SURGICAL CONDITIONS

General Surgery

Gall Stones

A gallstone, is a lump of hard material usually ranging in size from a grain of sand to 3-4 cms. They are formed inside the gall bladder as a result of precipitation of cholesterol and bile salts from the bile.

Types of gallstones and causes

• Cholesterol stones
• Pigment stones
• Mixed stones - the most common type. They are comprised of cholesterol and salts.

Cholesterol stones are usually yellow-green and are made primarily of hardened
cholesterol. They account for about 80 percent of gallstones. Scientists believe
cholesterol stones form when bile contains too much cholesterol, too much bilirubin,
or not enough bile salts, or when the gallbladder does not empty as it should for some
other reason.

Pigment stones are small, dark stones made of bilirubin. The exact cause is not known. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anaemia in which too much bilirubin is formed.

Other causes are related to excess excretion of cholesterol by liver through bile. . There is little association between high cholesterol levels in the blood and high levels in the bile.

They include the following

Gender. Women between 20 and 60 years of age are twice as likely to develop
gallstones as men.

Obesity. Obesity is a major risk factor for gallstones, especially in women.

Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or
birth control pills

Cholesterol-lowering drugs.

Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides.

Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.

Symptoms

Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called "silent stones."

Gallstone symptoms can be similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatushernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

Symptoms vary in severity and often follow fatty meals, particularly during the night. The liver and gallbladder are stimulated by fats an oils in the diet. As far as they are concerned it doesn’t matter whether these are “good fats” such as olive or safflower oil, or “bad fats” such as animal fats. All stimulate gallbladder contraction and can cause pain.

Symptoms include

• steady pain that increases rapidly and lasts from
  15 minutes to several hours - occasionally it can last for days
• the site of the pain can vary. It may be felt under the ribs on the right or in the back below the shoulder blade. At other times, it is felt mainly in the pit of the stomach or in the lower chest. This chest pain can be confused with a heart attack. However, it is always safer to assume that the problem could be due to the heart until proven otherwise. In other words, if you develop severe chest pain you should attend an emergency department and be checked for heart problems.
• nausea or vomiting

Ultrasound is the most sensitive and specific test for gallstones.

Other diagnostic tests may include

• Computed tomography (CT) scan may show the gallstones or complications – it is not as accurate as ultrasound for detecting gallstones, but is better at examining the pancreas.
• CT cholangiography – a special dye is injected, prior to the CT scan. This outlines the bile ducts and can be very useful for detecting stones in the bile duct, which may not be visible on ultrasound.
• MRCP – A magnetic resonance scan (MRI scan) is another way of looking at the bile ducts. It does not involve the use of injected dyes or radiation. It is contraindicated if you have a pacemaker or have had some types of brain surgery. Unfortunately at the present time Medicare does not contribute to the cost of MRI, when used for this purpose
• Endoscopic retrograde cholangiopancreatography (ERCP). A special type of gastroscope is used to visualize the opening of the bile duct into the duodenum. The doctor then injects a dye that outlines the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts. This may be required either before or after gallbladder surgery or if other problems such as bile duct or pancreatic cancer are suspected.
• HIDA scan. A small amount of radioactive material is injected into the veins. This is concentrated in the bile and then exreted into the gut. A HIDA scan can be useful to investigate people whose pain sounds like gallstone pain, but whose ultrasound is normal. It is also used for patients who have gallstones and are having pain, but it is not clear whether the stones are actually the cause of the pain.
• Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

Stones in the bile duct

If stones pass out of the gallbladder into the bile duct, serious problems may occur. These include:

• Jaundice – there is a build up of bile in the blood as the outflow of the liver is blocked. The whites of your eyes and then your skin becomes yellow. Urine becomes dark, like strong tea in colour. The bowel motions become pale.
• Cholangitis- Cholangitis is an infection of the bile within the ducts, usually secondary to a blockage of the duct, eg with a stone. The symptoms are typically pain, fever and jaundice– it can be very serious and needs urgent treatment
• Pancreatitis – as stones pass down the bile duct, they may temporarily block the pancreatic duct. This can cause inflammation of the pancreas or “pancreatitis”. This varies in severity from a relatively mild illness, to one which can lead to multisystem failure and even death

Gallbladder Cancer

Approximately 1% of people with gallstones will develop a gallbladder cancer. This mainly happens to old people, but younger people can sometimes be affected. Gallbladder cancer almost never occurs in people without gallstones. Unfortunately it is a very aggressive cancer, which is rarely cureable.

