Cholelithiasis, Cholecystitis and Cholecystectomy – their relevance for the African surgeon
1. Introduction
Cholecystectomy is the most common major general surgical operation performed
in North America and Europe. (1) In the 1990s laparoscopic
cholecystectomy LC swept through the countries of this region totally transforming
the approach to biliary tract disease. Review of the history of this technological
change provides insights into how medical care develops. The clinical conditions
resulting from cholelithiasis have a marked geographical distribution (see 3.
Epidemiology) and are not common problems facing African surgeons. This
may change, as diet, activity and longevity change with development. Knowledge
of the surgical approach to the gallbladder and biliary ducts is a fundamental
skill of general surgery. Moreover, there is enormous pressure to introduce
laparoscopic cholecystectomy in low-income countries. This Review will deal
with these questions as they relate to surgeons in the developing world. Subsequent
reviews will discuss other complications of cholelithiasis such as choledocholithiasis
and biliary pancreatitis in greater detail.
2. Surgical Anatomy and Physiology
Oddsdottir and Hunter give a succinct summary of gallbladder anatomy in their
chapter in Schwartz’s Principles of Surgery. (2) Understanding
the anatomy and its variants are key principles of general surgery. The relationships
of cystic artery, cystic duct and common duct in the triangle of Chalot, as
well as the recognized anomalies, are crucial to preventing bile duct injury.
The gallbladder stores and concentrates bile and excretes it into the duodenum
at the ampulla of Vater upon stimulation by cholecystokinin released from the
duodenum. Bile contains water, electrolytes, lipids, bile salts and bile pigments.
The bile salts conjugated with amino acids are important in the digestion and
absorption of fats. They are, in turn, reabsorbed in the terminal ieum.
3. Epidemiology
There is a large variation in the prevalence and type of gallbladder stone disease
throughout the world and ethnicity plays a major role. (3)
Age, diet, obesity and female sex are also important factors. Ten to fifteen
percent of white adults in developed countries harbor gallstones. In North American
Indians the disease is epidemic with up to 60% of women in these populations
being afflicted. The prevalence of cholelithiasis in Asians and Afro-Americans
is lower in the range of 5-10%, with brown stones predominating in Asians. In
sub-Saharan Africa the prevalence is even lower, less than 5%. The prevalence
in pregnant women in Nigeria was 2%. (4) South Americans, particularly
Amerindian populations, have a high prevalence of gallstones. Coelho in a study
from Brazil found that age, female sex and number of pregnancies all were strongly
correlated with gallstones. (5) Interestingly, fasting and
acute weight loss are both associated with symptomatic cholelithiasis. (6)
The genetic profiles leading to the development of cholelithiasis are just now
being worked out. (7)
4. Pathophysiology
The pathogenesis of gallstones is complex. (8) The secretion
of lithogenic bile, with ratios of bile acids, cholesterol and phospholipids
favoring cholesterol precipitation, abnormal gallbladder motility and delayed
large bowel transit times favoring re-absorption of deoxy-cholic acid have all
been implicated in gallstone formation. Local factors in the gallbladder are
important. (9)
The majority of gallstones form in the gallbladder. Choledocholithiasis (bile
duct stones) occur in about 10% of cases of cholelithiasis in the West. (10)
Stones in the bile duct may be either primary (forming de novo in the bile duct)
or secondary (passing from the gallbladder into the bile ducts). (11)
Common duct and intra-hepatic stones are more common in Asia (20%), where they
are more commonly primary in origin (30%). Primary common bile duct CBD stones
may also form as a result of biliary strictures and tumours.
