Long-term outcomes of endoscopic transpapillary gallbladder drainage using a novel spiral plastic stent in acute calculus cholecystitis.

BACKGROUND: Endoscopic transpapillary gallbladder stenting (EGBS) is considered for patients with contraindications to early surgery for acute calculus cholecystitis. However, evidence regarding the long-term outcomes of EGBS is insufficient to date. The aim of the study was to evaluate the feasibility of EGBS as a bridge to or alternative to surgery when there are contraindications. METHODS: We reviewed the cases of patients who underwent EGBS using a novel spiral-shaped plastic stent for acute calculus cholecystitis between January 2011 and December 2019. We retrospectively evaluated the long-term outcomes of EGBS using a novel spiral-shaped plastic stent. RESULTS: Forty-nine patients were included. The clinical success rate of EGBS was 97%. After EGBS, 25 patients (surgery group) underwent elective cholecystectomy and 24 patients did not (follow-up group). In the surgery group, the median period from EGBS to surgery was 93 days. There was a single late adverse event with cholecystitis recurrence. In the follow-up group, the median follow-up period was 236 days. Late adverse events were observed in eight patients, including recurrence of cholecystitis (four patients), duodenal penetration by the distal stent end (two patients), and distal stent migration (two patient). In the follow-up group, the time to recurrence of biliary obstruction was 527 days. CONCLUSIONS: EGBS with a novel spiral-shaped plastic stent is safe and effective for long-term acute calculus cholecystitis. There is a possibility of EGBS to be a bridge to surgery and a surgical alternative for acute calculus cholecystitis in patients with contraindications to early cholecystectomy.

A feasibility study of percutaneous transhepatic gallbladder filling (PTGBF) in a swine model.

Background: Treatments for acute cholecystitis include cholecystectomy and percutaneous drainage. However, some patients are at high risk for surgery, and prolonged drainage can decrease their quality of life. Purpose: To determine the feasibility of percutaneous transhepatic gallbladder filling (PTGBF) with n-butyl-cyanoacrylate (NBCA) in a swine model. Material and methods: After the induction of general anesthesia, percutaneous transhepatic gallbladder puncture to a pig weighing 49 kg using a 20-G-percutaneous transhepatic cholangio drain (PTCD) needle was performed under ultrasound guidance. A 2.1 F-microcatheter was inserted through the outer PTCD needle, then the cystic duct was coil-embolized. The microcatheter was removed, the gallbladder was filled with 25% NBCA-Lipiodol, then the PTCD needle was withdrawn without complications. Blood was sampled and CT images were acquired from the pig immediately after the procedure and on postoperative day 7. The pig was euthanized on postoperative day 7 and the gallbladder was evaluated by microscopy. Results: Vital signs were stable, and the CT images showed that the gallbladder contained NBCA-Lipiodol without complications such as leakage. Hepatobiliary enzymes were not elevated. Histological findings demonstrated loss of most mucosa with partial regeneration, and lymphocytic infiltration. The muscle layer was intact. Conclusion: This technique might offer a feasible alternative to surgery for high-risk patients with acute cholecystitis, but further studies are needed to determine the safety and long-term effects of this procedure.

Role of Bile Acids and GLP-1 in Mediating the Metabolic Improvements of Bariatric Surgery.

BACKGROUND & AIMS: Bile diversion to the ileum (GB-IL) has strikingly similar metabolic and satiating effects to Roux-en-Y gastric bypass (RYGB) in rodent obesity models. The metabolic benefits of these procedures are thought to be mediated by increased bile acids, although parallel changes in body weight and other confounding variables limit this interpretation. METHODS: Global G protein-coupled bile acid receptor-1 null (Tgr5-/-) and intestinal-specific farnesoid X receptor null (FxrΔ/E) mice on high-fat diet as well as wild-type C57BL/6 and glucagon-like polypeptide 1 receptor deficient (Glp-1r-/-) mice on chow diet were characterized following GB-IL. RESULTS: GB-IL induced weight loss and improved oral glucose tolerance in Tgr5-/-, but not FxrΔ/E mice fed a high-fat diet, suggesting a role for intestinal Fxr. GB-IL in wild-type, chow-fed mice prompted weight-independent improvements in glycemia and glucose tolerance secondary to augmented insulin responsiveness. Improvements were concomitant with increased levels of lymphatic GLP-1 in the fasted state and increased levels of intestinal Akkermansia muciniphila. Improvements in fasting glycemia after GB-IL were mitigated with exendin-9, a GLP-1 receptor antagonist, or cholestyramine, a bile acid sequestrant. The glucoregulatory effects of GB-IL were lost in whole-body Glp-1r-/- mice. CONCLUSIONS: Bile diversion to the ileum improves glucose homeostasis via an intestinal Fxr-Glp-1 axis. Altered intestinal bile acid availability, independent of weight loss, and intestinal Akkermansia muciniphila appear to mediate the metabolic changes observed after bariatric surgery and might be manipulated for treatment of obesity and diabetes.

Suturing with or without surgical glue is superior to surgical glue alone for sealing ex vivo swine gallbladders.

