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Gallstones, one of the gall bladder diseases, are usually classified as cholesterol or pigment stones, which are formed when the components of bile -including cholesterol and bilirubin- precipitate out of solution and form crystal. It can cause obstruction of the Cystic Duct. At any point, stones may obstruct the cystic duct, which leads from the gallbladder to the common bile duct. Patients usually experience no symptoms at all, whereas other experience excruciating pain in the upper abdomen, usually accompanied by fever. Some may suffer from nausea, indigestion and vomiting. The actual causes of gallstones still remain unclear, but it is believed that this problem arises when the bile contains either too much of cholesterol or bilirubin or both. Gallstone is a common medicine problem, affecting 10-30% of the population, therefore often being neglected. However, it brings complication such as acute cholecystitis, biliary colic and gall bladder cancer[1,2] which basically endanger our health that suggested that early-stage treatments are preferred. Therefore, what are the current available treatments for gallstones?
Diagram1. Gallstones 2. Gallstones in the gall bladder www.giconsults.com/Gallstones.htm
A Possible Solution
According to American College of Physicians, when a person has no symptoms of gallstones, the risk of both surgical and non surgical treatment outweighs the benefits. However, for people who are at high risk for complications such as people at risk for gall bladder cancer, Pima native American and patients with stones larger than 3cm, treatment is definitely insisted. In this case, surgical treatment is the best approach to cure gallstones patient as it guarantees the patients will not suffer a recurrence of gallstones.
There are 2 types of surgeries, namely Laparoscopic cholecystectomy and Laparotomy (open cholecystectomy). Until the past decade, cholecystectomy by laparotomy was the only treatment for gallstones, with mortality rate of less than 1%. Before the surgery is carried out, the patient is put under the effect of general anesthesia(unconscious and unable to feel pain). Then the surgeon will make a 5 to 7 inch incision in the upper right part of the patient's belly, just below the ribs. Bile duct and blood vessels that lead to the gall bladder will be cut and gall bladder is removed. During the surgery, a special X-ray called cholangiogram will be done which involves squirting some dye into the common bile duct and left inside your body after the gall bladder removal. This is to locate any gallstones that are formed outside the gall bladder. If any are located, surgeon will use special medical instrument to remove them.[5,6,8,13,14] Beside from this technique, minilaparotomy is another variant of open cholecystectomy but uses a much smaller incision. Therefore, from the studies posted in http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881423/, it has been proven minilaparotomy is superior than the conventional open cholecystectomy. It is due to the smaller incision used in minilaparotomy, indicates a faster recovery than the latter. In open cholecystectomy, not everyone is a appropriate candidate for this surgery. In this case, doctors will have to determine which groups of patients are suitably targeted. In general, patients who had extensive abdominal surgery before, patients with complications of acute cholecystitis (empyema, gangrene, perforation of the gallbladder) and older patients are more likely to undergo open cholecystectomy.
The need for prolonged hospitalization with open cholecystectomy and the lengthy period of convalescence have fueled interest in less invasive technique. Hence, with the advance of medical technology, Laparoscopic cholecystectomy was introduced in 1987 and rapidly become the standard treatment for patients with symptomatic gallstones.
Diagram 3.laparoscopic cholecystectomy and open cholecystectomy
The procedure of laparoscopic cholecystectomy is similar to the open surgery, just they differ in the size of incision on the abdomen. The surgeon will insert a lighted scope attached to a video camera (laparoscope) into one incision near the belly button. A video monitor is then used as a guide to insert surgical instrument into the other incision to remove the bladder. The patient will have a special X-ray procedure called intraoperative cholangiography, which shows the anatomy of the bile ducts. [5,6,8,13,14]
The introduction of laparoscopic technique has been proven to be more effective than open cholecystectomy or minilaparotomy. The table below which is self-construct using the data from several clinical studies show that there is an increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy
Increased rate of cholecystectomy in Scotland with the advent of laparoscopic cholecystectomy from 1989 - 1993
Overall increased rate
In 45 - 64 age group
In 65 - 74 age group
Table 1 constructed using the data in research by CM Lam, F E Murray and A Cuschieri http://gut.bmj.com/content/381212826abstract
This study confirmed there are more benefits for patients in laparoscopic cholecystectomy than open surgery. In laparoscopic surgery, the overall risk is relatively low and guarantee a faster recovery. Although complications during laparoscopic surgery such as bile duct injury is much more common, the injury rate is declining due to the increase surgical experience and the use of cholangiography. A research is carried out to investigate the laparoscopic surgery complication in China by Huang X, Feng Y and Huang Z by the aid of Department of Hepatabiliary Surgery, General Hospital of PLA, Beijing. A total of 39238 cases were investigated.
