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What Are Gallstones and
Gallbladder Disease
What Are the Symptoms of
Gallstones and Gallbladder Disease?
What Other Diseases Produce
Symptoms Similar to Gallstones and Gallbladder Disease?
How Serious Are Gallstones and
Gallbladder Disease?
Who Gets Gallstones and
Gallbladder Disease?
How Can Gallstones and
Gallbladder Disease Be Prevented?
How Are Gallstones and
Gallbladder Disease Diagnosed?
What Are the Treatments for
Gallstones and Gallbladder Disease?
Single Incision (Bellybutton) Gallbladder Removal
More
information (includes alternative treatments for
gallstones, and management of stones in the bile duct).
What Are Gallstones and Gallbladder Disease?
Gallstones are formed from bile, a fluid composed mostly
of water, bile salts, lecithin, and cholesterol. Bile is
first produced by the liver and then secreted through
tiny channels within the liver into a duct. From here,
bile passes through a larger tube called the common
duct, which leads to the small intestine. Then, except
for a small amount that drains directly into the small
intestine, bile flows into the gall bladder through the
cystic duct. The gallbladder is a four-inch sac with a
muscular wall that is located under the liver. Here,
most of the fluid (about two to five cups a day) is
removed, leaving a few tablespoons of concentrated bile.
The gallbladder serves as a reservoir until bile is
needed in the small intestine for digestion of fat. When
food enters the small intestine, a hormone called cholecystokinin is released, signaling the gallbladder
to contract. The force of the contraction propels the
bile back through the common bile duct and then into the
small intestine, where it emulsifies fatty molecules so
that fat and the fat-absorbable vitamins A, D, E, and K
can enter the blood stream through the intestinal
lining.
About three-quarters of the gallstones found in the U.S.
population are formed from cholesterol. Cholesterol
makes up only five percent of bile; it is not very
soluble, however, so in order to remain suspended in
fluid, it must be properly balanced with bile salts. If
the liver secretes too much cholesterol into the bile,
if the bile becomes stagnant because of a defect in the
mechanisms that cause the gallbladder to empty, or if
other factors are present, supersaturation can occur.
Cholesterol may then precipitate out of the bile
solution to form gallstones -- a condition known as
cholelithiasis. The process is very slow and most often
painless. Gallstones can range from a few millimeters to
several centimeters in diameter.
The other 25% of gallstones are known as pigment
gallstones. They are composed of calcium bilirubinate,
or calcified bilirubin, the substance formed by the
breakdown of hemoglobin in the blood. These black stones
often form in the gallbladders of people with sickle
cell anemia, hemolytic anemia, or cirrhosis.
At any point, stones may obstruct the cystic duct, which
leads from the gallbladder to the common bile duct, and
cause pain (biliary colic) or infection and inflammation
(cholecystitis). About 10% of people with stones in the
gall bladder also have stones in the common bile duct (the
medical term is choledocholithiasis),
which can lodge in the duct and cause blockage of the
bile duct, infection, or inflammation of the pancreas
(pancreatitis).
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What Are the Symptoms of Gallstones and Gallbladder
Disease?
About 80% of people with gallstones never experience any
symptoms. If symptoms do occur, the chance of developing
pain is about 2% per year for the first ten years after
stone formation, after which the chance for developing
symptoms decreases. Pain is usually the first symptom,
but some patients develop other problems from the
outset.
If you have
no symptoms but you know you have gallstones, then it
means that the stones probably showed up on tests done
looking for something else. Another situation may
be that the test was done looking for gallstones, but
the symptoms you have are not typical for pain caused by
gallstones. In such cases, there may be no need to
have your gallbladder removed. Some surgeons may
be more likely to recommend surgery in such cases than
others. The surgeons at DeKalb Surgical frequently
recommend a "wait and see" approach in such situations
where the gallbladder is not causing you any symptoms.
However, once you have any pain or other complication
from the gallstones, it's a different story, as
discussed below.
