38 GALLBLADDER DISEASE
Jeff Cross M.D.

1. What is the prevalence of gallstones in Western society for women and men 60 years of age?

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Women, 50%; men, 15%, although there is formidable ethnic predilection with gallstones endemic in Native Americans.

2. What percentage of asymptomatic gallstones convert to symptomatic gallstones?

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10% at 5 years, 15% at 10 years, and 18% by 15 years.

3. What is the incidence of gallbladder perforation in patients with acute cholecystitis?

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5%.

4. What organisms require antibiotic coverage?

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Escherichia coli, Klebsiella species, Streptococcus faecalis, Clostridium welchii, Proteus species, Enterobacter species, and anaerobic Streptococcus species.

5. What percent of patients with common duct gallstones have positive bile bacterial culture findings?

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90%.

6. Has the frequency of cholecystectomy increased in the laparoscopic era?

Show answer
Yes. It has increased 500,000 operations per year to > 700,000 per year.

KEY POINTS: GALLSTONES

1. Overall incidence in U.S.: women > 60 years old, 50%; men > 60 years old, 15%.
2. Genetic predisposition in Native Americans.
3. 15-20% of patiens with gallstones become symptomatic.
4. If gallstones become symptomatic, cholecystectomy is required.
5. In the U.S., 75% of gallstones are cholesterol stones; in Asia, pigment stones are more common.

7. What percent of patients undergoing cholecystectomy experience missed common duct gallstones? Show answer
2%.
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8. After a laparoscopic cholecystectomy, what is the difference between retained common duct gallstones and choledocholithiasis? Show answer
Gallstones found within 2 years of cholecystectomy are considered retained gallstones. Patients who develop choledocholithiasis more than 2 years after cholecystectomy are arbitrarily defined as having recurrent rather than retained common duct gallstones.
9. What is the incidence of acalculus cholecystitis? Show answer
10% of all cases of cholecystitis.
10. How does laparoscopic intraoperative ultrasound (LUS) compare with laparoscopic intraoperative cholangiography (LIOC)? Show answer
The sensitivity of LUS is high (90%) and comparable to that of LIOC. Potential advantages of LUS include less time and less dissection than LIOC. Disadvantages include less sensitivity in detecting gallstones in the intrapancreatic portion of the common bile duct.
11. What is postcholecystectomy syndrome? Show answer
Unexplained pain, similar to that noted preoperatively, occurred in 20% of patients in previous decades. The incidence of this “wastebasket” diagnosis has decreased recently in that more specific causes can now be identified.

12. What are these more specific causes of postcholecystectomy pain?

Common duct gallstones – Cystic duct remnant
Retained gallbladder – Stenosing papillitis
Traumatic stricture – Biliary dyskinesia

13. What is the conversion rate from laparoscopy to the open approach in acute cholecystitis and in symptomatic cholelithiasis?

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10% for acute cholecystitis and 5% for symptomatic cholelithiasis.

14. When a patient presents with acute cholecystitis, is there a difference in mortality and morbidity for cholecystectomy performed early compared with cholecystectomy performed late after the patient “cools down”?

Show answer
No.

15. What is the incidence of common bile duct injury in the laparoscopic era?

Show answer
0.7% for laparoscopic cholecystectomy and 0.5% for open cholecystectomy.
16. When, if ever, should laparoscopic cholecystectomy be performed during pregnancy? Show answer
Most attacks of acute biliary colic during pregnancy resolve spontaneously. In order to avoid a surgically induced abortion, cholecystectomy should be performed after delivery. If surgery is necessary, however, the second trimester is preferred for any surgical intervention.

17. What is the prevalence of gallbladder carcinoma found incidentally during cholecystectomy?

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Open, 1%; laparoscopic, 0.1%.

18. Why is cholecystectomy increasing in the pediatric population?

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Gallstone identification has increased because of the more liberal use of ultrasonography in patients with abdominal pain.

19. Should patients with asymptomatic gallstones undergo laparoscopic cholecystectomy?

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No. The risk of observation of patients with asymptomatic gallstones is less than or equal to the risk of operation.

20. In what groups of patients with asymptomatic gallstones is prophylactic cholecystectomy beneficial?

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* Patients with congenital hemolytic anemia who have gallstones at the time of splenectomy
* Obese patients undergoing bariatric surgery who have already developed gallstones

21. What is the optimal timing for laparoscopic cholecystectomy in acute cholecystitis?

Show answer
Within 72 hours of the onset of symptoms. Procedures performed within the first 20 hours generally are easier because the area of dissection is not yet maximally inflamed. Fibrosis and increased blood vessel proliferation have not yet occurred.

References
WEB SITES

1. http://www.acssurgery.com/abstracts/acs/acs0316.htm
2. http://www.acssurgery.com/abstracts/acs/acs0315.htm

BIBLIOGRAPHY
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