Ablation of the cystic duct and the gallbladder. Experimental basis and initial clinical observations

Bipolar radiofrequency electrocoagulation of the cystic duct by catheter can be performed safely and reproducibly using fluoroscopic control and induces endoluminal scar formation. The scar within the cystic duct forms a reliable barrier between the gallbladder and the biliary system and avoids recanalization of the cystic duct at a later date. Sclerotherapy of the isolated gallbladder with 95% ethanol and 3% STS can be performed without toxic or otherwise adverse effects and is suitable to ablate the porcine gallbladder. Initial clinical trials with this new technique on a small number of patients are promising and have demonstrated that the protocol can be applied safely to humans. The electrocoagulation technique by catheter appears suitable to ablate the human cystic duct. Follow-up evaluation of our first patients is under way and must determine whether our regimen is appropriate to ablate the human gallbladder on a long-term basis. Further development of this new approach may eventually enable definitive nonoperative treatment of cholecystolithiasis in selected patients.     

Echogenic material in the fetal gallbladder: sonographic and clinical observations.

Obstetric sonograms of 26 fetuses with echogenic material in the gallbladder were reviewed to describe the sonographic findings and clinical significance. Gestational age at the time of diagnosis ranged from 28 to 42 weeks (mean, 36.2 weeks). The echogenic foci were associated with distal shadowing in eight fetuses (30%), comet-tail artifact in nine (35%), and no distal artifact in nine (35%). No hemolytic anemias, other predisposing risk factors, or clinical sequelae associated with biliary tract disease were identified in any of the infants. Postnatal sonographic or pathologic follow-up studies were available in 17 cases. In nine of these 17 infants, the echogenic foci had resolved. In three, the foci have persisted, but none of the children have become symptomatic; the longest period of follow-up with stones still present is 4 1/2 years. Whether all echogenic foci in the fetal gallbladder represent true gallstones remains unknown. Echogenic foci may be seen in the fetal gallbladder during the third trimester. No predisposing fetal risk factors or clinical sequelae were evident in our series. Many echogenic foci, but not all, will resolve.     

Diagnosis of acute cholecystitis: value of contrast agent in the gallbladder and cystic duct on Gd-EOB-DTPA enhanced MR cholangiography

To evaluate value of %volume of contrast agent in gallbladder and contrast in cystic duct in diagnosis of acute cholecysititis with Gd-EOB-DTPA MRC obtained 60 min after contrast injection (T1-MRC60min). We included 16 acute cholecystitis (AC), 23 chronic cholecystitis (CC), and 40 healthy volunteers. Receiver operating characteristic analysis showed cutoff value of 30.5% as predictor of AC comparing with healthy volunteers (sensitivity 93.8%, specificity 100%, AUC 0.958) and cutoff of 0% as predictor of AC comparing CC (sensitivity 81.2%, specificity 82.6%, AUC 0.823). In AC absent or obliterated cystic duct on T1-MRC60min showed 81.3%, 100%, sensitivity and specificity, respectively. These can be helpful for diagnosis of AC.     

Percutaneous chemical gallbladder sclerosis after laser-induced cystic duct obliteration: results in an experimental model.

OBJECTIVE. Chemical gallbladder sclerosis has been attempted as a way to defunctionalize the gallbladder in patients who have undergone nonsurgical removal of gallstones and who are unable to undergo surgical/laparoscopic cholecystectomy. The purpose of this investigation was threefold: to study an animal model for chemical sclerosis of the gallbladder with 95% ethanol and 3% sodium tetradecyl sulfate, to attempt chemical sclerosis immediately after percutaneous cystic duct obliteration by laser thermocoagulation, and to assess histopathologic changes in the gallbladder after sclerosis. MATERIALS AND METHODS. Percutaneous cholecystostomy and laser thermocoagulation of the cystic duct was performed in 13 pigs. Eight pigs underwent immediate gallbladder sclerosis with 95% ethanol and 3% sodium tetradecyl sulfate while two pigs received 95% ethanol only. The remaining three pigs served as controls. The cholecystostomy catheter was removed immediately after the procedure. All animals were sacrificed 6 weeks after laser thermocoagulation. Multiple sections through the gallbladder, which included the adjacent liver, the cystic duct, and the common bile duct, were obtained for histologic examination. RESULTS. At autopsy, the gallbladder in all 10 animals who underwent gallbladder sclerosis was reduced in size compared with controls. In all treated animals, the gallbladder mucosa was denuded; however, in nine of 10 cases reepithelialization had occurred. Complete sclerosis without reepithelialization was achieved in one pig who received both ethanol and sodium tetradecyl sulfate. In the two animals who received ethanol only, the depth of wall necrosis around the gallbladder lumen was less than in those pigs who received both ethanol and sodium tetradecyl sulfate. No pigs showed signs of hepatic necrosis or injury to the common bile duct. CONCLUSION. Cystic duct laser thermocoagulation allows immediate gallbladder sclerotherapy without injury to the common bile duct. Sclerosis with ethanol and sodium tetradecyl sulfate results in denudation of the gallbladder mucosa. However, a single therapeutic session with immediate removal of the cholecystostomy catheter was inadequate for gallbladder ablation in this model because of reepithelialization.     