Biliary Pain
The mildest and most common symptom of gallbladder
disease is intermittent pain called biliary colic, which
occurs either in the middle or the upper-right portion
of the upper abdomen. The pain often is also felt in the
back, between the shoulder blades, as well. Large or
fatty meals can precipitate the pain, but it usually
occurs about one hour or more after eating, often at
night. Biliary colic produces a steady pain, which can
be quite severe and may be accompanied by nausea and
vomiting. Changes in position, over-the-counter pain
relievers, and passage of gas do not relieve the
symptoms. Biliary colic usually disappears after several
hours.
Pain from gallstones sometimes occurs higher up in the
lower chest, similar to pain like a heart attack. If a
patient has pain in this area, it is important to
consider the possibility of a heart problem first. If
no heart abnormality is found, then one can consider
whether gallstones might be the problem.
One of
the most common stories we hear from our patients with
gallstones is that they were awakened at about 2 am with
horrible pain, either in the chest, upper abdomen or
back. The pain was so bad they went to the
emergency room, where an ultrasound or other test showed
gallstones. In most of these cases the pain will
go away after several hours, or after a dose of strong
pain medicine. If your own story is like this,
then you should not delay in calling us for an
appointment to discuss surgery, since it is highly
likely you are going to have more such episodes unless
you have your gallbladder removed.
Acute Cholecystitis
Acute gallbladder inflammation (acute cholecystitis) is
a more serious problem than biliary colic. It begins
abruptly and subsides gradually. Nausea, vomiting, and
severe pain and tenderness in the upper right abdomen
are the most common complaints; fever is common but may
be absent. The discomfort is intense and steady and
lasts until the condition is treated with medicine or
surgery. Patients with acute cholecystitis frequently
complain of pain along the right lower rib cage when
taking a deep breath. Acute cholecystitis is usually
caused by gallstones, but, in some cases, can occur
without stones.
Chronic Cholecystitis
Chronic gallbladder disease (chronic cholecystitis)
basically refers to the changes that occur in the
gallbladder as a result of the presence of gallstones.
Scarring causes the gallbladder to become stiff and
thick. If you keep having episodes of pain
(biliary colic) over and over without surgery, it can
make the surgery a lot more difficult once you decide on
having your gallbladder removed. So again, if you
are having such symptoms you should not delay in talking
to us about surgery.
Common Bile Duct Stones (Choledocholithiasis) and
Gallstone Pancreatitis
Stones lodged in the common bile duct (choledocholithiasis)
can block the flow of bile and cause a yellowing of the
skin, called jaundice. Serious infection of the bile
duct (cholangitis) may develop that causes high fever,
chills, nausea and vomiting, and severe pain in the
upper-right quadrant of the abdomen. This is an
especially serious type of infection that requires
prompt treatment.
If stones
get in the bile duct they can also affect the pancreas,
causing its enzymes to back up in the pancreas,
essentially digesting itself. This can cause a
very serious problem, called gallstone pancreatitis, or
biliary pancreatitis. Although this condition
often subsides over just a few days, the inflammation
can in some cases progress very rapidly, and some
patients may even die from this. Most patients
with this problem get sick so quickly that they are
admitted through the emergency room to the hospital.
In almost all cases, surgery should be strongly
considered to remove the gallbladder (and any stones
remaining in the bile duct) before leaving the hospital.
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What Other Diseases Produce Symptoms Similar to
Gallstones and Gallbladder Disease?
The diagnostic challenge posed by gallstones is to be
sure that abdominal pain is caused by stones and not by
some other condition. Ultrasound or other imaging
techniques easily find gallstones. Nevertheless, because
gallstones are common and many cause no symptoms, simply
finding stones does not necessarily explain a patient's
pain.
Irritable bowel syndrome (IBS) has some of the same
symptoms as gallbladder disease, including difficulty
digesting fatty foods. In IBS, however, pain usually
occurs in the lower abdomen. Acute appendicitis,
pneumonia, stomach ulcers, hiatal hernia, pancreatitis,
hepatitis, kidney infections, and even a heart attack
may mimic a gallbladder attack, so it is important to
see a physician immediately if symptoms occur.
