Prophylactic cholecystectomy offered for asymptomatic cholelithiasis who have a higher risk of developing gallbladder cancer need to be identified.Age, geography, race, size of stone and stone / GB volume ratio to be taken into account. pre-emptive cholecystectomy or Prophylactic cholecystectomy is indicated in with patients with some benign conditions and anticipated long-term survival.
As per William J Mayo, 1904,there is no innocent gallstone .The word “asymptomatic gall stones”, looks to be a misnomer as it conveys that the gallstones are innocuous.Asymptomatic gall stones are defined as stones that have not caused biliary colic or other biliary symptoms.Nearly two-third of patients with gall stones are asymptomatic. The cumulative probability of developing biliary colic after 10 years ranges from 15 to 25 %. Cholelithiasis results from the abberation in metabolism of cholesterol, bilirubin and bile acid.Prevalence of cholelithiasis in Northern Indian is more than Southern Indian and this is more in females than in men.Gall stone disease being more common in north India occurs at a younger age than in the Western population. Number of patients with symptomatic gallstone present with features of pain right upper abdomen, vomiting , flatulent dyspepsia,biliary colic or gastritis. There may be presentation as an acute cholecystitis, mucocele,pyocele or empyema of gallbladder ,or jaundice or the chronic cholecystitis .Migration of stones from gallbladder lead to choledocholithiasis, obstructive jaundice,recurrent cholangitis,acute pancreatitis,Mirrizi’s syndrome or the Bouveret’s syndrome,a rare form of gallstone ileus caused by the passage and impaction of a large gallstone through a cholecysto-duodenal fistula in the duodenum,resulting in gastric outlet obstruction.Those who had attack of cholecystitis will have to undergo cholecystectomy as there are chances of frequent attacks and morbidity unless strict preventive steps taken.Long standing gallstones lead to to progressive changes in gallbladder wall(mucosa) from chronic cholecystitis, hyperplasia, metaplasia, dysplasia, carcinoma in-situ, to invasive cancer over course of time. Cholelithiasis in young adults and children because of higher cumulative lifetime risk of malignancy of gallbladder, life expectancy >20 years and geographical regions with a high prevalence of gall bladder cancer should have prophylactic cholecystectomy .
Increasing size and number of gallstones aggravate risk of gallbladder cancer especially if the stones occupy a significant volume of the gallbladder (higher GB stone to GB volume ratios).Stone size has pivotal role in incrimnating gallbladder cancer. Sessile ,and solitary stone have increased risk of leading malignancy than small one.Stone size ranging 2-2-2.9cm has relative risk of 2.4 and stone size of >3 cms. have relative risk of 10.7 in association with causation of gallbladder cancer.
Even if multiple small stone present in gallbladder, recommendation is that to have prophylactic cholecystectomy.Choledochal cyst,Porcelain gallbladder,anamalous pancreatobiliary duct junction,gallbladder polyp > 1 cm.,adenomyomatosis of gallbladder,chronic typhoid carriers are the premalignant conditions whenever existing in gallbladder, prophylactic cholecystectomy is to performed.
These small stones have potential ability to slip, get lodged in common bile duct or block pancreatic duct. Obstructive jaundice,cholangitis or an acute pancreatitis may precipitate and these highly morbid conditioons , even sometimes have mortality . In this endemic area, sometimes gallbladder ascariasis is encountered which may remain symptomatic or asymptomatic sometimes .Wandering nature of ascariasis often leads to their escape from gallbladder, but often may get impacted .These may trigger acute cholecystitis or the worm gets dead inside.Dead worm is nidus for stone formation ormay get calcified.In one or the other way, cholecystectomy to done as being endemic area to prevent gallstone formation and its complications.On rare occasions , tapeworm diagnosed inside gallbladder , being asymptomatic ,prophylactic cholecystectomy indicated.
There are surgical procedures with enhancing stasis factor gallstone formation.This staggering list has surgical procedures incorporating gastrectomy for cancer, small bowel resection, colonic resection, mesenteric vascular disease, splenectomy as well as all bariatric surgical interventions .Short-bowel syndrome with intestinal remnant length less than 120 cm, total parenteral nutrition required, and the terminal ileum resected have a significant risk for cholelithiasis should have prophylactic cholecystectomy.All have to have prohylactic cholecystectomy but the specific morbidity of cholecystectomy must be kept in mind
Consideration of prophylactic cholecystectomy along with appendectomy in astronaut and those going for space mission is with limited access to treatment is recommended to prevent the theoretical catastrophic loss of human life and expense mission in the unpredictable environment of extended duration space mission.
Dr Imtiaz Ahmed Wani IS Surgeon Specialist; DHS, Kashmir
imtazwani@gmail.com