All about gall

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All about gall

Sunday, 21 May 2023 | Archana Jyoti

All about gall

In this concluding part, ARCHANA JYOTI finds out from the doctors at AIIMS Delhi’s Department of Surgical Disciplines, led by HOD PROF SUNIL CHUMBER, about the types of surgeries, post-operative recovery of the patients with gallstones and how the disease can be significantly prevented through modified lifestyle and diet habits, apart from the timely intervention

In the first part of the article published last Saturday,  the doctors had presented a comprehensive medical reference information including symptoms, diagnoses and type of treatments for the gallstones, that is majorly due to unchecked dietary habits, sedentary lifestyles, and the rising prevalence of obesity and metabolic syndrome.

The doctors say, if your gallstones are small and are made up of cholesterol only, it may be possible to dissolve them by taking bile acids e.g. ursodeoxycholic acid tablets.

However, they warn that this can be disadvantageous also. Dr Devender Singh  informs that  the tablets need to be taken for a long time (up to 2 years), and is less effective in larger stones and you can get gallstones again after treatment has been stopped.

Further, no definitive tests are available to find the composition of stone, leading to unsuccessful  dissolution therapy in case of calcium containing stones. Small gallstones may pass through the cystic duct and cause complications like jaundice with or without fever, severe pain abdomen radiating to the back. In these scenarios, patient may be advised endoscopic intervention,

In frail patients, Dr Singh says extra corporeal shock wave lithotripsy may be attempted, where an ultrasonic wave is used for fragmentation of stone.  But it can have some disadvantages also. For instance, it may not be successful at times and fragmented stone can cause complications, as per Dr Singh.

Direct contact dissolution of cholesterol stones is of historical importance only, in which a chemical named methyl tertbutyl ether injected into gall bladder under ultrasound guidance. This procedure was abandoned long ago in view of increased liver and kidney toxicity.

Dr Brahma Kumar Rath points out that acute cholecystitis is characterised by right upper belly pain associated with a sense of vomiting, fever with or without organ failure. If a patient presents after 72 hours of pain, then conservative management is recommended.

Here the patient is advised not to eat or drink and intravenous fluids, antibiotics and analgesics are prescribed. The acute phase usually subsided within 2 to 5 days. Afterwards patients may be advised oral diet, medications and to review after six weeks for removal of gallbladder.

The overall medical management has a higher recurrence rate of gall stones and may be more expensive than that of surgical management, adds Dr Rath.

Thankfully, we have easy availability of ultrasound machines and other investigations that diagnose pathology in the body even if a patient does not have symptoms. Every individual occasionally undergoes a routine ultrasound and may find the presence of gallstones. This may cause fear in the patient or the relatives. Can this be cancer? May these stones lead to cancer in future?

Dr Rijuta Aphale points out that gallbladder cancer is overall 7 times more common in patients having gallstone disease. However, it may also be important to know that not every patient having a gall stone will get gallbladder cancer, which is a very rare type but aggressive type of cancer. A very high incidence is seen in the north Indian population in the Ganges belt especially in women.

There may be slightly higher risk in patients who have a large gallstone (>3cm) harboring for many years or those associated with gallbladder polyps (>1cm) and those living in the north Indian belt like Uttar Pradesh, Haryana, Punjab, Bihar.

Dr Yshwant Singh Rathore  advises that patients who have gallstone disease with symptoms like pain, belching, indigestion must go for gallbladder removal surgery. Patients who do not have symptoms, must talk to an expert general surgeon and may be able to defer or in certain situations avoid surgery altogether.

Types of surgeries

Open cholecystectomy                                                    

 Open cholecystectomy means removal of gall bladder via open approach. After one gets diagnosed with gallstone disease, basic blood investigations, chest x ray, ECG are done . Patient is sent for a pre-anesthetic check-up. After all clearances, the patient is admitted to the surgery ward.On the night before surgery, the patient is kept fasting for 8 hours, says Dr Ankita Singh.

On the other hand, says Dr Catherine Halam, Laparoscopic cholecystectomy is a minimally invasive surgical procedure used to remove the gallbladder. The procedure is typically performed under general anaesthesia.  Once the gallbladder is removed, the surgeon carefully inspects the remaining structures in the abdomen to ensure that there is no bleeding or other damage. The instruments and laparoscope are then removed, and the small incisions closed with stitches or staplers.

The entire procedure typically takes around one to two hours to complete, and most patients are able to go home the same day or the following day after the surgery. Recovery time varies depending on the individual, but most patients can return to normal activities within a week or two.

Talking about the importance of anaesthesia during surgery, Dr Anshul Singh says  that surgery for gallstone disease is done under general anaesthesia, where the patient is completely unaware and painless throughout the operation. “Be it laparoscopic or open cholecystectomy, the patient’s vein in one of the arms is cannulated for administration of anaesthetic and analgesic medications.  Some anesthesia drugs are given through masks and inhaled by the patient, after which the patient becomes unconscious."

For open cholecystectomy, we put an additional catheter in the midline of the back (spinal region) called an epidural catheter for administration of additional medications to ensure better pain relief to take care of larger skin incision sites and pain associated with it in open surgery.  A local anesthetic medication is given through this epidural catheter even after surgery, to ensure good pain relief, says the doctor.