4.1. Chemistry of Gallstones
Gallstones are traditionally divided into black pigment, brown pigment and cholesterol
stones. (8) Black pigment stones are composed of bilirubin
and calcium and are found in patients with hemolysis or jaundice. These occur
in sickle cell disease. Brown pigment stones contain, in addition to the above,
amorphous material and mucous glycoprotein. They are more common in Asia. Cholesterol
stones having, by definition, 70-90% cholesterol by weight predominate in the
West. By contrast, in Cameroon, the majority of patients had less than 25% cholesterol
in their stones and a higher percentage of amorphous material. (12)
In another report from Ghana, 34% of patients had cholesterol stones. (13)
Microlithiasis and sludge are real clinical entities in the West requiring similar
treatment to macroscopic stones. (14)
4.2. Gallbladder Motility
The role of impaired gallbladder motility in the development of cholesterol
stones is being elucidated. (15) Erythromcyin is a powerful
inducer of gallbladder contraction. (16) Its value in conditions,
such as prolonged fasting and total parenteral nutrition, which are associated
with cholelithiasis, is being studied.
5. Diagnostic Studies
5.1. Imaging
Historically a wide variety of tests have been used to detect gallbladder function
and stones. Today the transabdominal ultrasound US is the gold standard for
diagnosis of cholelithiasis. (17) It has sensitivity and specificity
of over 95% for stones greater than 1.5 mm in size and provides important information
on burden and mobility of stones, gallbladder volume, wall thickness and size
of the common duct. Other intra-abdominal organs can be scanned at the same
time. US is more sensitive than CT or MRI for gallstones. (18)
The US features of specific clinical entities will be discussed below.
While US is sensitive for common bile duct size, it may miss the presence of
small common duct stones (sensitivity <50%). Therefore alternative imaging
may be necessary. Endoscopic retrograde choledochopancreatography ERCP is a
highly sensitive and specific imaging modality, but is invasive and its acquisition
requires considerable training. It is not without morbidity which is related
to experience of the operator. Complications, such as pancreatitis, bleeding
and perforation of duodenum, occur each in 5-8% or patients particularly after
endoscopic sphincterotomy ES and the mortality rate is 0.5-0.8%. It is unlikely
to be available in low-income countries outside of major teaching institutions
for some time. Similarly Magnetic-resonance-choledocho-pancreatography MRCP,
which has slightly lower accuracy and no therapeutic capability, but significantly
lower morbidity than ERCP and is vying for dominance with it, is unlikely to
be available. (19) Nuclear medicine imaging, such as HIDA
scans, can accurately identify a blocked cystic duct often associated with acute
cholecystitis.
5.2. Haematology/Biochemistry
Blood tests play an important role in biliary tract disease. Elevated WBC may
be indicative of infection with cholecystitis or cholangitis. Jaundice is determined
by direct and indirect bilirubin. Liver function can be assessed biochemically:
cholestasis is indicated by elevated alkaline phosphatase and gama-glutamyltransferase
GGT; other aminotransferases will be normal unless there is cholangitis. With
biliary colic alone these tests are often normal. (2) Biliary
pancreatitis may be detected by elevated serum amylase. (20)
6. Clinical conditions
A wide variety of clinical conditions exist as a result of gallstones. These
can be divided into uncomplicated and complicated disease.
6.1. Uncomplicated Disease
6.1.1. Asymptomatic Gallstones
Asymptomatic gallstones are those found incidentally at US or other diagnostic
procedure. In the West, where large numbers of such patients have been identified,
the natural history of asymptomatic gallstones is understood. The majority of
patients with silent gallstones will remain asymptomatic. Only 10% of patients
will become symptomatic at 10 years and 20% at 20 years. (17)
Moreover the majority of patients developed symptoms before progressing to more
complicated disease. This information, developed in the period when open cholecystectomy
OC was the main surgical procedure, resulted in a consensus that asymptomatic
gallstones were not an indication for cholecystectomy. In the 15 years since
laparoscopic cholecystectomy LC has become the standard of practice in North
America, questions have been raised whether the indications for surgery should
be broadened. (21;22) There is no question
that the number of cholecystectomies has increased since the introduction of
LC. Possible candidates for prophylactic LC include: young patients, females
less than 60 years, those on waiting lists for transplant, patients with sickle
cell disease, diabetics, those with porcelain gallbladders or in populations
with a high incidence of gallbladder cancer. However, a recent systematic review
for the Cochrane Collaboration revealed that there were simply no randomized
controlled trials RCT comparing observation and cholecystectomy in patients
with asymptomatic gallstones.(23) There is therefore little
evidence on which to base a change in recommendations. Only morbidly obese patients
undergoing bariatric procedures would seem clearly to benefit from prophylactic
cholecystectomy.
