Gallbladder-Surgery

Gallbladder Surgery

The gallbladder serves as a reserve for bile that gets secreted by the liver. The bile gets secreted by the liver so that it can go into the intestine to help with the digestion of food, mainly the protein and fat contents of the food. The liver continues to secrete bile and the bile gets diverted into the gallbladder and the gallbladder reserves that bile until we have a meal and after the meal a hormone called cholecystokinin is secreted. Once the food is in the duodenum, cholecystokinin is secreted and it travels in the blood to order the gallbladder to contract and once the gallbladder contracts it will push all of the bile that has been secreted down the bile duct and in then into the intestine to help with the digestion and absorption of fatty food and protein material along with pancreatic enzymes. The gallbladder itself sits just underneath the liver on the right side of the abdomen underneath the rib cage and is attached to the main bile duct with what we call the cystic duct.

Gallstones are very common affecting 10% of the population. Surgical removal of the gallbladder is one of the most common operations performed by a general surgeon. This operation is usually performed laparoscopically in most cases. Gallbladder, unlike other organs is not essential for general health. When the gallbladder is removed the bile still flows to the intestine as usual.

Cholecystectomy:

This operation is usually conducted under general anaesthesia in a keyhole approach which gives you a faster recovery and earlier return to work. The surgeon makes a small cut around the belly button to insert the camera under direct vision; 2-3 other small  (5mm) cuts are made in the upper part of the abdomen, the peritoneal cavity is insuffulated with co2 for visibility , diathermy current is used to identify the important structures, there is an artery that provides blood supply that will need to be controlled with synthetic clips’ also the cystic duct is controlled in same manner. Prior to occluding the duct, usually an Xray test is needed to ensure there are no stones in the bile duct. Then the gallbladder is removed from its liver attachment and retrieved in a bag via the belly button.

Sometimes the surgeon will choose to leave in a plastic drain that is usually removed the next day or the day after. This occurs in cases when the gallbladder is extremely  inflamed  and a difficult operation was needed.

If there are stones in the bile duct your surgeon has two options, either removing the stones at the same operation or chooses to refer you for an endoscopy test called ERCP, in this procedure the stones are removed by endoscopy with no wounds.

Recovery:

1.  Hospital stay is overnight usually can be longer if the operation is complicated

2. You are reasonably pain free within a few days and may only require paracetamol

3. You can drive and resume work once the pain settles

4. It is common to feel tired after the operation and that may take a week to ten days to settle.

5. You don’t need to modify your diet after the operation, only about 10% of patients will develop loose bowel motions, in that case  they need to reduce fat intake. It usually settles down but may take a few months.

Condition, Treatment & Procedure

Biliary colic

Gallstones get impacted in the inner part of the gallbladder and they lead to contraction of the muscular wall of the gallbladder that leads to the pain and the nausea.

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Gallstone pancreatitis:

Other problems that can result from the presence of gallstones is what is called gallstone pancreatitis and this occurs because stones move down the gallbladder and pass into the bile duct and they get impacted at the junction of the bile duct and the pancreatic duct when they meet in the duodenum. As a result of the that the patient can develop acute pancreatitis and that can be quite severe but most of the cases are mild. However, pancreatitis as a result of gallstones can be a devastating disease if it is severe in its form and needs acute attention.

 

Acute cholecystitis:

Another problem that can arise from stones in the gallbladder is the term called acute cholecystitis which is a very common problem for people who have gallstones. The pain in patients with acute cholecystitis is similar to biliary colic in terms of the but usually the patient feels unwell and they run a temperature and their pain does not settle down, while the pain with biliary colic is expected to settle down in a matter of a few hours in acute cholecystitis the pain will not settle. Acute cholecystitis is an infectious problem because of the presence of stones gut bacteria can travel up to the gallbladder and when the gallbladder is obstructed by stones they flourish and lead to an acute infective problem. In most of these situations the patient will be admitted to the hospital and they will need antibiotics and emergency surgery to remove their gallbladder.

Obstructive Jaundice:

Other complications of the gallbladder is that occasionally stones can travel down the bile duct and they can actually block the bile duct where the patient can become jaundiced which is a yellowish discolouration of the sclera with dark urine and pale stools. All of these complications will need some sort of surgical intervention. If the stone gets lodged in the bile duct and the patient is jaundices they will be referred to a Gastroenterologist who will perform a procedure called an ERCP (Endoscopic retrograde cholangio-pancreatography). That is a procedure that happens under anaesthesia and the stones are removed via the endoscope from the bile duct without the need for surgical intervention. However, in this situation the patient will need their gallbladder to removed by surgery at a later date.

