- 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%)
- 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
- 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
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 ( les than 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
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
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)
Outcome
- Conversion rates typically about 5%
- Laparoscopic cholecystectomy associated with
- Reduced analgesic requirements
- Reduced postoperative stay
- Faster return to normal activity
Bile duct injury
- Occurs in between 0.1% and 0.5% of patients
- Risk related to surgical inexperience and problems identifying
biliary anatomy
- Outcome improved if recognised at time of initial surgery
- For most injuries hepaticojejunostomy is the treatment of choice
- If recognition of injury is delayed then associated with higher
morbidity and mortality
- Management then requires drainage of collections and control of
sepsis
- Long-term risk include stricture formation and cirrhosis
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
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