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Gallstones and gallbladder disease

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.

Alternative Names

Cholecystitis; Choledocholithiasis; Bile duct stones

Surgery

The gallbladder is not an essential organ, and even today, only surgical removal of the gallbladder ( cholecystectomy ) guarantees that the patient will not suffer a recurrence of gallstones. This is one of the most common surgical procedures performed on women and can even be performed on pregnant women with low risk to the baby and mother. The primary advantages of surgical removal of the gallbladder over nonsurgical treatment are both the elimination of gallstones and also the prevention of gallbladder cancer.

Open Procedures versus Laparoscopy. Until the early 1990s, open cholecystectomy (the removal of the gallbladder through a wide abdominal incision) was the standard treatment. Now, laparoscopic cholecystectomy (commonly called lap choly ), which uses small incisions, is the most commonly used surgical approach. First performed in 1987, lap choly is now used in most cholecystectomies in the United States. In fact, about 700,000 people now have their gallbladders removed each year -- 200,000 more than before the introduction of laparoscopy. Of concern, then, is a significant increase in its use in patients who have inflammation in the gallbladder but no infection or gallstones and in those who have gallstones but no symptoms.

Laparoscopy has largely replaced open cholecystectomy because of some significant advantage:

• The patient can leave the hospital and resume normal activities earlier than with open surgery.
• The incisions are small, and there is less postoperative pain and disability than with the open procedure.
• Laparoscopy has fewer complications.
• It is less expensive than open cholecystectomy in the long term. The immediate treatment cost of laparoscopy may be higher than the open procedure, but the more rapid recovery with lap choly and fewer complications translate into shorter hospital stays and fewer sick days and so a greater reduction in overall costs.

Some experts believe, however, that the open procedure still has a number of advantages compared to laparoscopy:

• It is faster to perform.
• It poses less of a risk for bile duct injury, which occurs in only 0.1% to 0.5% of open procedures, compared to about 0.3% to more than 2% with laparoscopy. (It has more overall complications than laparoscopy, however, and laparoscopy bile-duct injury rates are declining.)

The type of surgery performed on specific patients may vary depending on different factors.

Appropriate Surgical Candidates. Candidates for gallbladder removal often have one of the following conditions:

• After a very severe gallstone attack.
• After several less severe gallstone attacks.
• After endoscopic sphincterotomy for common bile duct stones in patients with residual gallbladder stones.
• In patients with cholecystitis (gallbladder inflammation).
• In patients with pancreatitis (inflammation of the pancreas).
• In patients at risk for gallbladder cancer (e.g., patients with anomalous junction of the pancreatic and biliary ducts or patients with certain forms of porcelain gallbladder).
• In some patients with acalculous biliary pain (gallbladder disease symptoms without the presence of gallstones). Best candidates are those with evidence of impaired gallbladder emptying.

Timing of Surgery. Cholecystectomy may be performed within several days to weeks after hospitalization for an acute gallbladder attack, depending on the severity of the condition.

• Emergency gallbladder removal within 24 to 48 hours is warranted in about 20% of patients with acute cholecystitis. Indications for surgery include deterioration of the patient's condition or signs of perforation or widespread infection.
• The timing and type of surgery in patients with acute cholecystitis whose condition improves and have no signs of severe complications are under debate. Previously, the standard was open cholecystectomy between 6 and 12 weeks after the acute episode. Some evidence now suggests that early surgery performed between 72 and 96 hours after symptoms have lower complications than surgery performed after that.

General Outlook. Although cholecystectomy is very safe, as with any operation there are risks of complications depending on whether the procedure is done on an elective or emergency basis.

• When cholecystectomy is performed as elective surgery, the mortality rates are very low. (Even in the elderly, mortality rates are only between 0.7% to 2%.)
• Emergency cholecystectomy carries a much higher mortality rate (as high 19% in ill elderly patients).

Long-Term Effects of Gallbladder Removal. Although removal of the gallbladder has not been known to cause any long-term adverse effects aside from occasional diarrhea, some researchers have been concerned about its long-term impact on the body's cholesterol levels.

