Laparoscopic Cholecystectomy
("Keyhole" Gallbladder Surgery)
In "keyhole" surgery to remove the
gallbladder, four small
incisions are made around the abdomen, including one in the navel
through which a tube with a tiny video camera is inserted. Guided by
the camera images on a video screen, other tiny instruments are
inserted through the other incisions and used to:
- probe the bile ducts to identify
the cystic duct.
- close off the cystic duct and
blood vessels to the gallbladder with metal clips.
- cut the cystic duct to separate
the gallbladder.
- drain the gallbladder of bile
through the navel opening.
- remove the gallbladder also
through the navel opening.
"Keyhole" surgery has replaced traditional
open surgery as the preferred method to remove the gallbladder, thanks
to shorter surgery time, a shorter hospital stay, and a shorter
recovery period. Among all the invasive methods of treatment, it offers
the fastest relief from gallstone colic.
However, the risks of "keyhole" surgery are inevitably higher simply
because it is performed without direct eye and hand contact. The
surgeon's visual and tactile judgment is restricted by the myopic
"keyhole" camera and the 2D flat video screen, as compared to the
direct 3D view and feel of open surgery. The outcome of surgery
depends almost entirely on the skill and experience of the surgeon, and
to a certain extent the quality of his video equipment.
Risks include cutting the wrong bile duct (fatal and difficult to
repair), nicking or puncturing adjacent bile ducts (bile leakage),
bowels (fecal leakage), or blood vessels (excessive bleeding), and
dropping a clip into the abdominal cavity.
Open Cholecystectomy (Open
Gallbladder Surgery)
In open gallbladder surgery, a single large
incision is made on the upper right side of the abdomen just below the
ribs. The liver is then moved in order to reach the gallbladder. The
connecting blood vessels and cystic duct are cut and tied, and the
gallbladder removed.
Traditional open surgery has been used to remove the gallbladder long
before the emergence of "keyhole" surgery, and will continue to be
important as a back-up and repair procedure. Some of the reasons for
converting from "keyhole" to open surgery are:
- accidental injury to any bile
duct, blood vessel or organ.
- unexpected pathology not conducive
to "keyhole" management.
- stones in the common bile duct.
- excessive bleeding .
- unclear anatomy.
Open surgery provides the surgeon with a
better view and direct feel of the patient's anatomy. The fact that
open surgery is used as a back-up to "keyhole" surgery suggests that it
is a safer procedure
which the surgeon can rely on with greater confidence. However, it
remains unpopular because of a longer hospital stay of 3 to 5 days, a
slow and painful recovery period of 4 to 6 weeks, and a long ugly scar.
Risks are the same as "keyhole" surgery but significantly lower. With
an open view of the anatomy, the risk of cutting the wrong bile duct is
almost zero.
Endoscopic
Retrograde Cholangiopancreatography (ERCP) and Sphincterotomy (ERS)
- Endoscope - a
hollow, flexible, lighted tube connected to a computer and video
monitor, through which other instruments can be inserted.
- Retrograde - in a
direction opposite to the normal flow of bile.
- Cholangiopancreatography - imaging
of the bile ducts (cholangio) and pancreas (pancreato).
To check for gallstones in the bile ducts,
ERCP is used
before or during gallbladder surgery. After sedation, an endoscope is
passed through the mouth, down the esophagus, through the stomach, and
into the small intestine. The opening in the small intestine where the
common bile
duct and the pancreatic duct meet (ampulla of Vater) is identified
before it is inserted with a plastic tube (catheter or cannula).
Radio-opaque contrast dye is then injected into the common bile duct,
and the images observed on the video monitor in order to locate the
problem.
ERCP was initially developed as a diagnostic tool to examine
abnormalities of the bile ducts, pancreas, and gallbladder. It has
since expanded into therapy to treat blockages of the bile and
pancreatic ducts. However, it cannot remove stones in the gallbladder.
