Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

Purpose: The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed. Methods: Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal. Results: Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. Conclusions: LC can be performed using different techniques, although the use of EBVS is highly recommended.

Ultrasonographic evaluation of cholecystoduodenostomy sites in six cats.

CASE SERIES SUMMARY: This case series describes the postoperative ultrasonographic findings in six cats that underwent a cholecystoduodenostomy as treatment for extrahepatic biliary obstruction. The surgery site was identified in all six cats, most often within the right cranial abdomen as a thick-walled gall bladder, with a broad-based connection to the descending duodenum. Postoperatively, the biliary tree often remained distended, similar to its preoperative appearance. Recurrent extrahepatic biliary obstruction was suspected in three cats with worsening hyperbilirubinemia. Common bile duct distension was progressive in one of these cats and unchanged in another, but improved in the third. Intrahepatic bile duct distension resolved in one cat following surgery but reappeared with suspected recurrent biliary obstruction. In two cats, progressive echogenic biliary contents were associated with locally aggressive cholangiocarcinoma. Our findings suggest that in cats with cholecystoduodenostomy and progressive increases in hyperbilirubinemia following surgery, progressive or recurrent biliary distension and/or progressive echogenic biliary contents should prompt further investigation. RELEVANCE AND NOVEL INFORMATION: Biliary diversion surgery in cats is associated with high morbidity and mortality. The ultrasonographic appearance of a postoperative cholecystoduodenostomy site has not been described, making differentiation of the expected appearance from postoperative abnormalities difficult. The goal of this study was to determine the expected ultrasonographic appearance, in order to assist in managing cats with recurrent, persistent or worsening clinical signs and biochemical abnormalities following surgery.

Evidence-Based Medicine: Ultrasound-Guided Percutaneous Cholecystocentesis in the Cat.

Cholangitis is a common cause of hepatobiliary disease in the cat. Feline cholangitis is characterized as neutrophilic (acute or chronic), lymphocytic, or caused by liver flukes. The neutrophilic form is caused by bacterial infection of the biliary system, and identification of the specific bacterial agent guides treatment. Bile is the sample of choice for cytology and bacterial culture in these cases, and percutaneous ultrasound-guided cholecystocentesis is used to obtain that sample. This review covers the literature that provides evidence for safety and usefulness of percutaneous ultrasound-guided cholecystocentesis as part of the diagnostic work-up of cats suspected of having hepatobiliary disease.

Feline abdominal ultrasonography: what's normal? what's abnormal? The biliary tree.

PRACTICAL RELEVANCE: Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. The biliary tree encompasses the liver, gall bladder and bile ducts, although only diseases affecting the latter two are discussed here. Diseases of the bile ducts and gall bladder are more common than those of the liver parenchyma and ultrasound plays an important role in their diagnosis. CLINICAL CHALLENGES: Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even differentiating between normal variation and pathological changes can be challenging for all but the most experienced. In addition, a lack of pathological change does not necessarily rule out disease; for example, absence of gall bladder and/or extrahepatic biliary distension is not sufficient to exclude the possibility of biliary obstruction, and in many cases of cholangitis the liver and biliary tree are unremarkable on ultrasound examination. EQUIPMENT: Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience. AIM: This review, part of an occasional series on feline abdominal ultrasonography, discusses the appearance of the normal and diseased biliary system. It is aimed at general practitioners who wish to improve their knowledge and confidence in feline abdominal ultrasound and is accompanied by high-resolution images. Percutaneous ultrasound-guided cholecystocentesis is also covered. Ultrasound examination of the liver was discussed in an article published in January 2019 and an upcoming article will cover hepatic vascular anomalies. EVIDENCE BASE: Information provided in this article is drawn from the published literature and the author's own clinical experience.

Advanced Roux-en-Y hepaticojejunostomy with magnetic compressive anastomats in obstructive jaundice dog models.