One study found that within 3 days of the operation, levels of total cholesterol and LDL returned to their preoperative levels. After 3 years, however, some types of cholesterol not ordinarily associated with coronary artery disease had risen significantly. These results did not necessarily indicate any increased risk for coronary artery disease, but they did show that the metabolism of cholesterol by the liver had been altered. People who have had their gallbladders removed should have their cholesterol levels checked periodically, as should every adult. Short-term treatment with the cholesterol-lowering known as statins, such as pravastatin (Pravachol), appears to lower cholesterol levels in surgical patients.

What Type of Surgery is Right for You?
Laparoscopy	Open Cholecystectomy
Treatment of choice for most adult gallstone patients, with or without symptoms, who have electively chosen to have their gallbladders removed.	Patients who have had extensive previous abdominal surgery.
Most patients with acute cholecystitis not accompanied by infection or perforation. (Up to 30% will need to convert to open surgery, however, depending on the severity of the condition.)	Patients with complications of acute cholecystitis (empyema, gangrene, perforation of the gallbladder).
Patients with acalculous gallbladder disease (without stones) who choose to have surgery. (The procedure of choice if such patients have inflammation, however, is percutaneous cholecystostomy--a procedure that drains the gallbladder.)	Very elderly patients. (Those over 80 are likely to have lower complication rates from open cholecystectomy than laparoscopy, although laparoscopy may even be appropriate in these patients.)
Patients with residual gallbladder stones after endoscopic sphincterotomy for common bile duct stones.
Candidates when experienced surgeons are available: Patients with acute gallstone pancreatitis that has subsided. Severely obese patients Patients with prior surgery in the upper abdomen. Patients with severely infected gallbladders. Pregnant women with symptomatic gallstones.	Seriously ill patients with acute cholecystitis who do not respond to fluid aspiration (percutaneous cholecystostomy).

Laparoscopic Cholecystectomy

The Procedure. With laparoscopy, removal of the gallbladder is typically performed as follows:

Laparoscopic cholecystectomy requires general anesthesia, although it is now mostly done as outpatient surgery.

• The surgeon inserts a needle through the navel and pumps carbon dioxide gas through it and into the abdomen to create space in the abdomen. (This step may raise blood pressure. The antihypertensive drug clonidine may be helpful during surgery to protect patients with high blood pressure or heart or kidney disease. Of note, a 2000 study recommended that elderly patients not receive gas. Such patients are more likely to require a longer operating time, and the on-going pressure from the carbon dioxide increases the risk for problems that require conversion to an open procedure.)
• Small incisions, one or two 10 to 12 mm (around half an inch) and three 5 mm (.20 inches), are made in the abdomen.
• The surgeon inserts a laparoscope (a thin telescope) which contains a small surgical instrument and a tiny camera that relays an image to a video monitor.
• The surgeon separates the gallbladder from the liver and other areas and removes it through one of the incisions.
• Evidence suggests that the use of cholangiography during the operation helps prevent injury in the bile ducts, a serious complication of cholecystectomy. (Cholangiography may also used be in laparoscopy.) With this procedure, a dye is injected into the bile duct and x-rays are used to view the duct.
• In general, 24-hour monitoring afterward is not necessary and the patient can go home the same day. It should be noted, however, that according to a 2001 study some patients may be at higher risk for readmission later on, including those who required more than an hour for the operation or who had thicker gallbladder walls

Risk Factors for Conversion from Laparoscopy to an Open Procedure. In about 5% to 10% of laparoscopies, conversion to open cholecystectomy is required during the procedure. Some reasons for conversion to open surgery include the following:

• Possible or known injury to major blood vessels.
• Internal structures not clearly visible.
• Unexpected problems that cannot be corrected with laparoscopy.
• Common bile duct stones that cannot be removed with laparoscopy or subsequent ERCP.
• Previous endoscopic sphincterotomy.
• A thickened gallbladder wall.

Complications and Side Effects of Surgery.

