What are gallstones?
Laparoscopic Cholecystectomy and Other Disorders of the Bile Ducts, Gallstones can form in the biliary tree and particularly in the gallbladder for a number of reasons. The most common cause in western countries is a diet high in cholesterol that leads to stone formation. Other less common causes include diseases that affect the blood and chronic infections of the biliary tree. Most people who develop stones of the gall bladder do not need any interventions.
Laparoscopic Cholecystectomy and Other Disorders of the Bile Ducts, This condition, if asymptomatic may be observed. Based upon large population studies, in fact, it appears that less than 20% of patients with such stones will progress and develop symptoms in their lifetime. Once symptoms develop, however, even if mild, the natural course in most patients is one of increasing pain leading to the diagnosis of symptomatic cholelithiasis (symptomatic gallstones).
Certain medications may decrease these symptoms. One popular remedy is ursodeoxycholic acid, a bile salt that taken orally may help to dissolve stones. Success, however, with symptomatic patients is unusual with any of these gallstone-dissolving agents. Thus, given the high failure rate of medical therapies for gallstones, it generally is accepted that once stones become symptomatic the stones, as well as the gall bladder should be removed.
A second problem of the gallbladder that may occur is an infection of the gallbladder in association with gallstones. This condition is termed acute cholecystitis. Laparoscopic Cholecystectomy and Other Disorders of the Bile Ducts This is a more serious condition and will require immediate antibiotics and surgery over the next few days.
What surgeries can help if I have gallstones that are causing me difficulties?
- Laparoscopic cholecystectomy remains the most common surgical procedure performed in the United States. Numerous community, regional, and University hospitals have great experience in performing these procedures. The University of Miami and Jackson Memorial have state-of-the-art facilities that will allow you to have this procedure performed in a safe and expedient fashion.
- Figure 1 demonstrates summary data from a previous manuscript on this topic we have published four years ago. These results include patients with symptomatic cholelithiasis (symptomatic stones), acute cholecystitis(acute infection of the gallbladder), and choledocholithiasis (stone also involving the common bile duct). Of note, it demonstrates a very low complication and conversion rate with both straightforward gallstone disease and the much more challenging conditions of acute cholecystitis and common duct stones.
- These results are very competitive with the very best results reported anywhere in the world. (Koniaris, L.G., Zimmers-Koniaris, T.A., Lillemoe, K.D., Sachs, S.A., Riggle, K. (2000) A method for easier laparoscopic cholangiography and common duct exploration. J Am Coll Surg 190(6):752-6.)
Figure 1. The outcome of 309 consecutive laparoscopic cholecystectomies. (Koniaris et al (2000) A method for easier laparoscopic cholangiography and common duct exploration. J Am Coll Surg 190(6):752-6.)
What if the stones are not only in my gallbladder?
Management of Common Bile Duct Stones.
Stone primarily arises in the gallbladder they can travel from there and enter the biliary tree. Alternatively, and much less commonly, stones may arise in the bile ducts (primary stones). Prior to surgery to remove the gallbladder your surgeon should treat for this possibility by performing certain blood tests and imaging studies of your gallbladder. The chemical studies should include serum bilirubin, alkaline phosphatase, and AST.
The imaging study may be either an ultrasound or a CT scan of the liver, gallbladder, and bile ducts. Stones may be seen by the ultrasound or CT or manifest primarily with high bilirubin. Many non-operative procedures are available to manage these conditions. These include endoscopic retrograde cholangiography (ERC or ERCP) and other transhepatic techniques.
Numerous experts in these non-operative as well as laparoscopic approaches are here at the University of Miami and would be happy to help or refer you. Surgery generally is reserved for cases where these non-operative approaches do not work. We have helped develop intraoperative approaches to common duct stones when they are appreciated at the time of surgery.
Figure 2 presents our published technique for the removal of the small cystic duct or common duct stones. Our general approach will be to utilize one of these minimally invasive approaches to treat common duct stones. Open surgery is reserved for cases when these minimally invasive treatments fail as may occur in situations of markedly enlarged (1-2 cm) ducts with multiple (greater than five) stones.
Figure 2: The described modifications for laparoscopic cholangiography.
- A. View of anterior trunk demonstrating ideal position for catheter placement (star), and position of diaphragm following insufflation (solid black line).
- B. Surgeon’s view of placed angiocatheter, showing its relationship to the cystic duct.
- C. Laparoscopic transcystic common duct procedure performed through a peel-away catheter inserted through the seventh intercostal space. Note lower grasper pinching the cystic duct around the catheter and providing a tighter seal for saline irrigation (black arrow). (Artist: L.G. Koniaris, M.D., used with permission)
What are some of the complications of prolonged untreated gallstone disease?
- Bile Duct Structures: This can occur following inflammatory diseases affecting the biliary tree (see above), following laparoscopic cholecystectomy, or with certain autoimmune disorders. As well, certain malignancies will present with a bile duct stricture that may mimic a benign condition.
Treatment of these structures is complex and may require stenting, biliary reconstruction, liver resection, or even liver transplantation. Stenting alone is effective for a number of these issues and should generally be considered as the first-line therapy in the treatment of benign strictures. Malignant strictures are best treated by surgical resection and surgery remains the only chance of cure for patients with biliary malignancies.
Frequently the difficulty in distinguishing benign from malignant strictures. This generally involves the use of many different imaging and diagnostic modalities which are generally tailored to each particular case. We would be happy to see and treat patients with these issues.
2) Mirrizzi’s Syndrome (Adapted from Salloum, R., Koniaris, L. Mirizzi’s syndrome mimicking a periampullary malignancy. Arch Surg (2004) 139:449-50). Biliary obstruction may result from strictures of the bile ducts (benign or malignant) (1), gallstones within the biliary tree (2), or from extrinsic biliary compression such as swelling of the pancreas (2,3). In 1948, P.L. Mirizzi (4) described an unusual cause of biliary obstruction secondary to extrinsic compression of the common bile duct in patients with chronic cholecystitis.
Mirizzi’s syndrome has since been redefined to encompass a spectrum of acquired biliary anomalies, which also include cholecysto-choledochal fistulae (3, 5). In type I Mirizzi’s syndrome, the cystic duct lies parallel to the hepatic or common bile duct and an impacted gall stone in the cystic duct or neck of the gallbladder leads to intermittent obstruction of the bile duct (Figure 2). Chronic inflammation and compression from cholecystitis may result in the development of a cholecysto-choledochal fistula (Mirizzi Type II to IV, figure 3). (2,3)
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