Wednesday, February 26, 2014

Gallbladder surgery goes back to the future in China

Chinese surgeons claim taking out just the gallstones without removing the gallbladder works well for most patients.

There were 65 patients with gallstones, 61 of whom underwent successful minimally invasive surgery for removal of just the stones leaving the gallbladder in place. The other four patients had laparoscopic cholecystectomies for various technical reasons. After an average follow-up of 26 months, the stone recurrence rate was 4.9% (3 cases).

Not mentioned in the abstract but noted in the methods section of the full article is that all patients were given a 3-month course of ursodiol postoperatively. The authors said it "adjusts the abnormal lipid metabolism in the gut-liver axis and prevents stone recurrence." This statement contains some truth up until the word "and." It's not clear how a short course of ursodiol would help.

Before the advent of laparoscopic cholecystectomy, doctors tried dissolution with ursodiol as a primary treatment. It worked 30-80% of the time for pure cholesterol stones, not those that were pigmented or calcified. About 50% of the time the gallstones recurred after the medication was stopped if the follow-up was long enough, that is, at least 7 years. [I had to go back to 1988 for this reference.]

Well over 100 years ago when open gallbladder surgery was first attempted, surgeons soon learned that removing the stones was inadequate treatment due to a high rate of recurrence.

Since the gallstone removal procedure involved general anesthesia and laparoscopy with two 10 mm and two 5 mm ports anyway, it makes absolutely no sense to just remove the stones. Most laparoscopic cholecystectomies are done with one 10 mm and three 5 mm ports so there is one less large incision which decreases the risk of postoperative hernias.

Here are some more issues.

Preoperatively, only 26 of the patients in the series had biliary colic. Gallstones with "atypical upper gastrointestinal symptoms" were present in 34, and 5 had no symptoms. Surgeons in the US generally would not have operated on patients in the latter two categories.

No mention was made of the duration of the operation, which involves laparoscopy with the 4 ports as noted above, insertion of a choledochoscope into the gallbladder, grasping the stones with a basket an unstated number of times, irrigation, and suture closure of the gallbladder wall.

The authors also that said except for the three recurrences of stones, gallbladder function was normal postoperatively. This was determined by ultrasonography after a fatty meal which took place every 6 months postop.

The three reoperations were done when stones were found by the ultrasound. Of those three, the authors said, "One patient remained asymptomatic, 1 patient experienced biliary colic, and the other patient had non-specific upper gastrointestinal symptoms (flatulence and dyspepsia)."

I don't see this procedure catching on here in the US. Do you?

UPDATE 3/25/14: See a follow-up post on this subject here.


peter said...

Not unless it can be done robotically. :)

Skeptical Scalpel said...

Peter, very funny. I have no doubt that someone will try it robotically.

artiger said...

Peter raises a good point though. If someone in NYC (or other serious metro area) does one of these successfully (and I would wager that it will happen within the next 5 years or less), we will be swamped by people wanting to keep their precious gallbladders sans stones. And robotic surgery will be the only answer.

Anonymous said...

This is a question from a med student applying to gen surg. Skep scalpel asks will this procedure catch on, I was wondering what keeps a surgeon from trying it anyhow? Do you have to do procedures only approved based on billing? Is there someone who approves a new procedure before you can try it?

Charles Decarlo said...

The cheapest way to deal with the problem is never in the best interest of the patient. Like most of modern medical care, it's always in the best interest of providers. Removing the gallbladder takes little skill, and leaves the patient with no place but the liver to continue to become congested with sludge. Removal and dissolution is the best for the patient.

Charles Decarlo said...

The most profitable and least thoughtful way to deal with the problem is removal of the gallbladder. It takes no skill, and the patient is left to the cholesterol crystals and sludge building up in the liver. It's very unhealthy. The Chinese have always tried to get the body to function properly, not simply profit from procedures and drugs. Consider this when weighing the differences in approach to the problem. The drug ursodiol was discovered in the bile of black bears. It's the only naturally occurring place it's found. The Chinese have harvested this bear bile for thousands of years to concentrate, and use medicinally to treat gallbladder disease. Canada has since been able to provide it un-harvested. But I use it, and I have been benefiting from it. I thought it a long shot, but it is working on a gallbladder that became full of sludge when I was in a 6wk coma in 2000, and my body consumed itself trying to stay alive with a undiagnosed ruptured mitral valve and Ards. I went from 240-155 in a little over a month. That caused the problem, and I had it since . It's worth researching if you are inquisitive and unbiased. You can learn a lot from the east. If you're able to concede that we're not mandated to be superior just because of our political persuasion. Which has been a embarrassment since Congress was taken over by anti-science, religions pandering, loons.

Anonymous said...

I would certainly want to try this option. American medicine tends to assume that problems occur because the patient is inherently, fundamentally, and therefore permanently defective, so "you can never get better" (a mantra repeated by several putative Experts to a family member of mine with heart problems that were reversed largely by complementary means). In fact, many cases of gallbladder problems are caused by inappropriate diets. Once you are symptomatic, it may be too late for a dietary change to cure the condition, but if you just had the stones removed, a change of diet might very well keep them from coming back. Then you would avoid the risk of a lifetime of unpleasant and sometimes life-altering digestive problems, which more than a few cholecystectomy patients report suffering. Possibility of needing more surgery later, vs. possibility of becoming needlessly disabled now; that kind of value judgement should be the patient's choice.