BACKGROUND: Although commonly used procedure, Roux-en-Y hepaticojejunostomy (RYHJ) remains to be complicated, time consuming, and has a relatively poor prognosis. We designed the magnetic compressive anastomats (MCAs) to perform RYHJ more efficiently and safely. MATERIALS AND METHODS: 36 dogs were divided into two groups randomly. After obstructive jaundice model construction, RYHJ was performed with MCAs in study group or by hand-sewn in control group. Both groups were followed for 1, 3, and 6 months after RYHJ. The liver function and postoperative complications were recorded throughout the follow-up. At the end of each time point, dogs were sent for magnetic resonance imaging (MRI) and sacrificed. Anastomotic samples were taken for anastomotic narrowing rate calculation, histological analyses, tensile strength testing, and hydroxyproline content testing. RESULTS: The anastomotic construction times were 44.20 ± 23.02 min in study group, compared of 60.53 ± 11.89 min in control group (p < 0.05). The liver function recovered gradually after RYHJ in both groups (p > 0.05). All anastomats were expelled out of the body in 8.81 ± 2.01 days. The gross incidence of morbidity and mortality was 33.3% (6/18) and 16.7% (3/18) in study group compared with 38.9% (7/18) and 22.2% (4/18) in control group (p > 0.05), and there is no single case of anastomotic-specific complications happened in study group. The narrowing rates of anastomosis were 14.6, 18.5, and 18.7% in study group compared with 35.4, 36.9, and 34% in control group at 1st, 3rd, and 6th month after RYHJ (p < 0.05). In study group, preciser alignment of tissue layers and milder inflammatory reaction contributed to the fast and better wound healing process. CONCLUSION: Perform RYHJ with MCAs is safer, more efficient than by hand-sewn method in obstructive jaundice dog models.

Cholecystopexy and Pericardial Pseudocyst Removal in a Dog with a Congenital Peritoneopericardial Diaphragmatic Hernia.

A 4 mo old spayed female golden retriever was presented with a peritoneopericardial diaphragmatic hernia (PPDH) that was diagnosed during neutering. Echocardiography revealed a fluid-filled structure and parts of the liver in the pericardial cavity. Computed tomography confirmed the existence of the PPDH and the herniation of the right medial liver lobe and the gallbladder. Cystic masses were observed in the pericardial and the peritoneal cavities, possibly communicating through the PPDH. A median laparotomy revealed a single lobulated cystic lesion extending into both the pericardial and peritoneal cavities through the PPDH. Because of the nonviable aspect of some parts of the liver parenchyma, the gallbladder was dissected from the fossa, and the central division of the liver was resected. A cholecystopexy was performed on the diaphragm to limit gallbladder mobility. The PPDH was closed in the standard fashion. Histopathology of the cystic structure was compatible with a pericardial pseudocyst. Two months postoperatively, the dog was healthy, and the results of blood biochemistry and abdominal ultrasonography were normal. A pericardial pseudocyst can be associated with a PPDH in young dogs. Moreover, cholecystopexy appears to be a safe and effective method of limiting gallbladder mobility after resection of the central hepatic division.

Percutaneous ultrasound-guided cholecystocentesis: complications and association of ultrasonographic findings with bile culture results.

OBJECTIVES: To retrospectively evaluate cases presented for percutaneous ultrasound-guided cholecystocentesis for associated complications, identify risk factors associated with complications and to assess ultrasonographic findings and relate these to bacterial culture results. METHODS: Data on 300 patients presented for percutaneous ultrasound-guided cholecystocentesis were retrospectively collected and ultrasonographic images were assessed for defined structural changes. The incidence of major complications was determined. Multi-variable multi-level logistic regression was used to investigate the association of ultrasonographic findings with positive bile culture. RESULTS: Three hundred percutaneous ultrasound-guided cholecystocentesis procedures performed in 201 dogs and 51 cats were included; 35 patients had the procedure performed more than once. The overall incidence of major complications was 8 of 300 procedures (2·7%). Bile peritonitis occurred in 2 of 300 procedures (0·7%). An ultrasonographically abnormal gall bladder was found in 52% of cases and had a sensitivity, specificity and accuracy of 82, 55·7 and 61·5% respectively, to predict a positive bile culture. CLINICAL SIGNIFICANCE: Percutaneous ultrasound-guided cholecystocentesis is overall a safe technique when carried out in selected patients. Abnormal ultrasonographic findings are only a fair predictor of a positive bile culture.

