Sunday, April 01, 2007

Stones and Knives

No chemist I, unable to explain solubility constants or crystal formation, I can only note and admire: gallstones come in all sizes, shapes, and textures. Hard and shiny like agates, faceted like emeralds, crumbly like clay. Mulberry-shaped, round, uniform or uneven; surfaces determined by their neighbor, or identically shaped as if manufactured. Green, black, bright yellow, fecaloid. They can occur by the hundreds in a single gallbladder, or fill up an entire bag in the form of one gigantic rock. Feeling like a magician, I liked to save a few from the lab and present them to their owners, more amazed than if I'd pulled a quarter from behind their ear. I always enjoyed looking at gallstones. Unless they were oozing out of a gooey gallbladder in the middle of an operation, like cockroaches from a garbage bin.

Learning surgical technique is an incremental process. The student may be allowed to cut some sutures, maybe even tie a few. Simple as that is, it allows a sense of tissue tension, unlearns the old way of holding scissors, teaches the new. Taking up a knife and cutting through the skin requires overcoming practically everything you ever knew. I was eventually allowed to "do" a hernia as a student (a rarity indeed), although I really had no idea what was happening, anatomically speaking. The resident held something in such a way that I had no question of what I was to do, and I did it. As an intern, I did more of them, getting better at maneuvering instruments, placing sutures where I aimed them, cutting without shaking so hard it was visible across the room. Taking out a gallbladder was, where I trained, too big a deal for an intern. It was real surgery, inside the abdomen, close enough to structures of significance, demanding enough of dissecting skills that we waited a year before getting the chance. So it always held special significance: like passing through a portal, like being taught the secret handshake. Tourists in fancy eateries are shown to the main dining area; locals get invited to the wood-paneled special rooms upstairs.

You can do some operations without knowing how to operate. In my book I wrote "with enough bananas, you could teach a monkey to take out an ovary." Some gallbladders are so easy to remove, hanging loosely under the liver like a pluckable plum, that I refer to them as "gynecologic gallbladders." If your first couple of gallbladders are like that, you can get lulled into thinking you know what you're doing. (Way back in my early practice days, when our community allowed more or less unfettered surgery privileges, more than once I was urgently invited in to bail out a family doc who discovered dramatically the mysteries held in the right upper quadrant, and who'd been epiphanized into the realization that knowing how to hold a scissors in one's hand does not a surgeon make.) In those same ancient times, it was believed that operating when the gallbladder was actively inflamed was to be avoided at almost all costs. Whereas it's true that most attacks of acute cholecystitis simmer down without the need for emergency intervention, they don't always. Gallbladders can get severely infected and can rupture (especially in diabetics); acute attacks can flare up again during a cooling off period. More recent studies tend to show that early intervention isn't associated with more problems than waiting. But it sure as hell requires knowing how to operate.

While serving in Vietnam, I "flew" EC-47s. The pilot would arrange power settings and trim, giving over to me the stick and rudder. I "did" takeoffs and landings, accomplished some cool maneuvers over the China Sea. Shit hot, as we pilots liked to say. On final approach, if the crosswinds were a little too harsh and I was coming in crabwise, at the last minute he'd say "I got it" and keep us alive. Under tight tutelage I removed a few gallbladders early in training, and came to feel I could do it. When I first encountered the real thing while helping a young 'un -- a red, swollen, pus-filled gallbladder, speckled with the black spots of gangrene and stuck tightly to the colon and liver -- I squealed for help like a kid who'd wandered out of the shallow end. Throughout my career, when I'd be working my way through such a mess with confidence, at some point I'd always remind myself of that first really scary one, and allow myself a smile. Behind the mask.

