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Digestive Disease Interventions 2022; 06(01): 046-051
DOI: 10.1055/s-0041-1742101
Review Article

Gallbladder Cryoablation: Clinical and Technical Considerations

Hugh McGregor 
1   Department of Radiology, University of Washington, Seattle, Washington
› Author Affiliations Funding H.M. has received research funding from Healthtronics and has a patent pending for a cryoablation device and related methods.
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Abstract

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.

Keywords

gallbladder - cryoablation - cholecystitis


Publication History

Received: 20 May 2021

Accepted: 09 November 2021

Article published online:
04 January 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Wadhwa V, Jobanputra Y, Garg SK, Patwardhan S, Mehta D, Sanaka MR. Nationwide trends of hospital admissions for acute cholecystitis in the United States. Gastroenterol Rep (Oxf) 2017; 5 (01) 36-42
    CrossrefPubMedGoogle Scholar
  • 2 Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Rep 2009; (11) 1-25
    PubMedGoogle Scholar
  • 3 Riall TS, Adhikari D, Parmar AD. et al. The risk paradox: use of elective cholecystectomy in older patients is independent of their risk of developing complications. J Am Coll Surg 2015; 220 (04) 682-690
    CrossrefPubMedGoogle Scholar
  • 4 Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006; (04) CD006231
    PubMedGoogle Scholar
  • 5 Livingston EH, Rege RV. A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 2004; 188 (03) 205-211
    CrossrefPubMedGoogle Scholar
  • 6 Goonawardena J, Gunnarsson R, de Costa A. Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors. Am J Surg 2015; 210 (03) 492-500
    CrossrefPubMedGoogle Scholar
  • 7 Shinall Jr MC, Arya S, Youk A. et al. Association of preoperative patient frailty and operative stress with postoperative mortality. JAMA Surg 2020; 155 (01) e194620
    CrossrefPubMedGoogle Scholar
  • 8 Kirshtein B, Bayme M, Bolotin A, Mizrahi S, Lantsberg L. Laparoscopic cholecystectomy for acute cholecystitis in the elderly: is it safe?. Surg Laparosc Endosc Percutan Tech 2008; 18 (04) 334-339
    CrossrefPubMedGoogle Scholar
  • 9 Wadhwa V, Trivedi PS, Makary MS. et al. Utilization and outcomes of cholecystostomy and cholecystectomy in patients admitted with acute cholecystitis: a nationwide analysis. AJR Am J Roentgenol 2021; 216 (06) 1558-1565
    CrossrefPubMedGoogle Scholar
  • 10 Bundy J, Srinivasa RN, Gemmete JJ, Shields JJ, Chick JFB. Percutaneous cholecystostomy: long-term outcomes in 324 patients. Cardiovasc Intervent Radiol 2018; 41 (06) 928-934
    CrossrefPubMedGoogle Scholar
  • 11 Alvino DML, Fong ZV, McCarthy CJ. et al. Long-term outcomes following percutaneous cholecystostomy tube placement for treatment of acute calculous cholecystitis. J Gastrointest Surg 2017; 21 (05) 761-769
    CrossrefPubMedGoogle Scholar
  • 12 Hung YL, Chong SW, Cheng CT. et al. Natural course of acute cholecystitis in patients treated with percutaneous transhepatic gallbladder drainage without elective cholecystectomy. J Gastrointest Surg 2020; 24 (04) 772-779
    CrossrefPubMedGoogle Scholar
  • 13 Girard MJ, Saini S, Mueller PR. et al. Percutaneous chemical gallbladder sclerosis after laser-induced cystic duct obliteration: results in an experimental model. AJR Am J Roentgenol 1992; 159 (05) 997-999
    CrossrefPubMedGoogle Scholar
  • 14 Getrajdman GI, O'Toole K, Logerfo P, Laffey KJ, Martin EC. Transcatheter sclerosis of the gallbladder in rabbits. A preliminary study. Invest Radiol 1985; 20 (04) 393-398
    CrossrefPubMedGoogle Scholar
  • 15 Salomonowitz E, Frick MP, Simmons RL. et al. Obliteration of the gallbladder without formal cholecystectomy. A feasibility study. Arch Surg 1984; 119 (06) 725-729
    CrossrefPubMedGoogle Scholar
  • 16 Iaccarino V, Niola R, Porta E. Percutaneous cholecystectomy in the human: a technical note. Cardiovasc Intervent Radiol 1988; 11 (06) 357-359
    CrossrefPubMedGoogle Scholar
  • 17 Becker CD, Quenville NF, Burhenne HJ. Gallbladder ablation through radiologic intervention: an experimental alternative to cholecystectomy. Radiology 1989; 171 (01) 235-240
    CrossrefPubMedGoogle Scholar
  • 18 Becker CD, Fache JS, Malone DE, Stoller JL, Burhenne HJ. Ablation of the cystic duct and gallbladder: clinical observations. Radiology 1990; 176 (03) 687-690
    CrossrefPubMedGoogle Scholar
  • 19 Aagaard BD, Wetter LA, Montgomery CK, Gordon RL. Heat ablation of the normal gallbladder in pigs. J Vasc Interv Radiol 1994; 5 (02) 331-339
    CrossrefPubMedGoogle Scholar