In patients with abdominal pain, causes other than
gallstones are often responsible if the pain lasts less
than 15 minutes, is present most of the time, frequently
comes and goes, or is not severe enough to limit
activities.
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How Serious Are Gallstones and Gallbladder Disease?
Many gallstones provoke no symptoms at all. In the
absence of symptoms, gallstones seldom lead to problems.
Death from gallstones is very rare, accounting for only
0.2% of annual deaths in the United States. Serious
effects from gallstones are usually from infection or
stones in the bile duct.
Gallbladder Cancer
Gallbladder cancer is very rare. Gallstones are present
in about 80% of people with gallbladder cancer. Less
than one percent of people with gallstones develop this
cancer. People who have symptomatic gallstones have four
times the risk as those without symptoms. Whether
gallstones themselves cause the cancer, or whether some
factor in bile is responsible for both conditions, is
unknown. One study demonstrated that gallbladder removal
reduced the likelihood of bile duct cancer, suggesting
that gallstones themselves were responsible for this
cancer.
Complications from Gallstones
Acute cholecystitis can cause severe inflammation and
even necrosis (tissue death) in the gallbladder.
Perforation and abscess formation may occur when severe
symptoms persist for days.. The risk for perforation
increases with a condition called emphysematous
cholecystitis, in which gas forms in the gall bladder.
This condition is most common in people with diabetes.
Empyema of the gallbladder, or pus in the gallbladder,
occurs in 2% to 3% of patients with acute cholecystitis.
Abdominal pain is usually severe and is typically
present for more than seven days. Mortality approaches
25% for those with empyema; death often occurs as a
result of septicemia (spread of infection through the
bloodstream). Both perforation and empyema require
prompt surgery. The complications can be avoided,
however, by seeing a physician as soon as gallbladder
symptoms occur.
Complications of Common Bile Duct Stones
Gallstones occasionally lodge in the common bile duct
instead of the gallbladder, a condition called
choledocholithiasis. When this occurs, stones can block
the flow of bile out of the liver, causing a type of
jaundice. Cholangitis (infection of the bile ducts) is a
serious complication of choledocholithiasis. If
antibiotics are administered immediately, the infection
clears up in 75% of patients. When cholangitis does not
improve the condition can be life threatening, and
either surgery or a procedure known as endoscopic
sphincterotomy is required to open and drain the ducts.
Elderly patients who develop acute cholangitis may
require special care. If they develop symptoms of wide
spread infection (fever, rapid heart beat, fast
breathing, mental confusion) or do not respond to
standard treatment, immediate drainage of the common
bile duct is necessary.
Pancreatitis
Gallstones are responsible for about 45% of all cases of
acute pancreatitis (acute inflammation of the pancreas),
a condition that can be life threatening. Alcohol
accounts for most other cases of pancreatitis.
Pancreatitis can result from stones in the bile duct,
because the pancreatic duct, which carries digestive
enzymes, joins the common bile duct right after it
enters the intestine and so may be blocked by common
duct stones. If a gallstone passes through or lodges in
the lower common bile duct, pancreatitis can result. It
is sometimes difficult to differentiate between
pancreatitis and acute cholecystitis, but a correct
diagnosis is critical since treatment is very different.
Blood tests showing high levels of pancreatic enzymes
(amylase and lipase) can usually indicate the diagnosis
of pancreatitis. Imaging techniques are useful in
confirming a diagnosis. Ultrasound is frequently used. A
computed tomography (CT) scan along with a number of
laboratory tests can help to measure the severity of the
condition. The initial treatment is intravenous fluids
and painkillers; also, the patient is not allowed to eat
or drink anything. Mild cases usually subside within a
week, and if gallstones are present, cholecystectomy
(removal of the gallbladder) is often then performed.
About 25% of pancreatitis cases are severe, and this
rate is much higher -- about 66% -- in people who are
obese. Urgent endoscopic retrograde
cholangiopancreatography (ERCP) with sphincterotomy and
drainage of the ducts to remove any stones may be very
beneficial in these cases (see
How Is Gallstone Disease
Diagnosed? below).
