Post on 05-Jul-2015
description
Gallstone Disease
Dr. Raghavendra C V
Institute of Digestive and Hepatobiliary Sciences
SAKRA WORLD HOSPITAL
Gallstone Disease
• Common clinical problem, has high prevalence
• Presentation
– Asymptomatic
– Symptomatic - Acute/Chronic
– Complications - Empyema, perforation
• Treatment
– Laparoscopic cholecystectomy is the gold standard
Cholecystectomy
• Uncomplicated disease
– Non inflamed gallbladder
– Better delineation of biliovascular anatomy
– Easy dissection
• Complicated disease
– Presence of pus, gangrene of the gallbladder
– Difficult anatomy with potential for bile duct injury
– Longer hospital stay due to sepsis and drain
video
Case Capsule - 1• 66 year old male presented with history of
– severe pain abdomen – 2 days
– Nonbilious vomiting and
– Fever for 2 days
• Status post CABG 2005; He had history of past stone disease complication and required ERC in 2012
• Surgery for Gall bladder deferred in view of cardiac status
• Known diabetic and hypertensive
• On examination, he had mild tachycardia; abdominal examination revealed mild tenderness and guarding RHQ
Evaluation
• Laboratory parameters
– Hb-11.2
– TLC-15800
– Neutrophils-86%
– Serum creatinine-0.95
– LFT:TB-0.8,SGOT-42,SGPT-46,GGT-24,Alb-2.8
– EF-45%
• CT scan
– Inflammed edematous thick walled gall bladder with multiple stones
video
Hospital course
• Lap cholecystectomy done
• Post-operative course-uneventful
• Discharged on POD 3
Case Capsule - 2
• 76 year old male presented with history of
– severe pain abdomen – 15 days
– High coloured urine – 1 week
– Fever for 4 days
• Pateint was out of station and hence continued on medical treatment for the past 10-14
• On examination, he had mild tachycardia; abdominal examination revealed severe tenderness and guarding RHQ
Evaluation
• Laboratory Parameters:
• Hb-12.4
• TC -14,400;
• Serum Creatinine - 1.6 mg%
• LFT :TB-3.4,DB-2.0,SGOT-23,SGPT-15,ALP-133,GGT-75,Alb-2.7
• Amylase-52,Lipase-65
• In view of raised creatinine, MRCP was done which showed distended gall bladder with perforation
Hospital Course
• Laparoscopic partial cholecystectomy + intra op ERCP and CBD stenting done on 6/5/14
• Post op stay uneventful; He had issues related to a urethral stricture with serous drain discharge, requiring a longer hospitalization. Patient discharged in stable state
• HPE : Acute gangrenous cholecystitis with intense edema and fibrinous degeneration of wall
Take home messages
• Complicated gallstone disease is technically challenging and requires good laparoscopy skills and expertise
• Patients are usually elderly with multiple co-morbidities which require specific attention
• Complicated disease can be managed laparoscopically with advanced suturing techniques and combined interventional endoscopic approach
• Early discharge with smooth recovery even in difficult cholecystectomies
THANK YOU