A guide towards aiding you in making an Informed Choice
Stones in the gall bladder is a common problem. Most patients undergo surgery to get the stones removed. But surgery is avoidable in a large number of those cases.
As part of a series of articles written with the endeavour of assisting you in making an informed choice, Dr. Baiju Senadhipan takes some time out to clear the air around popular misconceptions about gall stones and its treatment. Several myths surround this condition, including amongst medical practitioners. Dispelling those common myths is an important step towards empowering patients in making an informed choice.
Following are some of the common questions Dr Senadhipan gets from most patients and below each question are his answers for you to make an informed choice. Hope you find them useful
I have been advised surgery to remove gall bladder stones. Should I get a second opinion?
Yes. In my experience I have found that about 80% of operations for removal of gall bladder stones are avoidable. It is important to obtain a second opinion so that one does not undergo surgery unnecessarily.
In what kind of cases is surgery not required?
When gall bladder stones are not symptomatic, surgery may not be required except under certain conditions (as elaborated in the next answer). Symptomatic cases of gall bladder stones are those where the condition is accompanied by pain, uneasiness or bloating, particularly after a fatty meal. In other words, where there is no pain or discomfort, surgery may not be required. The patient can continue to live a normal life with the stones in the body.
In what kind of cases of asymptomatic gall bladder stones, is surgery necessary?
Most cases of gall bladder stones that are asymptomatic (i.e. not accompanied by pain/discomfort) do not require removal and surgery. However, they may be removed in the following cases :-
(a) the stone is larger than 3 cm in diameter;
(b) the stone is removed as part of another procedure;
(c) the area is being examined for surgery for some other problem;
If the asymptomatic stones do not fall under any one of the above three criteria, the stones can continue to remain in the body. They need not be removed.
What are the symptoms of gall bladder stones?
You would normally experience pain when gall bladder stones are symptomatic. The pain could be in the abdomen or sometimes it may even extend till the chest, shoulder blade or arm. It may be accompanied by nausea or vomiting. Pain could last for about half an hour after a meal or continue for several hours. If the gall bladder is inflamed, the pain in the upper abdomen can be severe and the area may become extremely sensitive to touch. Some patients may experience uneasiness or bloating after a fatty meal. Sometimes, the stones may move from the gall bladder into the bile duct, which is the tube that connects the gall bladder with the upper part of small intestine called Duodenum. Patients with this condition could suffer from jaundice and high fever. In such cases, the patient needs to undergo an additional endoscopic removal of the stones that are lodged in the bile duct.
If I have no symptoms, how will I know if there are stones in my gall bladder?
In several cases, gall bladder stones do not cause pain or result in any symptoms. It is therefore likely that a person with stones in the gall bladder is unaware of their existence. Sometimes, presence of the stones is detected during some other procedure such as an abdominal ultrasound, CT or MRI scan that is taken to diagnose a completely different problem.
Can complications arise in the future as a result of allowing the stones to remain in the body?
Mostly No. Where the stones are not causing any pain or resulting in any of the other symptoms specified above, and where the case does not fall under the three exceptions mentioned in the question above, there is no risk in allowing the stones to remain in the body. However, it is important to take note that the stones which are asymptomatic at present may become symptomatic in the future. There is no way of being sure that the stones don’t become symptomatic in future.
Do gall stones enlarge over a period of time? If my case has no symptoms now, and I find that surgery is not required, will I require surgery in the future?
Yes. Gall stones can enlarge in size over a period of time. But the size of the stone alone does not alter the method of treatment, unless the stone is nearing the size of 3cm. In other words, if the stone grows to a size of 3cm or more or if it becomes symptomatic in the future, surgery may be required at that point of time. This possibility cannot be ruled out.
I have been experiencing occasional pain after meals. In the course of the last two days, the pain has become more constant. Is this a case of symptomatic gall bladder stones?
It is likely to be. Pain in the condition of gall bladder stones is usually of two types :-
- Biliary colic where the pain comes on and off especially after a fatty meal. This happens when the gall bladder tries to contract against a resistance i.e. the stone;
- Pain due to inflammation of the gall bladder. Here the pain is constant and long lasting. In this case, the surgery is required to be performed within 48 hours of detecting the problem.
What is the correct method of treatment in case of symptomatic gall bladder stones?
In case the stones are symptomatic i.e. they are accompanied by pain as mentioned above, it is likely that the cause of the problem is not the stones but the gall bladder itself. In such a case, it is advisable to remove the entire gall bladder. Removal of stones alone is not advisable as it is the diseased gall bladder which is causing symptoms such as pain/discomfort.
Would removal of the gall bladder not lead to other complications?