Dr Nelson and Dr Vikram Saini share details about post-operative recovery of patients.

“With the advancement in surgical techniques and early recovery program, gall bladder surgery is now considered a day care surgery. The patient is usually discharged by same day evening or the next day morning. Very minimal medication is given postoperatively.

“Recovery from surgery is painless due to laparoscopic advancement and the availability of advanced pain relief medications. Patients are usually started on oral liquids six hours after surgery followed by a normal diet. Patients are encouraged for early mobilisation. Drains (tubings) are observed for bile leaks, active bleeding and removed the next day if uneventful.

Open cholecystectomy patients may be kept for another day or two as they have a larger abdominal wound and may need hospital care.

Patients are usually not given antibiotics in the postoperative period. On discharge, the patient's wound is examined and advised to take regular soap water baths and keep the wound dry and open. “The patients are advised to take a soft bland diet and follow up in OPD with a histopathology report for further management,” says Dr Nelson.

Once the patient is operated, follow-up has to be ensured for better outcome. Says Dr Geeta Prasad, “surgical removal of gall bladder is one of the most commonly performed surgeries all over the globe. After surgery, a patient can lead a normal life just like any other individual. Stitches are usually removed 7-10 days after surgery.

“It is important to trace the biopsy report of the removed gallbladder (histopathology) to confirm that there is no cancer or any problem in the gallbladder.

“In the early post-surgery period if a patient develops any fever, pain abdomen, jaundice or vomiting it should not be ignored and needs to be examined. Development of jaundice needs to be investigated thoroughly to rule out any stone in the common duct which drains bile from the liver and gallbladder.”

Any watery, pus or blood discharge from the suture site needs to be examined for any infection. In case of open surgery, there may be delayed return to normal daily activities and wound infections should be watched out.

Post-surgery, fatty, spicy and oily foods need to be avoided, as it can cause abdominal discomfort, gas and bloating. Patients can return to their routine work and activities after one week, added Dr Puneeth Thalasta.

Diet and gallstones

Cholesterol gallstones are the most common type of gallstones which are formed due to excessive deposition of cholesterol in the gallbladder. You can lower your risk of gallstones by following a healthy eating plan, and getting regular physical activity to help you reach and maintain a healthy weight, say Dr Devender Singh  and  Dr Jyoti Sharma  as they recommend the following to help prevent gallstones:

  • Eat more foods that are high in fiber, such as fruits, vegetables, beans, and peas.
  • Whole grains, including brown rice, oats, and whole wheat bread.
  • Eat fewer refined carbohydrates and less sugar.
  •  Eat healthy fats, like fish oil and olive oil, to help your gallbladder contract and empty on a regular basis.
  • Avoid unhealthy fats, like those often found in desserts and fried foods.

Losing weight too quickly may cause health problems. Very low-calorie diets and weight-loss surgery can lead to rapid weight loss and raise your risk of gallstones.

Foods to Avoid After Gallbladder Surgery

While your body adjusts, it’s a good idea to avoid high-fat foods for a few weeks after your gallbladder removal. High-fat foods include: Fried foods, like french fries and potato chips; high-fat meats, such as bacon, bologna, sausage, ground beef, and ribs; high-fat dairy products, such as butter, cheese, ice cream, cream, whole milk, and sour cream; pizza; foods made with lard or butter; creamy soups or sauces; meat gravies; chocolate; oils, especially palm and coconut oil

Skin of chicken or turkey; certain high-fiber and gas-producing foods can also cause discomfort after gallbladder surgery.

Management of gallstones in the elderly population

Prevalence of medical co-morbidities is higher in elderly population. Out of them, hypertension and diabetes mellitus are the most common co-morbid conditions. Early surgical intervention in elderly patients is preferred and must be advisable after optimisation of co-morbid conditions for good surgical outcomes. Hernias and gallstone disease are the most common elective surgical diseases found in elderly patients.

Surgery is often recommended if the elderly person has symptoms like abdominal pain, inflammation of the gallbladder, or gallstones induced pancreas problems. The surgery involves removing the gallbladder, which is usually done using a minimally invasive technique called laparoscopic or keyhole surgery.

This approach is preferred because it has fewer complications, a faster recovery, and a shorter stay in the hospital. Conservative management, on the other hand, is a non-surgical approach. It might be considered if the elderly person has gallstones but doesn't have any symptoms. In this case, the person's condition is regularly monitored.

However, it's important to know that conservative management doesn't get rid of the gallstones, and there is still a risk of symptoms or complications in the future.

The decision between surgery and conservative management depends on many factors like the overall health of the elderly patient, the severity of their symptoms, and any other medical conditions like high blood pressure, diabetes, heart conditions, lung diseases etc they might have. Some elderly people may choose surgery because it offers a more definitive solution, while others may prefer conservative management if they are at high risk for surgery or if they don't want to undergo an operation.

The decision is taken by the patient and their family after discussing the possibilities with the medical staff, taking into account their preferences and overall health, as well as the risks and advantages of each unique treatment option.             

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