Kaiser Permanente Santa Clara Gallbladder Overview

Author: KP Santa Clara

This presentation was developed as an information class for people who have some stages of gall bladder disease in who are considering gallbladder surgery. You may not have had any problems with your gallbladder or you may be here because you have had symptoms and your doctors are recommending that you consider surgery. Welcome to the department of Surgery. My name is Doctor Annette Chavez and I'm one of the surgeons at Kaiser Permanente Santa Clara.

In this presentation, we want to help you understand the symptoms and problems of gallbladder disease and guide you in your decision to have surgery. While you watch this presentation, you can use a video controls to pause go back, choose a topic and restart the video. As you think of questions, please write them down so you will remember them to discuss with your surgeon. You may want to pause and get a pen and paper to make notes. We hope this program will help you to understand and recognize the symptoms and potential problems of gallbladder disease. We want you to be informed about your health care choices so that you can be the primary advocate in your own health care.

You will be making a decision about the best thing to do regarding your gallbladder. We will discuss preparations for surgery, gallbladder surgery in detail, and what to expect after surgery. You are most likely here because your physician found that you have an issue with your gallbladder. Perhaps you have had abdominal pain or other symptoms that may be related to gallbladder. Maybe you received ultrasound test results that revealed gall bladder problems. Or perhaps you've had a gallbladder attack and came to the emergency room where they ordered the ultrasound and diagnosed you with gallstones. Approximately one in seven of the adult population in the United States develops gallstones. But only 30% of those who do will need surgery during the course of their lifetime.

In other words, most patients with gallstones never have any problem with them. There are different kinds of gallstones and there's evidence suggesting that genetics, or our family history may hold some reason for gallbladder disease Gallstones are created largely due to what we eat and our body chemistries. You may have had symptoms of gallbladder disease. The symptoms can be subtle.

Kaiser Permanente Santa Clara Gallbladder Overview

Many patients don't know they have gallbladder issues until they look back and noticed certain foods don't agree with them anymore. Perhaps after eating rich or high-fat meals they feel queasy, or have a slightly upset stomach. These can be very subtle signs. People can have bloating, burping and a lot of gas. We may have a these symptoms without gallbladder disease, but they can also be signs of gallbladder disease. What usually gets a patient's attention is a gallbladder attack.

The medical term for it is biliary colic It occurs thirty to forty minutes after eating. A person often feels sharp pain in their upper abdomen, usually towards the right side. Most people with the gallbladder attack cannot get comfortable, whether they walk, sit, or lie down. Gallbladder attacks can go on for minutes or hours. Usually, if it lasts more than a few hours, patients go to the emergency room because they become very concerned that something serious is going on.

Some people may have small, intermittent attacks that come and go. Others can have back or shoulder pain, located between the shoulder blades or the top of the right shoulder. If jaundice and fever accompany the pain, and more serious condition may exist that needs attention right away. Your colon and intestines fill most of the lower abdomen. Your stomach lies just behind the bottom of your left rib cage. The esophagus, or food tube comes from the mouth to the stomach.

Food travels through the esophagus into the stomach and then out to the small intestine to the duodenum. Finally food moves through the large intestine to the colon. This is the digestive system. The liver makes fluid called bile and the bile moves through a tube call the common hepatic duct on its way to the small intestine to help digest food.

Along the way, the hepatic duct joins up with the gallbladder, at the cystic duct. Together, they form a common bile duct. You make approximately one liter of bile per day and a small portion of that approximately a quarter cup is stored in the gallbladder. Most of the bile goes through to the beginning of the small intestine called the duodenum. When you eat a meal the stomach begins to let small portions of that food into the duodenum and the small intestine starts to digest the food. The duodenum causes the duodenum to squeeze and send additional bile into the duodenum. Attached to the common bile duct is another duct or tube to called the pancreatic duct. This carries digestive fluids from the pancreas, an organ that lies behind the stomach.