Charles Decarlo said...

I am in total agreement with "Anonymous". The department of veterans affairs medical center is my provider. They are the only single payer system in our country. They are the model for the nation's single payer system to come. I have a clinic that provides everything I need in one location, and has been on the cutting edge by going totally digital before anyone else. I have a website that gives me access to all my information, from labs & tests, to doctor patient communication. I have a personal pharmacist assigned to me in the clinic who I am able to safely discuss complimentary treatments for multiple chronic co-occuring conditions. With them providing a number of medications with side benefits, instead of side effects. They offer yoga, mindfulness meditation class, all evidence based treatments are on the table, not just a pill for every problem. The most exciting research is coming out of the veterans medical center due to the record keeping. The data is all digital now, and I have appointments with doctors at home. I have telemed and will be seeing my doctors with Cisco telemed in-house soon. I just entered into the million veterans program. A genomic study to help out with the science. I am the center of my team and I have been put on medications that I researched and evidenced as better for my needs with fewer side effects. We chose to pass on this as a national medical care system for the model we wanted for the free market capitalist system that is only serving profit, not health. The right whined and cried out socialism. I have the best care in the country, and it's cheaper than the free market. It's goal is health, not for profit, based on evidence. Perfect for wellness

Skeptical Scalpel said...

Charles and Anon, thanks for commenting.

You are entitled to your opinions. I call your attention to the link from 1988 in my post. It explains that chemical dissolution of gallstones did not work. That's why no one does it any longer. As far as costs are concerned, I'm not sure dissolution is cheaper. You would need to take the pills for the rest of your life even if they did work.

Gallbladder surgery is not that easy, especially in the midst of an acute attack.

I'm glad you are happy with your VA care. Not everyone is. For the record, I support a single-payer system, not the mess that the ACA has proven to be.

Skeptical Scalpel said...

Charles, I forgot to address you comment about sludge building up in the liver. That is just not true. Sorry.

@erikneves said...

The whole gallbladder is removed because it has a predisposition to form stones. If you just remove the stones, the gallbladder will make some new ones. So I was told in med school.
Now imagine for a second that the fault lies not in the gallbladder, but in ourselves as a whole. Some food for thought (hint: high-carb low-fat diets are bad):

Anonymous said...

As a non-medical, I would like to know if anyone would tell me to get a gall bladder operation if I'm pre-symptomatic. I found out I had gallstones about 10 yrs ago, ultrasound, they were small then, now I have one big one. I'm not wanting an operation, I asked about one once before and a surgeon said she'd do it, but I've heard of side-effects like not being able to eat any raw foods anymore. I am not sure what to do. My aunt had an operation in her 50's and she said her gallstone was the size of a baseball. I don't want mine to become acute & have to be rushed to surgery.

Charles Decarlo said...

It's true that dissolution doesn't work always, and needs the medication for the prevention of recurring stones. It's not been studied much, only little. We have far less data on it, and have not pursued the possibility of engineering medications that would make it more effective than ursodiol. We just stopped investigating after a few small studies of ursodiol. Contempt before investigation has led to the myopic thinking that what we've done is all we can do. I am certain that there is a way medicinally, we've just not looked for one. As far as removal of the gallbladder, many people are much better after its removed, and many people have suffered from common bile duct stones and have them form in the liver. I was over generalizing, and it was not as honest as it could have been. On my scans I have a grainy liver, and I was taking from my personal experience, and the data from studies I've read about the different outcomes from surgery and dissolution. I found less than a handful on dissolution. Contempt before investigation leads to no investigation. I said that gallbladder surgery was easy because as a surgical assistant in a mash and csh, I found it to be the easiest surgery in general surgery I scrubbed in on, except for a hernia repair. I am not in disagreement with anything that you said, and I may need to have it removed. I've had 3 open hearts since the accident that ruptured my valve in 2000, the most recent in may last year, and 2 laps, so I am obviously biased against the surgery with the incredible pain from adhesions I have, and not wanting to go through a probable lap again to gain access to the gallbladder. My opinion is not without extreme bias.

Skeptical Scalpel said...

Erik, thank you for the links.

Charles, I certainly understand your reluctance to undergo surgery. The incidence of common duct stones after cholecystectomy is not very high. A grainy liver on a scan would not be due to sludge. Good luck with you GB. I hope you can avoid an operation.

Anon, I cannot give you medical advice without seeing you in person. I will stick to what I said in the post. Most surgeons in the US would not remove a gallbladder for a patient without symptoms.

Anonymous said...

I am 93 years old. A sudden abdominal pain sent me to the nearest community hospital. They diagnosed the cause as gallstones. They insisted they were capable of removing the stones followed by the gallbladder itself. However, they were very vague about who was going to do what, in fact what procedures were necessary. I asked for my records so I could leave (there is perhaps the best-known hospital in the US only a two-hour drive away). They said my records would not be available for two days. In the midst of this argument a strange doctor appeared without introduction and announced "I am your surgeon". I asked politely what this was about and said to him I wanted to change hospitals. He became very irritated and said if I left it would be against medical advice and he would take no responsibility for the possibly dire consequences. He then walked out. My argument with the hospital ended with them finding that my records were available after all.