Treatment of Gallstone Disease

Non Surgical Treatment

Diet a very low fat diet reduces the risk of further attacks. It does not make the stones disappear and the risk of further problems remains.

Lithotripsy In the late 1980’s “Lithotripsy” technology was introduced to fragment stones with ultrasound. This has been a very successful treatment for kidney stones, but has been disappointing for gallstones. It works in less than 50% of cases and the stone fragments may cause serious problems as they pass down the bile duct. In those people in whom the stones were successfully treated, there was a high recurrence rate within the first 5 years. It has generally been abandoned for the treatment of gallstones.

Dissolution There are many folk remedies for gallstones involving drinking olive oil and lemon juice or other herbal concoctions. None of these have ever been demonstrated to work and some may actually cause an attack. A medicine called ursodeoxycholic acid is sometimes used in patients who repeatedly make stones in their bile ducts. For a time it was used in conjunction with lithotripsy to dissolve the stone fragments left behind. It is not recommended for the treatment of stones in the gallbladder.

Surgical Treatment

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. Just removing the stones is pointless in most cases, as they rapidly recur.

Cholecystectomy – surgical removal of the gallbladder, has been performed for over 100 years. However, for most of that time the surgery required a major abdominal incision. Since about 1990, it has been possible to do this with laparoscopic “keyhole” surgery, in most cases. I have personally done over 2000 laparoscopic cholecystectomies. There is always a small chance that the surgery needs to be changed to an open operation if there is significant inflammation or scarring in the area. In my hands, this is necessary in about 2% of cases.

The surgery is done under general anaesthetic. Several tiny incisions are made in the abdomen through which small surgical instruments and a miniature video camera are inserted. The camera sends a magnified image from inside the body to a video monitor, giving usa close up view of the organs and tissues

During the operation, I routinely perform an X ray of the bile duct (Operative cholangiogram) to check for stones within it.If gallstones are in the bile ducts, I may be able to remove them at the time of the laparoscopic operation. However, it is sometimes necessary to then refer you for an ERCP (see above)to remove them a couple of days later.

Small clips made of surgical grade stainless steel, are used to seal blood vessels and also the small duct that leads from the gallbladder to the main bile duct. These clips are permanent and cause no problems. (They are not detected when you pass through metal detectors.) I routinely insert a small drain tube, which generally is removed the next day. Approximately 1% of people will have some leakage of bile from the operative field in the first few days. Providing this comes out the drain tube it causes no harm. Sometimes it persists and an ERCP is performed (see above). Temporary insertion of a stent in the bile duct is sometimes required in this situation.

Most of the time laparoscopic cholecystectomy goes very smoothly and you can go home in 24 to 48 hours. Most people need to have about 1 week off work. Like all surgery there are some risks, and you must weigh these up against the pain and risks of the gallstones themselves.

Risks of laparoscopic cholecystectomy include:

• Anaesthetic risks
• Bleeding
• Damage to surrounding organs
• Intra-abdominal infection
• Minor bile leak
• Retained stone in the bile duct Damage to the bile duct - This is the most feared complication of gallbladder surgery. It is rare, but can require major corrective surgery if it were to occur. The experience of the surgeon is of paramount importance in minimizing the risk of this problem occurring.

Side effects of cholecystectomy

• Most people notice no difference after removal of their gallbladder.
• Some notice a tendency to loose bowel actions after a fatty meal
• It has been suggested that colon cancer may be more common in people who have previously undergone cholecystectomy. This has not been confirmed. Gallstones and colon cancer are both more common in obese people, which may explain the association. I recommend regular screening for colon cancer from age 50 (or younger if you have a family history of this disease) - whether or not you have had a cholecystectomy