Occlusion Of Cystic Duct Research Articles

A Comparative Study between Metal Clip Application and Suture Ligation of Cystic Duct in Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy has been performed for decades and is a fairly standardized procedure throughout the world. Occlusion of the cystic duct is popularly done with the help of metal clips. There are many other techniques described in the literature to deal with occlusion of the Cystic Duct. Suture ligation of the duct is one such way.To evaluate the effectiveness in term of cost, safety, and complication in occlusion of cystic duct with suture ligation compared to clip application. Materials and Methods: A prospective cross sectional comparative study was carried out From June 2020 to November 2020. Data were collected from 80 patients undergone laparoscopic cholecystectomy for Gall stone diseases. 40 patients were enrolled in each group by consecutive purposive sampling. Complete history was taken. Thorough clinical examination was done. Relevant investigations report was collected. Results: Female patients were predominant in both groups and most of the patients were underweight. Mean time for ligation was more in occlusion of cystic duct with clip application. Bile leakage was found and duration of drain in situ was more in occlusion with clip application. Cost was high in occlusion with clip application. Conclusion: : Time for ligation, Bile leakage, mean duration of drain in situ (days), and cost of Cystic Duct occlusion and port closure were significantly higher in Laparoscopic Cholecystectomy with conventional Clip application of Cystic Duct group in comparison to Laparoscopic Cholecystectomy with ligation of the Cystic duct with no-1vicryl by extra corporeal knotting group. Medicine Today 2023 Vol.35(1): 27-30

Ligature Technique: A Safe Outcome in Laparoscopic Cholecystectomy

Objective: To compare Extracorporeal Sliding knot (ECK) and clip ligation to ligation of the cystic duct in laparoscopic cholecystectomy. Patients and Methods: This study was conducted as prospective randomized study in Jeddah National Hospital in Jeddah Saudi Arabia, in surgical department carried out from June 2018 to June 2019. In the study 100 patients were selected and divided into two groups, in which we compared outcomes of patients in whom Cystic Duct Occlusion was done by clips (Group I n=60) and other group Ligatures endoloop knotting (Group II n=40). During laparoscopic cholecystectomy (LC), cystic duct occlusion can be done with titanium clips or ligature permanently in order to prevent leakage of bile into the peritoneal cavity. Results: Average age of the patients of clipping group was 43.68 years and the average age of the patients of knot group was 42.64 years, with male to female ration as 1:4.5. 1:2.3 of clipping and knot group respectively. Regarding operating time from initial incision to closure of wound is 61 to 65 minutes in clip group and 69 to 70 minutes in knot group. Longer operating times in knot group is due to learning curve effect for most surgeons as is evident from the fact that first twenty surgeries took longer time as compared to subsequent surgeries. The port site infection was in 03 cases of the clip group 01 in the knot group, drain was kept in 12 cases in knot group and 06 in clip group, bile leak requiring ERCP 02 cases in clip group and 01 in knot group, retained CBD Stones 01 was in clip group, obstructive Jaundice was seen in one cases of clip group, while no mortality was seen in both groups. Although the hospital stay after surgery in clip group was 1-2 days and in knot group also 1-2 days and in ERCP patients’ Hospital stay was 2 to 3 days. Conclusion: Cystic duct occlusion with knots/ligatures is a safe, cost effective, less post operative pain alternative to clips as various studies showed clips complications. It also showed less post-operative pain, less bile leak and port site wound infection. Safety of using knots/ligatures is even better than clips as is evident from this study comparing these two methods of cystic duct occlusion. Key words: cholecystectomy, surgical clips, surgical knots, surgical ligature, cystic duct occlusion, bile leakage

Abstract No. 215 Percutaneous cholecystolithotomy: a single-institution experience with SpyGlass DS cholangioscopy