OBJECTIVE: To assess the effectiveness of various sealing techniques in cholecystotomies under maximum intraluminal pressure stress using an ex vivo swine model. SAMPLE: 30 gallbladders from different animals were used. METHODS: The experiment was conducted ex vivo, with the formation of 3 groups, each comprising 10 samples. Group 1 utilized a traditional single-layer Cushing suture made from polydioxanone material. Group 2 employed a single layer of Cushing suture, also made from polydioxanone material, but in conjunction with surgical glue (n-butyl cyanoacrylate). Group 3 relied solely on the use of surgical glue (n-butyl cyanoacrylate) for sealing the edges of the surgical wound. The intraluminal pressure was gauged with a pressure transducer. RESULTS: The maximum intraluminal pressures (mean ± SD) sustained in G1, G2, and G3 were, respectively, 48.70 ± 21.32 mm Hg, 110.90 ± 37.52 mm Hg, and 10.9 ± 4.07 mm Hg. Comparisons between groups showed that G2 supported significantly higher pressures (56.1% higher) than G1 (P < .001) and G3 (90.2% higher; P < .001). When G1 was compared with G3, a significantly higher pressure (77.6%) was also observed (P < .01). CLINICAL RELEVANCE: The study's conclusions demonstrated the safest suture techniques for the gallbladder and provided advice regarding the use of surgical glue.

Primary clear cell carcinoma of gallbladder arising in porcelain gallbladder.

Gallbladder carcinomas (GBCs) are the most common carcinomas of the biliary tract. The clear cell variant is encountered rarely, accounting for approximately 1% of all GBCs.Due to its rarity, the exact incidence and pathogenesis of this variant are unknown. Though hyalinising cholecystitis (porcelain gallbladder) is an established risk factor for development of conventional adenocarcinomas of the gallbladder, its role in the pathogenesis of the rare variants of GBC is not well-established. The current case raises the possibility that clear cell carcinoma of the gallbladder may arise through the same pathways as conventional adenocarcinomas of the gallbladder.

A novel augmented reality to visualize the hidden organs and internal structure in surgeries.

BACKGROUND: Augmented reality (AR) is still a primarily theoretical concept in areas such as bowel, liver, gallbladder, and jaw surgeries because of the limitation of visualization accuracy of hidden organs and internal structures. This paper aims to improve the cutting accuracy, visualizing accuracy, and processing time of the augmented video. METHODOLOGY: The proposed system consists of an enhanced block-matching algorithm (BMA) with ghosting map technique. RESULTS: Results proved that proposed system reduced the visualization error, which ranges from 1.48 to 1.83 mm against the existing system visualization error 1.67 to 2.0. Similarly, the processing time also improved 59 to 72 ms/frame over the 50 to 58 ms/frame. CONCLUSION: This study showed the improvement and solved the problem soft tissue reconstruction and visualization on the AR video that used in bowel and gallbladder surgeries.

Successful endoscopic management of a persistent bronchobiliary fistula with Histoacryl®/Lipiodol® mixture.

Introduction A bronchobiliary fistula (BBF) following liver directed therapy (resection/ablation) is a rare complication in which an abnormal communication between the biliary tract and bronchial tree is formed. This case report describes the successful management of a persistent BBF following multiple liver wedge resections and microwave ablation in a patient with a metastatic neuroendocrine tumour of the terminal ileum. Case history A 69-year-old man presented with unexplained weight loss and was subsequently diagnosed with a neuroendocrine tumour of the terminal ileum and liver metastasis. Following elective right hemicolectomy and multiple bilobar liver wedge resections combined with liver microwave ablation, he developed an early bile leak. A month later, a right subphrenic collection was identified and four months following surgery, biloptysis was noted. Numerous attempts with endoscopic retrograde biliary drainage (ERBD) failed to achieve sufficient drainage. The patient was treated successfully with endoscopic injection of a mixture of Histoacryl® glue (B Braun, Sheffield, UK) and Lipiodol® (Guerbet, Solihull, UK). There was no evidence of the BBF one year following intervention. Conclusions This novel approach for persistent BBF management using endoscopic Histoacryl® glue embolisation of the fistula tract should be considered either as an adjunct to ERBD or when biliary tract decompression by drainage and/or sphincterotomy fails, prior to proceeding with surgical interventions.

Sutureless cholecystojejunostomy in pigs using an absorbable intraluminal stent and fibrin glue.

The absence of foreign bodies in sutureless anastomoses provides faster healing. The first sutureless cholecystojejunostomies were reported by Murphy in 1892. The common bile duct was tied and 11 cholecystojejunostomies plus 12 jejunojejunostomies were performed in 12 Landrace pigs employing sliding absorbable intraluminal nontoxic stents (SAINTs) and fibrin glue. One cholecystojejunostomy was not performed owing to a gallbladder morphologic anomaly. Three animals died of problems unrelated to the SAINT-glue anastomoses. Of the 18 anastomoses in the 9 remaining animals, all were patent at the verification times of 14, 30, 120, and 480 days. Morphologically,there was greater edema and reduced height of the glandular epithelium in the 30-day CJs when compared to the jejunojejunal anastomoses. Results indicate that the sutureless SAINT-fibrin glue procedure is quite versatile and may be utilized for cholecystoenteric anastomoses.