6.1.2. Symptomatic Gallstones
The primary symptom of symptomatic gallstones is recurrent attacks of pain,
often referred to as biliary colic. The pain is usually epigastric, but may
be in the right upper quadrant and may radiate through to the back or shoulder.
It is often severe and may be confused with a myocardial infarction. Nausea
and vomiting may occur and the symptom complex may be precipitated by a fatty
meal. (2) Recurrent pain of this character together with gallstones
on US make the diagnosis of symptomatic cholelithiasis. Pathologic findings
of chronic cholecystitis are invariably found. In the West with its high prevalence
of asymptomatic gallstones it is prudent to rule out other diseases which may
be causing symptoms. Sludge, cholesterolosis and adenomyomatosis all may cause
symptoms and can be diagnosed on US. (18) Whereas prior to
the introduction of LC there was debate as to the appropriate treatment for
symptomatic gallstones (see 7.1. Medical Treatment); today
there is fairly uniform consensus advocating LC.
6.2. Complicated Disease
6.2.1. Acute cholecystitis
When the gallbladder pain lasts for more than 24 hours, an obstructing stone
is usually present, either in the cystic duct or in Hartmann’s pouch.
A hydrops or mucocele of the gallbladder may develop. In some cases the pain
may settle. In others, infection of the obstructed gallbladder may subsequently
develop leading to acute cholecystitis AC. (24) Bacteria can
be cultured from 50% of patient gallbladders in early AC. Fever and leukocytosis
may be present, but their absence does not rule it out. US is diagnostic; identifying
stones, often with a hypoechoic and thickened wall (>3mm) and a positive
sonographic Murphy’s sign. There may be pericholecystic fluid.
Fever, leukocytosis and mild elevation of alkaline phosphatase may be indicative
of more severe disease. Antibiotics are usually prescribed. Cultured bacteria
range from enteric gram-negative aerobes to facultative anaerobes like strep
faecalis and anaerobes including clostridia and bacteroides flagilis. Broad
spectrum antibiotics are indicated. Most attacks resolve, but the disease may
progress to empyema of the gallbladder, gangrene, perforation or cholecystoenteric
fistula. These latter complications are more common in diabetics and in the
elderly. Cholecystoenteric fistula may be diagnosed by the appearance of air
on the biliary tree.
Older evidence favored early OC in acute cholecystitis. (24)
72 hours of symptoms were felt to constitute the window of opportunity, after
which edema and inflammation made OC more difficult. In the early years after
introduction of LC, acute cholecystitis was taken as a contraindication to this
procedure, but subsequent experience allows advocacy of early intervention.
However, it should be noted that the majority of patients with AC will settle
on bedrest, analgesia, intravenous fluids and broad spectrum antibiotics and
that this approach with interval cholecystectomy is a very acceptable management
practice. Patients, who arrive late or appear unfit for surgery, should be treated
in this manner; however 20% may require surgical intervention for complications.
6.2.1.1. Acute acalculous cholecystitis
Acute acalculous cholecystitis is a recognized entity, occurring classically
in diabetic patients, but also in the acutely ill and injured. (25)
Children may rarely also be affected. In Ameh’s study from Nigeria, 6
out of 7 children with cholecystitis had no gallstones. (26)
The disease may be very severe with marked toxicity, progression to gangrene,
perforation and high mortality rates. Modern treatment in the West uses percutaneous
cholecystostomy under ultrasound control, if perforation or gangrene can be
ruled out.