In the illustration above, you can see how the colon makes a sharp left turn (the "hepatic flexure" -- "left," by the way, orients vis a vis the patient). In life, it's immediately below the gallbladder, very often touching it. Same with the duodenum, which isn't marked but is the C-shaped tube at the bottom of the stomach. Uninflamed, those structures easily peel away from the gallbladder. There's a thin covering of the gallbladder which holds it to the undersurface of the liver, filmy, as if it were sprayed on, easy to navigate, buzzing a few small bleeders on the way. Down at the business end, the tube that connects the gallbladder to the main bile duct, and the artery that feeds the gallbladder (cystic duct and cystic artery) are usually not to hard to identify and divide: in most cases it takes a little dissection through a layer of fat to find them, typically not a great challenge. Ironically, though, some studies show that it's when things are "easy" that injury is most likely to occur: when your guard is down, you feel relaxed and floaty, recreational, and you might not attend as intently to the anatomy. So they say. Subtle anatomic variations occur here, and they can fool you. Still, with care, it's fun and safe.

Oh man! Not when the gallbladder is acutely inflamed or infected or both. That sprayed-on film is now thick as a the peel of a grapefruit. The colon -- duodenum, also, maybe -- is plastered to the mess and has become inflamed, too, such that where one ends and the other begins is anyone's guess. The adjacent surface of the liver, caught up in the raging redness, is gooified and extra bloody. And the little duct and artery? Good luck! Encased in dense edematous tissue and often indecipherable. This is where everything you've ever learned about handling tissues, every trick you were taught and every wrinkle you've come up with yourself needs to come front and center. When nothing is normal, no move has a predictable outcome.

How can I describe a combination of caution and boldness, of confidence and trepidation? What does it take to enter such a zone recognizing the danger but believing you can do it? (Not as much as entering a burning building or a free-fire zone.) In "Cutting Remarks," I came up with the term "delicate brutality." I like it (in fact, I've since thought that would have been a better title for the book.) You can't blunder into the foray swinging sledgehammers like an orthopedist. But if you diddle around forever, nibbling at the edges, afraid of the water, you'll drag the operation out too long: the sicker you are, the less you need a long anesthetic. So you resort to techniques that can move along briskly but respectfully. Blunt baby steps. A careful cudgel. Delicate brutality.


Dr. Charles said...

you could easily compile all these topic-related posts into a book, they are excellent.
i love when people bring in their kidney stones to the office. no one brings in their gallstones for obvious reasons, so thanks for the photos, too.

Annie said...

I agree with dr. charles - I even mentioned it as a late-entered comment on your last blog. So, go for it! Your adoring public would love wouldn't take a lot of additional work on your part and it would be a way to compensate you for the incredible effort that you put into this blog. Everyone would benefit!

Dr Dork said...

After those images, I am now craving fresh ground coffee and chocolates..mmmm.

rural_obgyn said...

while ovaries are indeed usually easy to remove (unless they are mixed up with the sigmoid :-) your monkey might have some trouble guaranteeing that the ureter isn't higher than it should be. I once saw a highly skilled surgeon in a hurry cut a ureter while transecting the infundibulopelvic ligament.

Anonymous said...

Just ordered your book.

I am a person with high expectations :)

Sid Schwab said...

rural: just kidding, heh, heh, heh

anon: hope you like it. It'll help if you lower them just a little.

Anonymous said...

Gosh - removing an infected gallbladder sounds exactly like operating on a tubo-ovarian abscess or resecting a bad endometrioma...

Cathy said...

lol@ Dr. Dork...yuck!

When I had my BG removed I had to stay over night because i needed a JP drain. How do you decide who does and doesn't need those things? Mine was infected so maybe that is why? Anyway, when my surgeon came in the next morning, he said..."You had alot of stones in there. For a minute I thought I was working in the M&M factory" They were almost all the size and shapes of M&Ms." I said to him.."You mean they were multi colored?" He replied that NO they were not, they were all an ugly grey color, but, they still reminded him of M&Ms.

See, I just can't imagine working in someones insides, and relating it to something we eat....:)Especially something as good as M&Ms.

happyj said...

Thank you for sharing those great pictures! I knew what a gall bladder looked like after your wonderful series when the Discovery Health Channel showed an operation (I think exploratory) and I could see it. This will probably sound dumb, but after being around surgeons and hospitals so much it feels very natural to see and learn about this stuff.

