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