I drove to the famous hospital and checked in. Their diagnosis was the same: gallstones. They had one doctor who they said was a wiz at removing gallstones without operating. I was lucky. Her procedure worked so I was saved an operation. They now said that my liver had become infected so a course of antibiotics would be required before my gallbladder could be removed. During the week that followed, I asked every member of the team who saw me--fellows, residents--if the removal was absolutely necessary. I am only a laymen but it seemed to me that if I had only one attack of gallstones in 93 years, I could afford to gamble it wouldn't happen again in the next, say, 7 years. They unanimously assured me a gallbladder removal was the only proper procedure. So I agreed.

What they didn't ask, and I didn't think to volunteer, was that all my life I have never been constipated but I have often suffered from diarrhea. Since my gallbladder was removed, the diarrhea has gotten worse, on occasion to the point where it is explosive. Without warning, a bowel movement occurs, within seconds and completely beyond my control. This has happened maybe three times in the short time since removal of my gallbladder as compared with three times in the preceding 93 years. I am afraid to eat anywhere except at home near my toilet.

Worse is that a doctor (not a general surgeon) to whom I recently told this story said that if my gallbladder had not been removed, I would have to undergo an ultrasound exam maybe every year or so to make sure gallstones were not forming as in the previous 93 years. Since I probably have a life expectancy of seven years, this means I have avoided maybe seven safe, comfortable ultrasound exams at the cost to me of a few unbelievable embarrassments completely without warning.

What is considered standard medical care should be changed.

KAC RN said...

Charles, is the shining model for the single payer where you nearly died with your ruptured MV flapping in the breeze? Seriously, dude, a stethoscope on your chest should have immediately alerted ANYONE there was a big problem there. I cannot say that I've never seen ARDS after an open heart procedure, because stuff happens, but you got the short end of that stick. Regarding the Lap-Choli. I had one and I could not be happier. Even thinking about another stone makes me want to flee to the smallest room in the house...

Charles Decarlo said...

The reason for the icu doctors in Holland were unable to detect the ruptured mitral valve is that I had a high energy impact to my chest. Normally the aorta would dissect and you would die instantly. However, I was conscious when brought in to the er, and I was told that I needed to be put on a respirator because I wasn't getting O2. They were forced to induce chemically a coma as ARDS, psudomonus, pulmonary edema, all hid the rupture from multiple Trans thoracic echocardiogram's. Anyone who has any sense knows that they were going to be consumed with battling with all I presented with, but nobody would have thought that a ruptured papillary muscle and torn leaflet were necrosing in my heart. The head of cardio thoracic surgery from the University of masstricht came to evaluate me after they couldn't wean me when the worst was over and wasn't able to come off vent. He did a Trans esophageal echo and saved my life. When I had my most recent surgery in America, I was getting sick for a year, I knew that it was my valve, nobody could hear it, but when we finally looked at the stenosis , we saw what no stethoscope could hear from the most trained and experienced University cardiologists. Sometimes stethoscopes miss what needs to be seen, and can't be heard

Anonymous said...


With all due respect and sympathy for all you have gone thru, it is hard to understand what you are talking about.

There is a certain body of knowledge and experience common to all physicians. You don't have it and basically you don't know what you are talking about. Sorry.

Anonymous said...

Questran could help for diarrhea after cholescystectomy

Anonymous said...

"Still a man hears what he wants to hear, and disregards the rest"
Simon & Garfunkel
Skeptical Scalpel is correct. The fact that stone dissolution has been found ineffective does not signify that no one has an interest in that research. Think now, would not many pharmaceutical manufacturers love to get marketing approval for a drug that avoids surgery, and that patients would be taking more or less for life? Why do you think that laparoscopic cholecystectomy became so popular? Not because surgeons and hospitals found it more profitable, but because patients were just not interested in having a big incision and 4-5 days in hospital versus a few small incision and one day stay. I had an open chole, my wife had a lap chole, believe me there's no comparison in the mobidity. As a former commenter stated, if you have ever had an attack of cholecystitis, you would never want to repeat that experience, and the best way to avoid it is removal of the diseased gallbladder.

Skeptical Scalpel said...

Good point about the Questran. It might help.

Skeptical Scalpel said...

Anon, thanks for the Simon & Garfunkel reference. Regarding ursodiol, you said what I wanted to say only better.

Anonymous said...

Well, I'm all for alternatives to surgery. I've read as well as met people who have had a cholecystectomy where a select few had no problems eating whatever after the surgery, and a moderate amount that get the dumping syndrome almost immediately after a fatty/greasy meal. There were also articles citing studies in which there was an increased risk of colon cancer (3-4%) associated with gall bladder removal. My own personal GI said he'd never heard of this; however, working in the medical field myself I've come across at least 2-3 people that have had a hx of colon cancer as well as cholecystectomy. Of course seeing as my family is highly predisposed to that form of cancer it makes me just a wee bit paranoid on that front. I am currently trying oral dissolution with Ursodiol after doing a scavenger hunt for a GI who'd allow me to try it. I know the research says I've got a slim chance at dissolving a large solitary stone, but I'm willing/patient enough to give it a try before allowing someone to slice and dice me to pluck out that rather rebellious organ of mine, meanwhile, suffering the criticism of family & most assuredly the eye-rolls of my poor doctors. In the mean time I can only hope more viable alternatives will be discovered.