Lynne said...

I have gallbladder cancer, and I guess my gallbladder was a mess when the surgeon removed it. I thought the photos, and this whole line of posts about the GB was very interesting. Loved those photos of the stones!

Since gallbladder cancer is rare, and those of us affected by it are trying to raise awareness of it, I'd appreciate your spending a post on GB cancer. If you removed all of those GBs, some of them must have been cancerous!

Also, if your posts are read by interns and surgeons training to be surgeons, could you reinforce the importance of removing the GB carefully, whether or not you know it's cancerous? (I was operated on at a teaching hospital.) I'm very happy with my surgeon, and this is not a criticism of him, but I have had two implants growing in my abdomen near the incision, and as my tumor markers climb, I wish they weren't there. Students, interns, residents need to learn early on to be extra, extra careful. This is a nasty, aggressive cancer!

And, I didn't know that my GB was robins' egg blue once upon a time! Amazing! Thanks for lots of good information.

medstudentitis said...

those green ones are pretty. I would wear a necklace made out of them, alghough I'm sure they smell or something.

Kathleen said...

Cathy, Curious how long your drian tube was in. Those things suck. If there is leak , you get a drian. I knew this guy, he had the whipple over 3 surgeries and do you know he had FIVE drain tubes!!!! Made me feel like an idiot for complaining but that's another story. So, yeah, they can get infected, any kind of tube or line can get infected. Just one more reason, if at all possible to stay out of hospitals.

Lynne, I am really sorry for your cancer. I have had some really great work done my students. I honestly got a great sew up job once by a student. Pople still oo and awe over how well it matches. I think students sometimes do a really awesome job because they are watching everything they do. Nothing is routine for them yet. All and all , teahing hospitals are really where you want to be when you have a major issue going on. Hang in there girly!

NotMySecondOpinion said...

Gallstones remind me of pearls. They are formed in much the same way, where a small little irritant forms a nidus which grows and grows.

We just finished up our GI subunit, so it was a pleasure to read your bit on gallbladders. Keep up the good work, Dr. Schwab!

The Independent Urologist said...

Sid, I can't get the image of the nurse on China beech peeling off her combat fatigues to reveal a bikini. Nice image.
The IU.

Cathy said...

Kathleen, I don't think my tube got infected I think my GB was infected. I didn't do well at explaining that..This tube was only in for 24 hours.

But, I have had bigger surgeries with multiple JP drains, that were in for days, and they must have snaked through my entire insides. I remember having those things pulled out..HOLY COW! There was no comparison to the one I had during that GB surgery. As far as drains go, this one for the GB, was nothing.

Sid Schwab said...

IU: an indelible image, all right, still fresh as that day. To other readers: the reference is to a passage in my book.

Anonymous said...

Cathy, Roger that. My worst drain wias with many whipple, it was in a few months and then one night around 2am I had enough and went into the bathroom and pulled it out. Life got more comfortable after that! LOL I just got a new tattoo to help cover up some of the scars and stuff...My GB was infected too. Warm Wishes, Kathleen

Anonymous said...

Thanks for great info ! I have read a lot about gall bladders today as my mother is mid-way through the process of possibly having hers removed. I am wondering if you have any input on the relationship of Celiac Disease to gall bladder inflammation or dysfunction ? Other sites I have visited note indicate there is a direct correlation . . .

Rositta said...

My offspring sent me to your blog. I'm having my gallbladder out in two days. I hope I don't have any complications. I never did have pain in my gut, only in my back below the right shoulder blade. It felt like a heart attack and sent me to ER, where dumb doctors didn't diagnose it. Here I am 4 months later waiting for surgery. Very informative posting, thank you...ciao

Amy said...

I have always been a pretty healthy eater and have always exercised. I'm 5' 7" and weighed around 145 till 4 years ago, when I suddenly put on 20 lbs that won't come off, I'm guessing related to the hormonal changes related to menopause. On 11/08/07 my cholesterol was HDL - 80, VLDL 26, and LDL 122, triglycerides 131.