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Who Gets Gallstones and Gallbladder Disease?
Age and Gender
Gallstones affect about 10% of all adults over 40. They
occur in nearly 25% of women in the U.S. by age 60 and
in up to 50% by age 75. About 20% of men have gallstones
by the time they reach 75 years of age. About 80% of
men and women over age 90 show evidence of gallstones.
Gallstone disease is relatively rare in children,
although those with a spinal injury or a history of
abdominal surgery are at risk. Children who have damaged
immune systems or who receive nutrition intravenously
also have a higher incidence of cholelithiasis. Girls do
not seem to be more at risk than boys.
Women are probably at increased risk because the female
hormone estrogen stimulates the liver to remove more
cholesterol from blood and divert it into the bile.
Increased risk of gallstone formation has been observed
in women who take oral contraceptives, and taking
estrogen replacement therapy after menopause doubles the
risk of gallbladder disease. Women of childbearing age
may want to select an oral contraceptive with a low
estrogen level to reduce their risk. Postmenopausal
women may benefit from estrogen administered through
skin patches, which does not appear to affect the liver
but still provides other health benefits
Obesity and Rapid Weight Loss
Obesity in both men and women increases the risk for
gallstones. Experiments using rats showed that obesity
resulted in lower levels of bile salts relative to
cholesterol in the bile causing a higher risk for
cholesterol supersaturation and the formation of stones.
The risk for gallstones is also increased, however, with
rapid weight loss. One study reported new gallstones in
28% of obese subjects consuming ultra-low calorie liquid
diets.
Cholesterol and Cholesterol-Lowering Drugs
Gallstone formation does not correlate with blood
cholesterol levels, but persons with low HDL cholesterol
(the so-called good cholesterol) levels or high
triglyceride levels are at increased risk. The
cholesterol-lowering drugs gemfibrozil (Lopid) and
clofibrate (Atromid-S) reduce blood cholesterol levels
by increasing the amount secreted into the bile, thus
increasing the risk for gallstones. These drugs, in any
case, have potentially serious side effects and are not
used for lowering cholesterol if other drugs can be
tolerated, including niacin and the statins, which do
not contribute to the formation of gallstones.
Other Factors
Conditions that decrease the flow of bile and therefore
increase the risk of gallstone formation include
fasting, pregnancy, and intravenous feeding. The disease
may progress more rapidly in patients with diabetes, who
tend to suffer worse infections. Native Americans are
especially prone to developing gallstones; women in this
population have an 80% chance of developing gallstones
during their lives. People of Asian and African descent
are at lower risk. In addition to the
cholesterol-lowering drugs mentioned above, the diuretic
thiazide may increase the risk for gallstones slightly.
Pigment Gallstones
Pigment gallstones are more likely to affect the
elderly, people with cirrhosis, and those with chronic
hemolytic anemia, including sickle cell anemia. People
of Asian descent who develop gallstones are most likely
to have the pigment type.
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How Can Gallstones and Gallbladder Disease Be Prevented?
Maintaining a normal weight and avoiding fasts are the
keys to reducing the risk of gallstones. For people who
are overweight who attempt ultra-low-calorie diets, one
study has shown that gallstones may be prevented by
taking ursodiol or ursodeoxycholic acid (Actigall),
which is ordinarily used to dissolve existing gallstones
(see
Non-Surgical Therapy for
Gallstones under What Are the
Treatments for Gallstones? below). It should be
noted that this medication is very expensive. A less
costly and easier solution was reported in another
study, which found that incorporating a modest amount of
fat (preferable monounsaturated fat) in a very low
calorie diet may reduce the risk of gallstone formation.
Alcohol in small amounts (one ounce per day) has been
found to reduce the risk in women by 20%, although it
should be stressed that alcohol is easily abused, and
higher amounts may increase the risk of many diseases,
including breast cancer in women. Some studies indicate
that vitamin C may be protective.