Percutaneous cholecystolithotomy using cholecystoscopy can be an alternative to cholecystectomy in high surgical risk patients with calculous cholecystitis. The purpose of this study is to describe our experience of percutaneous cholecystolithotomy using Spyglass direct visualization cholangioscopy (SpyGlass DS, 10F, Boston Scientific). The Institutional Review Board approved this retrospective study with a waiver of informed consent. Between January 1, 2018, and September 9, 2020, 18 patients (M:F = 13:5, mean 73 years) underwent percutaneous cholecystolithotomy using SpyGlass DS cholangioscopy for calculous cholecystitis. Percutaneous cholecystolithotomy was performed with SpyGlass DS cholangioscopy after placement of 16F sheath. Stone fragmentation was performed with EHL probe and stones were removed using baskets or saline flushing technique. Procedure details, technical success, complications, and clinical follow up were retrospectively analyzed. Eighteen patients underwent 28 percutaneous cholecystolithotomy procedures using SpyGlass DS cholangioscopy including seven patients for a second and three patients for a third cholecystolithotomy session. Conscious sedation was used in the majority of cases 86% (n = 24) versus general anesthesia 14% (n = 4) for the procedure. The median time interval between cholecystostomy tube placement and 1st cholecystolithotomy was 78 days. Overall technical success rate (removal of all stones) was 78% (14/18 patients) after repeat cholecystolithotomy. The median time from cholecystostomy tube placement to final tube removal was 111 days. Cause of technical failure were large, impacted stones (n = 3) and cystic duct occlusion (n = 1). There were three procedure related complications (acute pancreatitis causing mortality (n = 1), fistula to the skin requiring surgical excision (n = 1), bile leak requiring replacement of cholecystostomy tube due to gallbladder dyskinesia (n = 1)). There is no recurrence of symptomatic cholecystitis in patients with technical success. Three patients died because of reasons unassociated with the procedure during follow up. Percutaneous cholecystolithotomy using SpyGlass DS cholangioscopy can be performed with smaller sheath (16F) than conventional cholangioscopy (24F sheath) and can be a very useful alternate minimally invasive technique for gallstone management with high technical success rates.

Gallbladder Cryoablation for Chronic Cholecystitis in High-Risk Surgical Patients: 1-Year Clinical Experience with Imaging Follow-up

PurposeTo assess the short-term safety and efficacy of gallbladder cryoablation in high-risk patients. Materials and MethodsA single-center, retrospective review of clinical and imaging follow-up from patients who were referred for gallbladder cryoablation between August 2018 and July 2019 was performed. All patients had serious pre-procedural comorbidities and were unacceptable surgical candidates (mean age, 52.5 years; mean American Society of Anesthesiologists score, 3.67). Primary efficacy measures included technical success, absence of symptoms after cholecystostomy tube removal, and imaging evidence of cystic duct obstruction and gallbladder involution. The primary safety measure was the absence of Society of Interventional Radiology moderate or greater adverse events. ResultsTechnical success was 86%, with 1 of 7 patients unable to undergo cryoablation because of adhesions preventing hydrodissection of the colon away from the gallbladder. Mean duration of clinical follow-up after discharge was 278 days (range, 59–498 days). Abdominal pain was absent in all patients after ablation. Cholecystostomy tubes were removed immediately after ablation (n = 5) or on post-procedure day 11 (n = 1). Computed tomography or magnetic resonance imaging was obtained at 1–3 months (n = 6), 4–6 months (n = 4), and 6–12 months (n = 5) after the procedure and demonstrated gallbladder involution in 5 of 6 patients. One patient had asymptomatic distention of the gallbladder on follow-up imaging. Hepatobiliary iminodiacetic acid scans were completed in 5 of 6 patients 1 month after ablation and demonstrated cystic duct occlusion in all 5 patients. One moderate adverse event (infection) and 1 life-threatening adverse event (hemorrhage) occurred. ConclusionsGallbladder cryoablation might be a viable treatment option for high-risk patients with gallbladder disease and warrants further investigation.

