| Background Gallbladder stone(GS)is a familiar disease in digestive system.The incidence of the disease is increasing with age year by year.In China,the frequencie of GS has reached 10%in adults.Most of the stones do not cause symptoms,which called asymptomatic GS.A small group of GS is responsible for symptoms such as biliary colic,nausea and/or vomiting,fever and jaundice,etc.Treatment is needed for symptomatic GS as suggested.At present,there are many kinds of treatments for GS,include cholecystectomy,drug litholysis,extracorporeal shock wave lithotripsy(ESWL),gallbladder drainage,,choledochoscopic gallbladder-preserving surgery,laser lithotripsy,among which cholecystectomy is recognized as the first choice.In the past few years,laparoscopic cholecystectomy(laparoscopic cholecystectomy,LC)with the advantages of less cost,less trauma,shorter hospital stay,quicker recovery and so on,has gradually supplanted the traditional open surgery and wins good comments from patients and doctors;however,patients who lose physiological function of gallbladder after cholecystectomy,will develope some related complications,like steatorrhea,aversion to greasy food,and so on,which affects the quality of life to some extent.Meanwhile,as with open surgery,LC still needs to be performed under intravenous general anesthesia,cardiac and pulmonary insufficiency are considered to be contraindications for the disease.Drug litholysis by taking bile acid preparations and ESWL have the advantages of better safety and efficiency in treating GS,however,the follow-up investigation found that the recurrence rate of stones after the two methods was quite high.Related studies show that the combination of ESWL and drug dissolution can achieve a higher complete clearance for symptomatic patients with GS.For patients who develop acute cholecystitis,but have contraindications to surgery,gallbladder drainage is an effective method when conservative treatments are not satisfactory,and it can also prepare patients for follow-up operation.As the improvement of people's living standards,development of technology and increase of the demands for gallbladder preservation,new treatment methods emerge in an endless stream for GS,and the minimal invasive surgery with less trauma,simple and safe operation,gradually shows its unique advantages..In a report of the 1960s,Mondet et al.first applied the percutaneous transhepatic approach to handle common bile duct stone(CBDS),and opened the door to the operation for choledocholithiasis.On this basis,under the guide of the percutaneous transhepatic avenues,we can use laser lithotripsy,electrohydraulic lithotripsy(EHL),balloon dilation and other remedies to treat choledocholithiasis.Especially for patients with large and infectious choledocholithiasis who are not suitable for endoscopic procedures,percutaneous transhepatic approach combining with various auxiliary methods is an effective alternative technique.Frequency-doubled double-pulse neodymium YAG(FREDDY)laser lithotripsy adopts short-pulse and double frequency technology to form high-energy mechanical shock wave,which can disintegrate stones from the inside.FREDDY has large output energy and high efficiency for crushing stones,especially suitable for large GS that are difficult to be treated by traditional treatments.In addition,FREDDY laser can not be absorbed by human tissues basically,so there is no thermal effect causing tissue damage in the process.Therefore,FREDDY laser lithotripsy can improve the complications caused by holmium laser lithotripsy previously,such as gallbladder bleeding,perforation and nearby tissue and organ damage.At the moment,there are few studies on the treatment of GS with percutaneous transhepatic FREDDY laser lithotripsy.Nowadays,our department has put forward the idea of percutaneous transhepatic FREDDY laser lithotripsy for the treatment of GS on the basis of clinical developments of percutaneous transhepatic papillary balloon dilation(PTPBD)in the treatment of common duct stone.Objectives To investigate the safety,feasibility and effectiveness of percutaneous transhepatic FREDDY laser lithotripsy in the treatment of GS.Focus on the success rate,bleeding and perforation of gallbladder,damage of bile duct and other organs,peritonitis,pancreatitis,bile leakage,infection of biliary system,as well as the recurrence of stones and occurrence of gallbladder cancer during the follow-up,etc.,so as to provide some basis for the application of this technology in the treatment of GS.Materials and Method Ten patients with GS admitted to the Second Hospital of Shandong University from March 2017 to November 2019 were selected as the research subjects.Enrollment criteria:(1)diameter of GS?2.0 cm confirmed by imaging examination,;(2)symptoms associated with cholecystitis,such as pain and fever;(3)can not tolerate or refuse surgery,laparoscopic surgery,endoscopic surgery,or want to preserve the gallbladder;(4)KPS score>70.Exclusion criteria:(1)Severe cardiac dysfunction(New York Heart Association class:Grade ?