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Gallstone disease

Gallstone disease. Paras Jethwa MD FRCS Consultant Upper GI Surgeon SASH. A changing landscape. First LC in 1987 Early 1990’s - regularly 3 hours+ Routine surgery 8 mins - 4 hours Morbidity - 4% Mortality - 0.1% National conversion rate of 5%. Gallstones. Increasing incidence

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Gallstone disease

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  1. Gallstone disease Paras Jethwa MD FRCS Consultant Upper GI Surgeon SASH

  2. A changing landscape • First LC in 1987 • Early 1990’s - regularly 3 hours+ • Routine surgery • 8 mins - 4 hours • Morbidity - 4% • Mortality - 0.1% • National conversion rate of 5%

  3. Gallstones • Increasing incidence • Fatty diet • Post obesity surgery • Crash dieting • Diabetes • 4 F’s no longer diagnostic criteria • Increasing % male • 15 to 94 • Very frequent cause of acute admission

  4. Controversy • Recent AUGIS proposal that only UGI surgeons should perform LC • Rejected by ALS - but - should there be a basic laparoscopic competence • NPSA alert on iatrogenic complications

  5. Results 2008 -11 • > 250 cholecystectomies performed • No biliary complications • 30% daycase • >20% patients over 70 • In last year <1% conversion to open • Includes acute admissions • Pancreatitis • Acute cholecystitis • Empyema • Perforations • BMI up to 50 (45 as DC)

  6. SASH • Lowest in patient stay in the region • 3.4 to 1.4 days since 2008 • 92% patient satisfaction • Lowest readmission rates • Clear drive to increase daycase LC rates • Dedicated team & equipment • Anaesthesia & nursing • Risk stratification • 95% of DSU stayed as daycase

  7. Acute Gallbladders • Conventional wisdom • Antibiotics +/- repeat scan • Clinic • 6/52 operation • Acute operation • High rates of conversion(10%) • High rate of CBD injury • Representation • Severity of disease • Pancreatitis • Fistulas • Not for the unwary surgeon!

  8. VW video

  9. Acute perforated GB • 55 year old • A&E attendee with RUQ peritionism • Op on day 2 - home day 3 - back to work day 10

  10. Acute/non resolving Cholecystitis • 47 year old • Multiple attacks • Unable to work due to pain

  11. Deranged LFT’s • Obstructive jaundice • Dark urine/pale of stools • No history of ETOH • Coordinated approach • Discussion at weekly MDT • Dedicated ERCP service/UGI surgeon • GI radiologist/Specialist nurses/Oncologist • Surgical high dependency/ITU • Accurate diagnosis • MRCP +/- CT

  12. CBD stones • USS • MRCP • EUS • IOC • LCBD • ERCP

  13. Obstructive Jaundice • ERCP vs. Lap CBD • Younger patient • Impacted stones (at time of LC) • Short/Longterm effect of sphincterotomy • Concern of dysplasia • Stricture formation

  14. Case study • Elderly lady • Impacted CBD stone • Expedited admission • Cholecystodudodenal fistula • Large stone in her CBD • Multiple comorbidities

  15. Complications • Bleeding • Rare - cause of conversion • Haematoma +/- collection • Acute setting • Bile leak • 1 % incidence • CBD stump/ undersurface of liver/duct of Luska • Repeat scope - drainage • CBD injury • 1:300 in recent Swiss study (31 000) • Injury with LC greater magnitude than OC • IOC - not protective • Best dealt with by dedicated centre

  16. Complications 2 • Dyspepsia • Post Chole syndrome • Iatrogenic injury to other viscera • Retained (dropped) stone • Persistent fatty induced pain • Diarrhoea

  17. I didn’t get where I was today…

  18. The Future? • > 60% daycase rate • Increasing obese population • Extensive comorbidity • Social factors • Modification of anaesthetic techniques • Intrapertioneal instillation of topical anaesthesia • Currently designing RCT of IP vs. IT block • Use of surgical high energy for removal of viscera (SHERV)

  19. Questions?

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