3:00 PM Abstract No. 99 ■ DISTINGUISHED ABSTRACT Gallbladder cryoablation for chronic cholecystitis in high-risk surgical patients: early clinical experience and imaging follow-up

To assess the short-term safety and efficacy of gallbladder cryoablation in high-risk patients. Patients with cholecystitis previously treated with a cholecystostomy tube (n = 6) or biliary colic (n = 1), who were referred for gallbladder cryoablation between August 2018 and July 2019 were followed clinically and with imaging for 3-12 months. All patients had significant preprocedural comorbidities and were deemed unacceptable surgical candidates by an attending surgeon. Primary efficacy measures were technical success of the procedure, absence of symptoms at 1 month, and imaging evidence of cystic duct obstruction and gallbladder devitalization. The primary safety measure was the presence/absence of the Society of Interventional Radiology’s moderate or greater adverse events. There was no peri-procedure, early (<30 day), or in-hospital mortality. Technical success was 86% with 1 of 7 patients unable to undergo cryoablation because of adhesions preventing hydrodissection of the colon away from the gallbladder. Abdominal pain was absent in all patients 1 month after ablation. At least 1 CT or MR was completed 1-6 months after ablation and demonstrated evidence of gallbladder involution in 4/6 patients. Hepatobiliary iminodiacetic acid scans were completed in 5/6 patients 1 month after ablation and demonstrated cystic duct occlusion in all 5 patients. One moderate and 1 life-threatening adverse event occurred. These early outcomes suggest that gallbladder cryoablation may be a viable treatment option for high-risk patients with gallbladder disease and warrant further investigation.

Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy: A retrospective analysis of a prospective cohort.

BACKGROUNDLaparoscopic cholecystectomy (LC) is one of the most frequently performed surgical procedures. Cystic stump leakage is an underestimated, potentially life threatening complication that occurs in 1%-6% of the patients. With a secure cystic duct occlusion technique during LC, bile leakage becomes a preventable complication.AIMTo investigate the effect of polydioxanone (PDS) loop closure of the cystic duct on bile leakage rate in LC patients.METHODSIn this retrospective analysis of a prospective cohort, the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure. Logistic regression analysis was used to develop a risk score to identify bile leakage risk. Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTSOf the 4359 patients who underwent LC, 136 (3%) underwent cystic duct closure by a PDS loop. Preoperatively, loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients. In the loop closure cohort, zero (0%) bile leakage occurred compared to 59 of 4223 (1.4%) clip closure patients. For patients at increased bile leakage risk (risk score ≥ 1) rates were 1.6% and up to 13% (4/30) for clip closure patients with a risk score ≥ 4. This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients, which was not observed for loop closure patients.CONCLUSIONCystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Pilot Study of the Safety and Efficacy of Gallbladder Cryoablation in a Porcine Model: Midterm Results

PurposeTo investigate the midterm safety and efficacy of computed tomography (CT)–guided percutaneous gallbladder cryoablation in swine. Materials and MethodsThree swine underwent gallbladder cryoablation. Cryoprobes were positioned percutaneously at the gallbladder margins or within the gallbladder lumen under CT guidance. Two freeze/thaw cycles were performed. One animal was euthanized on postprocedure day 4 as a result of hematemesis unrelated to the ablation. The other 2 animals were euthanized at postprocedure days 30 and 48, respectively. The gallbladder and bile ducts were resected and examined microscopically. ResultsGallbladder cryoablation was completed with freeze/thaw cycle durations of 7.5–10 minutes (mean, 9.4 min ± 1.3) and ablation margins of 5.8–11.5 mm (mean, 7.8 mm ± 1.9). No nontarget ablation was observed. Laboratory values at postprocedure day 4 and the time of euthanasia were within normal limits. Two of 3 animals thrived and exhibited appropriate activity and weight gain. Contrast-enhanced CT immediately before euthanasia demonstrated delayed linear enhancement of the gallbladder wall. Gross inspection at autopsy revealed fibrotic-appearing gallbladders. Cholecystography revealed no communication to the biliary tree. Histologic examination demonstrated complete gallbladder wall fibrosis. Autopsy of the animal euthanized on day 4 revealed a gastric mucosal ulcer distant from the ablation site with no gastric serosal injury. ConclusionsGallbladder cryoablation is a promising alternative to surgical cholecystectomy, with complete transmural gallbladder wall fibrosis and cystic duct occlusion seen at 30 and 48 days in swine. Further studies are required to establish procedural safety and long-term efficacy.

