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Management of gallstones in cirrhotic patients
Y Ishizaki1, Y Bandai, K Shimomura
1Second Department of Surgery, Faculty of Medicine, University of Tokyo, Japan.
Insights
Cholecystectomy in cirrhotic patients undergoing esophageal varices surgery increases bleeding risk, especially in Child C patients. Asymptomatic gallstones in Child A/B patients may not require surgery to avoid complications.
Area of Science:
- Hepatology
- Gastroenterology
- Surgical Oncology
Background:
- Cirrhotic patients often present with gallstones.
- Cholecystectomy is a common surgical procedure.
- Esophageal varices surgery (non-shunting operation) is performed in advanced liver disease.
Purpose of the Study:
- To evaluate the safety and outcomes of cholecystectomy in cirrhotic patients undergoing surgery for esophageal varices.
- To assess the risks associated with concurrent cholecystectomy for asymptomatic gallstones in this patient population.
Main Methods:
- Retrospective review of 34 cirrhotic patients who underwent cholecystectomy alone or with common duct exploration.
- Analysis of patient outcomes based on Child-Pugh classification (A, B, C).
- Correlation of gallstone presence, type (black stones suspected), and surgical intervention with morbidity and mortality.
Main Results:
- Low morbidity and no deaths in Child A and B patients undergoing cholecystectomy.
- All Child A/B patients requiring additional cholecystectomy during esophageal varices surgery needed blood transfusions.
- Cholecystectomy in Child C patients was associated with significant intraoperative bleeding and postoperative complications.
- No symptomatic biliary disease developed in 23 patients with untreated gallstones (suspected black stones).
Conclusions:
- Concurrent cholecystectomy during non-shunting esophageal varices surgery for cirrhotic patients, especially Child C, increases bleeding risk and complications.
- Elective cholecystectomy for symptomatic gallstones in Child A/B patients is generally warranted, but should be carefully considered for asymptomatic stones.
- Minimizing hemorrhage from additional cholecystectomies in Child A/B patients is crucial; consider surgical feasibility and ultrasonographic findings of black stones.
- For symptomatic gallstones in Child C patients, prioritize medical management; percutaneous transhepatic gallbladder drainage may be a safer option considering bleeding tendency and ascites.
Abstract:
34 cirrhotic patients who underwent either cholecystectomy alone or in conjunction with common duct exploration were retrospectively reviewed. In Child A and B patients morbidity was low and there were no postoperative deaths. However, all patients who underwent additional cholecystectomy during the non-shunting operation for esophageal varices required blood transfusion. Cholecystectomy in Child C patients is frequently associated with considerable intraoperative bleeding and subsequent postoperative complications. In the 23 patients who were not operated upon for gallstones, no patients developed symptomatic biliary disease. Ultrasonographically, most of these gallstones were strongly suspected to be black stones. Elective surgical intervention for symptomatic Child A and B patients would normally be warranted, but hemorrhage and resulting complications due to additional cholecystectomy for asymptomatic gallstones during the non-shunting operation should be minimized. An additional cholecystectomy should be considered, provided such a cholecystectomy is thought to be easily performed judging from the degree of development of collateral circulation around the hepatoduodenal ligament and unless black stones are suspected ultrasonographically. For symptomatic gallstones in Child C patients every type of medical treatment should be attempted. After considering the bleeding tendency or ascites, percutaneous transhepatic gallbladder drainage is considered to be one of the safest treatments.