Charles Decarlo said...

In diverging in my personal experience with a car accident that ruptured my heart valve and lacerated my liver, causing the rapid weight loss leading to the gallbladder problems, I've diverged way to much from the point. I know that there is a medication that can dissolve gallstones and sludge, and allow for the body to return to a normal digestive process... In the early 80s nobody thought it was possible to get a cure for impotence from a lead drug for treating heart disease. And from that drug, learn how erections are initiated and maintained, as well as vascular tone. I don't know how much money was wasted on research into drugs that were dead ends, but they stumbled upon a cure for the majority of men who have suffered through it in silence. I have met few people who have had the surgery and not had a issue with the digestive process. Like the man who had explosive diarrhea and was constantly burdened by it. Gallbladder attacks are very painful, I've lived with many monthly for 14yrs. I've unexpectedly reduced the number of attacks by over 70% with ursodiol. I am not a doctor, and I don't have the infallibility, or haven't experienced the apotheosis that becoming a doctor does to many. I'm free from the belief and constraints that a certain body of knowledge and experience box in the thinking of all physicians. I know that it's just not true. I have worked closely with many great surgeons, doing the dissection, cutting, tying, bovying, that would never be allowed in the civilian sector. It was necessary that I be able to do what they did, with them, prognosticate thier moves in advance, and do the other stuff a tech does as well. It was awesome, and I loved it. When the surgeon temporarily repaired the necrotic mitral valve in heart, he had never done that procedure before before. He improvised. It wasn't from a common body of knowledge. Discovery is usually from a uncommon place to look for solutions to stubborn problems. I reject that a good doctor is limited by the common body of knowledge that all physicians have. Those physicians are just middle men for drug companies and specialty care doctors. They are always changing what they believe to be the standard understanding of the problem, whatever it is, and the solution. It changes based upon what articles they choose to believe, and what drug companies they invest in. Or, sometimes you get a free thinker who knows that the common body of knowledge is based upon a system hijacked by a "free market system" that took all the power away from the patient and made them criminals if they did what thier great grandparents did freely. Walk into a soda shop, or apothecary and get a coca cola, laudinum, tincture of hemp and treat most of what patients see doctors for, general discomfort, chronic pain, and fatigue

Anonymous said...

Dr. Scalpel,

I didn't know that you supported a single payer system. Have you written a post about this that I have missed? Based on what I have read from you (a big fan, by the way), I definitely would NOT have thought you would be in favor of a single payer system. I would love to read a post in which you highlight your reasoning.

Charles Decarlo said...

The reason I am for a single payer system is that having two healthcare systems, one for the wealthy, and one for the poor, who are the majority of the people in our incredibly wealthy nation, and get the poorest care, is not morally acceptable in a country that believes itself to be exceptional. I have been all over the world, and spoken to the people for and against the systems of single payer health care in thier countries. The only people against a single payer system are the ones who have not gotten sick yet. They haven't had the heart attack that will lead to the quad cabg, or the stroke leading to decades of daily care in a facility, or in home. The only ones who are against the single payer system are people who have a hateful heart against those who they believe to be inferior to them and undeserving of the compassionate care that every human deserves. It's a evil thing.
Now, to answer your question as to why I am personally for the single payer system is that not only has my single payer health care plan from the veterans medical center been the most efficient and cost effective evidence based care I have ever received, it's also being done with less cost. We are using telemed, telephone, e-med, and doing amazing things that will be done in the free market for far more cost than the va is. I know for a fact, because I am in a high tech, low cost, and highly effective single payer system. People complain about the va health care system. But the people who do are the same people who would complain about anything else that you provide them for free and they have no clue what they have access to. I have everything for less money than the for profit system, and it's done more effectively and efficiently, because they are trying to make people healthy, who want to take part in, and responsibility for their own part in thier own health. The others complain about the miserable experience of being treated for diseases they created through behavior. The research is outstanding. Just notice how much of the studies being published are by the va. I believe that a for profit health care system can only do what it's always done. Serve itself, and screw the consumer. I know a single payer system would invest in the science of wellness, and healing, with less cost and more effective treatments, and educate the patient to the consequences of the behaviors. If you walk into the lobby of the veterans outpatient clinic in my neighborhood, on the tv is a series of educational information videos teaching the patient that diet leads to diabetes, and weight management, ways to increase health. I don't need to be taught this, but most people do. We bombard people with TV images of what to consume that eventually leads to disease. However, if the first lady discusses how to be healthy the right screams socialism. America is ass backwards. Single payer forces us to look at the solution, not just managing, indefinitely the problem for profit.

Skeptical Scalpel said...

First Anon, The vast majority of people who have cholecystectomies do not have any GI problems postop. There are about 700,000 of them done every year in the US. If there were a big problem with postop complications, I think we would have seen some evidence of it by now.

Second Anon and Charles, I haven't written about the single-payer system yet, but after watching the debacle that the ACA rollout has become, I think there's got to be a better way.

Charles, I am happy that the VA has served you so well. However, your experience has not been shared by everyone. There are many tales of delays, mix-ups, lost records, etc. In fact, it makes me leery of a single-payer system if it were to be modeled after the VA. I'm not sure the government can run anything, let alone something as complex as healthcare for 315 million people.

Charles Decarlo said...

