health Research Council. All the surgeries were performed as per HAMS interim policy for infection prevention and control during the COVID-19 pandemic. Data were extracted from the discharge sheet and outcomes in terms of duration of hospitalization, morbidity, mortality, and COVID -19 infection among patient and operating team staff after surgery were assessed. RESULTS: Out of 110 cases operated for gallbladder disease, 90 patients were included in the study with complete data. The most common presentations were dyspepsia (28) and biliary colic (22). Patients were managed with laparoscopic cholecystectomy (79), percutaneous cholecystostomy (4), laparoscopic subtotal cholecystectomy (5), open cholecystectomy (1). The median duration of hospitalization 22 hours. There was no COVID-19 transmission among staff and patients. CONCLUSIONS: Laparoscopic cholecystectomies are feasible during COVID-19 pandemic and safely performed following infection prevention guidelines. It can be still be performed in day case basis to decrease the bed occupancy and avoiding crowd in hospitals.

P-BN17 Laparoscopic subtotal cholecystectomy is a safe and effective treatment for gallstone disease

Background Laparoscopic cholecystectomy is the gold standard treatment of gallstones in fit patients with symptomatic gallbladder disease. If the critical view of safety cannot be achieved intra-operatively, there are few options, one of which is laparoscopic subtotal cholecystectomy. This study aims to ascertain the outcomes of subtotal cholecystectomy. Methods Retrospective review of all patients who underwent laparoscopic subtotal cholecystectomy by a single surgeon over a 5 year period. Results 37 consecutive patients who underwent subtotal cholecystectomy were included in this study; seventeen of which were males (49%); the median age was 69, and 18 were emergencies (49%).The most common reasons for conversion to laparoscopic subtotal cholecystectomy were adhesions (57%) and fibrotic Calot’s triangle (22%). One patient required ERCP and biliary stenting for ongoing bile leak and another returned to theatre for post operative bleeding during index admission. 6 patients (16%) required further hospital admissions for gallstone disease (1 for biliary colic, two for cholecystitis and three for CBD stones). 3 patients required ERCP. None required further gallbladder surgery. Conclusions Laparoscopic subtotal cholecystectomy is a safe and effective alternative to total cholecystectomy when the critical view of safety cannot be achieved. In our experience, only a small proportion of patients have recurrent biliary problems.

Gallbladder perforation with liver abscess; laparoscopic cholecystectomy converted to open: a case report

Gallbladder disease affects more than 20 million people in the United States. Acute cholecystitis is a clinic entity characterized by the inflammation of the vesicular wall that is usually manipulated by abdominal pain, right hypochondrial sensitivity and fever. The technique of choice for the diagnosis of cholecystitis is abdominal ultrasound; gallbladder perforation is a rare complication of acute cholecystitis (2%-11%). The presence of perivesicular abscesses is infrequent, its prevalence varies between 2.1% and 19.5%. Clinical record was reviewed of a 73 years old woman who attended a second level public care unit, with a clinical picture of acute chronic lithiasis cholecystitis, who underwent surgery consisting of open converted laparoscopic cholecystectomy with a finding of vesicular perforation with liver abscess, it was initiated with laparoscopic approach, it was not possible to identify anatomical structures, so it was decided to convert to open surgery. Cholecystectomy and abdominal lavage are usually sufficient in the treatment of gallbladder perforation.

Conversion of laparoscopic cholecystectomy to open cholecystectomy in a single center

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversions to open cholecystectomy are still inevitable in certain cases. Knowledge about the rate and underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decide to review the rate and causes of conversion of our LC series. This study included 320 consecutive laparoscopic cholecystectomies from January 2017 to December 2019 at Community Based Medical College Hospital Bangladesh, Mymensingh. All patients had surgery performed by same surgeon. Conversion to open cholecystectomy required in 15 (4.6%) patients. Out of 15 cases, the highest number of patients 10(66.6%) were in age group 50 to 59 years with a mean age of 60.1 years and standard deviation (SD) of 9.8 years. Of them 9 (60%) were male. The most common reasons for conversion of them were severe adhesions at calot's triangle 6 (40%) and acutely inflamed gallbladder 5 (33.3%), bleeding 2 (13%). No surgical procedures are complication free. The most common complication was superficial wound infection 8(2.5%). Delayed complications seen in our series is port site incisional hernia 2 (0.62%). Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. LC is the preferred method even in difficult cases. This study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands, the surgeons should keep a low threshold for conversion to open surgery. CBMJ 2020 July: Vol. 09 No. 02 P: 14-18

Association of Hospitalization Due to Vaso-Occlusive Crisis with Subsequent Sickle Cell Disease-Related Organ Damage Hospitalization: Retrospective Analysis of 3-Year Observational Study Data

