Gall Bladder and Gall Stone Surgery
Predisposition to gall stones
Female
Contraceptive Pill
Peak incidence of presention aged 50-60 in UK
Most cases have no predisposing factors
Haemolysis eg haemolytic anaemia, spherocytosis, mechanical heart valve
Gastric Surgery eg vagotomy and gastrectomy
Not highly selective vagotomyV
Not fat, fertile, fair, 40s, family history
High Mortality in elderly , low mortality in under 60s
Presentation
Chronic GB pain 55%
Acute (40%)
5 % other eg.
Pancreatitis
Jaundice
Cholangitis
Asymptomatic
Gall stone ileus, mucocele, fistula, subphrenic abscess
Typical Pain
Epigastric, radiating to right, flank, shoulder
blade
Severe, sudden onset, often short duration
Precipitated by fatty food (only 40%)
No relieving factors
Nausea,vomiting
No periodicity
No family history
May be entirely midline
May mimic angina or myocardial infarction
May occasionally be RIF and mimic appendicitis
Investigations
LFTs (may indicate CBD stones but often elevated in acute cholecystitis and not good at predicting the presence of CBD stones)
Coagulation screen in jaundice
Plain xray rarely helpful (only 5-10% of gall stones radio opaque)
Ultrasound scan - main investigation for gall stones. Also gives information on gall bladder wall thickness, biliary tree distension, inflammatory mass, may pick up gb polyps, may indicate pancreatic disease, may detect liver metastases.
Oral Cholecystogram - may show stones or non-function gall bladder. Used less often today. May be used if patient requests stone dissolution therapy to indicate a functioning GB
HIDA - gamma camera scan shows biliary tree and GB. Useful in acute cholecystitis showing non filling of GB.
MRCP - ie MRI scan of biliary tree. Highly accurate and non invasive. Set to replace more invasive tests such as ERCP and PTC as a diagnositic tool but not therapeutic.
CT - not routinely used but can detect gall stones and GB pathology. Useful in suspected GB carcinoma
For Common duct stones
Endoscopic retrograde cholangiopancreatogram ERCP
Per cutaneous cholangiogram
Infusion cholangiogram
Magnetic resonance cholangiopancreatogram MRCP
Endoscopic ultrasound
USS findings
Stones, gall bladder wall thickness , oedema, mass,
some functional info, polyps,
CBD stones not well seen, CBD diameter should be < 7mm except in elderly
up to 10mm
Some information on pancreas and liver
Options for treatment of gall stones
No treatment if asymptomatic or very frail
Dissolution therapy with ursi-deoxycholic acid but may take 18 months and stones may reform
Lithotripsy - for CBD stones
Percutaneous surgery
Open surgery
Laparoscopic surgery
ERCP for CBD stones
Relative contraindications to surgery (all
relative)
Obesity
Pregnancy
Acute GB
Fistula
Adhesions
Portal hypertension
Severe deformity
Controversies in gall stone management
Pre operative evaluation of CBD stones should be
in all cases or selective. Prior to lap chole all patients had operative cholangiography but most surgeons abandonned this policy with lap chole as it was technically demanding, used theatre time and faced a dilemma if stones found ie. proceed to open surgery, attempt lap exploration, complete lapchole and do post op ERCP. Some surgeons believe that failure to do cholangiography may increase risk of cbd injury but this is not proven.
What to do if CBD stones suggested by USS, jaundice, cholangitis, pancreatitis and when to do preoperative ERCP, Infusion cholangiogram, IVC, or per operative cholangiogram
Arterial clipping v diathermy during lap cholecystectomy
Causes of cbd injury, usually normal anatomy distorted by surgeon prior to injury
DVT prophylaxis may cause more bleeding complications than reduce thrombosis
Antibiotic prophylaxis in lap chole, no trial data and may be unnecessary as wound infection is uncommon
Day case surgery increasingly used
Place of same admission LC for acute cholecystitis - depends on surgical expertise
CBD stones best removed by ERCP with risk of pancreatitis, perforation and bleeding
or by laparoscopic surgery which is technically demanding and uses theatre time.
Increasing use of acute cholecystectomy for cholecystitis ie. same admission surgery which reduces risk of representation and shortens the course of illness, reduces total hospital stay but increases technical demands on surgeon and increased conversion rate in lap surgery.
Bile injury/leakage after surgery
Vague symptoms of pain, nausea, pyrexia, ileus
Few clinical signs
LFTs and USS may be normal in early stages
Management of bile leakage
High degree of suspicion
Early investigation
ERCP and stenting often sufficient
Most commonly from cystic duct stump due to poor application of clips or possible injury to cystic duct wall by clips
Laparoscopy required when moderate to severe contamination is suspected or in peritonitis to lavage and remove bile, reducing risk of late abscess formation and sepsis
If injury to CBD found the injury is usually complex and high, requiring hepatico-jejunostomy. Best referred to specialist centre for management. Significant long term problems often occur eg. cholangitis, stenosis of anastomosis etc.
Options in GS jaundice
ERCP only - used in elderly as up to 75% will have no further symptoms from gb stones once cbd stones have been removed
ERCP + lapchole - standard management unless GA contraindicated
Laparoscopic CBD exploration and lapchole - used in specialist centres
Open surgery may be required if ERCP fails
? drainage procedure eg Choledochoduodenostomy now rarely used
Risks of ERCP
Pancreatitis
Bleeding
Perforation
Mechanical (stuck basket)
Medical v Surgical management of acute cholecystitis
Deferring surgery causes
Prolongation of symptoms
Overall longer inpatient stay
30% risk of readmission
does not make subsequent surgery much easier
Gall stone pancreatitis
Most cases settle very quickly and these are best treated by total stone eradication at first admission
CBD visualation must be done by MRCP, ERCP (risk of making pancreatitis worse), operative cholangiography, ? infusion cholangiography
CBD stones must be removed by ERCP or surgery (lap or open)
Severe pancreatitis with necrosis has a high mortality. May need open surgery eg necrosectomy. Sequential CT scans assess progress of disease.
Mechanism of gs pancreatitis probably due to gall stone passing though ampulla of Vater and causing reflux of bile/duodenal content into pancreatic duct under pressure.
Evidence from
Operative cholangiography
Stones fall in incidence within first 5 days
ERCP
Animal work
Gall stone retrieval studies
Crystals in bile