Most people know about the pancreas because it makes insulin and if you do not produce enough insulin, you may have diabetes. Asymptomatic gallstone disease refers to a patient who has gallstones that can be seen on an ultrasound or CT scan but there are no physical symptoms. As we said before, seventy percent of patients with gallstones never have any problems with them.

The presence of gallstones is called cholelithiasis. When our liver and gallbladder produce bile for digestion, gallstones may be pushed with the bile fluid from the gallbladder through the cystic and bile ducts. Most stones are small enough to get through an out of the sphincter. 95% of the time they go out unnoticed and are never seen again. Most stones remain in the gallbladder and may pass at a later time.

Passing stones can, at times hurt as they go through. If the gallstone is too big to get through the cystic duct, or if it gets stuck anywhere along the way, that's where you can have problems. A gallbladder attack is the most common complication of gallstone disease. This occurs when a gallstone has become stuck in the neck of the gallbladder and the flow of bile blocked causing pain. A gallstone blocking the cystic duct is called biliary colic. The blockage causes pressure to build on the gallbladder and until the stone is removed and the bile can flow freely, you will continue to have pain. When a patient comes to the emergency room with a gallbladder attack we will give them medication to relax the neck of the gallbladder and allow the stone to fall back into the gallbladder.

That's when your pain should be relieved. However more stones are waiting for the next time that person has a rich meal or some other food, and they're going to have the same problem. It is unpredictable and you never know when you're going to have pain again. This is when we begin a discussion about removing the gallbladder. Another complication that can occur with gallstones is that acute cholecystitis.

This is when there's infection in the bile and the stone blocks the outflow of bile from the gallbladder allowing the infection to build up. If you come to the emergency room with pain and signs of infection including fever an elevated white count we will recommend admission to the hospital an emergency surgery to remove your gallbladder. If gallstones have blocked the common bile duct so the flow of bile is blocked, this condition is called called choledocholithiasis. This can be very quickly lead to more serious complications as the bile then begins to back up into the liver itself.

There are a lot of blood vessels in liver and when the bile gets backed up, it can spill into the blood and people can get jaundice, which is characterized by yellowing of the eyes and skin. You're urine gets very dark like coca-cola and stools can get very light like clay. If the bile ducts are blocked and the bile is infected, This is called Ascending Cholangitis. This is life threatening. Not only was a bile back up into the liver, it brings bacteria into the liver with it and the bacteria with the bile can spill into the blood then patients can become very ill.

Bacterial infection in the blood is a very dangerous condition. If not treated and relieved, it can kill people within 24hours. So if you wake up in the morning you look on the mirror and you have to jaundice, you have a fever, and you have abdominal pain, please come to the emergency room right away. If you're alone, call 9 - 1 - 1. Another organ we mentioned, the pancreas, secretes digestive fluids into the duodenum and small intestine.

The pancreatic duct is the connection between the pancreas and the common bile duct. A gallstone can block the pancreatic duct and prevent the flow of fluids and this time the fluids back up into the pancreas and cause inflammation. This condition is called gallstone pancreatitis. Treatment for this is admission to the hospital. We wait until the pancreatitis subsides and then recommend an operation during that hospitalization to remove your gallbladder. The standard surgery to remove a gallbladder has been called a cholecystectomy.

This operation is performed under a general anesthetic. You have to go completely asleep for the operation. At times, we perform what we call an open cholecystectomy. That's where we make a cut or incision below the rib cage directly over the gallbladder and remove it. The larger incision of the open cholecystectomy is fairly uncomfortable because it is right under the rib cage. Your hospital stay is approximately three days. Another form of surgery is called laparoscopic cholecystectomy.

We make a few small incisions instead of one large incision. This has become the preferred method of surgery. At the time will insert a small catheter tube into the abdominal cavity and pump in some carbon dioxide gas. This lifts the abdominal wall up off all the abdominal organs. The abdominal wall covers the organs in your abdominal region. You have a muscular abdominal wall; filled with muscle, skin and fat that covers everything. This will stretch out and enable us to work.

