Gallstones

  • Gallstones are found in 12% men and 24% women

  • Prevalence increases with advancing age

  • 10-20% become symptomatic

  • Over 10% of those with stones in the gallbladder have stones in the common bile duct

  • 40,000 cholecystectomies are performed annually in UK

  • More than 4,000 common bile ducts are cleared of stones

Pathophysiology

  • Three types of stones are recognised

    • Cholesterol stones (15%)

    • Mixed stones (80%)

    • Pigment stones (5%)

Multiple mixed gallstones

  • Mixed stones are probably a variant of cholesterol stones

  • 10% of gallstones are radio-opaque

  • Cholesterol stones result from a change in solubility of bile constituents

  • Bile acids act as a detergent keeping cholesterol in solution

  • Bile acids, lecithin and cholesterol result in the formation of micelles

  • Bile is often supersaturated with cholesterol

  • This favours the formation of cholesterol microcrystals

  • Biliary infection, stasis and changes in gallbladder function can precipitate stone formation

  • Bile is infected in 30% of patients with gallstones

  • Gram-negative organisms are the most common isolated

Clinical presentations

  • Acute cholecystitis  

  • Empyema of the gallbladder

  • Mucocele of the gallbladder

  • Biliary colic

  • 'Flatulent dyspepsia'

  • Mirrizi's syndrome

  • Obstructive jaundice

  • Pancreatitis

  • Acute cholangitis

Acute cholecystitis

Acute cholecystitis

  • 90% cases result from obstruction to the cystic duct by a stone
  • Increased pressure within the gallbladder results in an acute inflammatory response
  • Secondary bacterial infections occurs in 20% of cases of acute cholecystitis
  • Most common organisms are E. coli, Klebsiella and strep. faecalis

Clinical features

  • Constant pain (usually greater than 12 hours duration) in right upper quadrant
  • Fever, tachycardia
  • Tenderness in right upper quadrant
  • Murphy's sign - guarding in right upper quadrant on deep inspiration

Investigation

  • Ultrasound is the initial investigation of choice
  • Diagnostic features on ultrasound include
    • Presence of gallstones
    • Distended thick-walled gallbladder
    • Pericholecystic fluid
    • Murphy's sign demonstrated with ultrasound probe
  • If diagnostic doubt a HIDA scan may be useful
  • Will show failure of isotope (hydroxyiminodiacetic acid) uptake by gallbladder

Ultrasound appearance of a solitary gallstone

Management

  • Initial management is usually conservative
  • Patient is fasted, given intravenous fluids and opiate analgesia
  • Intravenous antibiotics (e.g. second generation cephalosporin) should be given to prevnt secondary infection
  • 80% patients improve with conservative treatment
  • If fit, should be considered for a laparoscopic cholecystectomy
  • Timing of surgery is controversial
  • Evidence now suggests that early surgery (<72 hours) is safe
    • Has low conversion rate
    • Avoids the complications of conservative treatment failure
  • If patient unfit for surgery, percutaneous cholecystotomy my be beneficial
  • Particularly useful in acalculus cholecystitis

Complications of acute cholecystitis

  • Gangrenous cholecystitis
  • Gallbladder perforation
  • Cholecystoenteric fistula
  • Gallstone ileus

Enterotomy to remove a large gallstone causing small bowel obstruction

Picture provided by Mr J C Campbell, Derriford Hospital, Plymouth

Treatment of gallbladder stones

  • First open cholecystectomy performed by Langenbuch in Berlin in 1882

  • Throughout this century open cholecystectomy has been associated with significant complications

  • Today mortality is approximately 0.5%

  • Morbidity includes:

    • Specific complications - bile duct damage, retained stones, bile leak

    • General complications - wound dehiscence, pulmonary atelectasis

  • Lead to the development of 'mini' cholecystectomy through a 5 cm transverse incision

