Pathophysiology and treatment of gallstones

Black bile of melancholy or gallstones of biliary colics: historical perspectives on cholelithiasis

Barely 130 years after its first description, cholecystectomies are among the most commonly performed surgeries in the USA. The success of this operation with subsequent technical improvements, such as laparoscopic approaches, caused a paradigm shift in the management of gallstone disease. However, symptoms persist in 10-40 % of successfully operated patients. Reviewing monographs, textbooks, and articles published during the last 300 years, several important factors emerge as likely contributors to limited or poor treatment responses. Early on, clinicians recognized that cholelithiasis is quite common and thus often an incidental finding, especially if patients present with vague or atypical symptoms. Consistent with these observations, patients with such atypical symptoms are less likely to benefit from cholecystectomy. Similarly, lasting improvements are more reliably seen in patients with symptoms of presumed biliary origin and documented gallstones compared to individuals without stones, an important point in view of increasing rates of surgery for biliary dyskinesia. While cholelithiasis can cause serious complications, the overall incidence of clinically relevant problems is so low that prophylactic cholecystectomy cannot be justified. This conclusion corresponds to epidemiologic data showing that the rise in elective cholecystectomies decreased hospitalizations due to gallstone disease, but was associated with a higher volume of postoperative complications, ultimately resulting in stable combined mortality due to gallstone disease and its treatment. These trends highlight the tremendous gains in managing gallstone disease, while at the same time reminding us that the tightening rather than expanding indications for cholecystectomy may improve outcomes.

Liver transplantation: the last measure in the treatment of bile duct injuries

BACKGROUND

Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI.

METHODS

Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test.

RESULTS

Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively.

CONCLUSION

Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.

Ultrasonography detected a higher incidence of gallstones in psychiatric inpatients

A total of 105 psychiatric inpatients (55 men, 50 women) were investigated for gallstones and associated factors by means of ultrasonography. Gallstones were detected in 27 (26%) of the 105 patients. The overall incidence tended to be higher in female patients than in males. The duration of mental illness and neuroleptic medication in patients with gallstones was significantly longer than in those without gallstones. A stepwise discriminant analysis revealed that the duration of neuroleptic medication was the most informative for discrimination between the 2 groups. These results, in combination with previous studies on the effects of neuroleptics on the bile and biliary system, suggests that neuroleptics may accelerate the formation of gallstones.