No. The role and function of the gall bladder in the human body is not indispensable. The gall bladder is a small pear shaped organ located below the liver. The bile produced in the liver is temporarily stored in the gall bladder for the purpose of aiding digestion. When fatty food passes through the small intestine in the course of digestion, the gall bladder contracts to release bile juice. This bile assists in the digestion of food. Where the gall bladder is removed, the bile goes directly
from the liver into the digestive tract without resulting in any complication or causing any side effects. Of course, it is necessary that the procedure be performed by a skilled surgical team in order to rule out chances of bile leak or any other complications.
Can gall bladder stones be dissolved using other methods or medication?
Drugs to dissolve gall bladder stones and other methods like the use of sound waves to shatter the stones have not been found to be effective. In the case of urinary / kidney stones, removal of stones solves the problem. Stones in the gall bladder is a slightly different kind of problem. Often, it is the diseased gall bladder and not the stones that is the underlying cause of the trouble. As a result, removal of stones alone will not provide long term relief to the patient. The problem might recur in the future.
What restrictions if any, is a patient of gall bladder stones required to face prior to and post the surgery?
Cardiac patients using drugs like aspirin or clopidogrel will require to stop medication for atleast five days prior to the surgery. Further, before undergoing a surgery to remove the gall bladder, a patient must be careful to avoid eating fatty good. There is no restriction on diet after removal of the gall bladder.
How is removing the gall bladder a more effective solution than removing gall stones?
Removal of gall bladder is a safe and a permanent solution to the problem. Removal of stones will provide temporary relief from the problem to a patient. It is important to take note that stones, once removed might recur in the future. This is because the cause of the problem is often not the stones but the gall bladder itself. Though removal of the gall bladder is a relatively minor surgery, it can occasionally result in complications,, particularly when the patient is in inexperienced hands. Therefore it is important that the surgery is done at a center where such cases have been handled successfully in order to avoid complications.
What kind of surgery is required for removal of the gall bladder?
The gall bladder can be removed through open surgery or through laparoscopic/ keyhole surgery. In the case of open surgery, about 6 inch incision (i.e. as long as palm of an adult hand ) is made in the abdomen to remove the gall bladder. This may result in a larger incision wound involving pain and a long recovery period. These problems are overcome in the case of laparoscopic surgery. Keyhole surgery has been a safe and effective method of surgery for over 30 years.
What is keyhole or laparoscopic surgery? What are its benefits over regular surgery?
Keyhole or laparoscopic surgery is a method of surgery where 3 to 4 mini incisions of about 5mm-10mm (i.e. the size of one to two grains of rice) are made in the abdomen and a viewing scope is inserted to enable the surgeon to view the internal body parts, images of which are magnified and transmitted onto a television screen. The abdomen is filled with inert gas to create space for the surgeon to operate. Small pencil-like instruments are also inserted through the incision which are used to perform the surgery. Unlike in an open surgery, this method is less invasive resulting in less pain. The recovery period is shorter and the risk of further infections and complications is reduced. The problem of post-operative scars is also done away with. Doctors today conduct several major operative procedures including for cancers, through the keyhole method. The gall bladder can also be removed laparoscopically through keyhole surgery.
Before agreeing to undergo removal of the gall bladder laparoscopically, what must I keep in mind?
It is important that the center performing the laparoscopic procedure has skilled and trained doctors to perform laparoscopic surgery. The necessary equipment and facilities for the same should also be available. It has been published that in about 15% to 20% of cases, semi-skilled centers and hospitals that claim to perform laparoscopic procedures, convert the operation into an open surgical procedure mid-way through the surgery owing to lack of skills.
How soon after detecting the problem must I go in for a gall bladder surgery?
In cases where the patient suffers from severe pain due to inflammation of the gall bladder, the surgery must be performed within 48 hours of detection. In cases where the patient is using drugs such as aspirin or clopidogrel for cardiac problems, the drug usage will have to be stopped for atleast five days before the surgery can be performed. Sometimes the surgery may have to be delayed if the patient is unfit for immediate anaesthesia.
At our center, we have performed hundreds of surgeries for gall bladder removal by laparoscopy
even after a week or two weeks of pain due to acute inflammation. It is safe provided the surgical team is skilled and experienced. This finding has been documented and published in the Indian Journal of Surgery. Interested readers may please follow the link for reading the publication: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726809
Has your center performed removal of gall bladder through keyhole surgery?
Yes, several thousands of them. Our center has successfully performed over 5000 gall bladder removal procedures laparoscopically so far and not a single case of conversion into an open surgery. None of our patients have had complications such as bile leakage subsequent to the surgery. This claim is substantiated in our publication in the Indian Journal of Surgery.
Before I decide to undergo surgery for removal of the gall bladder laparoscopically in a hospital, what factors should I take into consideration?
Try and get a second opinion from reliable and respected sources on whether at all surgery is required in your case. Obtain data from the center about the conversion rate of their laparoscopic procedures into open surgery. Speak to patients who have undergone similar procedures at the hospital/center before. Get to know your doctor. Dispel myths and overcome misconceptions. Make an informed choice.