Alpha Patient Education Series #2 – Gallstones

Laparoscopic Keyhole Surgery: Removal of Gallbladder

1. What are gallstones?

Gallstones are stones found within the gallbladder, a small bag-like organ which is attached to the lower surface of the liver.  The stones are composed of different materials (chemicals) such as cholesterol or bile pigments.  They vary in size from about 1 millimeter to a few centimeters.  Symptoms are not related to size of stones.  Rather, it is their location within the bile drainage system which is crucial.  In fact, small stones have the risk of dropping into the bile duct, thereby causing blockage of flow of bile from the liver to the duodenum.  The result is jaundice, a yellow discolouration of the skin and whites of the eyes – a potentially serious complication.

Before the modern era of surgery, many famous figures have suffered or died from gallstones.  Anthony Eden, a British prime minister during the Suez Crisis of 1956, was one such tragic victim.  Surgery was delayed as it was deemed to be too dangerous.  When it was eventually done, he remained very ill and required heavy medication which caused exhaustion and possibly impaired judgment.  It is often speculated whether the outcome of history might have been drastically different if only he could have had timely removal of the offending gallstone.

2. What are the symptoms?

Gallstones are usually asymptomatic (clinically silent) – the patient feels perfectly well.  They are detected during routine ultrasound scans of the abdomen, such as in pregnancy or during health check-ups. Common symptoms are gallstone colic (upper abdominal pain), abdominal discomfort and bloating, especially after heavy or oily meals. The pain will usually subside after about 3 to 4 hours. Occasionally, it may be so severe as to require injection medication.  Complications of gallstones are acute cholecystitis (inflammation of the gallbladder) which causes continuous, unremitting severe pain; bile duct obstruction resulting in jaundice; and pancreatitis (inflammation of the pancreas).  The latter two conditions may be fatal if treatment is delayed.

It should be noted that gallstone colic is often mistakenly attributed to gastric ulcer.

3. How are gallstones diagnosed?

Diagnosis is made from a good clinical history obtained by a trained specialist (surgeon or gastroenterologist).  Confirmation is via radiological scanning, either with ultrasound or computed tomography (CT, “CAT”) of the abdomen

4. What treatment is available?

Asymptomatic gallstones can be left alone.  Treatment is recommended only if there are symptoms or complications.  The risk of these events happening is about 1 to 2 % per year.  However, once symptoms develop, the patient will invariably suffer further attacks and treatment is strongly advised.  The gold standard of treatment is laparoscopic cholecystectomy, which is removal of the gallbladder via key-hole surgery. The main advantage of this method is that it is minimally invasive: the scar is small; post-operative pain is minimal; and hospital stay is consequently reduced.  In about 5 to 10 % of cases, the operation has to be converted to the open technique involving a surgical incision of 8 to 10 cm.  The usual reasons are either inflammation which renders it difficult to identify key anatomical structures, or complications such as bleeding.

The symptoms of gallstones will be relieved permanently after surgery.

5. More about laparoscopic cholecystectomy.

The patient is admitted to hospital for one or two days.  The operation is performed under general anaesthesia.  It takes about one hour.  Four small holes (5 to 12 mm in diameter) are made in the abdomen.  The surgeon places laparoscopy instruments into the abdominal cavity through these holes (ports) to perform the operation.  Titanium clips are placed on two vital structures (cystic duct and cystic artery) which have to be cut during the operation.  These clips are specifically designed for this operation and will remain in the body; they do not produce any side effects. The entire gallbladder, including the stones it contains, is removed (“delivered”) through one of the ports. The procedure is recorded and the patient can have a hard copy such as on DVD.

6. What are the complications of laparoscopic surgery?

The main complication is bile duct injury, which happens in about 1 to 2 % of operations. Treatment depends on the extent of injury and whether the injury is recognized immediately during the surgery or delayed post-operatively. Options range from stenting the bile duct (by placing a temporary plastic tube) for minor injuries, to major surgical reconstruction of the bile duct for complicated injuries, a difficult and hazardous process.

Obviously, such complications are best avoided.  The risk is related to previous scarring in the abdomen and the operative experience of the surgeon.

7. What are the long-term effects of laparoscopic cholecystectomy?

Patients will lead normal lives after the operation.  No more dietary restrictions!  Long-term follow-up is not required.

Alpha Patient Education Series #1 – Breast Lumps

1. What are breast lumps?

Breast lumps are swellings felt within the breasts.  They may be single or multiple.

2. How are breast lumps detected?

Breast lumps are usually discovered by the patient herself.  This may be on self-examination or during unrelated activity e.g. during a shower.  They can also be detected by a doctor during a health check-up.  Breast lumps are reliably detected on screening by breast imaging, either with ultrasound or mammogram.

3. What are the related symptoms?

Most breast lumps are painless.  Pain is found in a rapidly growing lump or if there is infection (abscess).  Pain is not a feature in breast cancer.

Your doctor will ask relevant questions when you present with a breast lump.  These include whether you had a previous history, how long it was there, fluid discharge from the nipple, the number of children you have, taking oral contraceptives (the ‘Pill’), whether you still have periods or if you are menopausal, and whether you have a family history of breast cancer.  These questions aid in diagnosing the nature of the breast lump.

4. What are the types of breast lump?

Breast lumps are either cystic (liquid-filled) or solid.  Cysts are almost entirely benign.  Solid lumps can be either benign or malignant (cancerous).  Benign lumps are mostly fibroadenomas (firm white lumps containing the protein collagen).  Other benign lumps include haematoma (old blood clots), galactocoele (collection of breast milk), mastitis (inflammation), abscess (infection) and granuloma (chronic infections including tuberculosis).

5. What are the tests required?

The ultrsound scan will distinguish between cystic and solid masses.  Mammography (‘Mammo’) is useful in detecting changes in the breast pattern (architecture) on plain x-ray films; some of these changes may indicate early cancer even before a ump is detected.  Mammograms are usually recommended after the age of 40.  Because these tests provide different kinds of information, a combination of both is often used.  In cystic swellings, the fluid may be aspirated (drawn out) and sent for cytology, which is a microscope test to look for cancer cells.  Solid lumps can also be studied by this method, namely fine needle aspiration cytology (FNAC).  The accuracy of this test is over 90%.

6. What is the treatment?

Cysts should mostly be left alone.  They can be aspirated if large and/or cause symptoms, such as discomfort.  Should a solid lump be left alone of removed?  Based on the history, physical examination, and ultrasound and/or mammogram, your surgeon will advise on the best treatment plan for you.  If there is any suspicion of cancer, urgent FNAC and/or excision is vital.

7. Surgery for breast lumps

Excision is done under general anaesthesia.  This is not a major surgery and can be performed in a day-care setting; i.e. you do not require overnight hospital stay.  It is a short procedure (about 30 minutes).  The scar will match the size of the lump.  If absorbable sub-cuticular (under the skin) sutures are used,  they do not have to removed and scarring is much less.  All excised lumps are sent to the laboratory for histological examination (HPE) to determine their exact nature.  Needless to say, early surgery offers the best chance of cure in breast cancer.