Cancer of the gallbladder:

Stones leads to chronic inflammation, in the long term if untreated is associated with a risk of cancer of the gallbladder.

The result of the chronic inflammation is that these cells become cancerous and they grow in a disrespectful manner to the surrounding tissues where they can actually invade the surrounding tissues. Also, cancers have the ability to spread via the lymph nodes and the blood vessels because they can travel by breaching the membranes of these structures and they can go to the lymph nodes. Also, they can infiltrate the liver in a direct manner and they can go via the blood stream into other organs, particularly the lungs.

Cancer of the gallbladder is a very uncommon disease and the majority of the cases occur in people who have gallstones. Occasionally it can be caused by other problems like primary sclerosing cholangitis which is an autoimmune inflammation of the biliary tree. Most people who get this disease are elderly in there 70’s and a lot of the cases at the time of diagnosis the disease is advanced and beyond curative treatment. However, it can be found incidentally, sometimes when your surgeon removes the gallbladder the pathologist will examine that and they will find a cancer in it. Most of these cases the cancer tends to be in its early stages and is usually treatable.

When you meet your surgeon you will need to ask him/her about the stage of the gallbladder cancer. There are a variety of systems of staging the gallbladder cancer and in brief there are four stages. In layman’s terms:

  • Stage 1 – when the cancer is limited to the inner lining of the gallbladder
  • Stage 2 – where it has invaded into the muscular wall of the gallbladder
  • Stage 3 – when the cancer has eroded into the overlying tissue just outside the gallbladder wall and in that case it might have invaded the liver
  • Stage 4 – which has invaded other organs

You also need to know the status of the lymph nodes whether they are involved or not and whether there is spread to other organs excluding localised direct invasion of the liver. Each of these details will have its implication on treatment and chemotherapy will be important for people who have advanced disease as well as radiotherapy.

Often the gallbladder cancer presents in an advanced stage where no curative treatment can be offered. However, a palliative form of treatment in the form of radiotherapy and chemotherapy can be offered and that can provide reduction of the symptoms and might have a small survival advantage to it. In that situation you really need to discuss that with your Doctors and ensure that you understand the benefit and the risk of having such a treatment because it can impact the quality of your life and some patients do prefer not to have any form of aggressive treatment when the situation is unlikely to be cured. However, these things are discussed extensively and you just need to be aware of the available options.

Gallbladder Cancer

Risk factors for gallbladder cancer involve mainly gender, most of these cases are seen in women. They can be seen in men as well with gallstone disease, however it effects women more than men. People who are overweight or obese are more likely to develop gallbladder cancer and also people who have gallstones. Chronic inflammation of the biliary tree can cause gallbladder cancer like people with primary sclerosing cholangitis.

If your surgeon is concerned about gallbladder cancer, this will come in two ways, one of them the gallbladder has been earlier removed and the pathologist has looked at it and found that there is a spot of cancer in the gallbladder. In that situation and also in the situation where your surgeon suspects that you might have gallbladder cancer they will do further tests. These tests will involve blood markers for tumours and also the basic blood tests which involve liver function, kidney function and full blood count. In addition to this, detailed imaging would be required and it would be minimally in the form of a CT scan to look at the gallbladder. A CT scan benefit is also to see if there is any disease in the liver, the lymph nodes and whether there is spread to the lungs. If there are suspicious lesions then your surgeon will ask for a further more sophisticated test which is called a PET scan. A PET scan is a whole body scan and the purpose of that scan is to see whether the disease has actually spread to other organs away from the gallbladder and the lymph nodes.

Image result for cancer of the gallbladder chile

Once all of the details are available and the information obtained by these scans your surgeon will give you the available options for treatment. Most cases of gallbladder cancer are beyond surgical treatment. However, early cases can be curable. The surgery involves radical excision and removal of the gallbladder and the lymph nodes that drain the gallbladder and also part of the liver tissue which is the segment of the liver that sits directly adjacent to the gallbladder. Very often the lymph nodes are involved. When they are removed they will be looked at under the microscope and in that situation it is likely that you will require chemotherapy and the role of radiotherapy will also be discussed with you after the completion of surgery.