  • Laparoscopic cholecystectomy introduced in 1988

  • Dissolution therapies

    • High complication rate

    • Poor long-term results

  • Extra-corporeal shock wave lithotripsy

    • Poor stone clearance

Bile duct stricture after open cholecystectomy

Laparoscopic cholecystectomy

  • Shown to be equally as effective as open cholecystectomy in controlled trials

  • Pre-operative ERCP is indicated if:

    • Recent jaundice

    • Abnormal liver function tests

    • Significantly dilated common bile duct

    • Ultrasonic suspicion of bile duct stones

Technique

  • Routine use of nasogastric tubes and catheter controversial

  • CO2 pneumo-peritoneum induced using either Veress needle or open technique

  • Open (Hasson) technique is believed to be safer

  • Over half of bowel injuries are caused by Veress needles or trocars

  • Abdominal pressure set to 12-15 mm Hg 

  • High intra-abdominal pressure can:

    • Reduce pulmonary compliance

    • Decrease venous return

    • Higher end-tidal CO2 levels 

  • Surgery usually performed using 4 standard ports (2 x10 mm & 2 x 5 mm)

  • Patient positioned with head up tilt and rolled to the left

  • Calot's triangle dissected using a retrograde technique

  • Cystic duct and artery identified

  • Ligated with clips or endo-loops

  • About 50% surgeons routinely use intra-operative cholangiography

  • Cholangiography allows:

    • Definition of biliary anatomy

    • Identification of unsuspected CBD stones (~10% patients)

laparoscopic cholecystectomy

Outcome

  • Conversion rates typically about 5%

  • Laparoscopic cholecystectomy associated with

    • Reduced analgesic requirements

    • Reduced postoperative stay

    • Faster return to normal activity

Laparoscopic surgery in acute cholecystitis

  • In those with acute cholecystitis operation has usually been deferred 6-8 weeks

  • Recently shown that early laparoscopic cholecystectomy is safe

  • Associated with reduced conversion rate

  • Trend towards early surgery during first admission

Potential future improvements

  • Gasless pneumoperitoneum using mechanical abdominal wall retractors

  • Narrower ports and instruments

Bibliography

Dennison A R,  Azoulay D,  Oakley N et al.  What should I do about my patients gall stones.  Postgrad Med J 1995;  71:  725-729.

Downs S H et al.  Systematic review of the effectiveness and safety of laparoscopic cholecystectomy.  Ann R Coll Surg 1996; 78: 241 - 324.

Darzi A,  Gould S.  Minimally invasive surgery. In:  Johnson C D,  Taylor I eds.  Recent advances in Surgery 22.  Churchill Livingston 1999;  63-72.

Chitre V V,  Studley J G N.  Audit of methods of laparoscopic cholecystectomy.  Br J Surg 1999;  86:  185-188.

Cuschieri A.  How I do it:  laparoscopic cholecystectomy.  J R Coll Surg Ed 1999; 44:  187-192. 

Geoghegan J G,  Keane F B.  Laparoscopic management of complicated gallstone disease.  Br J Surg  1999;  86:  145-146.

Indar A A,  Beckingham I J.  Acute cholecystitis.  Br Med J 2002;  325:  639-643

Kiviluoto T,  Siren J,  Luukkonen,  Kivilaakso E.  Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis.  Lancet 1998;  351:  321-325.

Lomas D J,  Gimson A.  Magnetic resonance cholangiopancreatography.  Hosp Med 2000;  61:  395-399.

Parks R W.  Biliary tract emergencies.  Hosp Med 2002;  63:  226-229

Perrisat J.  Management of bile duct stones in the era of laparoscopic cholecystectomy.  Br J Surg 1994. 81; 799 - 810.

Paterson-Brown S.  Emergency laparoscopic surgery.  Br J Surg 1993; 80: 279 - 281.

Svanvik J.  Laparoscopic cholecystectomy for acute cholecystitis.  Eur J Surg 2000;  166 (Suppl 585):  16-17.

Tait N,  Little J M.  The treatment of gall stones.  Br Med J 1995;  311: 99-105.

 

 
 

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