I am all for a healthy skepticism about a single payer system. I also know that the reason records were lost in the va was due to the fact those records were on paper, then microfilm, and we're lost in a fire. Many people, including myself, got screwed over because of the antiquated system used then. Those were DOD, not veterans medical records. The veterans medical center is keeping them all digitally now. So I can go anywhere in the country and get seamless care. Everyone has heard complaints about a percentage of people who have had bad experiences with the va medical care system. If I had made my determination about it based on the opinions of people who are pathologically unhappy with everything, and will never be happy with the va because of the difficulty they had in the past, I would not have the incredible care I do now, and will continue to in the future. The same is true for the ACA. It's not what anyone wants. Because we are a schizophrenic society, we have a plan that tried to pander to the far right by subsidizing a self serving system that cares not for the patient, but only for itself. When we roll out anything new it's not perfect from the beginning. I am not so nearsighted and don't judge something based upon a snapshot in time. Especially in its birth. Birth is the most messy, and ugly part of life, even the birth of the ACA. It can be anything we make it into from birth. It's not about the birth, it's about the willingness to make it better, and not willing it to fail because you choose to believe it can't be better tomorrow then it is today

Anonymous said...

I haven't made it through all the posts here -- definitely enjoy the active dialogue, though.

As a surgeon in training I can appreciate the comments from the medical community and have not yet lost complete touch with the words of the laymen.

I do think that it is silly and misinformed to consider undergoing all of the risks of a laparoscopic operation with the certain additional risk of bile spillage (mandatory creation of a cholecystostomy) -- to ultimately leave the gallbladder in place.

As one of my mentors likes to say, "…always better to do the right operation as the first operation".

Just thought I'd add a little rule to the fire:

Anonymous said...

As a surgical resident, I rotated in both VA hospitals and private hospitals. There was no comparison. Half of the employees of the VA were disgustingly lazy and incredibly open about it. If it weren't for the residents, the place would have collapsed. Stupid rules and regulations were rampant, and were generally designed to impede work flow and patient care. Vets would drive 3 hours to have surgery, wait NPO all day, and then get cancelled in late afternoon. Others would get rescheduled repeatedly prior to surgery day, while they suffered with painful conditions, or while tumors enlarged, etc etc. Nursing staff, anesthesia, and other services were inferior; doctor's orders were not reliably carried out; the electronic medical records turned doctors into secretaries and made everything take twice as long as it should have. I have known patients and healthcare workers from other VAs, and they have told me similar stories. Unfortunately, that is what we all will get soon; even now, our fatally-poisoned healthcare system takes its last breaths.

Skeptical Scalpel said...

Anon, thanks for the reality check from the VA.

Libby said...

Being Canadian I am served by a single payer system (run by an organization that is suppose to be at arm's length from the government).
The people who are for a two tier system are not those who have never been sick, it is those who have been or are on extremely long wait lists to see a specialist or get a procedure done (either surgery or otherwise). Hip replacement seems to have a very long wait list at a couple of years I believe. Waiting for cancer treatment apparently is a long wait. I waited 4 months for an MRI a couple of times and ultrasounds can take a while also.. We have private DI places now that are contracted to the Alberta Health Services so that has eased that load. I don't really understand how it has since there hasn't been a huge increase in radiologists...unless there has & I'm not aware of it. People will drive or fly to Montana for imaging and some even do it for surgery-though Mexico and Caribbean Islands are popular destinations now. There is a doctor here who will fly with you to a hospital/clinic on some island who'll operate and then do your post-op care back here.
Since each province administers their health care system, there are differences in what is covered/decided as a basic/essential health care need and what is not, so some people will province hop for certain procedures. I'm sure they pay some out of pocket fees for it although there is some reciprocity between provinces for things like cancer & specialized disease treatments.
In a way we do have a dual tier system, there is the basic care that is given to all residents (lets not look over the immigration/refugee coverage here) and then there is extended health care that can be bought privately or is through employment plans-which vary is greatness depending on what plan THEY buy for their employees.

Basic coverage (not an exhaustive list): visits to doctor's office, ER, Urgent Care Centre's, Walk-In Clinic etc.; hospital stay- all inclusive for ward and semi-private rooms unless private room is all that is available (either no other type is available or like our new hospital which has possibly only one 4 patient room on each unit) or is needed because of reason for admission (isolation...). Treatment for most diseases, conditions, incl. surgery. It is a long list.
Not covered by basic coverage (not exhaustive by any stretch): ambulance rides, drugs (unless in hospital/clinic/urgent care), elective breast enhancement (unless it is reconstruction after surgery), they were going to delist gender assignment treatment and surgery but the LGBQT groups threw up a stink. Oh, and paperwork required by 3rd parties for doctor's to fill out.
As you can see it isn't a simple system! But at least I know that when I show up at the ER I don't have to worry about getting a $3000 bill for being rehydrated like I did in Phoenix (thank goodness for travel insurance which covered what the provincial plan didn't).
This is just my superficial knowledge of what is happening here in Canada...and I know a bit more than the common person!
Anyway you look at it, health-care is expensive and complicated to administer.

George Gasman said...

Remember attempts at extracorporeal shock wave for cholelithiasis? That didn't work out too well, if I recall. I fail to see how the Chinese approach is much different, other than methodology. But, then, I'm just a gas passer...what do I know from gallbladders?