We put a hollow tube with a camera and light source in that space to see inside. The camera takes pictures of your organs that are sent to two video screens on either side of the operating room table so the surgeon and their assistant can see what's going on. We handle the gallbladder itself through other hollow tubes and instruments inserted in the top part of the abdomen.

We remove the gallbladder from the underside of the liver with a special bag and remove it from the abdominal cavity. Then we remove all of the air, so the abdominal wall goes back down on top of the organs. After surgery there is some discomfort from stretching the abdominal wall, but this usually resolves in a few days. Some people say their waste as a little stretched out for a while, and after a couple of weeks it should go back down to normal. We place absorbable stitches on all of the incisions and some skin glue or steri-strips on the small incisions and then we'll wake you up. We know that patients would rather have the smaller incision or laparoscopic surgery. However, 3% of patients are not be able to undergo a laparoscopic cholecystectomy.

If we do not discover this until after the surgery is already begun, we have to do a conversion to an open cholecystectomy. Before surgery, you sign a surgical permit that gives us permission to do the open surgery, if in our judgment it is the safest way to go for you. For those few where we have to change our approach to open surgery, it's usually because their gallbladder is infected.

The gallbladder can be very diseased and it's very difficult for us to manipulate it through the small incisions. So, if you have an infected gallbladder, it's more likely you'll need an open surgery. There a couple of other things that will cause us to have to convert you to an open surgery. If patients have had prior operations, such as taking out part of their stomach, liver or colon and have a lot of scarring in the abdomen, it may prevent us from lifting the abdominal wall off to the organs to make the workspace. At that point, we would have to do an open cholecystectomy. When doing the surgeries, the images are put up on video screens. Our cameras and equipment are very sophisticated, but sometimes it's just not as good as being directly in front of the tissue.

If we cannot see clearly, or not sure what we're seeing, we will take the open approach to be on the safe side. No discussion about an operation is complete without discussing the possible risks and complications. Bleeding can occur; It's more common in patients with liver disease or on blood thinning medications.

It is unusual, but can happen Common bile duct injuries can occur as well as injury to adjacent organs. In surgery, you want to be able to get in, remove the organ you are concerned with and leave, without damaging any organs on the way in or on the way out. If there's a large amount of infection there is more chance these things can occur. One of the reasons that we would be using open surgical approach is to prevent these kinds of complications Infection of the incisions are within the abdominal cavity are fairly unusual. Incisions are small for the laparoscopic surgery. The rate of infection is less than 1%.

But again, it can happen. Another possible complication is a Retained Common Duct Stone. This is where a stone is caught in your common bile duct.

If we have evidence that you have stones in your common bile duct, we would do an ERCP; or endoscopic retrograde cholangiopandreatogram. That's where the gastroenterologist places a camera down through the stomach and into the duct to remove the stones. If we know about this ahead of time, we'll have them remove the stones before the surgery. If it is not evident until after the operation, we'll have them do it after the surgery.

It's rare to happen at all, but we tell patients just in case. If you're a healthy person without any significant allergies and your heart, lungs and kidneys work well, it's unlikely you will have any problem with anesthesia. But, problems can occur.

All of our medications are very sophisticated. They use a cocktail of about seven to ten drugs to put to sleep and wake you up. If people have significant medical problems, it can be a bit more complicated to do the anesthesia.

The Anesthesia department will discuss that with you prior to your operation. Pneumonia and blood clots can occur after surgery. These are usually related to a patient not being active after their procedure. It's very important after surgery to move around, walk around the house, not do any heavier strenuous activity, but just be active to prevent pneumonia or blood clots. We perform this operation about 750 times per year, which means 10-15 operations a week. All of our surgeons have been involved in a few hundred to a few thousand laparoscopic cholecystectomies.

