keyholesurgerycentre.co.uk | Gallstone Surgery

Gallstones are one of the most common surgical problems in the developed world. In the UK, more than 40,000 cholecystectomies are performed each year. Gallstones form when liquid stored in the gallbladder hardens into pieces of stone-like material. The liquid, called bile, is used to help the body digest fats.

Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason.

The cause of pigment stones is uncertain. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders, such as sickle cell anemia, in which too much bilirubin is formed.

It is believed that the mere presence of gallstones may cause more gallstones to develop. However, other factors that contribute to gallstones have been identified, especially for cholesterol stones.

Obesity. Obesity is a major risk factor for gallstones, especially in women. A large clinical study showed that being even moderately overweight increases the risk for developing gallstones. The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying.
Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, both of which can lead to gallstones.
Ethnicity. Native Americans have a genetic predisposition to secrete high levels of cholesterol in bile. In fact, they have the highest rate of gallstones in the United States. A majority of Native American men have gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women have gallstones by age 30. Mexican American men and women of all ages also have high rates of gallstones.
Gender. Women between 20 and 60 years of age are twice as likely to develop gallstones as men.
Cholesterol-lowering drugs. Drugs that lower cholesterol levels in blood actually increase the amount of cholesterol secreted in bile. This in turn can increase the risk of gallstones.
Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids increase the risk of gallstones.
Rapid weight loss. As the body metabolises fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.
Fasting. Fasting decreases gallbladder movement, causing the bile to become over-concentrated with cholesterol, which can lead to gallstones.

The most common symptom of gallstones is pain which is called biliary colic. A typical attack can cause:

steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
pain in the back between the shoulder blades
pain under the right shoulder
nausea or vomiting

These attacks often follow fatty meals, and they may occur during the night. Other gallstone symptoms include:

abdominal bloating
recurring intolerance of fatty foods
colic
belching
gas
indigestion

People who also have the above and any of following symptoms should see a doctor right away:

chills
low-grade fever
yellowish color of the skin or whites of the eyes
clay-colored stools

Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called "silent stones." They do not interfere with gallbladder, liver, or pancreas function, and do not need treatment.

Ultrasound uses sound waves to create images of organs. Sound waves are sent toward the gallbladder through a handheld device that a technician glides over the abdomen. The sound waves bounce off the gallbladder, liver, and other organs such as a pregnant uterus, and their echoes make electrical impulses that create a picture of the organ on a video monitor. If stones are present, the sound waves will bounce off them, too, showing their location. Ultrasound is the most sensitive and specific test for gallstones.

Other investigations like CT scan, Magnetic Resonance Cholangiogram or ERCP are used in cases where there are complications related to gallstones.

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.)

The most common operation is called laparoscopic cholecystectomy. For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions.

Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. This operation can be undertaken as a day-case procedure. Otherwise patients usually go home the next day. Most patients are fully recovered within 2 to 3 weeks of operation.

If the surgeon discovers any obstacles to the laparoscopic procedure, such as infection or scarring from other operations, the operation may have to switch to open surgery. In some cases the obstacles are known before surgery, and an open surgery is planned. It is called open surgery because the surgeon has to make a 5- to 8-inch incision in the abdomen to remove the gallbladder. This is major surgery and may require up to a 7-day stay in the hospital and several more weeks at home to recover. Open surgery is required in about 5 percent of gallbladder operations.

I have been performing laparoscopic cholecystectomy operations for more than 10 years and have undertaken well over 500 of these procedures successfully. My conversion rate to open operations is less than 2% and I have had no bile duct injuries.

Non-surgical approaches are used only in special situations—such as when a patient has a serious medical condition preventing surgery—and only for cholesterol stones. Stones usually recur after non-surgical treatment.

Oral dissolution therapy. Drugs made from bile acid are used to dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix), work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs cause mild diarrhoea, and chenodiol may temporarily raise levels of blood cholesterol and the liver enzyme transaminase.
Contact dissolution therapy. This experimental procedure involves injecting a drug directly into the gallbladder to dissolve stones. The drug—methyl tertbutyl ether—can dissolve some stones in 1 to 3 days, but it must be used very carefully because it is a flammable anaesthetic that can be toxic. The procedure is being tested in patients with symptomatic, non-calcified cholesterol stones.