  • 20 Lee JH, Won JH, Bae JI, Kim JH, Lee HS, Jung SM. Chemical ablation of the gallbladder with acetic acid. J Vasc Interv Radiol 2009; 20 (11) 1471-1476
    CrossrefPubMedGoogle Scholar
  • 21 Atar E, Khasminsky V, Friehmann T, Choen A, Bachar GN. Cystic duct embolization with chemical gallbladder ablation for the treatment of acute calculous cholecystitis in high-risk patients: a prospective single-center study. J Vasc Interv Radiol 2020; 31 (04) 644-648
    CrossrefPubMedGoogle Scholar
  • 22 Mohan BP, Khan SR, Trakroo S. et al. Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis. Endoscopy 2020; 52 (02) 96-106
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Walter D, Teoh AY, Itoi T. et al. EUS-guided gall bladder drainage with a lumen-apposing metal stent: a prospective long-term evaluation. Gut 2016; 65 (01) 6-8
    CrossrefPubMedGoogle Scholar
  • 24 Garnon J, Cazzato RL, Caudrelier J. et al. Adjunctive thermoprotection during percutaneous thermal ablation procedures: review of current techniques. Cardiovasc Intervent Radiol 2019; 42 (03) 344-357
    CrossrefPubMedGoogle Scholar
  • 25 McGregor H, Woodhead G, Patel M. et al. Gallbladder cryoablation for chronic cholecystitis in high-risk surgical patients: 1-year clinical experience with imaging follow-up. J Vasc Interv Radiol 2020; 31 (05) 801-807
    CrossrefPubMedGoogle Scholar
  • 26 McGregor HCJ, Surman A, Fernandez A. et al. Pilot study of the safety and efficacy of gallbladder cryoablation in a porcine model: midterm results. J Vasc Interv Radiol 2018; 29 (03) 340-344
    CrossrefPubMedGoogle Scholar
  • 27 McGregor H, Woodhead G, Conrad M. et al. First in-human gallbladder cryoablation in a patient with acute calculous cholecystitis initially treated with a cholecystostomy tube. J Vasc Interv Radiol 2019; 30 (08) 1229-1232
    CrossrefPubMedGoogle Scholar
  • 28 McGregor HC, Saeed M, Surman A. et al. Gallbladder cryoablation: proof of concept in a swine model for a percutaneous alternative to cholecystectomy. Cardiovasc Intervent Radiol 2016; 39 (07) 1031-1035
    CrossrefPubMedGoogle Scholar
  • 29 Bornman PC, Terblanche J. Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis. Surgery 1985; 98 (01) 1-6
    PubMedGoogle Scholar
  • 30 Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H. Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 2015; 150 (02) 159-168
    CrossrefPubMedGoogle Scholar
  • 31 Nezami N, Peters G, Moon JT, Kokabi N, Shaikh J, Majdalany BS. Laser ablation of the cystic duct followed with cryoablation of gallbladder: leave nothing behind. J Vasc Interv Radiol 2021; 32 (10) 1505-1508
    CrossrefPubMedGoogle Scholar
  • 32 Stewart L, Griffiss JM, Jarvis GA, Way LW. Bacteria entombed in the center of cholesterol gallstones induce fewer infectious manifestations than bacteria in the matrix of pigment stones. J Gastrointest Surg 2007; 11 (10) 1298-1308
    CrossrefPubMedGoogle Scholar
  • 33 Woodfield JC, Rodgers M, Windsor JA. Peritoneal gallstones following laparoscopic cholecystectomy: incidence, complications, and management. Surg Endosc 2004; 18 (08) 1200-1207
    CrossrefPubMedGoogle Scholar
  • 34 Patel N, Chick JFB, Gemmete JJ. et al. Interventional radiology-operated cholecystoscopy for the management of symptomatic cholelithiasis: approach, technical success, safety, and clinical outcomes. AJR Am J Roentgenol 2018; 210 (05) 1164-1171
    CrossrefPubMedGoogle Scholar
  • 35 Sabel MS. Cryo-immunology: a review of the literature and proposed mechanisms for stimulatory versus suppressive immune responses. Cryobiology 2009; 58 (01) 1-11
    CrossrefPubMedGoogle Scholar
  • 36 Seifert JK, Morris DL. World survey on the complications of hepatic and prostate cryotherapy. World J Surg 1999; 23 (02) 109-113 , discussion 113–114
    CrossrefPubMedGoogle Scholar
  • 37 Ramadori G, Armbrust T. Cytokines in the liver. Eur J Gastroenterol Hepatol 2001; 13 (07) 777-784
    CrossrefPubMedGoogle Scholar
  • 38 Seifert JK, Stewart GJ, Hewitt PM, Bolton EJ, Junginger T, Morris DL. Interleukin-6 and tumor necrosis factor-alpha levels following hepatic cryotherapy: association with volume and duration of freezing. World J Surg 1999; 23 (10) 1019-1026
    CrossrefPubMedGoogle Scholar
  • 39 Ng KK, Lam CM, Poon RT. et al. Comparison of systemic responses of radiofrequency ablation, cryotherapy, and surgical resection in a porcine liver model. Ann Surg Oncol 2004; 11 (07) 650-657
    CrossrefPubMedGoogle Scholar
  • 40 Stewart L, Oesterle AL, Griffiss JM, Jarvis GA, Aagaard B, Way LW. Gram-negative bacteria killed by complement are associated with more severe biliary infections and produce more tumor necrosis factor-alpha in sera. Surgery 2002; 132 (02) 408-414
    CrossrefPubMedGoogle Scholar