Percutaneous cholecystocentesis in cats with suspected hepatobiliary disease.

Objectives The objective was to evaluate the safety and diagnostic utility of percutaneous ultrasound-guided cholecystocentesis (PUC) in cats with suspected hepatobiliary disease. Methods Medical records of 83 cats with suspected hepatobiliary disease that underwent PUC were retrospectively reviewed. Results At the time of PUC, at least one additional procedure was performed in 79/83 cats, including hepatic aspiration and/or biopsy (n = 75) and splenic aspiration (n = 18). Complications were noted in 14/83 cases, including increased abdominal fluid (n = 11), needle-tip occlusion (n = 1), failed first attempt to penetrate the gall bladder wall (n = 1) and pneumoperitoneum (n = 1). There were no reports of gall bladder rupture, bile peritonitis or hypotension necessitating treatment with vasopressor medication. Blood products were administered to 7/83 (8%) cats. Seventy-two cats (87%) survived to discharge. Of the cats that were euthanized (9/83) or died (2/83), none were reported as a definitive consequence of PUC. Bacteria were identified cytologically in 10/71 samples (14%); all 10 had a positive aerobic bacterial culture. Bile culture was positive in 11/80 samples (14%). Of the cases with a positive bile culture, cytological description of bacteria corresponded to the organism cultured in fewer than 50% of cases. The most common cytologic diagnosis was hepatic lipidosis (49/66). The most common histopathologic diagnosis was cholangitis (10/21). Conclusions and relevance PUC was safe in this group of cats with suspected hepatobiliary disease. Complications were likely associated with ancillary procedures performed at the time of PUC. Bile analysis yielded an abnormal result in nearly one-third of cats with suspected hepatobiliary disease. Complete agreement between bile cytology and culture was lacking. Further evaluation of the correlation between bile cytology and bile culture is warranted.

Life-threatening perianaesthetic complications in five cats undergoing biliary tract surgery: case series and literature review.

Case series summary The aim of this case series was to describe the intra- and early postanaesthetic complications occurring in five cats undergoing major surgeries involving the gallbladder and the biliary tree. The five cases of this series were admitted to the Queen Mother Hospital for Animals between June and December 2015, and were all overseen by the same senior anaesthesist. Pre-existing pancreatitis was a common finding. Observed life-threatening events were persistent, unresponsive hypotension in the absence of major blood loss, which occurred mainly during surgical manipulation of the biliary tract, and postoperative renal failure. Relevance and novel information Biliary surgery carries the potential for life-threatening complications in cats. The pathogenesis of such morbidities is likely to be multifactorial. The perianaesthetic use of haemoglobin-based oxygen-carrying solution may be considered as an alternative treatment option when hypotension is unresponsive to fluids and traditional positive inotropes and vasopressors.

Percutaneous Ultrasound-guided Cholecystocentesis and Bile Analysis for the Detection of Platynosomum spp.-Induced Cholangitis in Cats.

BACKGROUND: Examination of bile could be useful to diagnose Platynosomum spp.-induced cholangitis in cats. Obtaining bile via percutaneous ultrasound-guided cholecystocentesis (PUC) is possible but raises safety concerns in cats with severe cholecystitis. OBJECTIVES: The objectives of this study were to investigate the use of PUC to collect bile samples from cats with known platynosomosis and to determine if bile analysis could be a diagnostic test. ANIMALS: Twenty-seven free-roaming cats positive for Platynosomum spp. eggs via fecal examination. METHODS: In this prospective study, fecal egg counts were performed by double centrifugation with Sheather's solution. Bile was collected using PUC from anesthetized cats. Egg counts in bile were performed with a stereoscope. Euthanasia and postmortem examination were performed immediately after PUC. RESULTS: All cats had ultrasound (US) evidence of cholangitis or cholecystitis. Thirty-nine PUCs were performed with 14 cats having 2 PUCs 12 or 24 days apart. Postmortem examinations showed no overt gallbladder damage or leakage but fresh blood was noted in the gallbladder lumen of 3 cats. Median Platynosomum spp. egg counts were higher in bile (1450 eggs/mL; IQR, 400; 5138 eggs/mL) as compared to feces (46 eggs/mL; IQR, 10; 107 eggs/mL) (P < .001). CONCLUSION AND CLINICAL IMPORTANCE: Bile egg count analysis is an alternative method with higher egg counts as compared to fecal egg count analysis for the diagnosis of platynosomosis. Obtaining bile via US guidance is technically feasible and safe in cats with cholangitis/cholecystitis. Cholecystocentesis and bile analysis are especially relevant for those cats with chronic cholangitis/cholecystitis and negative fecal egg counts for Platynosomum.