6.2.2. Choledocholithiasis
While a detailed discussion of this condition can be left to a subsequent review
on obstructive jaundice, a number of points are warranted here. In the West,
common bile duct CBD stones are found in between 6-12% of patients with cholelithiasis.
Their presence increases with age to about 20% after age 60. They may be silent
in a majority of cases. GGT is felt to be the most sensitive biochemical indicator
of their presence.
However, the consequences of common duct stones, cholangitis, obstructive jaundice
and biliary pancreatitis, may be severe. During the period when OC was the most
common surgical procedure performed these facts led to the recommendation of
routine intra-operative cholangiography IOC. (27) During this
period, ERCP with endoscopic sphincterotomy ES was less widely available and
it seemed prudent to rule out CBD stones which might cause significant morbidity
and require re-operation. With both the widespread use of LC and the availability
of ERCP and ES this practice has been questioned. (10) (See 7.2.3.1.)
The risk in any particular patient of harboring silent CBD stones can be classified.
Patients with large stones, no history of jaundice or pancreatitis, and no liver
function abnormalities have a low <5% risk. Patients with moderate (10-50%)
risk have a small stones and/or any of the above. Patients with high (>50%)
risk of CBD stones have jaundice or cholangitis, dilated CBD or evidence of
choledocholithiasis on US. Management of these last two classes can include
pre- or post-operative ERCP with ES or LC with IOC and trans-cystic exploration
of the CBD, depending on local resources and expertise. (28)
A recent meta-analysis of studies comparing ES and endoscopic removal versus
surgical removal showed no advantage to either approach. (29)
6.2.3. Biliary Pancreatitis
As with choledocholithiasis, the discussion of biliary pancreatitis awaits a
fuller review of pancreatitis in general. However, gallstones are the most common
cause of pancreatitis in the West. The immediate management of the gallstones
depends very much on the severity of the pancreatitis. (30)
Those with mild pancreatitis may receive LC with IOC on their first admission.
If choledocholithiasis is found, transcystic CBD exploration may be undertaken
or ERCP and ES post-operatively. Those with more severe pancreatitis require
ICU monitoring and treatment directed at early recognition of sepsis and pancreatic
necrosis. In the past, ERCP was considered contraindicated in pancreatitis.
Today it is indicated to detect and remove obstructing calculi, if there is
cholangitis or in severe cases which fail to resolve.
6.2.4. Carcinoma Gallbladder
Carcinoma of the gallbladder, while relatively uncommon in the West, is a highly
lethal condition with most cases being diagnosed late. (31)
It is more common in women and has marked geographical variability being most
common in India. (32) 75-90% of cases are associated with
gallstones and the risk rises with gallstones size. (33) This
finding has led some to recommend prophylactic cholecystectomy in patient with
asymptomatic gallstones from populations with a high incidence of gallbladder
carcinoma. The porcelain gallbladder, which is characterized by mural calcification,
has a high (11-33%) association with gallbladder carcinoma. Most cures occur
in Tis and T1 cancers discovered incidentally at cholecystectomy. Stage II and
IIIA cancers warrant extended cholecystectomy with excision of the surrounding
liver bed and CBD lymphadenectomy.
7. Treatment
7.1. Medical
Prior to the introduction of LC there were significant discussions in the literature
about alternative methods of treating gallstones, particularly oral administration
of bile salts and lithotripsy. (34) Bile salt administration,
primarily ursodeoxycholic acid UDCA, has been used to dissolve cholesterol stones.
There are considerable restrictions to this therapy: patients with frequent
symptoms are excluded, the gallbladder must function, stones must be primarily
cholesterol without significant calcification. Stones greater than 5 mm have
only a 50% chance of dissolution after 9 months of therapy. For these reasons
alone, gallstone dissolution is unlikely to be practical in low-income countries.