I had my 1st attack on 7/24/08 at 3:00 pm that lasted till around 5:00 pm. I thought for sure it must be a heart attack and would have called 911 but I was in so much pain. Then nothing after that.

I just turned 49 on 8/11. Around 1:00 am on 8/13, 14, 15, and 16 I woke up with pain in the same area, felt like having a knife stuck up under the center right rib and like a truck had parked across my midback. Each night it was gone after a couple of hours.

The next 2 days, nothing.

On 8/19 at 10:00 am while having an eye exam, another attack came and sweat was pouring out of every part of my body. The DR was just around the corner, and she ordered an ultrasound.

The ultrasound results state in part 'the common duct measure 2.6 mm AP, within normal limits. Cholelithiasis is noted with a 7 mm echogenic mobile shadowing. No gallbladder wall thickening or pericholecystic fluid is identified.'

If there were multiple gallstones, would it have been mentioned in the results?

They immediately scheduled me for a consult with a surgeon and I scheduled surgery for 9/15/08.

I have not had another attack since the one on 8/19. I've been reading that more attacks are likely, but if I don't have any more attacks before 9/15, I think I should cancel the surgery. I really don't want to jump the gun and remove something if there is a possibility that I won't have any more attacks and I've only had 6 so far. Since the ultrasound only mentioned the one stone, it is too big to actually get out and cause damage down the line.

Is it possible the increased estrogen from the cycle of menopause has caused the gallstone and once I have completed the cycle of menopause, the incidence of gallstones will decrease? I'm thinking if I can just get through this hormonal period, it will be ok.

I am not on any hormone replacement and I only used birth control for about a year in my teens and none since.

Sid Schwab said...

amy: as I've said elsewhere, I nor anyone else has a crystal ball. People who form stones tend to form stones; people who have attacks tend to keep having attacks. It's impossible to make a prediction for an individual. The odds would say you'll have many more attacks; it's possible you'll have none. If you want to cancel surgery, it's certainly your option. You seem to know the data. The only situation where there's no option is if the gallbladder gets infected/inflamed enough to have rupture, or if there are certain other serious complications.

When Dirty Harry asked the guy if he felt lucky, it turned out the gun was empty.

By the way, a 7 mm stone is only a little bigger than a quarter inch: plenty small enough to pass into the main duct and cause other kinds of problems.

Leigh Ann said...

Thank you so much for this blog, it helped me so much when I had my gallbladder removed several years ago. This year I dx'd myself with bile acid absorption, after being tested for celiac, crohns, etc. due to chronic diarrhea. Dr. tried to label it as IBS, but I kept digging for an answer. I take a bile acid binder (prevalite) and it has changed my life. What can you tell me about this disorder? I have found some articles online but the way you explain things makes more since to me. I know they say that this can be a result of having the gall bladder removed, but I began having symptoms well over a year before my surgery.

Sid Schwab said...

Leigh Ann: I assume you mean malabsorption. I'm guessing that, having researched it, you know more about it than I do. There are many causes; or maybe it's better to say associations, because as far as I know the mechanisms aren't well understood, except in obvious situations such as having had part of your distal small bowel removed, or in specific bowel diseases like Crohn's.

In my view, irritable bowel syndrome is frequently a pretty vague diagnosis; the fact that binders such as you're taking seem to help some people with presumed IBS means... who knows what in terms of your diagnosis?

Since it predated your surgery, it seems unrelated to that. The main thing is you're getting relief, and that's a good thing, whatever the cause.

Anonymous said...

I'm due to have a lap chole to remove my gallbladder. I have multiple small gallstones but no inflammation. I already suffer from chronic pancreatitis and have had a few acute attacks of pancreatitis, plus possibly biliary colic, which my doctors seem to think are caused by the gallstones. My CP predates my gallstones by some years so it isn't classic gallstone pancreatitis. The reasoning behind the lap chole appears to be primarily prevent acute pancreatitis attacks.