You are considered an expert if you perform 50 laparoscopic cholecystectomies. So all of us are experts many times over and you have the benefit of two surgeons there at the same time. I reassure patients that all of our surgeons are extremely capable in performing this operation. And it's not just the surgeons; it's the anesthesia teams, the recovery room nurses, the pre-op nurses and the scrub techs in the operating room. Everybody knows what to expect with these operations. Our pre-op clinic will call patients to make sure that everything in the medical record is up-to-date. If they have any concerns about medical issues, they will ask you to come in and see one of our doctors or anesthesiologists.

Please let them know if you have a history of previous surgeries. For most patients a physical is done the day of surgery. If you're a smoker, you'll be asked to come and attend our pre-op class for smokers. This is a very informative class and greatly educates our patients about the risks of smoking prior to an operation.

It's very important to avoid any additional gallbladder attacks prior to your operation. The best way to do this is to keep to a no or low-fat diet before your operation. Disability papers It's very important to get started early on this process. If you need to file state disability forms, we have been at Patient Records, Department 160 and they'll be happy to help you to fill out your forms.

Once we get a date for surgery, the doctors can put me in the work-release for two weeks from the date of surgery. Beginning at midnight, the night before a surgery, you must not have anything to eat a drink. If you are on medications that we feel you need to take prior to your operation, the pre-op clinic will specifically instruct you on what to do. When you arrive, you will check in at the Admitting office of the Ambulatory Surgery Center on the first floor of the the hospital building. If you are having your operation in the main operating room this will be in the hospital on the 2nd floor. The nurses and anesthesia staff will check with you and ask a number of questions. Some of the questions may be asked more than once, especially if you're talking with different people, as we want to make sure that we do not forget anything.

It can be a little annoying so we ask for your patience because we don't want to make any mistakes. If anybody in your families had problems with anesthesia, it's important that you tell us. You may have allergies to some medications and again, make sure that we were informed of these things, If have had anything to eat or drink after midnight on the day if your surgery, please tell us. It is unsafe to put you to sleep with food in your stomach, as the junction between your esophagus and stomach relaxes and anything in your stomach can actually come up and go into your lungs. This is called aspiration pneumonia and can be very serious. People make mistakes and we understand that.

Just make sure and call us and inform us of what you did eat or drink and we can modify our surgery schedule to accommodate you. The operation lasts between one and two hours. If you are having laparoscopic surgery, you will stay approximately 2 hours after the operation and then you are able to go home. The recovery after laparoscopic surgery is very straightforward You can go home and you can eat lightly for the first few days. As soon as you have a bowel movement or pass gas, that indicates that your system is ready to take in foods. Until that time, be careful and need very lightly, such as soups, juices, and fluids. We discharge patients with pain pills and stool softeners. Some of the surgeons prescribe anti-nausea medications as well.

People undergoing the laparoscopic cholecystectomy are usually sore and tired for the first week. After the first week, you should be able to assume most of your activities and after 2 weeks you should be able to return to all your duties. One week following surgery, your surgeon will have a telephone appointment with you to check up on you and see how you doing. You will not need to come in as there are no stitches to remove.

If you've had an open cholecystectomy, your recovery time will be a little bit longer. The larger incision will require more time to heal and you will give it more time by resting and avoiding any heavy lifting. After surgery, you will remain in the hospital for approximately 3 days. There will be more discomfort and your activity level need to be very light for the first couple of weeks.

You should plan to be home 4-6 weeks from work and you cannot lift anything heavy for six weeks. There'll be no dietary restrictions after the operation. I've given you a lot of information in a short period of time.

We hope that we have helped you to better understand the situation with your gallbladder. The department looks forward to meeting you, answering your questions and performing surgery if you decide to remove your gallbladder. If you choose not to have the operation, please review the complications of gallstones again.

If you experience fever, jaundice, unrelenting abdominal pain, please come to the emergency room or call 9 - 1 -1.

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