Cholecystectomy:
Indications,
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Procedure, Complications
What Are Gal stones?
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? Smal , pebble-likesubstances
? Multiple or solitary
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? May occur anywhere withinthe biliary tree
? Have different appearance -
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depending on their contents
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Pigment Stones
? Smal
? Friable
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? Irregular? Dark
? Made of bilirubin and
calcium salts
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? Less than 20% of
cholesterol
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? Risk factors:? Haemolysis
? Liver cirrhosis
? Biliary tract infections
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? Ileal resectionCholesterol Stones
? Large
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? Often solitary
? Yellow, white or green
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? Made primarily of cholesterol(>70%)
? Risk factors:
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? 4 "F" :
? Female
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? Forty? Fertile
? Fat
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? Fair (5th "F" - more prevalent in
Caucasians)
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? Family history (6th "F")Mixed Stones
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? Multiple? Faceted
? Consist of:
? Calcium salts
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? Pigment? Cholesterol (30% - 70%)
? 80% - associated with chronic cholecystitis
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Gal stone Prevalence? 10% of people over 40 yrs.
? 90% "silent stones"
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? Risk factors for becoming symptomatic:
? Smoking
? Parity
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Risk Factors? Women
? Age > 60 years
? American Indians & Mexican Americans
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? Overweight or obese men and women? People who tend to fast or lose weight quickly
? Family history of gallstones
? Diabetes
? Diet high in cholesterol
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? Use of OCPs? Pregnancy
Gal stone Pathogenesis
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? Bile = bile salts, phospholipids, cholesterol? Gallstones due to imbalance rendering cholesterol & calcium
salts insoluble
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? Pathogenesis involves 3 stages:Cholesterol supersaturation in bile
Crystal nucleation
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Stone growth
Definitions
Symptomatic Wax/waning postprandial epigastric/RUQ pain due to transient
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cholelithiasis cystic duct obstruction by stone, no fever/WBC, normal LFT
Acute
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Acute GB inflammation due to cystic duct obstruction. Persistentcholecystitis RUQ pain +/- fever, WBC, LFT, +Murphy's = inspiratory arrest
Chronic
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Recurrent bouts of colic/acute chol'y leading to chronic GB wall
cholecystitis inflamm/fibrosis. No fever/WBC.
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AcalculousGB inflammation due to biliary stasis(5% of time) and not
cholecystitis stones(95%). Seen in critically ill pts
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Choledocho- Gallstone in the common bile duct (primary means originated there,
lithiasis
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secondary = from GB)Cholangitis
Infection within bile ducts usu due to obstrux of CBD. Charcot triad:
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RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic
shock
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Differential Diagnosis Of RUQ Pain? Biliary disease
? Acute cholecystitis, chronic cholecystitis, CBD stone,
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cholangitis
? Inflamed or perforated duodenal ulcer
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? Hepatitis? Also need to rule out:
? Appendicitis, renal colic, pneumonia or pleurisy,
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pancreatitis
Symptoms
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? Pain in the RUQ
? Most common and typical symptom
? May last for a few minutes to several hours
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? Mostly felt after eating a heavy and high-fat meal? Pain under right shoulder when lifting up arms
? Fever, nausea and vomiting
? Jaundice (obstruction of the bile duct passage)
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? Acute pancreatitis (gallstone enters the duct leading to pancreasand blocks it)
Murphy's Sign: Inspiratory arrest with manual pressure
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below the gal bladder
Complications Of Gal stones
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? In the GB:
? Biliary colic
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? Acute and chronic cholecystitis? Empyema
? Mucocoele
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? Carcinoma
? In the bile ducts:
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? Obstructive jaundice? Pancreatitis
? Cholangitis
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? In the gut:
? Gallstone ileus
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Mirizzi syndrome0.1?0.7% of patients who have gallstones
Csendes classification :
? Type 1: external compression of the common bile duct ? 11%
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? Type 2: cholecystobiliary fistula is present involving <1/3 rd the circumferenceof the bile duct ? 41%
? Type 3: a fistula is present involving upto 2/3 the circumference of the bile
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duct ? 44%
? Type 4: a fistula is present with complete destruction of the wall of the bile
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duct ? 4%Diagnosis
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? Ultrasound? Computerized tomography (CT) scan
? May show gallstones or complications, such as infection and rupture
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of GB or bile ducts
? Cholescintigraphy (HIDA scan)
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? Used to diagnose abnormal contraction of gallbladder or obstructionof bile ducts
? Endoscopic retrograde cholangiopancreatography (ERCP)
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? Used to locate and remove stones in bile ducts
? Blood tests
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? Performed to look for signs of infection, obstruction, pancreatitis, orjaundice
USG
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CT Scan
Management
? Asymptomatic gallstones do not require operation
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? Whilst awaiting for surgery
? Low fat diet
? Dissolution therapy (ursodeoxycholic acid) generally useless
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Surgical options
? Cholecystostomy
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? Subtotal cholecystectomy? Open cholecystectomy
? Laparoscopic cholecystectomy
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Cholecystostomy? Patients at high risk related to multisystem organ failure
? Severe pulmonary, renal, or cardiac disease
? Recent myocardial infarction
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? Cirrhosis with portal hypertension? Acalculus cholecystitis after severe trauma, burns, or surgery
? Empyema or gangrene of the gal bladder
Subtotal Cholecystectomy
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? Severe inflammation renders identification of the
anatomy impossible, eg. Gangrenous cholecystitis
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? Scarred partial y intrahepatic gal bladder? Severe cirrhosis and portal hypertension
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CholecystectomyLaparoscopic Surgery
? Advantages:
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? Less post-op pain
? Shorter hospital stay
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? Quicker return to normal activities? Disadvantages:
? Learning curve
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? Inexperience at performing open cholecystectomies
Cholecystectomy when to perform?
? After acute cholecystitis, cholecystectomy traditionally performed after 6
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weeks
? Arguments for 6 weeks later
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? Laparoscopic dissection more difficult when acutely inflammed? Surgery not optimal when patient septic/dehydrated
? Logistical difficulties (theatre space, lack of surgeons)
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? Arguments for same admission
? Research suggests same admission lap chole as safe as elective chole (conversion to
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open maybe higher)? Waiting increases risk of further attacks/complications which can be life threatening
? Risk of failure of conservative management and development of dangerous
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complication such as empyema, gangrene and perforation can be avoided
? National guidelines state any patient with attack of gallstone pancreatitis
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should have lap chole within 3 weeks of the attackComplications of Lap Cholecystectomy
? Trocar/Veress needle injury
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? Hemorrhage? Wound infection and/or abscess
? Ileus
? Bile leak
? Gallstone spillage
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? Deep vein thrombosis? Retained common bile duct (CBD) stone
? CBD injury & stricture
? Pancreatitis
? Conversion to open procedure
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? Nonsurgical treatment:
? Only in special situations
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? When a patient has a serious medical condition preventing surgery
? Only for cholesterol stones
? Oral dissolution therapy
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? Ursodeoxycholic acid - to dissolve cholesterol gallstones
? Months or years of treatment may be necessary before all stones
dissolve
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? Contact dissolution therapy
? Experimental procedure
? Involves injecting a drug directly into the gallbladder to dissolve
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cholesterol stones
Prevention
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A sensible diet is the best way to prevent gall stonesAvoid crash diet or very low intake of calories
Eat good sources of fiber
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