Annals of the Royal College of Surgeons of England (1992) vol. 74, 218-221
Six hundred patients
with
gallstones
David J Warwick FRCS* Senior House Officer
Michael H Thompson
MD FRCS
Consultant Surgeon
Department of Surgery, Southmead Hospital, Bristol Key words: Cholecystectomy; Endoscopic sphincterotomy; Exploration of the common bile duct
A total of 610 patients with galistones were treated over an 8-year period in a single surgical unit. Of these patients, 384 had cholecystectomy, 86 surgical duct exploration and 140 endoscopic sphincterotomy. Four patients died after cholecystectomy (1%), but there were no deaths after the treatment of duct stones. The proportion of patients with duct stones having endoscopic sphincterotomy with the gallbladder in situ rose considerably during the 8-year period, from about 20% to 75%. Gallstones tend to present in the elderly as duct stones, and in the young as gallbladder stones. The majority of patients over 75 years of age had endoscopic sphincterotomy, whereas the younger patients were usually treated surgically.
As new methods, such as extracorporeal shock wave lithotripsy (ESWL) and laparoscopic cholecystectomy, are introduced for the management of selected patients with gallstones, it is important to define the contemporary standard of treatment on which the majority of patients will continue to rely. The aims of this study are to assess the results of conventional treatment in a district general hospital, to note any trends in patterns of management of gallstones and to examine the influence of age on treatment and
was defined as elective when performed at a time convenient to patient or hospital; urgent surgery was that carried out during the hospital stay after an acute admission once the initial symptoms had settled. Emergency surgery was that undertaken within 48 h of an acute admission. Cholecystectomy was performed through an upper right transverse incision with single dose cephalosporin prophylaxis. The use of drains was abandoned during the latter part of this study (1,2). Endoscopic sphincterotomy was carried out with an Olympus JFI-lT endoscope. Prophylactic antibiotics were used in all cases. The stones were allowed to pass spontaneously or with the aid of a Dormia basket or balloon catheter. No rigid protocol was devised to select patients for endoscopic or surgical treatment; each patient was treated on clinical grounds, with appropriate consideration of presentation, concurrent medical conditions and age.
Results A total of 610 patients were treated in the 8-year period
(Fig. 1).
outcome.
Patients and methods Records of all patients treated on a single surgical firm for gallbladder disease over an 8-year period were collected prospectively and then reviewed. Operative treatment Present appointment: Senior House Officer, Welsh Centre for Burns, Plastic and Reconstructive Surgery, Chepstow, Gwent Correspondence to: Mr M H Thompson, Department of Surgery, Southmead Hospital, Bristol BS10 5NB *
Cholecystectomy Of the patients, 384 underwent cholecystectomy alone, electively in 290 cases and as an urgent or emergency operation in 94. The average age was 52.3 years and 63% were female. There was one death among the elective group (0.34%) from congestive cardiac failure and a femoral embolus. He was 83 years old and had previously had his duct cleared endoscopically but the continued passage of stones down the duct with several resultant hospital admissions suggested that cholecystectomy was required. Of the 94 cases undergoing urgent or emergency surgery, there were three deaths (3.2%); one aged 63
Six hundred patients with gallstones
F
ENDO SPHINC 140 23%
SURG DUCT EXPL 86 14%
Figure 1. Management of 610 patients.
years from a pulmonary embolism 48 h postoperatively and one each from pre-existing renal failure and ischaemic heart disease, aged 79 years and 83 years. Complications occurred in 23 patients (6%): chest infection (6 cases); urinary retention (5 cases); wound infection (3 cases); deep vein thrombosis (2 cases); pulmonary embolus (2 cases); subphrenic abscess, unexplained pleural effusion, wound dehiscence, cerebrovascular accident and severe urinary tract infection in one case each.
Exploration of the common bile duct (ECBD) Exploration of the bile duct was required in 86 patients. In one case there had been a previous cholecystectomy. The average age was 61.3 years and 58% were female. A total of 45 patients (52%) required operation urgently or as an emergency, for which the most common indication was jaundice, others having severe biliary colic, cholangitis or pancreatitis. There were no deaths, but significant morbidity occurred in 11 cases (12.8%). There were two severe urinary tract infections, and one case each of jaundice, ileus, urinary retention, bile leak, pulmonary embolus, wound infection, pseudomembranous colitis, chest infection and common bile duct injury (repaired at the time of injury and with normal liver function 3 years later). Six explorations were negative. Ten patients had a biliary drainage procedure performed, either choledochoduodenostomy (seven cases) or transduodenal sphincteroplasty (three cases). Of the 86 patients, 12 (14%) having ECBD had previously undergone an endoscopic sphincterotomy. Three of these patients had also had the gallbladder removed previously. Retained stones occurred in two cases, which were extracted with a Dormia basket through the T-tube track.
