Gallstone Surgery

Dear Dr. B: Who needs treatment for gallstones?

Answer: Sooner or later all patients with gallstones need treatment. The treatment is surgery. The question is: should it be sooner or later?

Once upon a time, the surgical procedure of choice was open cholecystectomy. In fact, Langenbuch carried out the first cholecystectomy in 1882. Patients who undergo open cholecystectomy have a long surgical incision in the abdominal wall, have to stay in the hospital three to five days, consume fair amount of pain killers for post-operative pain and the recovery time at home is three to six weeks.

Things have changed in the last 15 to 20 years. Now most patients undergo laparoscopic cholecystectomy when there is an indication for surgical removal of the gallbladder. Laparoscopic cholecystectomy was first performed in France in 1987. In this procedure, there are four tiny incisions in the abdominal wall, the hospital stay is usually overnight, the amount of pain killers required after surgery is minimal and the recovery time at home is usually less than one week.

Prophylactic cholecystectomy is done only in few exceptional cases. Otherwise, gallstone surgery is required only if you have symptoms. The most common symptom is recurrent attacks of biliary colic. The colicky pain is in the upper abdomen usually on the right side. Sometimes the biliary colic can present as chest pain and some people think they are having a heart attack.

The timing of surgery depends on how often you get the attacks of pain. If you are getting recurrent attacks then the surgery is planned to be done within a few days. If you settle down after one or two attacks then the surgery can be done within a few weeks.

Second most common indication for surgery is complications of the disease such as acute cholecystitis and obstructive jaundice. In acute cholecystitis, the gall bladder is acutely inflamed and the patient undergoes urgent surgery, usually within 24 to 48 hours of hospitalization. If the gallbladder is very inflamed and the patient is very sick then the surgeon may elect to drain the gallbladder and plan further surgery to remove the gallbladder after three to six weeks.

In obstructive jaundice the gallstone is usually lodged in the common bile duct which effectively blocks the drainage of bile from the liver and the gallbladder to the small intestine. Patients with obstructive jaundice are not acutely sick but the blockage should be taken care of before patient undergoes surgery for the gallbladder.

Patients who have vague abdominal symptoms and are found to have gallstones (gallstone dyspepsia) need careful assessment to establish gallstones are indeed the cause of the symptoms. In some of these patients, the symptoms may be due to other causes such as irritable bowel syndrome or gastro-oesophageal reflux disease. Removing the gallbladder in these instances will not help.

In gallstone pancreatitis, a stone from the gallbladder passes through a common channel formed by the common bile duct and the pancreatic duct. In the majority of patients this results in a mild attack of pancreatitis and recovery is uneventful. The majority of stones that cause pancreatitis pass spontaneously. These patients should have laparoscopic cholecystectomy done during the same hospital stay.

Early surgery in these patients does not increase post-operative complications or mortality. Early surgery also eliminates the risk of recurrent attacks of pancreatitis while the patient is waiting for elective surgery. Patients with worsening pancreatitis require further investigations as the stone may be jammed in the common and pancreatic duct.

Cholecystectomy is a very common operation and appropriate timing of the surgery is very important for patient care and safety.

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