Triple ligation technique of clipless laparoscopic cholecystectomy: a spanner especially for complicated cholecystitis

Background: Although in the era of laparoscopic cholecystectomy cystic duct occlusion has been tried by clips, harmonic and plasma kinetic quite effectively but cost, availability and inadvertent injury to biliary duct are concerning factors. Intra-corporeal ligation has evolved to address these issues effectively as a boon especially for the peripheral centres where availability and cost of energy sources weighs heavier than their associated ease. Triple ligation technique is a time preserving modification without any compromise in safety and quality of surgery. The aim of our study is not only to elucidate the importance of intra-corporeal ligation in safety and cost of surgery but also to enlighten its role in safe management of even difficult cases of cholecystitis.Methods: A retrospective observational study. All cases of symptomatic gallstones operated by laparoscopic triple ligation technique were included in the study.Results: More than half (63.4%) of the cases in our study were having chronic cholecystitis was reported in 63.4% of the cases while 36.4 % cases have acute cholecystitis. Mean duration of surgery was 46.4 and 71.2 minutes in chronic and acute cases respectively. No case of bile duct or vascular injury has been reported in our study. Only 3.8% of the cases were converted to open. Gallbladder perforation was most common complication noted in 12.8% of the cases.Conclusions: Triple ligation technique of laparoscopic cholecystectomy is not only a time sparing modification but is also a veritable, safe and frugal tool with excellent results even in complicated cholecystitis without compromising its outcome and prime.

Clipless Versus Conventional Laparoscopic Cholecystectomy

Abstract Laparoscopic cholecystectomy has been the gold standard technique for cholecystectomy and has proven more effective than the conventional open technique. The laparoscopic technique utilizes surgical clips for cystic duct occlusion, which come with their own set of complications. With the advent of new vessel and duct sealing technology, alternative energy instruments have been explored for the occlusion of the cystic duct without the use of clips. The Harmonic(®) scalpel (Ethicon Endo-Surgery, Cincinnati, OH) has become one of the more widely used instruments. In this retrospective study, 208 patients received surgical clip placement or the Harmonic scalpel was used for cystic duct occlusion. The postoperative complications were documented, and rates were calculated for outpatient follow-up, for re-admission, and specifically for the complications of a bile leak. When adjusted for the cause of bile leak (cystic duct versus common bile duct versus accessory duct), the use of the Harmonic scalpel versus clip placement had comparable rates of bile leak at 1.75% and 0.66%, respectively. The use of the Harmonic scalpel is deemed safe and comparable to clip placement at the discretion of the surgeon for cystic duct ligation. Further research with larger homogeneous studies and assessments of cost-effectiveness would further enhance the increasing use of the Harmonic scalpel in laparoscopic cholecystectomy.

Functional hepatobiliary MR imaging in children

Clinical application efforts for the hepatocyte-specific MRI contrast agent gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) have mainly been directed toward detection and characterization of various hepatic masses in the adult population. Here we report our initial experience with Gd-EOB-DTPA for evaluating congenital and acquired hepatobiliary pathologies in the pediatric population. Twenty-one consecutive children receiving Gd-EOB-DTPA for functional hepatobiliary evaluation at our institution were retrospectively identified with IRB approval. The use of Gd-EOB-DTPA was classified in each case as definite, potential, or no clinical utility, focusing on the clinical value gained beyond traditional noncontrast fluid-sensitive MR cholangiopancreatography (FS-MRCP) and other imaging modalities. Definite added value of Gd-EOB-DTPA was found in 12 patients, with potential value in 4 patients, and no value in 5 patients. Benefit was seen in cases of iatrogenic and non-iatrogenic biliary strictures, perihepatic fluid collections for biliary leak, hepatobiliary dysfunction in the absence of hyperbilirubinemia, and in the functional exclusion of cystic duct occlusion that can be seen in acute cholecystitis. This is the first reported series of children with Gd-EOB-DTPA and this early work suggests potential pediatric applications.