Extra-corporeal shock wave lithotripsy ESWL has been considered as an alternative
to surgery. (35) Again there are restrictions in terms of
patient selection. With the introduction of LC these approaches have languished
and no scientific studies have been conducted comparing their efficacy to surgery.
However with the proliferation of LC procedures issues of cost effectiveness
need to be considered. (36) All non-surgical approaches to
gallbladder disease suffer from their inability to eliminate the gallbladder
itself, the site of gallstone formation and therefore recurrences are a problem.
7.2. Surgical procedures
Surgical extirpation of the gallbladder has been the gold standard of treatment
for symptomatic and complicated gallbladder disease for over 100 years.
7.2.1. Cholecystostomy
Cholecystostomy has been used in the past as a salvage operation when cholecystectomy
appears too dangerous or when a skilled operator is unavailable. (37)
Today it is used primarily in the West as a percutaneous drainage procedure
for acalculous cholecystitis.
7.2.2. Open cholecystectomy
The first open cholecystectomy OC was carried out by Langenbuch in 1882. Since
then the procedure achieved predominance as the most appropriate treatment for
symptomatic cholelithiasis, acute cholecystitis with or without gallstones,
gangrene of the gallbladder, after initial cholecystostomy, after trauma to
gallbladder or cystic duct and for carcinoma of the gallbladder. The various
technical details are well described by Ellis in Maingot’s Abdominal Operations.
(37) The mortality rate in large series has been well below
1%. During most of the 20th century certain principles were associated with
OC -routine intra-operative cholangiography IOC and routine drainage of the
gallbladder. The latter has clearly fallen into disrepute except in difficult
procedures where the risk of bile leak is considerate high or where there is
a peri-cholecystocholic abscess. (38) Routine drainage has
in fact been shown to be associated with higher risk of fever and wound infection.
The rationale for routine IOC has been discussed above. It was considered important
not only for the recognition of CBD stones, but also of inadvertent injury to
the bile ducts. Large series show a 0.2% risk of bile duct injury with OC.
The results of OC in large series have been excellent with only 5-10% of patients
having residual symptoms. Some of these are a result of misdiagnosis; some the
result of retained, missed or recurrent CBD stones and to bile duct injury;
some to the “post-cholecystectomy syndrome” – probably biliary
dyskinesis in many cases. All this changed with the introduction of laparoscopic
cholecystectomy.
7.2.3. Laparoscopic cholecystectomy
Laparoscopic cholecystectomy was first performed in Germany in 1985 and subsequently
spread throughout the developed world. (39) This technique
has effectively displaced OC in the West for the last 15-20 years. Its proven
advantages are: less pain, shorter hospital stay, faster routine to work and
fewer incisional hernias. Initially acute cholecystitis was felt to be a contraindication
to LC, but with experience it is no longer felt to be an impediment. (40)
Conversion to OC is related to a number of factors and falls with experience,
but 5% conversion rates are acceptable. Complications specific to or of increased
frequency with LC have, however, emerged. (41) Injury, either
to bowel or vessels, may result from establishing the pneumoperitoneum and these
represent one-half of all complications with LC. This has resulted in a general
advocacy of open establishment of the pneumoperitoneum with a Hasson blunt trocar,
rather than the “blind” Verres needle approach. The most serious
complication is bile duct injury BDI, which may be minor or major. Early series
indicated a marked increase in BDI, up to 2% which would be 10 times that of
OC. Even with improved experience after a learning curve of 50 LCs, the BDI
rate plateaus at 0.8%, 4 times the rate of OC, in most series. Some of these
can be controlled with percutaneous drainage and ERCP with ES; some require
laparotomy to ligate the leaking cystic duct; others require major biliary reconstruction
and have significant implications for long term health. Despite the increased
risk of biliary leak, routine drainage after LC has been discouraged. An algorithm
of management of these cases has been developed. (42) Spillage
of gallstones is more frequent during LC and infrequently causes complications.