Endoscopic sphincterotomy (ES) A total of 140 patients, average age 70.4 years, were treated by endoscopic sphincterotomy. Of these, 71
219
(50.7%) still had their gallbladder in situ. The average age of those with their gallbladder in place was 80 years and of those who had a previous cholecystectomy it was 53 years. The main indications for sphincterotomy were biliary colic (32%), jaundice (29.1%), cholangitis (16%) and pancreatitis (9%). There were no deaths attributable to the procedure but 15 patients (11%) endured some morbidity; pancreatitis was mild and transient in five, but severe in one. There were probable retroperitoneal leaks in two cases, both treated successfully with antibiotics and nasogastric aspiration. Three patients had cholangitis, one patient had some unexplained pain and two some minor bleeding which, while not serious, obscured further views of the ampulla. The Dormia basket impacted in one patient and required operative removal. Of the patients who had been treated primarily by ES, 12 (8.6%) subsequently underwent surgical treatment, five urgently for biliary sepsis. Three patients had previously had a cholecystectomy so had surgical duct exploration alone. Nine still retained their gallbladder (ie 12.7% of those originally treated endoscopically leaving the gallbladder in), and so needed both cholecystectomy and surgical duct exploration. The average age of these 12 patients was 76.4 years.
Patterns of treatment Figure 2 reveals that the proportion of patients having cholecystectomy, ES or ECBD remained roughly constant through the 8-year period of the study. The most striking change is that the proportion of patients having ES with their gallbladder in situ rose steadily, from 20% to 75%. In the latter 4 years, 16 jaundiced patients had stents placed endoscopically after sphincterotomy as part of the endoscopic management of their stones. In two cases these stents have remained for a long term with good results.
81
82
83
84
86
85
87
88
year cholecystectomy
+ E.C.B.D
+ ES.
8
% E.8.GB in-situ
Figure 2. Percentage of patients undergoing a procedure in each year. % ES, GB in situ refers to the percentage of those having ES who had not had a previous cholecystectomy.
220
D J Warwick and M H Thompson
1985-19J89
-1981-1985 (n =48)
75 years 1C) 7
( t-15!9)
7
75 years
Six hundred patients
with
gallstones
David J Warwick FRCS* Senior House Officer
Michael H Thompson
MD FRCS
Consultant Surgeon
Department of Surgery, Southmead Hospital, Bristol Key words: Cholecystectomy; Endoscopic sphincterotomy; Exploration of the common bile duct
A total of 610 patients with galistones were treated over an 8-year period in a single surgical unit. Of these patients, 384 had cholecystectomy, 86 surgical duct exploration and 140 endoscopic sphincterotomy. Four patients died after cholecystectomy (1%), but there were no deaths after the treatment of duct stones. The proportion of patients with duct stones having endoscopic sphincterotomy with the gallbladder in situ rose considerably during the 8-year period, from about 20% to 75%. Gallstones tend to present in the elderly as duct stones, and in the young as gallbladder stones. The majority of patients over 75 years of age had endoscopic sphincterotomy, whereas the younger patients were usually treated surgically.
As new methods, such as extracorporeal shock wave lithotripsy (ESWL) and laparoscopic cholecystectomy, are introduced for the management of selected patients with gallstones, it is important to define the contemporary standard of treatment on which the majority of patients will continue to rely. The aims of this study are to assess the results of conventional treatment in a district general hospital, to note any trends in patterns of management of gallstones and to examine the influence of age on treatment and
was defined as elective when performed at a time convenient to patient or hospital; urgent surgery was that carried out during the hospital stay after an acute admission once the initial symptoms had settled. Emergency surgery was that undertaken within 48 h of an acute admission. Cholecystectomy was performed through an upper right transverse incision with single dose cephalosporin prophylaxis. The use of drains was abandoned during the latter part of this study (1,2). Endoscopic sphincterotomy was carried out with an Olympus JFI-lT endoscope. Prophylactic antibiotics were used in all cases. The stones were allowed to pass spontaneously or with the aid of a Dormia basket or balloon catheter. No rigid protocol was devised to select patients for endoscopic or surgical treatment; each patient was treated on clinical grounds, with appropriate consideration of presentation, concurrent medical conditions and age.
Results A total of 610 patients were treated in the 8-year period
(Fig. 1).
outcome.