Methods of cystic duct occlusion during laparoscopic cholecystectomy

During laparoscopic cholecystectomy, it is necessary to occlude the cystic duct permanently. Traditionally, this has been performed through the application of non-absorbable metal clips. Use of absorbable materials to occlude the cystic duct has been suggested as an alternative for metal clips for various reasons. To assess the benefits and harms of the different methods of occlusion of cystic duct in patients undergoing laparoscopic cholecystectomy. We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2010. We included all randomised clinical trials comparing different methods of occlusion of cystic duct. We collected the data on the characteristics, methodological quality, bile duct injury, bile leaks, operating time, and incidence of recurrent common bile duct stone from each trial. We analysed the data with both the fixed-effect and the random-effects model using RevMan Analysis. For each outcome we calculated the risk ratio (RR) in the presence of more than one trial for the outcome or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis. In the presence of only one trial under a dichotomous outcome, we performed the Fisher's exact test. Three trials including 255 patients qualified for this review. In two of the trial, a total of 150 patients were randomised to absorbable clips (n = 75) and non-absorbable clips (n = 75). In the third trial, a total of 105 patients were randomised to absorbable ligatures (n = 53) and non-absorbable clips (n = 52). All three trials were of high risk of bias. There was no difference in the morbidity between the groups. There was statistically significant longer operating time (MD 12.00 minutes, 95% CI 1.59 to 22.41) in the absorbable ligature group than non-absorbable clips. The duration and method of follow-up were not adequate to determine the incidence of long-term complications. We are unable to determine the benefits and harms of different methods of cystic duct occlusion because of the small sample size, short period of follow-up, and lack of reporting of important outcomes in the included trials. Adequately powered randomised trials with low risk of bias and with long periods of follow-up and assessing all of the important outcomes for patients and professionals are necessary.

Hepatobiliary Scan Findings in Chronic Cholecystitis

Hepatobiliary scintigraphy, most often referred to as the HIDA scan, is often performed to assess cystic duct patency or occlusion in patients with suspected acute cholecystitis. The imaging diagnosis of chronic cholecystitis is generally made by sonographic demonstration of calculi in a setting of chronic recurrent abdominal pain or nonspecific dyspeptic symptoms. When a stone blocks the gallbladder neck or cystic duct, it precipitates an attack of acute cholecystitis that could be confirmed by performing the HIDA scan. In the course of performing HIDA studies, several incidental findings suggesting chronic cholecystitis may be encountered. Recognition of these suggestive patterns should increase the suspicion of chronic disease that can be further confirmed with sonography, gallbladder ejection fraction determination with sincalide cholescintigraphy, or other clinical findings. The material selected for this atlas is accumulated from many years of experience with HIDA scan. Illustration of the several scintigraphic patterns suggesting chronic rather than acute cholecystitis is presented to familiarize the reader with these findings. Correlation with clinical, radiologic, and pathologic findings is presented, as well. The illustrated findings, though not definitive, may explain the etiology of the underlying symptoms of chronic cholecystitis and direct further management.

Chemical Ablation of the Gallbladder with Acetic Acid

Chemical ablation of the gallbladder may be a useful alternative to surgery for inoperable disease. The purpose of this study was to investigate the feasibility of chemical ablation of the gallbladder with acetic acid in a canine model. Five beagle dogs underwent percutaneous transhepatic cholecystostomy. Percutaneous occlusion of the cystic duct was performed with use of n-butyl cyanoacrylate (NBCA) and coils. After confirmation of occlusion of the cystic duct, sclerotherapy of the gallbladder was performed with 4-7 mL of 50% acetic acid through the drainage catheter. Acetic acid was retained for 20 minutes with intermittent position change. The drainage catheter was removed immediately after sclerotherapy. The dogs were euthanized 8 weeks after the procedure. The gallbladders and adjacent organs were evaluated grossly as well as microscopically. All dogs survived without serious complications during the experimental period. Sclerotherapy was technically successful in all dogs. Gross specimens of the gallbladder showed shrinkage and fibrotic change without retention of any bile, mucus, or pus. Histologic examinations from the body and fundus of the gallbladder demonstrated complete ablation of the mucosa. However, the neck region of the gallbladder near the cystic duct, where NBCA and coils for cystic duct occlusion were located, had focal areas of remnant or regenerating mucosa. Chemical ablation of the gallbladder with 50% acetic acid was effective and safe. Complete ablation was achieved in the majority of gallbladder mucosa except for a small portion located in the gallbladder neck.