The VA? Inefficient? True story: Back when dinosaurs walked the earth, a colleague was called (in the middle of the night) to a cardiac arrest. Upon arrival, she saw a nurse's aide sitting on a chair in the hall.

"Where's the arrest?"

"In there," she said, as she pointed over her shoulder.

She walked into the room to see the victim getting CPR *from his roommate*.

Skeptical Scalpel said...

Libby, thanks for a glimpse of the Canadian system. We talk about it a lot here in the US, but we really don't know it on the level you do.

George, nice story about the cardiac arrest. The shock wave machinedidn't work too well because, unlike ureteral stones which usual pass into the bladder without incident after being blasted, gallstones pass into the common duct where they can cause havoc. Also, patients would have to take ursodiol to keep the stones from recurring. As mentioned above, ursodiol doesn't work that well and must be taken forever.

Dr Robert Israel said...

Have not heard about that new method yet.

Skeptical Scalpel said...

Well, now you have.

Anonymous said...

What do they hope to achieve by leaving the gallbladder in place? Did the authors mention any improved outcome they sought to achieve?

Skeptical Scalpel said...

They feel that the gallbladder should be left in place because because of unspecified complications of cholecystectomy and preservation of GB function, two non-issues in my opinion.

Anonymous said...

I find this whole post/discussion riveting and timely. As an American in his mid-40's now living in the UK and using the NHS for the first time, I just went through my first-ever bout of biliary colic - 3rd episode in a week, the first two woke me up at night and were painful but manageable. The third had me on my hands and knees at 1 a.m. in the local ER begging for pain relief. 10 mg of IV morphine only put a dent in the pain, and then I was given diclofenac and acetaminophen, and the combo helped calm things down. 3 hours later, I felt pretty much fine, no fever or unusual blood results, they tried a very low-power handheld ultrasound in the ER but found nothing, and discharged me as a case of uncomplicated acute biliary colic with a prescription of 325 mg acetaminophen/5 mg dihydrocodeine for the pain, which I did not even need.

Things felt better, however to get a referral for an NHS scan takes 2-4 weeks through your GP, therefore being impatient and worried I arranged for a private transabdominal US scan ($700). I had some swelling and discomfort in my URQ, but nothing hugely debilitating. TUS was done by a proper MD radiologist, not a tech, and it showed distended GB (10 cm), no wall thickening or inflammation, no stones, no dilated ducts, some biliary sludge with possible microliths (too small to visualize). I asked the radiologist (who looked like he was in his 60s and had seen thousands of me) whether I could treat this conservatively, and he saw no reason/rush to take the GB out.

Anonymous said...

The next day, I felt even worse, and ended up back in the ER for more pain meds and a proper re-diagnosis. I had darkened urine, and the attending doc (a smart young post-grad from Oxford) said he would check my blood but based on my appearance I would be going home. Blood work came back, to the surprise of the doc, with CRP of 247, elevated WBC, elevated bilirubin, but normal amylase so no apparent pancreatitis. They admitted me for antibiotics and observation. Next day, blood work showed WBC down, but CRP up to 275, so one more night in hospital. Next day, I was feeling better, CRP down to 245 so they discharged me with pain meds and antibiotics (it was the weekend so they did not elect to run any imaging on me). I went home, felt OK but not great the next day, and even worse the following day.

Even with a full load of tramadol (400 mg), ibuprofen, and acetaminophen, the pain became unbearable again and I ended up back at the ER for oral morphine. They ran my bloods and CRP was up to 390, along with elevated WBC and bill. They put me on a stronger IV antibiotic, oral morphine as needed, and scheduled me for an ERCP. I argued to have an MRCP first, since there was no sign of stones in my US. They then performed a TUS (same as first, but GB even more distended and signs of wall thickening consistent with cholecystitis) and a CT scan which also did not detect any stones but did see inflamed distended GB and some nearby fluid in peritoneal cavity. MRCP following day showed no stones anywhere, no dilated ducts, but a 4 mm filling defect in GB neck/associated cystic duct, likely due to sludge/microliths. I was told that even had we gone ahead with ERCP they would not have been able to touch this blockage due to the complexity of the cystic duct. The next day, my CRP was down to 225, and I was sent home again with ABs and pain meds.

While in hospital I researched the heck out of this (thanks, internet!) and read quite a few things about biliary sludge and ursodiol. Drug seems safe as it is even prescribed to pregnant women with cholestasis (feels like my problem actually). Seems like I only have sludge, and due to the small but not insignificant complications associated with lap chole, I convinced the docs to prescribe ursodiol. I have changed my diet and lifestyle radically (but I am in reasonably good health, BMI of 23, have no problem getting my HR up to 150-160 on a road bike for an hour at a time, try to take 10k steps a day etc.).

I am not averse to taking things out if they have to come out - I had my appendix out 2 years ago laparoscopically in NYC (Cornell NYH). But since I have not had even a single stone, I feel I am a relatively low risk case for recurrence provided I stick to a healthier diet (low fat/sat fat, high fiber, high fruit/veg/whole grain intake, low refined carbs, etc) along with ursodiol to help break up the sludge.