• Pain and fatigue are common side effects of any abdominal surgery. Patients should abstain from light recreational activities for about two days and from work and more strenuous activities for about a week.
• There is a relatively high incidence of nausea and vomiting after laparoscopic cholecystectomy, which can be treated with injections of metoclopramide. Preoperative anti-nausea agents, such as granisteron, may prevent these effects. One study reported that patients who received a local anesthesia at the incision sites (in addition to general anesthesia) before surgery had less pain and nausea afterwards.
• Injury to the bile duct. Bile duct injury is the most serious complication of laparoscopy. It can include leakage, tears, and the development of narrowing (strictures) that can lead to liver damage. In order to minimize such injuries, some experts recommend that surgeons perform laparoscopy with a procedure called cholangiography, in which a dye is injected into the bile duct and x-rays are used to view the duct. Bile duct injury has been a more common problem than with the open procedure but increasing surgical experience and the use of cholangiography is reducing this complication and studies are now reporting more comparable rates between the two procedures.
• In about 6% of procedures, the surgeon misses gallstones or they are spilled and remain in the abdominal cavity. In a small percentage of these cases, the stones cause obstruction, abscesses, or fistulas (small channels) that require open surgery.
• As with all surgeries, there is a risk for infection, but it is very low.

Patients should not be shy about inquiring into the number of laparoscopies the surgeon has performed. (It should not be fewer than 40.) Obese patients were originally thought to be poor candidates for laparoscopic cholecystectomy, but recent research indicates that this surgery is safe for them.

Open Cholecystectomy

Before the development of laparoscopy, the standard surgical treatment for gallstones was open cholecystectomy (surgical removal of the gallbladder through an abdominal incision), which requires a wide incision and leaves a larger surgical scar. The patient usually needs to stay in the hospital for 5 to 7 days and may not return to work for a month. Complications include bleeding, infections, and injury to the common bile duct. The risks of this procedure increase with other factors, such as the age of the patient or if the surgeon needs to explore the common bile duct for stones at the same time.

Other Procedures

Percutaneous Cholecystostomy. Percutaneous cholecystostomy is a procedure that may be used in seriously ill patients with severe gallbladder infection who cannot tolerate immediate surgery. It is also the standard treatment for patients with acalculous cholecystitis (gallbladder inflammation without stones). This procedure uses a needle to withdraw fluid (aspirate) from the gallbladder. A drainage catheter is inserted through the skin and into the gallbladder while the fluid drains out. In some cases, it may be left in place for up to 8 weeks. After that time, if possible, laparoscopy or an open cholecystectomy may be performed. Without a laparoscopy, recurrence rates with this procedure are high.

Gallbladder Aspiration. With this procedure, fluid is aspirated in one procedure while the gallbladder is viewed using ultrasound. It does not require an indwelling catheter afterward and may have fewer complications than percutaneous cholecystostomy.

Investigative Procedures

Mini-Laparotomy Cholecystectomy. Mini-laparotomy cholecystectomy uses small abdominal incisions but, unlike laparoscopy, it is an "open" procedure and the surgeon does not operate through a scope. The surgical instruments used are very fine caliber (2 to 3 mm in diameter, or about a tenth of an inch). Eventually this technique may reduce operative time and improve results compared to laparoscopy.

Needlescopic Cholecystectomy. Procedures that use even fewer and smaller incisions than laparoscopy are being developed. There are many variations, including those referred to as twin-port, mini-site, or mini- or micro-laparoscopic surgeries. These procedures make even fewer incisions (two to three) and smaller ones (1.2 to 3 mm, or less than a tenth of an inch). It should be noted, however, that these procedures still require one large incision (10 to 12 mm, or about half an inch). They are still investigative and have some disadvantages:

• Fiberoptics, used to view the surgical areas, do not provide light that is as bright as light in conventional laparoscopy.
• The instruments are very fragile.
• The field of vision is very limited.

Although experience is very limited, studies are showing promise for reducing postoperative pain and improving recovery time beyond that of standard laparoscopy.

Telerobotic Surgery. In one high-tech experiment, a woman in Stasbourg, France had her gallbladder successfully removed by surgeons in New York using laparoscopy controlled by a remote robotic device. The procedure took 54 minutes and was free of complications.

• Review Date: 6/12/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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