Aussagefähigkeit der sonographischen Gallenblasenfunktionsprüfung bei Cholezystolithiasis

Decrease in gall-bladder volume after intake of a test meal was assessed by ultrasound in 30 patients (24 females, 6 males; mean age 55 [22-82] years) with indications for elective or early elective cholecystectomy for cholelithiasis. Patients were assigned to three groups, based on intraoperative and histological gall-bladder changes: group 1 (n = 17), without changes or with mild chronic cholecystitis; group 2 (n = 4), with severe chronic inflammatory changes; group 3 (n = 9), with acute cholecystitis or cystic duct occlusion. A volume decrease of at least 30% after the test meal excluded only acute wall inflammation (negative predictive value 95.5%), while a volume reduction of at least 50% made it possible in a high percentage of cases (negative predictive value 88.2%) to predict correctly an absence of severe chronic wall changes. Before organ-preserving treatment (extracorporeal lithotripsy or local litholysis) is undertaken, gall-bladder volume reduction of at least 50% should be documented.

Changes in silent gallbladder stones. Roentgen-diagnostic and symptomatologic observations over 30 years

Between 1950 and 1980, a total of 145 patients with pain-free gallstones in the gallbladder and open cystic duct were followed for a mean observation period of 13.5 years. Pigment stones made up 25.5% of the total, cholesterol the rest. Growth of stones was noted in 70% of cases, new stones in 14%, and calcification in 25%. Colics occurred in 29%, severe ulcerative cholecystitis in 4% and passage of stones with pancreatitis in 5.5%. Constant cystic duct occlusion occurred in 18%, causing mild gallbladder inflammation in 40% of them. Cholecystectomy should be limited to large, old stones, to prevent gallstone ileus. Recently formed cholesterol stones should be removed as soon as possible by litholysis. Otherwise expectant waiting with regular follow-up is indicated.

Direct lymphatic spreading route into the liver from the gallbladder: an animal experiment using pig.

In the special occasion that the physiological lymphatic flow is obstructed, gallbladder carcinoma (GBC) may spread into the liver via lymphatic route. Therefore, this study was conducted to find out the direct lymphatic route draining into the liver from the gallbladder using pigs with ligated cystic ducts. After injecting the carbon particle suspension (CH40) or the contrast medium (Lipiodol) into the subserosal layer of the gallbladder, the lymphatic route into the liver was examined both macroscopically and histologically. In controls, CH40 or Lipiodol drained along the cystic duct toward the hepatoduodenal ligament. After occlusion of cystic duct, CH40 was interrupted at the ligated point, and then spread into the liver nearby the gallbladder bed, running off to the liver hilus, toward the hepatoduodenal ligament. This route was confirmed by the Lipiodol drainage into the right median lobe of the liver, equivalent to the segments V and IV a in humans. We presented for the first time the emergence of lymphatic drainage from the gallbladder into the liver after the occlusion of physiological lymphatic route using pigs. This implies that the direct spread into the segments V and IV a of liver should be considered in the surgical treatment of advanced GBC.

An experimental study on effects of occlusion of the cystic duct in mice with or without emptying of the gallbladder.

To study consequences of cystic duct occlusion, 121 NMRI mice were operated: 40 had cystic duct ligature (L group), 41 had cystic duct ligature and evacuation of bile from the gallbladder (LE group), and 40 were sham-operated (S group). Ten mice from each group were sacrificed at 1 week, 1, 3 and 6 months, respectively. All but 2 mice showed signs of wellbeing during the observation time, and weight gain was the same in the three groups. Distended gallbladder occurred in 14 animals, 7 each in the L and the LE group, more frequent after 3 and 6 months. In the remainder mice the gallbladders were smaller than at the time of operation (p < 0.0001). Fibrosis and adhesions around the gallbladder were frequent in the L and the LE groups, and more pronounced in the latter (p = 0.0001). At microscopy there were signs of inflammation in the gallbladder wall in 16 cases in the L group, 28 in the LE group and 2 in the S group, and the degree of inflammation was more pronounced in the LE group than in the L group (p = 0.002). Eleven mice in the LE group had empyema, and slight intralumininal inflammation was more frequent in the LE group than in the L group (p < 0.0001). In conclusion, despite a high incidence of microscopic inflammation the study gave no indication that occlusion of the cystic duct did serious harm to the mice in this series.