Exercising regularly and vigorously may reduce the risk
of gallstones and gall bladder disease. One study
indicated that men who performed endurance-type exercise
(such as jogging and running, racquet sports, and brisk
walking) for thirty minutes five times per week reduced
their risk for gallbladder disease by up to 34%. The
benefit depended more on the intensity of activity than
the type of exercise. Some researchers guess that in
addition to controlling weight, exercise helps normalize
blood sugar levels and insulin levels, which, if
abnormal, may contribute to gallstones.
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How Are Gallstones and Gallbladder Disease Diagnosed?
History and Physical Examination
The diagnosis of any disease begins with asking
questions of the patient about their symptoms. A
physical exam often reveals tenderness in the right
upper area of the abdomen in acute cholecystitis and
sometimes in biliary colic. There is usually no
tenderness in chronic cholecystitis.
Laboratory Tests
Laboratory tests are usually normal in people with
simple biliary pain or chronic cholecystitis. In acute
cholecystitis, and especially choledocholithiasis
(stones in the bile duct), however, blood tests of the
liver show elevations of the enzyme alkaline phosphatase
and bilirubin. Bilirubin is the orange-yellow pigment
found in bile; high levels cause jaundice, which gives
the skin a yellowish tone. A high white blood cell count
(leukocytosis) is another common finding but should not
be relied on to establish a diagnosis of acute
cholecystitis.
Ultrasound
Ultrasound, the diagnostic method most frequently used
to detect gallstones, is a simple, rapid, and
noninvasive imaging technique. Ultrasound detects
gallstones as small as two millimeters in diameter with
an accuracy of 95% to 98%. The patient must not eat for
six or more hours before the test, which takes only
about 15 minutes. During the same procedure, information
can be obtained about the liver and common bile duct, as
well as the pancreas, kidneys, spleen and blood vessels.
Cholescintigraphy (HIDA Scan, or Hepatobiliary Scan)
Cholescintigraphy, another imaging technique, is
non-invasive and is occasionally useful. In this
procedure, a chemical containing a radioisotope is
injected intravenously. This material is excreted into
bile and, in normal patients, can be seen filling the
gallbladder. In acute cholecystitis, however, the dye
does not enter the gallbladder, indicating that the
cystic duct is blocked. Cholescintigraphy takes 60 to 90
minutes. Though the scan can detect obstruction of the
cystic duct to the gallbladder it cannot identify
individual gallstones. Occasionally, the scan gives
false positive results, particularly in alcoholic
patients with liver disease or patients who are fasting
or receiving all nutrients intravenously. Other terms
used for this test include hepatobiliary scan, nuclear
gallbladder scan, or HIDA or DISIDA scan.
Oral Cholecystography (OCG)
Cholecystography relies on an abdominal x-ray. It was
once the standard method for evaluating the gallbladder,
but has been essentially replaced by ultrasound and
cholescintigraphy, so this test is almost never used
anymore. In this procedure, tablets containing
an iodine compound that appears on an x-ray is taken one
day before the test. The tablets are absorbed by the
intestine, excreted by the liver, and concentrated in
the gallbladder, where it will be seen on an x-ray taken
the following day. Stones may be outlined by the dye. A
diseased gallbladder, however, will not be seen, because
its outlet is blocked and so will not absorb the dye.
CAT Scan
Gallstones
may or may not be seen on a CAT scan when present in the
gallbladder. As it turns out, the ultrasound is
really better than CAT scan to know for sure. But
it is not uncommon for gallstones to be seen on a CAT
scan ordered for other reasons.
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Diagnosing Common Bile Duct Stones (Choledocholithiasis)
If there is evidence for common bile duct stones, such
as dark urine, jaundice, clay-colored
stools, pancreatitis, or elevation of certain liver
function tests, then more extensive tests may be
appropriate.