Complications of 1.04% ( 409 in 39238) from 1994-1995 which includes
Bile duct injury
Complications of laparoscopic surgery
Postoperative cystic duct leak
Postoperative bile leak
The research group come out with conclusion that laparoscopic cholecystectomy is operation with low morbidity and mortality rate. This explains the phenomenon of increased rate of laparoscopic surgery than open cholecystectomy when patient is given a choice to choose between both.
Besides, laparoscopic surgery is less painful and ensure patient a shorter hospital stay( 1day as compared with 2 to 4 days for open surgery). This in term provides a choice based on financial purpose as the cost of laparoscopic surgery is less expensive over the long term. The immediate cost may be expensive, but more rapid recovery and fewer complications translate into shorter hospital stays, therefore give a greater reduction in overall cost.[13,15] However, laparoscopic surgery is not the absolute replacement for open surgery as there are times when laparoscopic is needed to convert to open cholecystectomy when severe complications or other reason occur.[1,4,5]
Therefore, both techniques are still widely practiced to cure gallstones patients. In other words, both techniques is precious and beneficial to patients and open cholecystectomy technique should not be denied when a better technique is invented.
" we believe it is unethical to allow patients to dictate that they want laparoscopic cholecystectomy when we are unable to guarantee that this operation is safer than minilaparotomy. More effort should be put into improving the minilaparotomy technique rather than bypassing itâ€¦â€¦Without wanting to prejudge the outcome of such trial,we believe that laparoscopy and minilaparotomy technique would be found to be so similar that they could be used interchangeably"-J N Baxter, P J O'Dwyer, 29 Feb 1992
Laparoscopic surgery has become the gold standard procedure in cholecystectomy as the benefits outweigh its risk. As a result, it is widely accepted by patients and surgeon. However, communication between surgeon and patient for this procedure raises ethical issue. Surgeon usually require patient's consent for the operation and this consent normally requires an explanation of the principles and risk of the procedure, as well as the consequences of not undergoing the proposed surgery and the discussion of alternative treatments. For information, there are 9 common complications (bile duct injury, retained calculi, port site hernia, shoulder tip pain, conversion to open cholecystectomy, wound infection, respiratory complications, thromboembolic complica-tions and death) after the surgery. According to a study by Kaushik Bhattacharya and A Neela Cathrine, sadly to tell only 3 out of 9 are mentioned to patients. This raises awareness that patients should have the rights to be well-informed before the treatment, especially the potential risk.
Laparoscopic surgery is effective in curing gallstones, but patients might carry a financial burden which includes surgery cost, surgeon consultation fee and hospital stay. This undeniably causes deeper impact to those who away from work just to receive treatment.
Moreover, all laparoscopic surgeries are demanded to use disposable instrument but the extremely high cost of that force them to reuse the instrument until wear out. Besides, the high cost of sterilisation of instrument also cause economical impact to the medical sector as well as government.
Benefits and risks
Laparoscopic surgery is the most effective treatment compared to the others. In terms of economics and cost-effectiveness[8,18], this treatment has widely accept by patients as the cost is much more lower compared to open cholecystectomy over the long term. Immediate cost may be expensive, but a shorter hospital stay outweigh this disadvantage. Besides, due to the smaller incision, this treatment guarantees patients a faster recovery that usually discharged within 1-2 days postoperatively[4-12]. Decreased scar tissue results in rapid rate back to normal work activities has encouraged the growth of this laparoscopic technique. It is because patients usually choose to go back to their workplace which outweighs the urgent need for treatment. However this treatment is not 100% safe as there are several complications and side effects. It potentially causes bile duct injury. So patients may need subject to stent placement to diminish the outflow resistance intrinsic to the intact ampulla and divert bile from the leak.