(43) The entire displacement of OC by LC in the West occurred
without any scientific verification. As Strasborg noted in 1997, of the 700
references published over 5 years, almost all were local case reports. (24)
Part of this transformation was patient-driven – without doubt, LC provides
an improved cosmetic result, less pain and faster recovery; part of it was surgeon-driven.
Having personally carried out hundreds of LC over 10 years, I can attest to
a subjective impression of improved patient recovery. Only recently has scientific
evidence been available to compare these procedures. Keus et al. published several
systematic reviews for the Cochrane Collaboration comparing LC, standard OC
and mini-OC. (44-46) In the randomized trials they studied,
comprising 2338 patients, they could find no differences in mortality, overall
complications or operative time. LC patients had a shorter hospital stay and
faster return to work. Similar overall conclusions can be drawn for the small
incision cholecystectomy which has a shorter operating time than LC, a shorter
hospital stay and faster return to work than OC. Surprisingly the risk of bile
duct injury was identical in these studies – prompting one to wonder how
reflective these are of the general experience.
7.2.4. Routine intra-operative cholangiography
Despite the proven value of intra-operative cholangiography IOC in identifying
CBD stones and biliary injuries, its routine use, long advocated in OC, has
been abandoned in LC. (27) With more widespread stratification
of risk of CBD stones and the availability of pre- or post-operative endoscopic
techniques for diagnosis and management, selective IOC has become the standard.
7.2.5. Is laparoscopic cholecystectomy appropriate
in low-income countries?
As explained above (see 3. Epidemiology) gallbladder disease
is not a common condition in most communities of Africa. A Medline literature
search of 1996-2007 database combining Laparoscopic cholecystectomy (4570 citations)
with Africa or the developing world (49976 citations) yielded only 13 citations.
Despite this, there is enormous interest/pressure to introduce LC in low-income
countries. Surgeons in these countries naturally want to apply the most modern
techniques. Thomson in a series from South Africa was able to enroll 50 patients
per year, in a study, comparing OC and LC retrospectively. (47)
Major duct injuries were actually more common in the OC group and mortality
rates were equivalent. The conversion rate was a high 17%. Chauhan in a report
of 373 patients operated on in India in 1 year demonstrated the feasibility
of day care LC. (48) In a report from Mexico in 2004, the
LC rate in public hospitals was 50% compared to 90% in private hospitals. (49)
In this author’s opinion the following factors should be considered before
introducing LC:
Technical questions: LC is dependent on a number of
high grade technological systems: an optical system using high energy light
sources, digital microprocessors and 3 chip video cameras, high flow CO2 insufflators
for pneumoperitoneum, specialized instrumentation and hemostatic devices such
as electrocautery and clips. (50) It goes without saying that
the technical support to maintain this equipment, not to mention a continuous
source of electricity for their safe operation, need to be assured. These conditions
are certainly not consistently available in low-income countries, especially
the last two. Reports of gasless LC speak volumes about attempts to surmount
technical problems. (51) Furthermore LC, as currently practiced
in the West with selective IOC, relies on ancillary interventions like ERCP
which may not be available in low-income countries.
Education programs and learning curve: Teaching programs
for LC in high-income countries are now incorporated into standardized resident
training programs and use a combination of didactic methods, simulation, animal
models and graded operative responsibility. (52) There appear
to be a number of Western surgeons who are interested in teaching LC to surgeons
in the developing world. However, where the surgical caseload is low; the learning
curve for acquisition of skills may be prolonged. This may not hold true in
countries of South America or in India, with intermediate or high prevalence
of gallbladder disease; as much as it does in sub-Saharan Africa. Maintenance
of quality assurance is essential. Considering the issue of teaching surgical
skills of an uncommon clinical problem, it is imperative that the skills of
open surgery for gallbladder disease be maintained and transmitted to the next
generation. Recognizing this, the 2005 Syllabus for Fellowship status of the
College of Surgeons of East, Central and Southern Africa COSECSA require practical
acquisition of open cholecystectomy skills as opposed to those for LC.