Invasive Diagnostic Procedures
Detection of common bile duct stones must often rely on
endoscopic retrograde cholangiopancreatography (ERCP)
This procedure involves the use of an endoscope -- a
flexible telescope containing a miniature camera and
other instruments -- which is passed through the mouth,
the stomach, and into the upper small intestine, where
the bile duct empites. This is a difficult procedure and
patients should be sure their physician is experienced
in performing it. (For more detailed information on ERCP,
see
Treatment for Common Duct Stones (Choledocholithiasis)
under What Are the Treatments for Gallstones?,
below.)
Another x-ray technique, percutaneous transhepatic
cholangiography, uses a long, thin needle inserted
through the skin into the liver to inject a contrast dye
into the bile duct.
Both of these techniques are expensive, invasive, and
have rare but serious risks; they should be used only
when disease is considered likely. These invasive
procedures are not necessary if preoperative ultrasound
and blood tests are normal and there is no history of
jaundice or pancreatitis (see
Treatment for Common Bile Duct
Stones (Choledocholithiasis) under
What Are the Treatments for Gallstones? below).
Cholangiography is also sometimes used during surgery to
determine if there are any stones in the common bile
duct, and to confirm the position of the bile duct.
Imaging Techniques
Less invasive imaging techniques are being investigated
for diagnosing common bile duct stones. Ultrasound,
which is accurate in diagnosing stones in the
gallbladder, is not as sensitive for showing if there
are stones in the common bile duct.
A relatively new test which provides pictures similar to
those obtained by ERCP is called magnetic resonance
cholangiopancreatography, or MRCP. This study is
similar to a CT scan or MRI, with the addition of a
contrast agent injected into the veins, which is
concentrated within the bile duct system. This test has
the advantage of being less invasive than ERCP. On the
other hand, when ERCP is done, treatment can be done at
the same time to remove the common duct stones.
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What Are the Treatments for Gallstones and Gallbladder
Disease?
There are three approaches to gallstone treatment:
expectant management; nonsurgical removal of the stones;
or surgical removal of the gallbladder.
Expectant Management
Guidelines from the American College of Physicians state
that when a person has no symptoms, the risks of both
surgical and nonsurgical treatment for gallstones
outweigh the benefits. Experts suggest a wait-and-see
approach for such patients, which they have termed
expectant management. Exceptions to this policy are
people at risk for gallbladder cancer; subgroups at high
risk for complications of gallstones (including Pima
Native Americans); those with stones larger than three
centimeters; and people who have polyps in the
gallbladder (or at least for polyps more than 1
centimeter in size). One study reported that very small
gallstones increase the risk for acute pancreatitis, a
serious condition; some experts therefore believe that
gallstones smaller than five millimeters warrant
elective surgery even without symptoms.
There are some minor risks with expectant management.
Gallstones almost never spontaneously disappear, except
sometimes when they are formed under special
circumstances, such as pregnancy or sudden weight loss.
At some point, then, the stones may cause pain,
complications, or both, and require treatment. For
30-year olds with asymptomatic gallstones, the
probability of eventually needing an operation is about
30%; for 50-year olds it is 20%; and for 70-year olds it
is 15%. In addition, the slight risk of developing
gallbladder cancer might encourage younger people who
are asymptomatic to have their gallbladders removed.
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Surgical Removal of the Gallbladder (Cholecystectomy)
General Considerations for Gallbladder Removal
Every year, about 500,000 people have their gallbladders
removed. The gallbladder is not an essential organ, and
even today, only surgical removal of the gallbladder (cholecystectomy)
assures that the patient will not suffer a recurrence of
gallstones and their symptoms. This is one of the most
common surgical procedures performed and can even be
performed during pregnancy with low risk to the baby and
mother. The primary advantage of surgical removal of the
gallbladder over nonsurgical treatment is that the
potential risk of complications from gallstones is
basically eliminated.
Until the early 1990s, open cholecystectomy (the removal
of the gallbladder through an abdominal incision) was
the standard treatment. Now, laparoscopic cholecystectomy (commonly called lap chole
([pronounced "lap KOHL-lee"), which uses
small incisions, is the most commonly used surgical
approach. First performed in 1987, laparoscopy is now
used in nearly all cholecystectomies in the United
States
Candidates for surgery include patients who have
experienced one or more typical gallstone attacks, or
who have other complications due to their gallstones,
such as jaundice, cholangitis, or gallstone (biliary) pancreatitis.