Post Operative Care

You will stay overnight in the hospital which will be mainly for observation and pain control. You will be able to eat and drink once you wake up. The next morning you will usually be reviewed and likely discharged home.

There is no need for diet modification. Recovery will take an average of about one week after which you can drive and go back to work. Once at home you will need regular Panadol for two days. You will be advised not to lift anything heavy for six weeks and no strenuous exercise. Walking and jogging and normal daily activities are fine after one week.

Complications of Gallbladder Surgery

Bile leak

One complication of gallbladder surgery is the rare event of bile leak. When the surgeon divides the cystic duct they put metal or plastic clips. Occasionally if the tissues are inflamed and friable these metal clips can fall off and they can lead to leak of bile. When your surgeon is concerned they might leave a drain in and this might appear in the drain the next morning or a few hours later on or in the first few days. Occasionally if the surgeon has not left a drain in the patient will become unwell with increasing pain and probably with a temperature and they will need to have further procedures. Usually complications like this can be solved endoscopically. However, sometimes the patient will need an additional drain or a return to theatre.

Bleeding:

Bleeding is a risk in any operation, it is a rare complication after removal of the gallbladder, which may require another operation to fix and the patient may need a blood transfusion.

Bile duct injury

Injuries of the bile duct are very uncommon these days as surgeons are more experienced in dealing with keyhole surgery for the gallbladder. However, it still does happen. There is a small risk that the surgeon could injure the bile duct and that can lead to either leakage of bile after the operation, the surgeon may identify that at the time and recommend repair by a specialised hepatobiliary surgeon or it might appear a few days later when the patient becomes unwell with bile leak or they become jaundiced if the bile duct has been blocked. A complication like this is regarded as major trouble as the patient may need definitive repair of the bile duct by a specialised hepatobiliary surgeon.

Longterm complications:

Usually there are no long term complications as a result of removing the gallbladder itself for the process of digestion and nutrition. However, occasionally people can develop loose bowel motions. This can happen in about one in ten patients. A lot of these cases will resolve in three to six months but they can be permanent and they can occasionally need some form of treatment. So if you develop diarrhoea you would need to talk to your surgeon for a replacement treatment of bile salts. For the treatment with Cholestyramine which absorb bile salts and prevent diarrhoea.

Bile reflux and alkaline gastritis:

Another very unusual complication is that some patients after gallbladder surgery could develop reflux of the bile from the duodenum into the stomach and that can be troublesome. Again most of these patients will improve on medical treatment that ensure adequate drainage of the stomach but very occasionally people can be troubled by it and if you have such problems you need to talk to your surgeon. An extreme solution to that is surgery in the form of bypass of the biliary floor into the intestine.

Diet

You will not require a different diet unless you have diarrhoea where your doctor will ask you to cut down on the amount of fat that you eat. Other than these problems removing the gallbladder is pretty harmless and has no other implications.

Gallbladder Polyp

A polyp is a growth that forms a projection from the inner surface of the gallbladder which in reality looks like a large wart hanging from the surface of the skin. These polyps are relatively commonly reported on ultrasound scan. However, the overwhelming majority are harmless. Most gallbladder polyps are caused by excessive cholesterol deposition in the mucosa of the gallbladder which will hang out of the inner lumen of the gallbladder to make it look like a polyp. They are benign and totally harmless.

Having said that there are certain situations where a gallbladder polyp will need surgical attention or a surveillance ultrasound examination. Most polyps that are less than 5mm have no consequences and they are usually cholesterol polyps and harmless. However, when the polyp size is bigger than 5mm it might need to be followed up with an ultrasound scan every six months to ensure that it is stable and that it does not increase in size.

In certain patients like people with a primary sclerosing cholangitis, people with stones, older people above the age of 50 and when the size of the polyp is bigger than one centimetre, or when it continues to grow on surveillance ultrasound then these are the warning signs that a neoplastic polyp might exist and in that situation you will need to talk to your surgeon to consider removal of the gallbladder. Occasionally these polyps can be early cancers. There is a form of gallbladder cancer that is called papillary carcinoma of the gallbladder and that usually grows in the form of a polyp. However, that type of growth constitutes less than 10% of all gallbladder cancers.

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