Tuesday, March 25, 2014

Gallbladder surgery: Double jeopardy


Last month, I blogged about a paper from China that advocated removing just the gallstones and leaving the gallbladder in place. I wrote that such procedures had been tried in the early days of gallbladder surgery and failed because the stones recurred. You can read that post here.

It's not often that one gets to see almost immediate follow-up on a blog post like this, but I am happy to say that I can share a brief story with you.

A 44-year-old man (who consented to my blogging about him) underwent a cholecystectomy by a friend of mine a few weeks ago. The patient presented with right upper quadrant abdominal pain. He said that he had gallbladder surgery in a South American country in 2009 and had a large right subcostal incision to show for it.

In the emergency department of the hospital, a CT scan showed a large gallstone in what appeared to be a shrunken gallbladder. My friend obtained a copy of the operative report and a handwritten note from the original surgeon. See below.
The surgery that had been performed was a partial cholecystectomy and removal of a 6 cm gallstone.

My friend (and yes, he is still my friend) performed a robotic cholecystectomy. He said the surgery was difficult due to omental adhesions and the small size of the gallbladder. The specimen contained six 2 to 3 mm stones. The patient did well and was discharged.

OK, one case is an anecdote and doesn't prove anything, but its timely appearance doesn't hurt my position that just removing the stones won't cut it. (Pun intended.)

16 comments:

artiger said...

Yeah, it's just anecdote, but what do we need? A patient with GB cancer years after a partial cholecystectomy?

I will say that 6cm is a trophy of a stone, and that cholecystostomy or partial cholecystectomy might have been the thing to do as a temporary measure, but I would do so only with the intent to stabilize and return.

Skeptical Scalpel said...

True, especially in a man that young.

Chris Porter MD said...

I've not heard of partial (or subtotal, as indicated in the note pictured) cholecystectomy as a temporizing measure, with a planned return for completion chole - is that what artiger and SS are advocating?

Skeptical Scalpel said...

Chris, If I could not safely remove the gallbladder in the usual way, I would remove all the stones and do a cholecystostomy followed by a cholecystectomy in 6-8 weeks. On two occasions in my career for an extremely necrotic GB, I removed all but the wall of the GB in the liver bed and sutured the cystic duct closed from within. I have never simply removed the stones and closed the GB.

artiger said...

Chris, I was trying to think of an extreme situation, where maybe a 6cm stone would be removed and part of the GB resected to facilitate that...certainly an extreme situation. No, I haven't done that before. I've drained a few and come back later though.

CholeraJoe said...

You could always remove the stones and do a cholecystojejunostomy so any stones that form will pass harmlessly into the jejunum. If you're feeling lucky.

Skeptical Scalpel said...

Joe, that would be an elaborate procedure for such a simple problem. I would never have felt that lucky.

Alex said...

As a PGY-5 in Mexico, I've encountered many a necrotic or severely inflamed gallbladder. I'd rather not cause a bile duct injury and for that reason have performed the operation you described in your 2nd comment (with the approval of my attendings). Is it not better for the patient to have a recurrence than a bile duct injury?

Skeptical Scalpel said...

Alex, I'm not sure which procedure you are doing for a necrotic GB. Can you be more specific? I agree just about anything is better than a CBD injury.

Alex said...

Specifically in situations where full dissection of Calot's triangle seems near impossible without risking injury... a near complete cholecystectomy, suturing the cystic duct from within the gallbladder, and closing the remainder (theoritically only a portion of Hartmann's would be left). I know it is far from ideal, but again, sometimes, the alternative route seems way too risky.

Skeptical Scalpel said...

I understand. What I had done was simply to ligate the cystic duct by closing it from inside of the GB lumen and excise as much of the GB wall as possible. A portion of the wall is left in the liver bed. Some say to cauterize it so the mucosa would be destroyed.

William Reichert said...

My mother had gall stone pain at age 28 after childbirth. Had surgery . At age 64 she had surgery for pancreatic cancer and she was found to have a shrunken GB intact . Never had GB pain for 36 years.
A series of one but still.......

Skeptical Scalpel said...

William, she was lucky. Most patients who have pain at that age will eventually have symptoms again. It's also possible that her original pain was not caused by the stones.

itmaiden said...

Is the removal of the lymph gland in the Calot's triangle an absolute in all gallbladder removal surgeries ?

itmaiden said...

I must ask about edema existing as a result of a large gallstone. A number of women have noted a correlation. Also excessive drying of skin and hair loss...maybe from nutrient deficiencies from a blocked gallbladder and inability of the small intestine to properly process nutrients ?

Skeptical Scalpel said...

The lymph node at Calot's triangle is removed most of the time. I am not aware of any complications caused by the absence of that node.

I have never heard of edema, dry skin, or hair loss secondary to a gallstone. The gallbladder does not directly participate in digestion. It simply stores and releases bile. After the gallbladder is removed, the bile is stored in the liver and common bile duct. The only patients I've ever seen who had digestive problems after GB surgery were those who had them before surgery too.

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