Patients and methods Records of all patients treated on a single surgical firm for gallbladder disease over an 8-year period were collected prospectively and then reviewed. Operative treatment Present appointment: Senior House Officer, Welsh Centre for Burns, Plastic and Reconstructive Surgery, Chepstow, Gwent Correspondence to: Mr M H Thompson, Department of Surgery, Southmead Hospital, Bristol BS10 5NB *
Cholecystectomy Of the patients, 384 underwent cholecystectomy alone, electively in 290 cases and as an urgent or emergency operation in 94. The average age was 52.3 years and 63% were female. There was one death among the elective group (0.34%) from congestive cardiac failure and a femoral embolus. He was 83 years old and had previously had his duct cleared endoscopically but the continued passage of stones down the duct with several resultant hospital admissions suggested that cholecystectomy was required. Of the 94 cases undergoing urgent or emergency surgery, there were three deaths (3.2%); one aged 63
Six hundred patients with gallstones
F
ENDO SPHINC 140 23%
SURG DUCT EXPL 86 14%
Figure 1. Management of 610 patients.
years from a pulmonary embolism 48 h postoperatively and one each from pre-existing renal failure and ischaemic heart disease, aged 79 years and 83 years. Complications occurred in 23 patients (6%): chest infection (6 cases); urinary retention (5 cases); wound infection (3 cases); deep vein thrombosis (2 cases); pulmonary embolus (2 cases); subphrenic abscess, unexplained pleural effusion, wound dehiscence, cerebrovascular accident and severe urinary tract infection in one case each.
Exploration of the common bile duct (ECBD) Exploration of the bile duct was required in 86 patients. In one case there had been a previous cholecystectomy. The average age was 61.3 years and 58% were female. A total of 45 patients (52%) required operation urgently or as an emergency, for which the most common indication was jaundice, others having severe biliary colic, cholangitis or pancreatitis. There were no deaths, but significant morbidity occurred in 11 cases (12.8%). There were two severe urinary tract infections, and one case each of jaundice, ileus, urinary retention, bile leak, pulmonary embolus, wound infection, pseudomembranous colitis, chest infection and common bile duct injury (repaired at the time of injury and with normal liver function 3 years later). Six explorations were negative. Ten patients had a biliary drainage procedure performed, either choledochoduodenostomy (seven cases) or transduodenal sphincteroplasty (three cases). Of the 86 patients, 12 (14%) having ECBD had previously undergone an endoscopic sphincterotomy. Three of these patients had also had the gallbladder removed previously. Retained stones occurred in two cases, which were extracted with a Dormia basket through the T-tube track.
Endoscopic sphincterotomy (ES) A total of 140 patients, average age 70.4 years, were treated by endoscopic sphincterotomy. Of these, 71
219
(50.7%) still had their gallbladder in situ. The average age of those with their gallbladder in place was 80 years and of those who had a previous cholecystectomy it was 53 years. The main indications for sphincterotomy were biliary colic (32%), jaundice (29.1%), cholangitis (16%) and pancreatitis (9%). There were no deaths attributable to the procedure but 15 patients (11%) endured some morbidity; pancreatitis was mild and transient in five, but severe in one. There were probable retroperitoneal leaks in two cases, both treated successfully with antibiotics and nasogastric aspiration. Three patients had cholangitis, one patient had some unexplained pain and two some minor bleeding which, while not serious, obscured further views of the ampulla. The Dormia basket impacted in one patient and required operative removal. Of the patients who had been treated primarily by ES, 12 (8.6%) subsequently underwent surgical treatment, five urgently for biliary sepsis. Three patients had previously had a cholecystectomy so had surgical duct exploration alone. Nine still retained their gallbladder (ie 12.7% of those originally treated endoscopically leaving the gallbladder in), and so needed both cholecystectomy and surgical duct exploration. The average age of these 12 patients was 76.4 years.
Patterns of treatment Figure 2 reveals that the proportion of patients having cholecystectomy, ES or ECBD remained roughly constant through the 8-year period of the study. The most striking change is that the proportion of patients having ES with their gallbladder in situ rose steadily, from 20% to 75%. In the latter 4 years, 16 jaundiced patients had stents placed endoscopically after sphincterotomy as part of the endoscopic management of their stones. In two cases these stents have remained for a long term with good results.
81
82
83
84
86
85
87
88
year cholecystectomy
+ E.C.B.D
+ ES.
8
% E.8.GB in-situ
Figure 2. Percentage of patients undergoing a procedure in each year. % ES, GB in situ refers to the percentage of those having ES who had not had a previous cholecystectomy.
220
D J Warwick and M H Thompson
1985-19J89
-1981-1985 (n =48)
75 years 1C) 7
( t-15!9)
7
75 years