Panel 1: Costs, risks, and benefits of treating gallstones
Clinicians' time (eg, surgeon and anaesthetist)
Other medical personnel's time (eg, nurse, technician)
Drugs (eg, bile salts)
Medical devices (eg, ultrasound lithotripsy)
"Hotel" costs (eg, food, electricity)
Time away from family
Lost leisure time
Other societal costs
Costs to other agencies
Relief of biliary pain
Relief of other symptoms (eg, vomiting, fatty food upset, heartburn)
Prevention of complications (eg, cholecystitis) and hence mortality
Major complications (eg, bileduct damage)
Minor complications (eg, wound pain, discomfort)
Table 3. http://www.ptolemy.ca/members/archives/2007/Cholelithiasis/brazier2001.pdf
Ursodeoxycholic acid treatment
Ursodeoxycholic acid is a bile acid currently approved for gallstone dissolution in suitable patients. This drug works by reducing the cholesterol saturation by inhibiting HMG CoA reductase, a vital enzyme in cholesterol biosynthesis[1,3]. Besides, this acid forms highly soluble multilamellar vesicles and prolongs the nucleation time of bile. The ideal candidate for dissolution therapy has small floating noncalcified stones in a gallbladder demonstrated to be functional on oral cholecystography. Nonfloating stones are not an absolute contraindication to treatment. From clinical studies, this usage of ursodeoxycholic acid has not much significant side effects, except for diarrhea which is unusual.
TABLE 3. Lipid concentration, lipid composition, and cholesterol saturation of hepatic bile
and gallbladder bile (Individual data and means f SEM)
Lipid concentration(g . dl-')
Patients with cholesterol gallstones, treated with ursodeoxycholic acid
4.0 ± 0.5
3.4 ± 0.3
Patients with cholesterol gallstones untreated
Table 4. http://www.jlr.org/cgi/reprint/24/4/461.pdf
Ursodeoxycholic acid treatment resulted in reduction of the relative concentration of cholesterol in hepatic
as well as gallbladder bile.
However, the need for serial imaging studies and high recurrence rates( at least 50%) after therapy diminish the interest for patients in this treatment unless for those who are at unusually high risk and refuse surgery.
Extracorporeal shock wave lithotripsy (ESWL)
This treatment was developed because of its initial success in renal stone dissolution. In ESWL, a high intensity shock wave( 500-1500 shocks over 30-120 minutes) is used to disintegrate gallstones into small pieces enough to pass through the bile ducts into the intestines. 3 types of ESWL have been used, namely electrohydraulic, piezoelectric and electromagnetic lithotripter which focus the wave onto gallstones.. Not every patient is potential candidate, ESWL is only effective and safe for patients with fewer than 3 stones, normal weigh, cystic duct should be patent and stones must be radiolucent. These limited conditions explain only less than 15% of patients are eligible.
"ESWL has also shown limited success in patients with calcified gallbladder calculiâ€¦..The number of treatment sessions and shock waves administered were limited, and the desired degree of fragmentation could not be achieved."
(Brijendra Rawat,MD in research of Extracopereal Shock Wave Lithotripsy of Calcified Gallstones)
However ESWL brings adverse effect. Examples shock wave injury to surrounding organs like the kidneys (back pain with or without bloody urine), post procedure biliary colic and pancreatitis. Other side effect in the form of local petechial bleeding, asymptomatic liver hematoma and transient hematuria should be considered before receive the treatment.[1,21] In addition, this treatment does not guarantee permanent recovery as gallstones normally recur. Therefore, despite its clear benefits, this treatment has limited enthusiasm due to cost, long duration of treatment and follow-up, high rate of recurrence and as according to above quotes, The number of treatment sessions and shock waves administered were limited, and the desired degree of fragmentation could not be achieved
From reference [http://www.ncbi.nlm.nih.gov/pubmed/11735013#], it is known that laparoscopic surgery offers more benefits such as smaller incision, faster recovery and cost effectiveness thus is better than open cholecystectomy and any other treatment. This source is reliable since the numerical data provided regarding complication and development of surgery agrees with many other sources including a medical book [Current Diagnosis & Treatment in Gastroenterology] by its author Ira M. Jacobson in the section Gallstones," Laparoscopic cholecystectomy, introduced in 1987, has rapidly become the standard method of cholecystectomy". The previous source is a service of U.S. National Library of Medicine and the National Institutes of Health which is trustable. Besides, the medical book mentioned later is written by distinguished expert and published by Prentice Hall, which is a major prestigious educational publisher. Therefore this medical book is recognized.
Source from [http://www.chem-tox.com/gallstones/index.htm] also provide me with information about gallstones which is based on testimonial from gallstones patient world-wide and research from several renowned medical institute or sources such as University of Florida's medical library, American Journal of Surgery, British Medical Journal and etc. Therefore the combined personal experience from patients themselves and distinguished researches serve as reliable sources.