-?),severe lung diseases(determined by consulting respiratory specialists),liver dysfunction(Child-Pugh liver function grade:C)or kidney diseases(Grade 3 chronic kidney disease);(2)Severe coagulopathy(prothrombin time>17s and/or platelet count<60 ×1012/L),malnutrition(albumin<30g/L),anemia(hemoglobin<90g/L);(3)Poor gallbladder contraction function showed by gallbladder contraction test(gallbladder contraction rate<40%);(4)pregnant and lactating women.Collect and record patients' general information,imaging data,white blood cell(WBC),alanine aminotransferase(ALT),aspartate aminotransferase(AST),direct bilirubin(DBIL),total bilirubin(TBIL),albumin(ALB),serum lipase and amylase(AMY),and tumor marker carbohydrate antigen 199(CA199)1 week before and after operation,as well as operation condition(numbers of operations,whether lithotripsy is successful,causes of surgical failure,intraoperative complications,etc.)and postoperative follow-up(periodical review of transabdominal ultrasound,CT or MRCP,and the above-mentioned laboratory tests such as blood routine and liver function,to observe whether there were any long-term complications such as chronic cholecystitis,gallbladder cancer,and recurrence of stones).All statistical analyses were finished using GraphPad Prism 7.05 Categorical variables were presented as number and percentage.Continuous data were presented as means±standard deviations.We used paired t-tests for the identical indexes before and after the procedure in the same patient.A P-value of less than 0.05 was considered statistically significant.Results In this study,10 patients with GS were admitted,including 4 male and 6 female.The patients were all middle-aged and elderly with the average age of 60.2 ±17.0 years old(23-80 years old).The average diameter of GS was 26.3±3.0mm(22.0-31.0mm).There were 4 cases with simple GS and 6 cases with common bile duct stones.All stones were smashed completly,and the success rate of lithotripsy was 100%(10/10).See Table 1.WBC,ALT,AST,TBIL,DBIL,ALB,AMY,,CA199 and other indicators were reviewed 1 week after surgery.Among them,AST,AMY,lipase,TBIL,DBIL and WBC decreased when compared with preoperative values,and the difference was statistically significant.ALT,CA19-9,ALB reduced after surgery,but we found no statistic difference in the mean values.The contraction function of the gallbladder was improved to some extent after operation without statistic difference(See Table 2).One patient suffered from abdominal pain,fever and other discomfort after operation.Considering the occurrence of peritonitis after operation,it was improved after the symptomatic treatment such as anti-infection and pain relief;one had much blood drainage after surgery,accompanied by a drop in blood pressure.Healing gallbladder hemorrhage due to surgery,it was improved after giving blood transfusion and fluid supplement.No adverse events such as pancreatitis,biliary tract perforation,and infection occurred,the incidence of complications was 20.0%(2/10).After 2 years of follow-up,we found 1 Sediment-like stone and 1 microstone with the diameter of 3.0mm in the ultrasound images of the GS patients,the stone recurrence rate was 20.0%(2/10).Conclusion This study has initially proved that the application of percutaneous transhepatic FREDDY laser lithotripsy for GS patients consistent with indications better reflects the superiority of interventional minimally invasive surgery,which ensures the integrity of the biliary system and the normal physiological function of the gallbladder after surgery,and satisfies patients' demand for preservation of cholecyst,At the same time,the bile duct obstruction is relieved,the clinical symptoms of the patient are improved,and the physical and mental afflictions of the patient is reduced.FREDDY laser adopts frequency-doubled double-pulse technology,with high successful rate of lithotripsy and significant effect on larger stones.The FREDDY laser can not be easily absorbed by the human soft tissue,and there is no thermal effect in the lithotripsy process,which is associated with low morbidity,and patients recover quickly after percutaneous transhepatic approach with low incidence of postoperative complications.Therefore,percutaneous transhepatic FREDDY laser lithotripsy is expected to become a safe and effective alternative method for GS with larger size or that can not be treated by other gallbladder-preserving instruments.However,because of the small sample size of this study,the short follow-up time,and the lack of prospective randomized controlled studies compared with surgery and other gallbladder-preserving procedures,more data is needed to explain this standpoint. |
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