I am very risk averse and thought of complications fills me with dread. I think a bile duct injury would probably be the end of me in combination with CP. From what I've read it's considered a disaster on it's own let alone if you have something like CP as well. I know it's quite a small risk (1 in 200) but it does happen. Given already I have quite severe steatorrhea I think the chances of further severe acute attacks seems fairly unlikely as I must have lost most of my exocrine function already, and additionally the lap chole could further degrade my already damaged digestion/absorption. Hence, I am debating whether it is worth the risk to have the lap chole ? Any thoughts ?

Sid Schwab said...

I really am in no position to make specific recommendations. I can make some general statements, of the sort that I told my patients.

I think it's pretty well agreed that if a person has had acute pancreatitis and has documented gallstones, that removing the gallbladder is indicated. As you're aware, the situation with chronic pancreatitis is less clear. ( I'd say that when gallstones are present, there's rationale behind the idea that removal might play a role in preventing more damage. I've done a few operations for chronic pancreatitis, in at least one case of which gallstones were present, and I removed the gallbladder as well. That was, however, a pretty extensive open operation (Peustow procedure, referred to in the link below), and the cholecystectomy added little additional time or risk.

Digestive problems after cholecystectomy are relatively uncommon, despite what's out there online: of the hundreds of thousands of people who undergo the operation every year, you only hear from the ones that have problems.

In the hands of a well-experienced surgeon, the chance of bile duct injury is very low. The biggest problem is if it occurs and isn't recognized at the time. Given the low risk of injury and the high probability of recognizing and fixing it, the chances of long-term consequences are low.

Here's a link to a department with lots of specialists in pancreatic surgery, and links to them within the article. Maybe you could inquire with them.

Rick said...

recently diagnosed with addisons I was experiencing discomfort also right upper quadrant had hida scan 14% ejection result. No stones ultra sound. Pain to me feels like a burning sensation does any body else describe it this way. Read a blog which suggested possability of sub clinical infection from gall bladder not discernable by lab tests causing adrenal damage. ever heard of this?

Discomfort comes and goes. No pain caused by HIDA scan. Pain not duplicated.Could my gall bladder be poisioning me.With 14% is removal appropriate? I have never had surgery and am nervous at the prospect.

Sid Schwab said...

Rick, adrenal failure can result from overwhelming sepsis; it's hard to see how a "subclinical" infection anywhere would do it. Haven't heard of it. Which is not to say it's impossible.

I can't tell you whether or not to have surgery. All I can do is repeat the general information and opinions I've written about HIDA scans before: in my opinion and experience, when the HIDA shows significant impaired emptying, AND the injection reproduces the pain, AND the pain syndrome is highly suggestive of gallbladder origin, there's a good chance removing the gallbladder will help.

The people best able to advise you are the doctors directly involved.

Rick said...

Thank you, Sid.I take your point. Look for all three.Most of the discomfort I feel in the upper right quadrant I describe as a burning sensation. This can eventually go around the bottom of the right rib cage.I do not find other's describing their pain as burning sensation. Did any of your paitients describe it this way?
Before I was medicated for Addison's I tried Levothyroxine for sub clinical hypothyroid. This produced stabbing pain on both sides in what I describe as my kidney area.Upon learning of Addison's I believed it to be my adrenal glands. I have been told that is not likely since ther is very little nerve tissue in this area.Stabbing pain stopped when levothyroxine stopped.In the process I had the HIDA. I still wonder if stabbing pain in back both sides was adrenal glands rather than classic gall bladder.I would appreciate any thoughts you care to share.Thank you for your previous reply

Sid Schwab said...

Rick, there's a pretty broad spectrum of pain syndromes that can be of gallbladder origin. When it's "classical," and the imaging is consistent, the diagnosis is pretty easy. When the symptoms aren't typical, such as burning, it becomes less clear; but burning is a description I've heard more than once.

I can't explain how taking levothyroxine would cause any of it.

Beyond that, I can only repeat what I said: work with your docs. Sometimes it takes a long time to figure things out, when it's uncommon.