胆囊管综合征的诊断与治疗

目的:探讨胆囊管综合征(cystic duct syndrome,CDS)的诊断方法及治疗措施.方法:回顾分析36例CDS的临床症状、诊断流程及治疗结果.结果:36例CDS均具有典型的胆绞痛症状.术前常规进行腹部超声、口服胆囊造影等检查,21例行MRCP检查提示胆囊管迂曲、慢性胆囊炎或胆囊积液.12例病程中发现继发性胆囊结石.合并急性化脓性胆囊炎6例.31例顺利实施腹腔镜胆囊切除术,其中2例行经脐单孔腹腔镜胆囊切除术.5例实施开腹胆囊切除术.术中所见及术后病理学检查均支持CDS的诊断.结论:CDS的诊断需综合考虑临床症状、影像学检查、术中发现及术后病理学检查等因素,腹腔镜胆囊切除术是CDS的理想治疗方法.     

嵌顿性胆总管或胆囊管结石的介入性综合治疗

目的 评价多种介入性取石技术综合应用于１组患有嵌顿性胆管结石,且被视为手术高危病人的治疗效果。方法 ９例（男２例,女７例,平均年龄５０．７岁）患者中,６例曾有接受内窥镜下取石失败或手术直视下取石再复发的病史;在发生部位上,计有７例胆总管结石,１例胆囊管结石,１例胆总管合并胆囊管残端结石;多发性结石５例,单发性结石４例;最大结石直径约为３．０ｃｍ。在处理方法上,建立经皮肝胆管和内窥镜下经十二指肠逆向     

The cystic duct: normal anatomy and disease processes.

The cystic duct can be depicted with a variety of imaging modalities but is optimally visualized with direct cholangiography or magnetic resonance cholangiopancreatography. Nevertheless, unrecognized anatomic variants of the cystic duct may cause confusion on imaging studies and complicate subsequent surgical, endoscopic, and percutaneous procedures. Primary entities involving the cystic duct include calculous disease, Mirizzi syndrome, cystic duct-duodenal fistula, biliary obstruction, neoplasia, and primary sclerosing cholangitis. The cystic duct may also be secondarily involved by adjacent malignant or inflammatory processes. Postoperative alterations are seen after liver transplantation or cholecystectomy when a portion of the cystic duct is left behind as a remnant. Recognized postoperative complications include retained cystic duct stones, cystic duct leakage, and malposition of T tubes in the remnant. Pitfalls encountered in cystic duct imaging include pseudocalculous defects from overlap of the cystic duct and common bile duct, underfilling of the cystic duct during direct cholangiography, and admixture defects at the cystic duct orifice. Pseudomass or pseudotumor defects may result from an impacted cystic duct stone or from a tortuous, redundant cystic duct. Familiarity with the imaging appearance of the normal cystic duct, its anatomic variants, and related disease processes facilitates accurate diagnosis and helps avoid misinterpretation.     

Motor function of the gallbladder: measurement and clinical significance

Abnormalities in gallbladder emptying commonly occur in gallstone patients. Similar changes can be found in patients without gallstones that have disease that may predispose to stones, such as diabetes. Decreased contractility of the gallbladder can be measured clinically with variety of radiological techniques, and ultrasonography seems to have a number of advantages over others. In addition to a role in pathogenesis, decreased gallbladder emptying may determine the clearance of gallstones from the gallbladder during dissolution and after lithotripsy.