Laparoscopic Cholecystectomy
With laparoscopy, removal of the gallbladder is guided
by a laparoscope, which is a bit like a periscope. The
surgeon first creates space in the abdomen by filling it
with carbon dioxide, which flows out of a tube inserted
through the navel. Four small incisions in the abdomen
enable the surgeon to insert instruments and a
laparoscope -- a thin lighted optical telescope that can relay an image
of the area to a video monitor. The surgeon separates
the gallbladder from the liver and removes it through
one of the incisions. Laparoscopic cholecystectomy
requires general anesthesia, but patients can still
leave the hospital earlier than with open surgery, and
there is less post-operative pain and disability than
with the open procedure. Patients usually go home on the
same day as the surgery, and return to work within ten
days.
As experience with laparoscopy has grown, patients are
tending to have the operation earlier and electively and
are therefore less likely to develop acute cholecystitis
or common bile duct stones. If cholecystitis or common
bile duct stones are present, a laparoscopic procedure
may be more challenging to perform, and the procedure
may have to be "converted" to the traditional open
technique. Others at higher risk for conversion to open
surgery are those with thick-walled and contracted gall
bladders, those whose gallbladder can be felt as a
palpable lump before the operation, and patients who
have undergone multiple abdominal operations. In about
5% of laparoscopies, conversion to standard, or open,
cholecystectomy is required.
The most serious potential complication of laparoscopy
is injury to the bile duct, which can cause serious
liver damage, and other complications. Fortunately, this complication is rare,
occurring on average in only 1 out of every 1000 cases.
Other potential complications include bile leakage into
the abdominal cavity from where the gallbladder was
removed, or injury to the bowels.
Single Incision (Bellybutton) Gallbladder Removal
In December 2008, Dr. Michael Champney performed the
first single incision
laparoscopic cholecystectomy
at DeKalb Medical. Laparoscopic techniques for
gallbladder removal developed rapidly in the late
1980’s, with a quick evolution of improved instruments
and equipment, including high resolution cameras and
monitors, refined graspers and trocars, and clips. For
the past 20 years, most surgeons have utilized fairly
standard methods for the actual procedure, which
typically includes the use of four separate small
incisions for trocars and instruments. Although this
was a marked improvement over the previous traditional 6
inch long incision, options for further minimizing the
invasiveness of the procedure are now being exploited.
The new technique utilizes a single incision virtually
hidden within the umbilicus (belllybutton), through
which all the necessary instruments are passed.
Improved trocars, instruments and optics allow for a
safe and efficient operation, with further cosmetic
improvement over the now standard four incision
technique. Patients benefit from a further decrease in
postoperative pain, potentially more rapid return to
normal activities and improved cosmetic result.
Although this new technique might not be appropriate for
all patients, it is a welcome addition to our
armamentarium. If you or a patient are interested in
more information or would like to schedule a
consultation, please call our office at 404-508-4320, or
contact Dr. Champney at
drchampney@dekalbsurgical.com.
Open Cholecystectomy
Before laparoscopy, the standard surgical treatment for
gallstones was open cholecystectomy (surgical removal of
the gallbladder). As in laparoscopic cholecystectomy,
bile duct injury is a possible complication. Injury to
the common bile duct requires additional operations that
may be difficult to perform. This occurs, however, in
only 0.1% to 0.2% of procedures. Because the procedure
requires an abdominal incision, the patient usually
needs to stay in the hospital for two to six days and
might not return to work as quickly.
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Non-Surgical Therapy for Gallstones
With the advent of laparoscopic cholecystectomy,
surgical treatment of symptomatic gallstones is usually
the preferred management. For patients who are
unwilling to undergo surgery or who have serious medical
problems that increase the risks of surgery, nonsurgical
therapy for gallstones is available. Non-surgical
treatment, however, usually cannot be used for patients
who have acute gallbladder inflammation or common bile
duct stones since delaying or avoiding surgery could be
hazardous in these cases. The introduction of
laparoscopic cholecystectomy has greatly reduced the use
of non-surgical therapies.