Current concepts in hepatobiliary surgery.

The most common hepatic procedures performed in companion animals are liver biopsies and partial hepatectomies. Surgery of the biliary tract most often involves the gallbladder, although surgical intervention of the bile duct may also be performed. Hepatobiliary surgery is often challenging, being performed in patients with significant systemic illness and associated with potentially life-threatening complications. An in-depth understanding of the regional anatomy, use of a team concept for patient management, particularly for patients undergoing partial hepatectomy surgery, and provision of intensive perioperative monitoring and support helps minimize complications and maximize outcome.

Botulinum toxin A as a treatment for delayed gastric emptying in a dog.

A toy Australian shepherd dog was referred for bile peritonitis following excision of a biliary mucocele. Subsequent delayed gastric emptying was refractory to prokinetic therapy but responded to injection of botulinum toxin A into the muscularis layer of the pylorus; a novel therapy for delayed gastric emptying in dogs.

Toxine botulinique : Traitement de la vidange gastrique retardée chez un chien. Un chien Berger australien miniature a été référé pour une péritonite biliaire après l'excision d'une mucocèle biliaire. La vidange gastrique retardée subséquente a été réfractaire au traitement stimulant la motilité gastrique mais a répondu à l'injection de la toxine botulinique A dans la couche musculeuse du pylore; un traitement innovateur pour la vidange gastrique retardée chez les chiens.(Traduit par Isabelle Vallières).

Complications of the extrahepatic biliary surgery in companion animals.

Surgery of the biliary tract is demanding and is associated with several potentially life-threatening complications. Veterinarians face challenges in obtaining accurate diagnosis of biliary disease, surgical decision-making, surgical hemostasis and bile peritonitis. Intensive perioperative monitoring is required to achieve early recognition of common postoperative complications. Proper treatment and ideally, avoidance of surgical complications can be achieved by gaining a clear understanding physiology, anatomy, and the indications for hepatobiliary surgery.

Choledochotomy and primary repair of extrahepatic biliary duct rupture in seven dogs and two cats.

OBJECTIVE: To report clinical findings and outcome in dogs and cats undergoing choledochotomy or primary repair of extrahepatic biliary duct rupture. METHODS: Retrospective study of dogs (n=7) and cats (n=2) that had choledochotomy or primary bile duct repair. RESULTS: Extrahepatic biliary obstruction was confirmed at surgery in all cases. The underlying cause in four dogs and both cats was choledocholithiasis, two dogs had gall bladder mucocoeles with associated bile duct rupture, and one dog had inspissated bile obstructing the bile duct secondary to gall bladder carcinoid tumour. Three dogs and both cats had choledochotomies performed to relieve extrahepatic biliary obstruction, and four dogs with bile duct rupture underwent primary repair of the defect. One dog with a bile duct rupture was re-explored four days postoperatively and had suffered dehiscence of the repair; this rupture was re-repaired. All animals were discharged from the hospital, and did not have clinical recurrence of extrahepatic biliary obstruction. CLINICAL SIGNIFICANCE: Choledochotomy and primary repair of extrahepatic biliary duct rupture were associated with low perioperative morbidity and no mortality in this small cohort of cases. These techniques are reasonable options either alone or in conjunction with other procedures when bile duct patency cannot be re-established by catheterisation or bile duct discontinuity exists.

