Most people don’t even know they have gallstones (stones) – pebble-like objects made from bile material that most of the time will not cause a problem, and they don’t take it seriously until they end up in the emergency room (ER) writhing in pain. Gallstones are typically harmless, but can sometimes lead to disease states.
Surgical oncologist Dr. Don Major said about 30 percent of the Bahamian population has gallstones, but that approximately 20 percent of them become symptomatic – upper-right abdomen pain (after eating a fatty meal), jaundice (yellowing of the skin and whites of the eyes), nausea and vomiting, fever and chills.
“There are a lot of people who have gallstone diseases, and stones in the bladder. Most people don’t even know they have gallstones until they have the pain which usually brings them to the ER,” said Major.
The surgical oncologist said he and his peers do “quite a bit” of gallbladder surgeries. He said he averages between two or three gallstone surgeries a month, and he knows medical professionals who are doing two to three gallstone surgeries a week.
“If you combine all surgeries, roughly, we take out 20 gallbladders a week,” said Major.
The gallbladder, part of the digestive system, is a small, pear-shaped organ with the main function to store bile. Bile is the fluid the liver produces that helps digest fats in the food eaten. Stones can form in the gallbladder, which are known as gallstones. Whenever there is an imbalance in the components of bile – most commonly an excess of cholesterol – these gallstones can develop. Major said some people have multiple tiny stones, some people he said may have one giant stone, while some he said may have multiple individual stones.
“Most gallstones develop because of cholesterol imbalance from a high cholesterol diet, and gallstones occur in overweight women during reproductive years.”
According to Major, individuals who commonly develop gallstones are females over the age of 40, who are overweight and who have had children. He said men and children can also develop gallstones, and that men tend to have more difficult gallbladders to remove as they tend to ignore their symptoms.
“Men don’t like to go to the doctor, so they will have pain and take medication and sit on it until it’s so bad. They tend to be the worst gallbladders and they take quite a bit of work, because when they do seek help, the gallbladder tends to be severely inflamed or scarred down,” he said.
“The worst case I’ve seen was in a male and he had quite a bit of inflammation in the gallbladder and liver, and the small bowel and colon was also stuck up to it, so trying to dissect without causing injury took about three hours for a surgery that takes 30 minutes to 60 minutes.”
Patients with gallbladder issues tend to present with abdominal pains – most commonly in the upper-right abdomen. Major said they may have associated nausea or vomiting, fever with chills, or they may have belching and bloating. The symptoms tend to be recurrent and can be severe at times, requiring hospital admission and emergency surgery.
Diagnosis includes an examination for tenderness over the area of the gallbladder, baseline laboratory investigations for signs of infection and dehydration, followed by an abdominal ultrasound, looking for gallstones and any signs of inflammation surrounding the gallbladder. Once the result is positive, the patient is referred to a surgeon for a consultation regarding gallbladder removal.
Surgery to remove the gallbladder is called a cholecystectomy which the doctor said can be performed by an open incision or laparoscopic, where smaller incisions are used and instruments placed via the incisions to remove the gallbladder. Another way he said involves the use of the robot to remove the gallbladder.
“Laparoscopic and robotic cholecystectomies have the benefit of using smaller incisions that cause less pain, shorter hospital stays and some patients may be able to go home several hours following the procedure.”
Major said the most common form of gallbladder removal is laparoscopic cholecystectomy.
“It is rare that an open cholecystectomy [surgeon operates through one large incision] will be performed but there are still reasons that we may want to choose an open approach.”
No matter which approach is chosen, the doctor said the principles in gallbladder removal remain the same. Patients require general anesthesia and must be put to sleep which requires an operating theater; they will get antibiotics prior to the beginning of the operation; and may also have a catheter placed in the urinary bladder to allow decompression.
He said they also receive local anesthesia (numbing medication) at the incision site, and all incisions will be closed with sutures that absorb. After surgery, he said patients will be allowed to eat several hours following the operation and discharged six to 24 hours post-procedure. Patients will be advised not to lift any heavy objects. The bandages are usually removed 48 hours after the surgery.
People who have had gallbladder surgery he said can expect to follow up with their surgeon one to two weeks after surgery. They will get their pathology report on the follow-up visit which would confirm inflammation involving the gallbladder and which also rules out the rare finding of gallbladder cancer. He said they can be expected to be off work for two to six weeks.
While there are certain complications that are related to the removal of the gallbladder, Major said they tend to occur based on the difficulty level surrounding the gallbladder removal.
“Immediate complications include bleeding which most time can be controlled laparoscopically but may require conversion to an open procedure to stop the bleeding. Intermediate complications are bile leak from the cystic duct stump, liver bed or bile duct injury. Bile duct injury can occur which can be a serious complication requiring drains and repeated surgical interventions and sometimes death. However, bile duct injuries occur 0.5 percent of the times in a laparoscopic cholecystectomy. Delayed complications are hernias at the site where the ports were placed – most commonly at the belly button.”
According to the doctor, most people who have had their gallbladder removed, can expect to live a perfectly normal life after gallbladder surgery, but he said they may experience temporary side effects related to the way their digestive system processes fatty foods.
Symptoms may include loose stools or diarrhea, bloating, cramping, and excess gas in response to meals or certain foods. He said they are factors that tend to resolve with time and that once the gallbladder is removed, they may go back to eating a regular diet of their choosing.
According to the doctor, education is important to help people understand the seriousness of the disease.
“Most people don’t take it seriously until they end up in the ER writhing in pain. Most people don’t even know until they have the pain which usually brings them to the ER.”
To ward off gallstone flares, the doctor said people need to be aware of their diet and to eat a balanced diet, trying to minimize fats taken in – and to exercise.
“A lot of things we deal with in medicine can be prevented just by eating right and [eating the right portion] size.”
Major said anyone suffering upper-right quadrant or abdominal pain should seek medical attention from their general physician, or at the ER if it is really bad.