SS already pointed out to me in a PM that I risk another bout of acute cholecystitis and therefore the need for an urgent cholecystectomy with higher risk of CBD injury etc. vs just having the damn thing out now. I feel however that my bout of cholecystitis was partly due to incomplete/improper handling at my first ER presentation. I feel that had I been prescribed ABs then, I would not have had the swelling/inflammation/infection that probably led to extrinsic pressure on the CBD leading to elevated bilirubin etc.

I feel this time around I am fully armed - with pain meds, ABs, and a full workup with imaging so that if I have a recurrent episode I can nip things in the bud and avoid another full-blown round of cholecystitis. I would prefer to keep my GB and GI tract intact - evolution put it there for a reason I presume - and the occasional stories of explosive diarrhea etc. give me further hesitation, vs. say just having my appendix removed. Ursodiol has been shown to clear up persistent biliary sludge very well, and in those cases the PBS can clear up never to return.

I am hoping I am one of those cases, but am I crazy? All thoughts welcome.

Anonymous said...

PS on the NHS:

By the way, the NHS experience has been quite positive, especially once they decide you really are having a serious episode of something. The only complaint I have was the amount of time it took to get the first dose of morphine on my first ER visit, and also the total lack of any appropriate handoff to a specialist after you have been in the ER for a serious issue . . . one should not have to wait 4 weeks after acute biliary colic to get an ultrasound, in my opinion . . .

Skeptical Scalpel said...

I see nothing wrong with your plan to try to avoid surgery, but . . .

Here are some things to think about. Surgeons remove 600,000 to 700,000 gallbladders every year and have done so for at least 30 or 40 years. Cholecystectomies have been done for well over 100 years. If there was a problem with people who have no gallbladder, don't you think someone would have discovered it by now?

You understand that you may have to take ursodeoxycholic acid for the rest of your life. Here's something I wrote not long ago which touches on this topic

A week is not a long enough follow-up period, Let's see how you feel in 6 months. Will you be able to keep up with the diet, the UDCA, and the exercise? I'm not sure how abstaining from alcohol will help.

If you have another GB attack, it might not resolve. An emergency cholecystectomy is more risky than an elective one. If you understand that risk, then go for it.

I would love to hear how this turns out.

Anonymous said...

Thanks, SS - I will keep everyone posted as this "natural experiment" with me as the guinea pig plays out! I have a follow up appointment with a specialist in 2 weeks, will update then, or if I have any untoward developments in the mean time . . . fingers crossed I won't!

Skeptical Scalpel said...

We look forward to your outcome report. Good luck.

itmaiden said...

Skeptical Scalpel, you posted the following:

"Here are some things to think about. Surgeons remove 600,000 to 700,000 gallbladders every year and have done so for at least 30 or 40 years. Cholecystectomies have been done for well over 100 years. If there was a problem with people who have no gallbladder, don't you think someone would have discovered it by now?"

First of all, after gallbladder removal, the surgeon generally sees the patient one time, but there is no longer term follow-up of the patient for symptoms or complications. There are many people who do report problems but are "blown off" or ignored by their doctors or told to take some prescription drug. Patients suffer and their voices go unheard and unreported...unless of course you intentionally look for their complaints on the Internet or know someone personally with problems. But many people are too embarrassed to speak of bowel elimination problems. Some are suffering in too much pain to go out or to socialize. They just take pain medications and hope it will all go away someday, not realizing the medications they are taking are taking a toll on the liver and possibly setting them up for more stones to develop in the liver or the ducts.

I find it highly disturbing that most doctors have very little training in diet and nutrition and fail to discuss diet and foods with the patients or to set them up with someone who is knowledgeable. But is anyone educated enough both on the digestive system and diet to advise patients ? When I see a nutritionist advising pregnant women that a healthy balanced meal involves Polish Sausage which is heavy in sodium nitrates known to cause cancer, and in fats, I can hardly feel that a nutritionist is trustworthy. Then you have to consider pregnant women are at high risk for developing gallstones during pregnancy and a nutritionist is advising them to eat something like Polish Sausage.

It is important for patients to remove meat and dairy fats and proteins from the diet, limiting their animal proteins to small amounts of chicken, turkey and fish (and none of those products fried), and to remove sugars, as well as anything that contains non-food ingredients such as food dyes, preservatives, and fillers and other non-food substances. Sodium also needs to be watched. Basically, if it is in a box or a can, and not all organic then it needs to be avoided. And Sodas...are especially bad. I feel the culprit in Soda's to be sodium phosphates which are added to a lot of food products.

I also find that patients are not advised on the potential of medications to impair digestive system function and to cause stones, and to avoid taking over-the-counter drugs unless absolutely necessary.

Diet and Food preparation methods have to be taught to patients whether they are not undertaking surgery at the moment or if they have already had surgery. It really should be discussed prior to surgery and post surgery as well.

The other area of failure I see in the medical community it to properly assess all symptoms and other possible contributing factors before removing the gallbladder. Patients feel the surgery is a fail if they are experiencing pain and maybe more so post surgery, or other symptoms they didn't have before, not understanding there may be other causes. But these patients are left in limbo with no answers.

My understanding that removing the gallbladder can be fatal if someone has other existing liver disease or has food allergies. I am concerned that these factors are not properly considered before a decision to operate.


itmaiden said...

Regarding gallstone recurrence, I was reading a study that the NIH was reporting on that involved following up on patients who had gallstones removed only. Most patients preferred that if the stones did recur, that they would rather go through the surgery again, rather than have their gallbladders removed. As far as the stones go, the study stated that gallstone recurrence would take many years.

