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.)

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.

Is it really best to take out a gallbladder in the daytime?

Under the headline "Best to take out gallbladder in daytime," MedPage Today reports on a study that says people who have laparoscopic cholecystectomies at night have more complications.

The work was presented at Digestive Disease Week in Orlando.

Ordinarily, I would not critique a paper that I had not read completely but I have to make an exception in this case.

There are some serious issues with both the research and the reporting. If the MedPage article is not read carefully, patients may receive inappropriate or delayed care.

According to the article, the paper comprised 549 patients who were mostly female (84%) with 65% having surgery in the daytime (defined as 7 a.m. to 7 p.m.), and 62% had surgery that was not elective—that is, urgent or emergent.

Those operated on at night had a longer median hospital length of stay, 3 days vs. 1 day and were more likely to have had non-elective surgery, p < 0.001 for both.

The article also says the nighttime patients "were more likely to have a discharge diagnosis." I'm only guessing, but I think they may have meant to say "a discharge diagnosis of acute cholecystitis."

"Bile leaks, bile duct injuries, retained stones, pneumonia, and readmission occurred at rates that did not differ significantly," says the report. The only complication that differed significantly was that of superficial wound infection, which occurred in 5% of the night and 2% of the day patients, p = 0.04.

Multivariate analysis showed that nighttime surgery increased the odds of complications by just over 3 times but with a wide confidence interval of 1.01-10.7 and a barely significant p value of 0.05.

So, what's the problem?

At the very end of the nearly 500-word article, we find that elective patients were excluded from the multivariate analysis with no explanation why. It could be that when the elective patients were included, there was no difference in outcomes.

The first part of the last sentence is even more revealing: "The authors also did not have data on postoperative length of stay and severity of gallbladder disease."

Perhaps some of the length of stay of 3 days for the nighttime patients was due to waiting for an available operating room, workup for possible common duct stones or stabilization of lab values.

But in my opinion, the factor that makes the entire study invalid is not knowing the severity of the gallbladder disease. A patient with a more severely inflamed gallbladder is obviously more likely to have a complication.

There is also no mention of co-morbidities like diabetes or heart disease which may have been more prevalent in the nighttime group.

I don't understand how this study ever saw the light of day, why it was selected as a featured paper by MedPage or why the misleading headline was used.

If you are a patient with a sick gallbladder, many recent studies have shown that you should have it removed as soon as possible—less time in the hospital, less cost better outcomes.

If your surgeon can do it at 8 p.m., please go ahead with the surgery. Don't wait until the next day.

Choosing antibiotics for appendectomy and cholecystectomy: Are "big guns" needed?

An emergency medicine physician asked me to comment on the use of antibiotics in patients having surgery for acute appendicitis and acute cholecystitis. He said in hospitals where he has worked in three different areas—New York, Miami and San Francisco—surgeons are using Imipenem for cholecystitis and Zoysn for appendicitis.

He wondered why those drugs were chosen and offered a few theories. They are as follows:

1) Surgeons are trying to avoid resistant bugs, so they’re using bigger guns

2) There is more pressure to reduce post-op complication numbers, so they’re using bigger guns

3) It’s easier to give one antibiotic to cover multiple bacterial types, instead of, say, cipro/flagyl or cefoxitin/flagyl

4) Patients do better with these big gun antibiotics

5) Residents are being taught incorrectly, and are just developing bad habits

Yes, it is mandated that everyone needs a dose of prophylactic antibiotics within an hour of surgery for appendicitis and cholecystitis. Of course, there are nuances.
 
Appendicitis is a disease involving an inflamed, eventually infected appendix so the use of antibiotics is possibly therapeutic and not simply prophylactic.
 
For acute cholecystitis, a similar argument can be made. The problem here is that it is often difficult to tell acute cholecystitis (with possibly infected bile) from biliary colic (pain caused by a gallstone impacted in the neck of the GB) without infection. Sometimes the GB ultrasound says acute cholecystitis, the surgeon says acute cholecystitis and the path report says chronic cholecystitis. There are many other permutations of those three observations. (e.g., US-biliary colic, surgeon-biliary colic, path-acute cholecystitis, etc.)
 
Note: I do not routinely culture peritoneal fluid in appendicitis or bile in cholecystitis because by the time the culture report comes back, most patients have been home for two or three days. There is evidence to support not culturing either fluid.
 
Honestly, I’m not so sure that people with early acute appendicitis really need antibiotics. Unless the appendix is perforated, I use only one preop dose. There are also similar differences in the imaging reports, surgeon description and path reports for this disease too.

I doubt that patients with biliary colic benefit from antibiotics either. The problem is that one may not discover that acute cholecystitis is present until one is in the abdomen. The same issue occurs with appendicitis where an unsuspected perforation may be found at surgery.

At least for now, at least one pre-op dose of an appropriate antibiotic seems reasonable.
 
Where I practiced for the last few years, we did not use Imipenem for GBs and only occasionally is Zosyn used for appys. Most of us used Unasyn for both except in the penicillin-allergic patient. For that patient, we used Levaquin and Flagyl. The problem with the latter two drugs is that they each are supposed to be infused over an hour. This is not always possible because the surgery may be started within an hour in certain circumstances, such as when an operating room happens to be vacant and the patient is ready to go. It’s a rare event, but it does happen.
 
There is no evidence that patients with either disease, who usually present from home, have resistant bacteria, and postoperative complications, especially infections, are not common with either disease. There is no evidence that patients do better with “big gun” antibiotics. In fact, most of the evidence that prophylactic antibiotics are even needed in these two operations comes from the pre-laparoscopic era. Wound infections are extremely uncommon with laparoscopic appendectomies and cholecystectomies. This is probably due to the fact that the wounds are small and in most cases, the specimen is removed in a plastic bag so the infected organ does not touch the subcutaneous tissue.
 
If residents are being taught to use “big gun” antibiotics for these two diseases, I agree it’s incorrect. There is little hope of changing this.

It is similar to the unfounded practice of giving everyone who is NPO a proton pump inhibitor, which I wrote about here. There is no scientific rationale for it. Yet everyone does it, and no amount of discussion will convince people to stop.

[Note: A version of this post appeared on General Surgery News a few weeks ago. The version above is better because I thought about it more.]