Intraoperative vital and haemodynamic monitoring using an integrated multiple-channel monitor in rats.

The aim of this study is to give a hands-on description of the successful monitoring procedure established for extended liver resections and liver transplantations in rats and to provide the typical range of data as obtained before and after a hepatobiliary surgical procedure (right median hepatic vein [RMHV] ligation) in healthy male Lewis rats. All manipulations were performed in anaesthetized (3% isoflurane in O(2) 1 L/min) healthy male Lewis rats (250-350 g) with an integrated multiple-channel intraoperative monitor (Powerlab system) using a series of sensors for data acquisition. Vital parameters (body temperature, electrocardiogram, respiratory rate and heart rate), haemodynamic parameters (mean arterial blood pressure [MAP] and central venous pressure) and liver perfusion parameters (inferior hepatic venous pressure, portal vein pressure [PVP], blood flow of portal vein and inferior hepatic cava) were monitored. Catheters were placed in microsurgical technique after careful exposure guided by anatomical landmarks. Vascular incisions were closed with interrupted sutures. Complete instrumentation of animals was performed within 1 h. No specific complications occurred. Vital and haemodynamic parameters such as MAP (94 +/- 16.2 mmHg) or portal pressure (9.6 +/- 1.34 mmHg) were in the same range as known for humans (MAP = 100 mmHg, portal pressure = 5-10 mmHg), whereas parameters dependent on the size of the body or organ such as flow rates (portal blood flow = 16.2 +/- 6 mL/min) were obviously different compared with those of humans (portal blood flow = 800 mL/min). In conclusion, the normal range for vital, haemodynamic and liver perfusion parameters was reported as reference values to allow quality control for future surgical hepatobiliary research projects. As the procedure can be easily learned, the extensive intraoperative monitoring can be used routinely.

Hilar liver resection in dogs.

OBJECTIVE: To describe hepatic vasculobiliary anatomy important to hilar liver lobe resection in the dog. STUDY DESIGN: Experimental study. ANIMALS: Canine cadavers (n=7). METHODS: The vasculobiliary system of 7 fresh canine livers was injected with a polymer. The parenchyma was dissected at the level of the hilus to determine the vascular and biliary supply to each liver lobe, and then macerated with a corrosion preparation. The information gathered was used to describe a surgical approach for hilar liver lobe resection. RESULTS: Each liver lobe had a single hepatic artery and biliary duct. The location of these structures was consistent, although minor variations existed (dorsal versus ventral to the lobar portal vein) in the left lateral lobe and papillary process in 2 specimens. Most liver lobes (34/49) were supplied by 1 lobar portal vein and drained by 1 lobar hepatic vein (39/49). The location of the portal and hepatic veins was consistent among specimens. CONCLUSIONS: The left division is the most mobile of the liver lobes and each lobe can be removed separately or en bloc. Because of the location of the hepatic veins, the central division is best removed as a single unit. The right lateral lobe can be removed individually or together with the caudate process. The papillary process is removed by itself. CLINICAL RELEVANCE: A hilar liver lobectomy technique can provide an alternative approach to conventional procedures for tumors that encroach upon the hilus of the liver.

Long-term survival of dogs after cholecystoenterostomy: a retrospective study of 15 cases (1981-2005).

Fifteen dogs with extrahepatic biliary tract disease underwent cholecystoenterostomy. Long-term survivors were significantly older at presentation (mean age 140.5 months) than dogs that survived the first 20 days after surgery but subsequently died from causes related to the surgery or hepatobiliary disease (mean age 72 months). Dogs that died during the first 20 days had significantly more complications in the hospital than dogs that survived this period. The type of underlying hepatobiliary disease (i.e., benign or malignant) was not associated with either short-term outcome or long-term survival. Eight dogs died from causes related to surgery or hepatobiliary disease. Long-term complications included hepatic abscesses, acquired portosystemic shunts, pancreatitis, and vomiting.

Treatment of pancreatitis-associated extrahepatic biliary tract obstruction by choledochal stenting in seven cats.