Patients should be informed that when the problem is found, diagnostic
ERCP may be converted on the spot to treatment such as:
- sphincterotomy (ERS) - using an
electrified wire (sphincterotome) to cut the sphincter of Oddi, the
muscle which controls the opening where the common bile duct and the
pancreatic duct meet. This will enlarge that opening through which
gallstones are passed or other endoscopic tools inserted.
- inserting a balloon into the
common bile duct,
inflating it to stretch the obstructed areas of the duct before
withdrawing it to allow the stones to pass.
- trawling the bile duct with a
basket to capture the stones and pull them out.
- inserting a plastic stent into a
narrow area of the bile duct to help drain out the stagnant bile.
Risks include adverse cardiac, respiratory or
other reactions to the radio-opaque dye, abrasion along the path of the
endoscope leading to inflammation of the bile duct or pancreas, and
perforation of the bile duct (bile leakage) or small intestine
(bacteria leakage).
Extracorporeal Shock Wave
Lithotripsy (ESWL)
ESWL uses high frequency sound waves to
shatter
cholesterol gallstones into pieces small enough to pass through the
bile ducts into the intestines. This treatment is often combined with
bile acid therapy to dissolve the fragments. The combination of ESWL
and bile acid therapy helps to speed up gallstone clearance faster than
either treatment used alone.
ESWL has not gained wide acceptance because of its poor results
in relieving gallstone colic. It is useful only to a small percentage
of gallstone patients with these conditions:
- non-calcified cholesterol stones.
- stones less than 30mm in diameter.
- three or fewer stones.
- bile ducts which are not blocked
or inflamed.
- a functioning gallbladder which is
not inflamed.
- a pancreas which is not inflamed.
- not pregnant.
Many patients do not fulfill all the above
conditions, and are therefore not fit for ESWL. For those who do
take the treatment, usually with bile acid therapy, the results are
slower compared to gallbladder removal.
Risks include shock wave injury to surrounding organs
like the kidneys (back pain with or without bloody urine), liver and
pancreas (abdominal pain), and stone fragments in the bile ducts
(gallstone colic).
Oral Dissolution Therapy (Bile
Salt or Bile Acid Therapy)
Because chenodiol (chenodeoxycholic acid)
produces strong side effects, ursodiol (ursodeoxycholic acid) has
become the main drug used in oral bile acid therapy to dissolve
gallstones in the gallbladder. Tradenames for ursodiol include
Actigall, Urso, and Urso Forte.
Ursodiol suppresses cholesterol production in the liver, thereby
reducing the amount of cholesterol in bile. Low-cholesterol bile
reabsorbs the cholesterol that had formed stones in the gallbladder,
and gradually reduces the size of the stones.
Ursodiol is used to treat small stones not more than 5mm which float
unattached to the gallbladder wall, a condition which can be achieved
with the help of ESWL. Since the dissolved stones are passed through
the bile ducts into the intestines, ursodiol therapy requires certain
conditions similar to ESWL: non-calcified cholesterol stones, a
functioning gallbladder, a normal pancreas, and bile ducts which are
not blocked or inflamed.
Certain drugs are not compatible and should not be taken together with
ursodiol. Antacids containing aluminium reduce ursodiol absorption into
the body, while birth control pills and hormone therapy may raise
cholesterol levels and negate the effects of ursodiol.
Ursodiol is a slow-acting drug, requiring 6-18 months of therapy and
monitoring. If the size or number of stones have not been clearly
reduced after 1 year, treatment should be discontinued. On the other
hand, gallstones which have been cleared or reduced in size may recur
if medication is stopped. It is therefore not surprising that only a
small proportion of people with gallstones use bile acid therapy.
Though milder compared to chenodiol, some of the wide-ranging side
effects of ursodiol include abdominal pain, nausea, diarrhea,
constipation,
headache, muscle ache, skin rash, fatigue, cold sweat, fever, cough,
dizziness, back pain, bladder pain, difficult urination, bloody urine,
swollen lips, tongue or face, difficult breathing and swallowing, chest
pain, irregular heartbeat, or simply a general feeling of discomfort.
|
