A second look at a first-line treatment

Gall bladder surgery: a second look at a first-line treatment

Leah R. Garnett

When laparoscopic gallbladder surgery debuted in 1990, it was not only a hit, it was practically an overnight success. In the past six years, it has replaced conventional surgery to become the “gold standard” for relieving gallstone pain. Today, 90% of all cholecystectomies (gallbladder removals) in the United States are done using this minimally invasive approach.

Unlike so-called open gallbladder surgery–in which the surgeon makes an incision in the abdomen–the laparoscopic method requires only several tiny punctures in the belly to allow for the insertion of a small video camera and surgical instruments.

Although the procedure has been a success by most measures, it is not without risk nor detractors. For example, some experts believe it has led to unnecessary gallbladder surgeries; over the past few years, cholecystectomy rates have skyrocketed by more than 40% in some places. In addition, the surgery is technically demanding, and inexperienced surgeons have been known to make grievous mistakes. Although it is uncommon, injury to the common bile duct–a serious and potentially fatal complication–is about three times higher than for conventional surgery.

Making comparisons

In a recent study of 200 patients, British researchers reported that laparoscopic cholecystectomy takes longer to do than so-called mini-incision surgery (a two-inch opening) and offers no added benefit in recovery time, length of hospital stay, and time back to work.

These results were surprising, because earlier evidence showed that people who undergo laparoscopy recover more quickly–one night in the hospital and a few days at home–and with less pain and scarring than those treated with conventional open surgery. (Nowadays, some patients even go home the same day.) In these studies, however, laparoscopic surgery was compared with a procedure that required a 5″-8″ incision through the abdominal muscles; patients were generally in the hospital for a week and required several additional weeks of recuperation at home.

The British researchers’ comparison of laparoscopy and mini-incision surgery is meaningless now, because surgeons began perfecting the latter technique just as the former burst on the scene. “There was a gigantic stampede for laparoscopic cholecystectomy, probably because it was sexy and new. The mini-incision surgery never had the same appeal,” said Thomas Dent, professor of surgery at Temple University School of Medicine in Philadelphia and chairman of surgery at Abington Memorial Hospital.

The fact is, there was no information about how mini-incision surgery compared to laparoscopic cholecystectomy until last April, when the British researchers published their results in The Lancet. But by then it was too late. “Lap choly”–as it’s nicknamed by doctors–was here to stay.

Despite the Lancet study, most U.S. physicians still favor the laparoscopic procedure, primarily because it enables surgeons to get a view of the abdominal cavity they would not otherwise have. In addition, the surgery can be easily performed on heavy people; the mini-incision can’t be done on patients with lots of abdominal fat.

Open surgery is generally used in cases where laparoscopy is too difficult to do. Sometimes doctors switch midstream when complications arise, much as a Cesarean section might be performed when unexpected problems occur during a delivery.

A complex matter

While most gastrointestinal surgeons can competently perform the open procedure, lap choly requires meticulous skill. “It’s a very difficult operation to learn,” said gastrointestinal surgeon David C. Brooks, associate professor of clinical surgery at Harvard Medical School.

First the surgeon makes several small incisions in the abdomen to allow for the insertion of instruments and a small video camera. This sends a magnified image to a monitor, giving the doctor a close-up view of the organs. The surgeon must watch the monitor as he or she painstakingly manipulates instruments through the tiny incisions, separates the gallbladder from the liver and other structures, and removes it through one of the perforations. (See illustration.)

“We want to cut the connection between the gallbladder and the common bile duct–which carries bile from the liver to the intestine–but we don’t want to touch the duct,” said Dr. Brooks. If the bile duct is damaged, surgical repair is required and permanent liver damage may occur if this fails.

Each year, more than half a million Americans have their gallbladders removed due to painful stones. As small as a grain of sand or as large as a golf ball, they form when substances in the bile–usually cholesterol–form hard, crystal-like particles.

Roughly 10% of the U.S. population has gallstones, but most don’t even know it. These “silent stones” are usually detected during an abdominal x-ray, ultrasound, or computed tomography (CT) scan for an unrelated problem.

For some people, however, the stones are anything but silent: a typical gallstone attack causes severe pain in the upper abdomen and may be accompanied by nausea or vomiting. People may also experience pain between the shoulder blades or only in the right shoulder. These episodes can last from 20 minutes to several hours and may occur every few weeks or be months or even years apart. Once one occurs, subsequent attacks are likely. Especially at risk are women over 20, particularly those who have had several children, men over 60, and anyone who is overweight.

Getting relief

Rising rates of gallbladder removal prompted some researchers to take a new look at laparoscopic cholecystectomy. They found that the increase reflects a “lowering of the threshold” for the operation- meaning that the surgery is being used for less acute or less well-defined conditions than in the past. However, few physicians would argue that a lower threshold is inappropriate if the surgery alleviates a patient’s suffering. “How do you measure the cost of doing more operations if the benefit to society is that more people are relieved of their disease?” said Andrew Warshaw, chief of general surgery at Massachusetts General Hospital and a professor of surgery at Harvard Medical School.

Some researchers believe that increased use may also stem from a backlog of patients who decided that they’d rather live with gallstone attacks than subject themselves to major surgery. Once lap choly became an option in the early 1990s, many of these people jumped on the bandwagon.

Meet me in court

Meanwhile, malpractice claims for bile duct injuries have grown fivefold since laparoscopic cholecystectomy was introduced. The rate of these injuries in open surgery is very low–less than 0.2%–and it’s been estimated at 0.2%-0.9% for lap choly.

Although these percentages are small, they are not considered negligible because many people who undergo gallbladder surgery are young and could have lifelong problems from a bile duct stricture. Several studies indicate that most injuries to the bile duct are caused by surgeons who have done fewer than 30 laparoscopic cholecystectomies, suggesting that proper monitoring or better training would help.

Nevertheless, many physicians believe the increase in malpractice suits is due not only to a rise in injury rates but to an expectation that laparoscopy is foolproof. People may not realize that complications can occur even when the surgeon is a veteran. “We really haven’t educated the public that laparoscopic cholecystectomy is not a minimal procedure–it’s just a minimally invasive way of doing the procedure,” said Dr. Dent of Temple University;

It is the small but real risk of injury that has caused some researchers to question whether the widespread use of lap choly is justified. A major challenge facing primary care physicians is determining whether a patient’s symptoms are attributable to gallstones or are merely coincidental, said gastroenterologist David F. Ransohoff, professor of medicine and epidemiology at the University of North Carolina at Chapel Hill, who coauthored an editorial on the subject in the Journal of the American Medical Association last year.

Irritable bowel syndrome, for example, may cause symptoms that resemble a gallbladder attack, and some people have similar complaints because their systems can’t handle fatty foods, said Dr. Ransohoff. “There is remarkably little data on why more people are getting this surgery and which of them are benefiting.”

Although laparoscopic cholecystectomy may be overused to some degree, it is far from a public health problem, Dr. Ransohoff noted. “Surgery should certainly be done if someone is saying ‘I never want to have this kind of pain again’ and the doctor is pretty sure it’s due to gallstones.”

But in cases where the cause is not so clear or where gallstone attacks are few and far between, a little temperance may go a long way toward reducing the number of unnecessary operations. “We just want to alert people that watchful waiting is an acceptable option to consider,” said Dr. Ransohoff.

Clearly, the decision to have surgery is an individual one. People with infrequent gallstone attacks may be able to live with the prospect of having another down the road, while those whose episodes are more common or severe may find that laparoscopic cholecystectomy greatly improves the quality of their lives.

SCOPING OUT TROUBLE

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