Oral Dissolution Therapy
Oral dissolution therapy uses bile acids in pill form to
dissolve The technique is generally safe but only
moderately effective, since gallstones recur in the
majority of patients. In addition, this therapy works
only on cholesterol-based stones that are less than 1.5
cm in diameter and is less effective in obese patients.
Ursodiol or ursodeoxycholic acid (Actigall)
is the oral bile
acid drug which is approved for dissolution. Patients with small stones of high cholesterol
content are most likely to benefit from this treatment,
although a recurrence rate of 10% per year for the first
five years has been reported in patients on this
therapy. The drug is considered to be one of the safest
common drugs and does not seem to have significant side
effects. Gallstones that are calcified or composed of
bile pigments are not amenable to oral dissolution
therapy. Only a small percentage of patients are
candidates for oral dissolution therapy. Ursodiol is
very expensive; the treatment can take up to two years
can cost thousands of dollars per year, and may
ultimately be unsuccessful. For these reasons,
this option is rarely considered to be appropriate for
symptomatic gallstones.
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Treatment for Common Bile Duct Stones (Choledocholithiasis)
Laparoscopic Common Bile Duct Exploration
If stones are detected in the common bile duct during
the course of a laparoscopic procedure, they can
sometimes be removed at the same time. Exploration of
the common bile duct by laparoscopy is technically more
difficult than removal of the gallbladder. But if the
stones can be removed safely at the time of surgery,
there is no need for any further procedures. If the
surgeon chooses to leave detected stones in the bile
duct, they would be removed at a later date using the
ERCP technique described below.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
with Endoscopic Sphincterotomy
In cases where stones are left in the common bile duct
after surgery, endoscopic retrograde
cholangiopancreatography (ERCP) with endoscopic
sphincterotomy, also called papillotomy, is used to
remove the stones. Also, in cases where stones are
detected in the common bile duct before surgery, ERCP
with sphincterotomy may be considered. It also has a
role for cholangitis caused by common bile duct stones
and in cases of acute pancreatitis caused by gallstones,
although its use in this latter condition is
controversial.
In this procedure, the endoscope is passed through the
mouth and stomach and into the duodenum (top part of the
small intestine) to the common bile duct. After
injection of contrast material into the duct orifice,
ERCP allows visualization by x-ray of the biliary tree
and any contained stones. In endoscopic sphincterotomy,
tiny incisions are made through the scope to widen the
ampulla of Vater (the junction between the common bile
duct, pancreas, and intestine). The catheter passes into
the common bile duct and the stones are captured,
usually in a microbasket, and pulled back into the
intestine. Endoscopic sphincterotomy is the procedure of
choice when stones remain after gallbladder surgery.
Complications of ERCP and endoscopy sphincterotomy occur
in up to 9.8% of cases and can be serious. Of major
concern is inflammation of the pancreas (pancreatitis);
younger adults are at higher risk for pancreatitis than
the elderly. Pancreatitis is caused by certain enzymes
that are produced in increased levels if the pancreas is
irritated during the procedure. In such cases,
obstruction can occur and the condition can become life
threatening. The use of a drug called gabexate may lower
the risk for this problem, though studies on this drug
have had mixed results. The next most common
complications are bleeding and infection. Antibiotics
may be given before the operation to prevent infection,
although one study reported that they had little
benefit. All of these complications are the same whether
the procedure is used for diagnosis or treatment. This
procedure is difficult and patients must be certain
their physician is experienced with it; ideally he or
she should have performed at least 180 ERCPs.
Choledocholithotomy
Choledocholithotomy, or traditional common bile duct
exploration, is an open surgical procedure that is still
used in difficult cases. In this procedure, the
physician removes the stones through an incision in the
common bile duct. A special T-tube is routinely left in
the common bile duct after surgery. This tube is
brought out through the skin and is left in place for
about two weeks.
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