Gallstone Surgery
Gallstones form in the gall bladder which is a blind ending sac attached to the bile duct which drains bile out of the liver (See Fig 1. below).
What are gallstones?
Bile is produced in the liver and is a mixture of the byproducts of metabolism and important components for digestion. Bile contains cholesterol, bile salts and waste products like bilirubin (a pigment formed from the breakdown of old red blood cells). In general some of these components are very soluble (bile salts) and others are difficult to keep in solution (i.e. breakdown products of fats and cholesterol). The balance of soluble products to insoluble products partially determines an individual’s liability to form gall stones. There are two basic types of gallstone.
- Cholesterol gallstones are the main type in the UK and form if you have too much cholesterol in your bile.
- Pigment gallstones form when there is too much bilirubin in your bile. These gallstones tend to develop if you have liver disease, infections in your bile tubes or some inherited blood disorders.
Most of the bile drains directly from the liver, through the bile duct into the duodenum but some enters the gall bladder. The gall bladder partially empties after eating but there is always residual bile remaining. It is in this static pool of bile that there is a tendency for the insoluble components of the bile to precipitate out and form stones. Some people have many very small stones, like fine gravel, and some have a single stone that's big enough to completely fill the gallbladder.
What symptoms are gallstones likely to cause?
Gallstones are often discovered by accident, when you have an X-ray or ultrasound scan for another reason. In these cases, it's usually best to leave them alone however there are one or two unusual situations in which intervention may be thought prudent.
The commonest symptom that gallstones cause is pain. This occurs when a stone moves within the gallbladder and blocks its outlet (the cystic duct). The pain is intense, in the upper abdomen and may be associated with pain in the back and shoulder tip. It lasts for hours until either the stone dislodges or pain killers are given. This is known as biliary colic.
If a patient with biliary colic continues to have pain after several hours and develops signs of an infection it is likely that the impacted stone has remained lodged in the cystic duct and that the bile trapped in the gall badder has become infected. This is a more serious condition and is known as acute cholecystitis.
Stones that move out of the gall bladder can lodge in the common bile duct [see figure 1]. This may lead to pain very similar to that of biliary colic but by blocking the main duct leading from the liver it results in the products of the liver accumulating in the blood. The most obvious external manifestation is the development of a yellow pigmentation in the skin and the whites of the eyes – jaundice. The urine will also become very dark (often described as tea like) and the stools will become very pale. This picture is known as obstructive jaundice. In patients with obstructive jaundice if the bile is infected there is a very serious risk of septicaemia and such patients are altogether more severely unwell than those with gallstones contained within the gall bladder. This combination of an obstructed bile duct and infection is known as ascending cholangitis, and is a clinical emergency.
As can be seen from the diagram below, the common bile duct enters the duodenum with the pancreatic duct. In patients unfortunate enough to lodge a stone at the confluence of these two ducts there is the risk of not only cholangitis but also back pressure on the pancreas resulting in acute pancreatitis. Pancreatitis can vary from a self limiting minor illness to a very significant life threatening disease. The first and major symptom is severe upper abdominal pain.
Should I have treatment for my gallstones?
There is no answer to this question that fits all patients – we are all different. The important points to consider are:
- The severity of the symptoms experienced
- The frequency with which symptoms are being experienced
- Your general level of fitness which will determine the risks associated with any treatment
It is likely that if you have had symptoms related to your gallstones they will return at some stage but it is impossible to say when. The best guide is what has already happened i.e. someone experiencing biliary colic on a monthly basis is likely to continue with this pattern of pain unless the gallbladder is removed. Alternatively someone who had an attack of pain 5 years ago and has not had another attack is less likely to suffer another episode in the near future but the risk is still there. If you have had a severe illness with your gallstones i.e. pancreatitis or cholangitis it is more advisable to undergo a cholecystectomy.
Obviously all of this has to be balanced against the risks of surgery; these are likely to be increased if you are over weight or have: severe chest problems, heart disease or had a stroke. It is advisable for anyone with symptoms related to their gallstones to be seen by a surgeon and have a discussion about the relative risks of treatment.
Is there an alternative to surgery?
The short answer, which is correct in most cases, is no. Life style alterations such as avoiding fatty foods may make an attack less likely but will not eliminate the risk altogether.
There are some types of gallstones (most common in the Far East and in certain metabolic disorders) which respond to dissolution therapy. However this is a very unusual situation in the West and although dissolution therapy has been attempted it is seldom successful.
About 15 years ago there was a vogue for external beam lithotripsy. The idea of this treatment is to concentrate ultrasound waves on the gallbladder shattering the stones within. Unfortunately this did not always work and it led to significant complications. Furthermore when the treatment stopped there was a very high risk of recurrence of the stones and further symptoms.
What does surgery involve?
The operation to remove the gallbladder is known as a cholecystectomy. It involves securing the cystic duct, which connects the gallbladder to the common bile duct, and dividing it. Thereafter the cystic artery, which is the blood vessel feeding the gallbladder has to be secured and divided. The gallbladder can then be removed from the undersurface of the liver. This sounds very straight forward and in most cases it is however the presence of infection and scarring can make it very difficult to determine the anatomy and it is important that great care is taken to do so.
Generally cholecystectomy is performed using a laparoscopic (or “keyhole”) approach. This involves 4 small incisions to allow a camera to be placed within the abdomen thereafter instruments are inserted to manipulate the gallbladder clip the cystic duct and artery and divide any adhesions between the liver and the gall bladder. Recovery from the laparoscopic approach is very much improved compared with the conventional approach of performing the same operation through an abdominal incision. This is possibly a combination of reduced post operative pain and reduced trauma associated with the surgery.
Recently there has been much interest in performing laparoscopic cholecystectomies using a single incision hidden in the umbilicus. This certainly has a superior cosmetic result and may further speed up recovery by reducing further the trauma of surgery.
Are there any risks associated with surgery?
Surgery is an invasive procedure requiring general anaesthesia so there are always risks associated with any operation but every precaution will be taken to minimise these.
It is possibly best to consider the risks of any operation under general risks and risks specific to that procedure. The general risks are those related to the anaesthetic and these include in descending order of frequency: chest infections, pain and discomfort, venous thrombosis, cardiac events and unexpected reactions to anaesthetic agents. All of these will be minimised by taking the precautions that will be discussed pre-operatively.
The specific complications associated with gall bladder surgery include bleeding, leakage of bile, a retained gallstone and damage to the common bile duct. Some patients will experience a change in bowel habit most commonly loose stools after their surgery but this is usually self limiting.
What if my gallstones have moved out of the gallbladder?
If there is any suggestion from your history or your scans have shown there is the possibility of stones in the common bile duct it is likely that you will need to undergo a further type of scan (a Magnetic Resonance Chaogiogram[MRC]) to confirm or refute this. If stones are present in the common bile duct these can either be removed with an endoscope – a procedure known as an ERCP, or at the time of any planned surgery. If the stones in the common bile duct are removed surgically this does involve a slightly longer and bigger operation [see exploration of common bile duct]. The decision on whether to remove stones surgically or by ERCP will be dependent upon the size of the stones, the symptoms they are causing and subsequent management plans.