Considering that the gallbladder returns blood to the liver, and the presence of the Lund's node, or Mascagni's lymph node (often erroneously referred to as Calot's node), and what is the sentinel lymph node of the gall bladder; one cannot say that the gallbladder is not an important organ. Obviously the gallbladder plays a role in nutrient processing and in helping filter out pathogens or harmful substances.

Also considering what appears to be some correlation between the heart and the gallbladder I have to ask has anyone done any comparative studies to see if heart disease or congestive heart failure is prevalent in patients who have had their gallbladders removed, who did not demonstrate prior heart issues ?

Blood carries many substances, and blood flow goes from the liver to the gallbladder and vice-versa. We do not know what other complex and important chemical interchanges are occurring.

In medicine ones assumes it is okay to always remove the gallbladder because a patient does not die immediately from removal, and those who have had it removed live for many years afterwards. But are they living a compromised quality of health, and are they more susceptible to other diseases as a result ? What about lifespan ? Has it been shortened ? What about mental health and the future potential for dementia? One only has to experience living with someone who has developed liver cirrhosis from "fatty liver disease" with hepatic encephalopathy to understand the important role of liver health and the mind.

itmaiden said...

Regarding the Chinese and the new technique they use to remove the gallstones only, there is a man from the UK who traveled to China to have this procedure done. You can watch a video of the procedure and read special notes from him, other contributors and the Chinese doctors themselves on this procedure at this link:

You do have to scroll down a ways to get to the discussion. Look for input by Dr. Wang and the "Wang Gang". Wang Gang states in one reply that in the method of the technique they do the following:

"Wang Gang:
June 7, 2013 at 17:23
When we do the operation, we pull the bottom of the gallbladder out of the abdominal wall. It needs not to cut it loose from the liver. In most of the people the bottom of the gallbladder is not adhere to the liver. After remove stones, we stitch the wound of the gallbladder and put it back to the abdomen. It will recover as usual.
My email "

Now as a candidate for gallbladder surgery myself, I have wondered about whether a incision could be made into the gallbladder to remove a large stone and to then suture it back up. This answers that question (bear in mind that is not all the Chinese do, you need to learn the rest of what they do during the gallstone removal procedure)

A huge question I have is in what direction to make an incision into the gallbladder so as to minimize long term post-operative pain, since the gallbladder contracts and would be affected by the scar tissue. I would want the best and healthiest function of the gallbladder's normal movements possible. So which incision direction is best for helping the gallbladder contract in as normal way as possible ?

Being a female who has undergone an emergency C-Section in which I received a vertical cut the length of the uterus instead of the newer bikini cut, I can tell you that the vertical cut and scar tissue impacted contractions, cramping and peri-menopause with having symptoms in the latter of severe uterine spasms where the muscle would lock...much like a charlie horse of the uterus. Extremely painful..screaming painful for hours. Speaking with an ob-gyn they had never heard of symptoms like that. So I assume it was because of the vertical cut. So then I have to wonder about cutting into the gallbladder and the direction of the incision and how it may affect post-operative pain/problems later for the patient.

Skeptical Scalpel said...

ITmaiden, I appreciate your interest and comments.

The reason surgeons only see patients once or twice after GB surgery is that the vast majority do well. Believe me, the ones who don't do well haunt surgeons offices. Also, those who don't do well usually had asymptomatic gallstones in the first place. Removing their GBs was not going to help them if they had a different problem that was causing their pain.

You wrote "blood flow goes from the liver to the gallbladder and vice-versa." That is completely wrong. The gallbladder does not carry blood to liver and the liver does not carry blood to the gallbladder. Also, the gallbladder does not process or filter anything. It simply stores bile that the liver produces.

I'd like to see the link to the NIH study you referred to in your second comment. I am skeptical that the NIH did such a study.

The direction of an incision in the gallbladder would make no difference in the amount of pain a patient would have after the surgery. The GB does not have innervation that senses that type of pain.

I hope you read my follow-up post on this subject. If not, here's the link.

I wish you well as far as your GB is concerned. Good luck.

Anonymous said...

Well, I had an earlier post where I talked about trying oral dissolution therapy. Sad to say that Ursodiol did not melt my stone. It was really a far stretch since my stone was a 15mm solitary stone 6 months ago. Now it's apparently 19mm big. Sigh.....seems to be growing at an exponential rate. Still, I am glad I attempted it at the least. Now I am looking for a good surgeon. Hoping to find someone that uses Needlescopic instruments for their laparoscopic procedure, since 2-3mm incisions would be lovely in the non-umbilical ports. Anyway, made the decision to have it removed since it is growing & my sister who was less symptomatic than me had to have an emergency cholecystectomy, which she said almost killed her. Does anyone know of any surgeons in WA state that offer needlescopic cholecystectomy?

Skeptical Scalpel said...

Sorry that your experiment didn't work out. You are wise to go ahead with the elective surgery before you need an emergency procedure. Most 4-port laparoscopic cholecystectomies are done with a 10-12 mm port at the umbilicus and 3 5 mm ports. The difference in healing and pain between a 5 mm and a 2 or 3 mm port is negligible. I'm not even sure that anyone does needlescopic GBs anymore. Why bother?

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