Surgery:

The gallbladder is not an essential organ, and its removal is one of the most common surgical procedures performed on women. It can even be performed on pregnant women with low risk to the baby and the mother. The primary advantages of surgical removal of the gallbladder over nonsurgical treatment are elimination of gallstones and 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 it offers some significant advantages:

• The patient can leave the hospital and resume normal activities earlier, compared to 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 therefore 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 - 0.5% of open procedures, compared to about 0.3 - 2% with laparoscopy. Open surgery has more overall complications than laparoscopy, however, and bile-duct injury rates with laparoscopy 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, or have had, one of the following conditions:

• A very severe gallstone attack
• Several less severe gallstone attacks
• Endoscopic sphincterotomy for common bile duct stones (in patients with residual gallbladder stones)
• Cholecystitis (gallbladder inflammation).
• Pancreatitis (inflammation of the pancreas)
• High risk for gallbladder cancer (such as patients with anomalous junction of the pancreatic and biliary ducts or patients with certain forms of porcelain gallbladder)
• Acalculous biliary pain (gallbladder disease symptoms without the presence of gallstones). The best candidates are those with evidence of impaired gallbladder emptying.

Pregnant women who have gallstones and experience symptoms are also candidates for surgery.

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

• Emergency gallbladder removal within 24 - 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 - 12 weeks after the acute episode. Some evidence now suggests that early surgery performed between 72 - 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 0.7 - 2%.)
• Emergency cholecystectomy carries a much higher mortality rate (as high 19% in ill elderly patients).

Long-Term Effects of Gallbladder Removal. Removal of the gallbladder has not been known to cause any long-term adverse effects aside from occasional diarrhea.

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 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.
• One or two 10 - 12 mm (about one-half inch) and three 5 mm (about a fifth of an inch) incisions 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. With this procedure, dye is injected into the bile duct, and moving x-rays are used to view the duct.
• In general, the patient can go home the same day, although those whose operation took longer than 1 hour, or who had thicker gallbladder walls, may be at somewhat higher risk of complications from early discharge.

Risk Factors for Conversion from Laparoscopy to an Open Procedure. In about 5 - 10% of laparoscopies, conversion to open cholecystectomy is required during the procedure. The rate of conversion to open surgery is higher in men than in women. This may be due to the higher rate of inflammation and fibrosis in men with symptomatic gallstones. Other reasons for conversion from laparoscopic to open surgery include:

• 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 2 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 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 cholangiography Bile duct injury has been a more common problem in laparoscopy compared to the open procedure, but increasing surgical experience and the use of cholangiography is reducing this complication. Studies are now reporting more comparable rates between the two procedures.
• In about 6% of procedures, the surgeon misses some gallstones, or they spill 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 (the minimum should be 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 large surgical scar. In this procedure, the patient usually stays in the hospital for 5 - 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 the need to explore the common bile duct for stones at the same time.

Candidates for whom cholecystectomy may be a more appropriate choice:

• Patients who have had extensive previous abdominal surgery
• Patients with complications of acute cholecystitis (empyema, gangrene, perforation of the gallbladder).

Older patients. Those over 80 are likely to have lower complication rates from open cholecystectomy than laparoscopy, although laparoscopy may also be appropriate in these patients.

Whether or not to insert a drain in the wound after surgery is under debate. Many surgeons implant drains primarily to prevent abscess or peritonitis. That practice may change. A recent analysis of all randomized clinical trials comparing drains versus no drains, or the type of drain used found that patients who received drains had a dramatically increased risk of wound and chest infection. The type of drain used made no difference.

ERCP with Endoscopic Sphincterotomy (ES)

Reasons for performing the procedure:

• Before gallbladder surgeries, when there is strong suspicion that common bile duct stones are present.
• After gallbladder surgeries in which the surgeon detects stones in the common bile duct (only if there are experts in ERCP present, and equipment is available).
• For patients with gallstone cholangitis (serious infection in the common bile duct). In such cases urgent ERCP and antibiotics are required.
• When acute pancreatitis is caused by gallstones. In such cases urgent ERCP and antibiotics are required. (The use of ERCP compared to conservative treatment has been controversial. One study reported that only patients who had infection and persistent obstruction in the ducts benefited from urgent ERCP intervention. In a 2000 analysis of four studies, however, ERCP significantly improved survival rates and reduced complications in patients.)

The ERCP and ES Procedure. A typical ERCP and endoscopic sphincterotomy (ES) procedure includes the following steps:

• The patient is given a sedative and asked to lie on his or her left side.
• An endoscope (a tube containing fiber optics connected to a camera) is passed through the mouth and stomach and into the duodenum (top part of the small intestine) until it reaches the point where the common bile duct enters. This does not interfere with breathing, but the patient may have a sensation of bloating.
• A thin catheter (tubing) is then passed through the endoscope.
• Contrast material (a dye) is injected through the catheter into the opening of the duct. The dye allows x-ray visualization of the biliary tree (the system of ducts through which bile flows, including the common bile duct) and any stones contained in the area.
• Instruments may also be passed through the endoscope to remove any stones that are detected.
• The next phase of the procedure is known as endoscopic sphincterotomy (ES). (It is also sometimes referred to as papillotomy, although this is a slightly different variation.) ES widens the junction between the common bile duct and intestine (the ampulla of Vater) so that the stones can be extracted more easily. With ES, a tiny incision is usually made in the orifice of the common bile duct and through the muscles that enclose the lower common bile duct (the sphincter of Oddi).
• One recent alternative to ES is the use of a small inflatable balloon (a procedure known as endoscopic balloon dilation) that opens up the ampulla of Vater to allow stones to pass. This variation does not involve cutting muscles. According to 2003 studies, it is equal in effectiveness to ES but offers no advantage at this time.
• Once the junction has been opened, the stones may pass on their own, or they may be extracted with the use of tiny baskets or balloons.

Complications. Complications of ERCP and ES occur in 5 - 8% of cases, and some can be serious, with mortality rates of 0.2 - 0.5%. They include the following:

• Pancreatitis (inflammation of the pancreas) occurs in 3 - 9% of cases and can be very serious. Younger adults are at higher risk than the elderly. The risk is also higher with more complex procedures. The drugs somatostatin or gabexate are sometimes used to reduce the risk, although recent evidence suggests somatostatin may not actually reduce this risk. Gabexate appears to be more effective, although studies are mixed on whether its benefits are significant, particularly with short-term treatment.
• Postoperative infection. Antibiotics may be given before the procedure to prevent infection, although one study reported that they had little benefit.
• Bleeding occurs in 2% of cases. There is an increased risk for bleeding in patients taking anti-clotting drugs, and those who have cholangitis. This complication is treated by flushing the area with epinephrine.
• Perforations (rare).
• Long-term complications include stone recurrence and abscesses.

ERCP and ES are difficult procedures, and patients must be certain their doctor and the medical center have experience with them. The surgeon should have performed at least 180 ERCPs. Under such circumstances, ERCP can usually be performed successfully even in critically ill patients on mechanical ventilators.

ERCP and Gallbladder Removal (Cholecystectomy). ERCP is often performed after gallstones in the common duct are discovered during cholecystectomy.

In some cases, stones in the gallbladder are detected during ERCP. In such cases laparoscopic cholecystectomy is usually warranted. There is some debate about whether the gallbladder should be removed in such cases at the same time as ERCP, or if patients should wait. A 2002 study suggested that immediate gallbladder removal is preferred, since the risk for recurring symptoms is very high.