OBJECTIVES: To report the clinicopathological findings and outcome in cats with pancreatitis-associated extrahepatic biliary tract obstruction (EHBO) treated by choledochal tube stenting. METHODS: Medical records of cats with EHBO secondary to pancreatitis that underwent choledochal stenting were reviewed. Information on outcome was obtained by re-examination of the cat or by telephone interview with the owners. RESULTS: All cats had pancreatitis confirmed by histopathological examination of biopsy samples (n=6) or suspected based on gross examination at surgery (n=1). In six cats, a section of 3.5 to five French gauge red rubber catheter and in one cat a section of 22 G intravenous catheter were used as a choledochal stent. Two cats developed re-obstruction of the biliary tract within a week of the original surgery. One cat had confirmed episodes of ascending cholangitis postoperatively. Two cats had chronic intermittent vomiting in the postoperative period. Two cats died during the perioperative period. Five cats survived to discharge, three of which died seven to 24 months postoperatively and two of which remain alive to date. CLINICAL SIGNIFICANCE: Choledochal stenting is an alternative to biliary diversion for management of feline pancreatitis-associated EHBO in select cases. However, there may be greater morbidity with this technique in cats compared with dogs.

Choledochal tube stenting for decompression of the extrahepatic portion of the biliary tract in dogs: 13 cases (2002-2005).

OBJECTIVE: To determine clinicopathologic features, surgical management, complications, and long-term outcome associated with diseases of the extrahepatic portion of the biliary tract treated via choledochal stent placement in dogs. DESIGN: Retrospective case series. ANIMALS: 13 dogs. PROCEDURE: Data were obtained from medical records, and follow-up information was obtained via reexamination or telephone interview with owners or referring veterinarians. RESULTS: 10 dogs had extrahepatic biliary obstruction (EHBO), 6 as a result of pancreatitis. Two dogs had rupture of the common bile duct associated with cholelithiasis. In 1 dog, a stent was placed prophylactically after gastroduodenostomy was performed for a perforated duodenal ulcer. Nine of 13 dogs survived the perioperative period and were discharged. No recurrence of EHBO or other complications developed in the discharged dogs while the stents were in place. Median follow-up period from surgery to last owner contact was 13.3 months. In 1 dog, the stent was removed endoscopically 10 months after surgery and EHBO recurred 9 months after stent removal because of cholangitis. In 4 of 5 dogs that were discharged from the hospital, in which the fate of the stent could be confirmed and the stent was secured to the duodenal wall with absorbable suture materials, the stents were passed in the feces 1 to 11 months after surgery. CONCLUSIONS AND CLINICAL RELEVANCE: Choledochal tube stenting is an effective method of decompression of the extrahepatic portion of the biliary tract in dogs and provides a less complex alternative to traditional cholecystoenterostomy techniques in select cases.

Therapeutic percutaneous ultrasound-guided cholecystocentesis in three dogs with extrahepatic biliary obstruction and pancreatitis.

Three dogs were examined because of acute pancreatitis. In all 3, distension of the gallbladder was seen ultrasonographically, and extrahepatic biliary tract obstruction (EHBO) was diagnosed on the basis of ultrasonographic findings and serum biochemical abnormalities (i.e., high serum bilirubin and cholesterol concentrations and increased hepatic enzyme activities). In all 3 dogs, percutaneous ultrasound-guided cholecystocentesis (PUCC) was used to decompress the gallbladder, with cholecystocentesis performed multiple times in 1 dog. Serum bilirubin concentration was substantially decreased following the procedure in all 3 dogs. Two of the 3 dogs did not require surgery to resolve the obstruction. In the third dog, an exploratory laparotomy was performed because of concerns about development of abdominal effusion following the procedure. Bile staining of the mesenteric fat was seen during the laparotomy, but no defect in the gallbladder wall could be identified. In most dogs with EHBO secondary to pancreatitis, the obstruction resolves spontaneously as the acute pancreatitis improves so that surgery is not required. In those few dogs in which EHBO does not resolve or in which EHBO results in complications, therapeutic PUCC may be useful in relieving gallbladder distension.