Cost and Efficacy: While Western donors of various kinds
may be interested in donating laparoscopic equipment to low-income countries,
it remains to be seen whether sustainable programs can be developed. Previous
reviews in this course (see March and April 2006) have indicated other surgical
procedures, such as video-assisted thoracic surgery VATS for thoracic empyema
and diagnostic laparoscopy for abdominal pain in women, where there might be
a sufficient caseload for safe acquisition of new skills which would have a
positive impact on patient care. Cost analyses showing reduced costs with LC
always rely on shortened hospital stays and reduced time off work. (53)
Procedural costs are always higher. (54) Small-incision cholecystectomy
has been promoted as a procedure equivalent to LC but more suitable for low-income
countries. (55) Since infrastructure is one of the major challenges
in low-income countries, it is reasonable to ask whether LC is an efficient
use of scarce resources for surgical care. (36)
7.2.6. Exploration of the Bile Duct: Open, Trans-cystic,
Endoscopic and Transduodenal
While it is not the intention of this Review to consider in detail the various
approaches to choledocholithiasis, a number of management issues need to be
discussed. Because of their potential for serious complications, all CBD stones
should be removed. (56) The options are: open choledochotomy
via laparotomy (either at the same time or subsequent to cholecystectomy); trans-cystic
exploration of the CBD at the time of LC (an advanced skill); endoscopic spincterotomy
ES at the time of ERCP and open transduodenal spincterotomy/plasty for otherwise
irremovable stones. Csendes et al. from Chile discuss their approach to CBD
stones and the role of open choledochotomy. (57) Boerma from
the Netherlands discusses a less invasive approach. (28) Martin
in a systematic review for the Cochrane Collaboration showed that open choledochotomy
was superior to ERCP with a lower primary treatment failure (retained stones).
(58) In the same report trans-cystic laparoscopic CBD exploration
was found to be generally equivalent to ERCP and ES. Clearly, even in the countries
with highly developed, multiple approaches to CBD exploration, open choledocotomy
may still play a role. The technical details are described by Ellis in Maingot’s
Abdominal Operations. (59) Exploration should be carried out
by saline irrigation with soft rubber catheters. The use of rigid Bates dilators
is to be condemned. Choledoscopy is extremely useful to assess residual stones.
T-tube insertion, even after clearance of stones, has in the past been considered
mandatory. Recently Gurusamy reviewed randomized studies comparing T-tube versus
primary closure after both open and laparoscopic CBD exploration and concluded
that primary closure was safer. (60;61)
T-tubes, however, play a role in the approach to residual stones if ERCP is
not available.
8. Conclusions
Clearly the approach to gallstone disease has undergone a profound development
in the West during the last 30 years with a proliferation of minimally-invasive
procedures, many of which have been shown to be equivalent or superior to older
techniques. These approaches cannot simply be applied to the conditions facing
surgeons in low-income countries without thoughtful consideration.
9. Recommendations
1. The gold standard for the diagnosis of gallstones is the trans-abdominal
ultrasound. Gallbladder thickness and CBD diameter and presence of stones should
be assessed at the same time.
2. Patients with gallstones should have pre-operative bilirubin and liver function
tests including alkaline phosphatase and GGT.
3. Asymptomatic patients with gallstones should be observed for the development
of symptoms.
4. All patients with symptomatic or complicated gallbladder disease should be
considered for cholecystectomy.
5. Early cholecystectomy should be considered in cases of acute cholecystitis
if seen within the first 72 hours of symptom onset.
6. Open cholecystectomy and choledochotomy are indispensable surgical skills.
7. Routine intra-operative cholangiography is appropriate when open cholecystectomy
is being undertaken.
8. Before the introduction of any minimally invasive approaches to gallbladder
disease, the technical, educational, cost and sustainability implications should
be thoroughly explored.
Brian Ostrow MD, FRCSC
Office of International Surgery
University of Toronto
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