Background: Hospitalization due to vaso-occlusive crisis (H-VOC) is common in individuals with sickle cell disease (SCD), with an increasing occurrence of SCD-related complications, including organ damage, as the disease progresses. Evidence regarding the relationship between H-VOC and SCD-related organ damage, however, is lacking. Aim: To assess whether H-VOC is associated with hospitalization due to SCD-related organ damage, through retrospective analysis of data collected prospectively during a 3-year, multicenter, observational US study (NCT01220115) that aimed to better understand disease burden and management of SCD in individuals aged ≥2 years. Methods: Of the 498 individuals with SCD who were recruited into the US study, data were analyzed from 202 (100 men and 102 women) who were aged ≥16 years and had available hospital admission data. Organ damage was defined based on hospital discharge diagnosis. 1 Variables tested at baseline, in addition to H-VOC, included demographics, blood measures, and treatment history. Age and sex were included by default in all models based on literature suggesting they are relevant factors influencing organ damage. Hazard ratios (HRs) for the time from H-VOC to the first subsequent hospitalization due to SCD-related organ damage were estimated using multivariable Cox regression. Worsening of pre-existing organ damage was not considered as an event due to potential confounding (ie worsening of organ damage related to the pre-existing condition rather than as a consequence of the VOC). Results: During median 3-year follow-up, 55 (27%) individuals experienced at least one hospitalization due to SCD-related organ damage; 2 19 (9%) had multiple visits. Within the 12 months preceding baseline, 22 (11%) individuals had a history of organ damage, there was a median of two H-VOC in the 90 (45%) individuals with history of H-VOC, and 43 (21%) individuals had received chronic transfusion (≥6). History of H-VOC (HR 2.54, 95% confidence interval [CI] 1.46 to 4.43 in past 12 months), genotype (HR 2.69, 95% CI 1.34 to 5.41 for HbSS), and sex (HR 1.90, 95% CI 1.08 to 3.34 for women) were all significantly associated with subsequent hospitalization for SCD-related organ damage. Discussion and conclusion: This analysis demonstrates that history of H-VOC within the preceding 12 months is significantly associated with a higher rate of subsequent hospitalization due to SCD-related organ damage, independent of age, sex, and genotype, and may therefore help identify individuals at high risk of developing organ damage. Despite 21% of individuals receiving chronic transfusions at baseline, this factor did not remain significantly associated with the outcome when also considering genotype and H-VOC. Age and sex were unexpectedly insignificantly associated with the outcome; this is likely due to the relatively short follow-up time. Extending the historical timeframe of organ damage to 5 years did not change our findings, except that age also became significantly associated with subsequent hospitalization for organ damage. Acute chest syndrome and pneumonia were the most common types of historical (baseline) organ damage, whilst gallbladder disease was the most common organ damage observed during the follow-up period that was not observed at baseline. Our data have limited statistical power and generalizability; additional studies are required to confirm these findings. Nevertheless, our findings support the existing evidence of the impact that VOCs may have on individuals with SCD, and highlights the importance of preventing and reducing H-VOC. 1Acute chest syndrome or pneumonia; avascular bone necrosis of hip(s), shoulder(s) or spine; cardiac failure; central nervous system disease (ie abnormal transcranial Doppler, silent infarct, stroke and transient ischemic attack); gallbladder disease; leg ulcer; liver disease (ie hepatic fibrosis/ cirrhosis, hepatic sequestration/sickle-hepatopathy/intrahepatic sickling, pulmonary fibrosis, pulmonary hypertension); priapism; renal disease (ie acute renal failure, chronic renal failure-supportive, dialysis, microalbuminuria/ proteinuria, transplant); retinopathy; and splenic sequestration. 2The top 3 reasons for hospitalization due to SCD-related organ damage were acute chest syndrome or pneumonia (n=29; 53%), renal disease (n=7; 13%) and gallbladder disease (n=6; 11%). Figure 1 Figure 1. Disclosures Heeney: Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; FORMA: Consultancy, Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Vertex / Crispr Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: DSMB; bluebird bio: Consultancy; Keros: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: DSMB; Cyclerion: Consultancy, Membership on an entity's Board of Directors or advisory committees. Pattipaka: Novartis: Current Employment, Current holder of individual stocks in a privately-held company. Fermont: Novartis Pharma AG, Basel, Switzerland: Current Employment, Current equity holder in publicly-traded company.

Accuracy of Endoscopic Transpapillary Gallbladder Drainage with Liquid-Based Cytology for Gallbladder Disease

<b><i>Introduction:</i></b> Gallbladder carcinoma is often difficult to distinguish from benign gallbladder diseases. While the diagnostic accuracy of endoscopic transpapillary gallbladder drainage (ETGD) has been reported, these results were obtained retrospectively. This prospective study aimed to evaluate the cytological diagnostic accuracy of ETGD in patients with gallbladder disease. <b><i>Methods:</i></b> This single-arm prospective clinical trial included a total of 35 patients scheduled to undergo ETGD between March 2017 and September 2019. A 5F pigtail nasobiliary drainage tube was inserted into the gallbladder, and bile was collected over 5 times; if ETGD failed, a drainage tube was placed into the bile duct. The endpoints were, first, the cytological diagnostic accuracy of ETGD and, second, technical success rates and adverse events. <b><i>Results:</i></b> Of the 35 patients, 19 were finally diagnosed with gallbladder cancer. The success rate of ETGD tube insertion was 85.7%, and the morphological pattern of the cystic duct with the angle down and located on the right side had a significantly lower success rate for ETGD than that of other cystic duct patterns (odds ratio, 13.5; 95% confidence interval, 1.7–143.7; <i>p</i> = 0.02). Cytological samples were collected 5 times on median. The sensitivity, specificity, and accuracy in all patients were 78.9%, 100%, and 88.6%, respectively, while those in 30 patients with successful ETGD were 87.5%, 100%, and 93.3%, respectively. Adverse events occurred in 3 patients: mild pancreatitis in 1 patient and obstructive jaundice in 2 patients; all complications were resolved with conservative therapy. <b><i>Discussion/Conclusions:</i></b> Cytology using an ETGD tube is useful in differentiating benign and malignant gallbladder diseases (Clinical Trial Registry No. UMIN000026929).