A CASE OF CALCIUM CARBONATE GALLSTONE

Calcium carbonate gallstones are found in approximately 10% of all limy biles. It is a relatively rare type of gallstone. Recent experience with a case of calcium carbonate gallstone is described with a reveiw of the literature. A 62-year-old man who had been treated for duodenal ulcer was pointed out abnormal calcification in the right upper quadrant on an abdominal X-ray film. The patient was referred to the hospital for further examination, and he was diagnosed as calcium carbonate gallstone combined with an incarcerated gallstone. Laparoscopic cholecystectomy was performed, and the resected specimen revealed a chalk-like calcium carbonate gallstone in the body and a cholesterol gallstone incarcerated in the neck of the gallbladder. Pathologic findings of the gallbladder indicated chronic cholecystitis. Etiologic factors for calcium carbonate gallstone may include cystic duct occlusion, chronic cholecystits, and some change in the bile component, but no clear explanation has been established as yet.

Refinement of a Technique for Thermocholecystectomy in an Animal Model

A modification of a thermal ablation system was tested for improved cystic duct occlusion and gallbladder mucosa ablation in an animal model. Fourteen domestic swine were included in group 1 with thermal treatment of the cystic duct to 75 degrees C for 15 minutes, followed by heating of the gallbladder lumen with a catheter/heating device to 54 degrees C for 30 minutes. One swine served as a control (group 2). A ligature was placed around the cystic duct without thermal treatment of the cystic duct and with the catheter/heating device placed into the gallbladder for 30 minutes without thermal treatment. All animals were killed after 3 weeks with histologic examination of the gallbladder, cystic duct, and surrounding organs. In group 1, technical failure due to catheter clogging occurred in the first three animals, which were killed immediately. Eleven animals were treated with a redesigned catheter system. Three weeks after treatment, 10 of the 11 animals had complete cystic duct occlusion and complete obliteration of the cystic duct mucosa. One of the 11 animals experienced partial cystic duct ablation. Nine of the 11 treated animals experienced complete mucosal ablation of the gallbladder. Five of the 11 animals had no residual lumen, whereas 6 of the 11 had a luminal volume that averaged 4 mL compared to 35 mL before treatment. In group 2, the control subject had a gallbladder volume of 50 mL and normal gallbladder and cystic duct mucosa. This study demonstrates improvement in both cystic duct occlusion and gallbladder mucosa ablation with standardization of the technique for thermocholecystectomy in an animal model. However, a better system is required to promote complete obliteration of the gallbladder lumen.

Immediate cystic duct occlusion using an endoluminal absorbable polyglycolic acid screw.

Endoscopic in situ occlusion of the cystic duct and ablation of the gallbladder could constitute a useful alternative to cholecystectomy in certain patients. The purpose of this study was to examine the feasibility of endoluminal occlusion of the cystic duct using a biodegradable polyglycolic acid screw and simultaneous gallbladder mucosal ablation with a Sotradecol-ethanol mixture. Eight pigs had operative cholecystotomy. A polyglycolic acid screw was twisted into the cystic duct after the proximal cystic duct mucosa was thermally ablated using electrocautery. Cholecystography confirmed occlusion of the cystic duct. Synchronous ablation of the gallbladder mucosa was then done by instilling absolute alcohol and 2% Sotradecol. The gallbladder was drained. Animals were sacrificed on days 14, 28, and 42. All animals survived operation and showed no untoward effects. Postmortem gross inspection showed gallbladders were shrunken and surrounded with adhesions from adjacent tissue. Cholangiography and cholecystography confirmed occlusion of the cystic duct in 6 of 8 pigs (75%). Histopathologic examination showed extensive areas of mucosal necrosis mixed with small areas of epithelial regeneration. Immediate occlusion of the cystic duct is possible using an endoluminal polyglycolic acid screw.