So you think you need . . . a gallbladder operation

Many surgeons believe that some organs in the body really aren’t necessary, so when things go wrong, they can be removed with no harm done. A common example of this is a cholecystectomy – surgical removal of the gallbladder. The gallbladder concentrates bile, the digestive juice made by the liver to help break down dietary fats.

Bile comprises water, mucus, pigments and salts. It is thought that changes in its composition lead to the formation of gallstones, the most common disease of the gallbladder, affecting 22 per cent of women and 11 per cent of men in the UK. Gallstones are the most common reason given for having your gallbladder removed. Nevertheless, most cases are asymptomatic.

Of the various types of gallstones, the most common are called ‘mixed’ stones, accounting for 80 per cent of all cases.

Symptoms are caused when the stones enter the bile ducts, causing a painful obstruction. Bile is then unable to enter the bowel, leading to biliary colic and its related symptoms – poor digestion, bloating, burping, flatulence, nausea, vomiting and sometimes jaundice.

A blocked cystic duct can also lead to cholecystitis – inflammation of the gallbladder – which, in turn, will encourage the development of yet more gallstones.

Repeated attacks of cholecystitis and biliary colic can be treated by either dissolving the stones with drugs, or breaking them up with the use of ultrasound waves – yet most surgeons prefer to remove the gallbladder altogether.

If your gallbladder must be removed, the surgeon may suggest either laparoscopic (keyhole) or open surgery under a general anaesthetic, though most surgeons tend to go for the keyhole option. In this case, the surgeon first pumps carbon-dioxide gas into the abdomen to lift the abdominal wall away from the underlying organs. After making several tiny incisions, he will then seal off the vessels serving the gallbladder, which is then cut free with lasers or electrocauterisation. As there is a tiny camera attached to the tip of the instruments, the surgeon’s actions are done while watching a videoscreen. Keyhole surgery may turn into open surgery if the surgeon encounters a problem, such as not being able to view the gallbladder properly.

Is it safe?
Gallbladder keyhole surgery has the same risks as other forms of keyhole surgery, where complications are mainly due to a lack of visibility. A study in Japan that followed over 17,000 patients (of whom 13,787 had undergone cholecystectomy) found that the complication rate for laparoscopy was about 2.7 per cent (Surg Endosc, 1997; 11: 1198-201). If you do have a complication, you risk:

* a one in 200 chance of serious injury to the bile duct, associated with a high risk of other disease and a longer hospital stay (Langenbecks Arch Surg, 2002; 387: 286-93)

* a 70 per cent chance of infectious complications, particularly with bile-duct injury (Scand J Gastroenterol, 2002; 37: 476-81)

* three times more chances of dying if you have bile-duct injury in the years after surgery, and a poorer quality of life (Ned Tijdschr Geneeskd, 2004; 148: 1020-4)

* a 0.5 per cent chance of other injury – most commonly, duodenal perforation – but also damage to the diaphragm, small intestine, right external iliac artery, portal vein and liver. These can be life-threatening (Indian J Gastroenterol, 2004; 23: 47-9)

* a hernia at the site of a surgical scar. In one study, five out of 124 patients suffered incisional hernias (Gut, 1987; 28: 1500-4)

* a small possibility of a pneumothorax (air in the chest outside of the lungs), which may be life-threatening, requiring rapid intervention and management (Surgery, 1993; 114 : 988-92)

* a slight chance of cardiac arrest during surgery (J Soc Laparoendosc Surg, 2004; 8: 65-8).

What doctors don’t tell you

* Your gallstones may indicate a functional gut disorder, with symptoms such as dyspepsia, bloating, flatulence, belching and diarrhoea that may not be relieved by gallbladder removal (Gut, 1987; 28: 1500-4). In one study of 583 patients, 28.1 per cent still had flatulence six weeks after surgery, and 9.3 per cent felt worse (Gut, 1994; 2: 311-9). Another study found that 12 per cent of patients still had dyspepsia, bloating and belching four years after surgery (Am J Surg, 1993; 165: 405-9).

* The chances are good that you will suffer abdominal pain after keyhole surgery. After about 31 months, 30.4 per cent still had, or had newly acquired, abdominal pain (Ann R Coll Surg Engl, 1998; 80: 25-32). In another study, 13 per cent were dogged by persistent pain six months later (Gut, 1996; 39: 863-6).

* New symptoms may appear after gallbladder removal, including heartburn (6 per cent), belching (3.5 per cent), sour burping (1 per cent) and vomiting (0.5 per cent) (Trop Gastroenterol, 2000; 21: 144-8).

* New food intolerances may appear after surgery (Chirurg, 1991; 62: 462-6).

* You may have changed bowel habits, including diarrhoea, due to having no gallbladder for excess bile storage. Of 51 patients, 6 per cent still suffered intermittent diarrhoea three months after surgery (Am J Gastroenterol, 2002; 97: 1732-5). Another study reported a 20 per cent rate of postoperative diarrhoea (Trop Gastroenterol, 2000; 21: 144-8).

You may also have an increased risk of:

* colorectal cancer, especially if you’re female. The risk is greatest for cancers of the proximal colon (that part of the colon close to the splenic flexure, on the left, where the colon turns down to enter the pelvic cavity) and rectum (Br J Cancer, 2003; 88: 79-83).

* increased bile reflux and, eventually, cancer of the oesophagus. Duodenogastric reflux – flow of gastric juices from the first part of the small intestine (duodenum) back up into the stomach – is increased after gallbladder removal. Oesophageal adenocarcinoma may be due to the toxicity of the duodenal juice repeatedly backing up into the stomach and up into the oesophagus (Gastroenterology, 2001; 121: 548-53).

* contracting a Helicobacter pylori (H. pylori) infection. This species of bacteria is associated with peptic ulcers and has been linked to 75 per cent of deaths due to stomach cancer (J Clin Gastroenterol, 1998; 27: 335-8).

Michelle Clare