[Microflora in patients with complicated forms of acute cholecystitis treated by low-frequency ultrasonics and sulfacrylate glue]. / Dinamika mikroflory u bol'nykh s oslozhnennymi formami ostrogo kholetsistita, lechennykh nizkochastotnym ul'trazvukom i sul'fakrilatnym kleem.

Investigation of microflora in patients with complicated acute cholecystitis treated with low frequency ultrasound in combination with sulfacrylate glue showed that Staphylococcus and Escherichia played the leading role in the complication etiology. Among the nonsporulating organisms bacteroides predominated. The combined use of low frequency ultrasound and sulfacrylate glue in treatment of complicated acute cholecystitis proved to be an efficient procedure providing more rapid sanation of the purulent inflammation foci.

How to build patient-specific synthetic abdominal anatomies. An innovative approach from physical toward hybrid surgical simulators.

BACKGROUND: According to literature evidence, simulation is of the utmost importance for training and innovative surgical strategies assessment. At present commercial physical simulators are limited to single or only a few anatomical structures and these are often just standard anatomies. METHODS: This paper describes a strategy to produce patient-specific abdominal silicone organs with realistic shapes and colors, starting from radiological images. Synthetic organs can be assembled in a complex physical simulator or, if paired with electromagnetic sensors, in a hybrid environment (mixed reality) to quantify deformations caused by surgical action. RESULTS: A physical trunk phantom with liver, gallbladder, pancreas and a sensorized stomach has been developed. It is coupled with consistent radiological images and a 3D model of the entire upper abdomen. The simulator has been evaluated in quantitative and qualitative terms to quantify its accuracy and utility, respectively. CONCLUSIONS: This simulator can be used in the field of abdominal surgery to train students and as a testing environment to assess and validate innovative surgical technologies.

Comparison of Dexon and Mersilene sutures in the closure of primary laparotomy incisions.

The study is a comparison of Dexon (polyglycolic acid) and Mersilene (polyester) sutures when employed for the primary closure of the peritoneum and aponeurotic layer in primary laparotomy incisions. The material comprises 308 closures of abdominal wounds with interrupted 2-0 sutures (United States Pharmacopeia) in the aponeurosis and continuous 2-0 suture of the peritoneum. One half of the wound was closed with Dexon and the other half with Mersilene, so that the patient acted as his own control. No significant difference was found between the two materials as evaluated from the occurrence of wound rupture within 10 days and incisional hernia within 90 days of the operation. Suture granulomas occurred in 9% of the half wounds sutured with Mersilene. The present clinical investigation demonstrates that Dexon sutures are as reliable as unabsorbable material. Dexon is superior to unabsorbable material as suture granulomas were not seen when Dexon was employed.

Endoscopic magnetic cholecystodigestive anastomoses: personal technique for palliative treatment of distal bile duct obstruction.

A new type of endoscopic surgery (magnetic cholecystodigestive anastomoses) is presented as an alternative to conventional palliative treatment of mechanical obstruction with icterus located below the bile duct inlet. By means of endoscopic technique, two clinically usable methods of creating delayed magnetic cholecystogastric anastomoses and one modality of implanting cholecystoenteric and enteroenteric anastomosis have been worked out in the experiment conducted on 50 mongrels with mechanical icterus. Ring-shaped or rectangular magnets were implanted in the gallbladder through laparoscopic cholecystostomy. Implantation into the stomach was accompanied by simultaneous gastroscopy. In clinical conditions, four endoscopic cholecystogastric anastomoses and one cholecystoduodenal anastomosis have been performed on patients suffering from malignant obstruction of distal bile duct due to cancer of the head of the pancreas, making any radical surgery pointless. The preliminary results indicate that endoscopic magnetic cholecystodigestive anastomoses can serve as a form of palliative treatment of distal bile duct malignant obstructions.

Hypertrophy of the rat Golgi complex during enhancement of cholesterol and bile acids synthesis.

There are some evidences that the Golgi apparatus could be involved in bile salts transport. In this study we investigate the morphology of the Golgi apparatus in rats with a chronic bile fistula or treated with 4% cholestyramine, a bile salts chelating agent. In both models liver histology was normal by light microscopy. With electron microscopy--compared to sham groups--the only obvious change was the enlargement of the Golgi complex. Morphometric data confirmed that the Golgi rich area volume density was almost doubled after chronic bile fistula or cholestyramine treatment. These data give another support for the participation of the Golgi complex in bile salts transport.

Cholecystectomy and hernioplasty during the same laparoscopic procedure.

Cholelithiasis and inguinal or femoral hernia usually coexist in the same patient. The simultaneous laparoscopic approach to these diseases benefits the patients, who avoid two separate admissions to the hospital, two operations, and twice the cost, recuperation, and potential morbidity and mortality. The authors describe a technique that facilitates cholecystectomy and hernioplasty during the same laparoscopic approach, thus avoiding the use of two separate procedures. The results of this procedure in the first six patients were excellent.