Gallstones and Gallbladder Surgery

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic Podcast exploring your digestive and surgical health from end to end.

Hi again, everybody and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. I'm very pleased to have a second time appearance here on Butts & Guts, Dr. Diya Alaedeen, Section Chief for the Department of General Surgery at Cleveland Clinic Fairview Hospital. Previous episode for our longtime listeners discussed appendicitis and we're going to talk about a different topic today, that's gallstones and gallbladder surgery. Diya, welcome back to Butts & Guts.

Diya Alaedeen: Thank you, Scott. Good to be here with you today.

Scott Steele: For those listeners that did not go back and listen to your background, we always like to start off with a little bit about where did you come from? Where did you train, how to get to the point that you're here at the Cleveland Clinic?

Diya Alaedeen: Thank you. I've been with the clinic now for 12 years. I started at Fairview Hospital right out of my fellowship. My fellowship was in advanced laparoscopy and endoscopy training, and I came straight to the Cleveland Clinic at Fairview Hospital. I've being here for 12 years, as I mentioned. 10 of those years, I've been the section chief of general surgery. My practice is mostly GI surgery, advanced laparoscopy and endoscopy. I trained at Indiana University before I came here and we have a very busy practice. Actually, I was doing a complex abdominal surgery right before we got onto this call. So we're always busy here and we're always welcoming our patients and trying to do best by them.

Scott Steele: Well, we're certainly glad to have you here. And so today we're going to talk a little bit about gallstones, something that is extremely common. You probably know somebody out there who has either had problems with gallstones or had their gallbladder removed, but let's just really start basic. What are gallstones and how do they develop?

Diya Alaedeen: Great question. You can't talk about gallstones without talking about the gallbladder. The gallbladder is at pear shaped organ that is attached under the surface of the liver. And the only function of the gallbladder is to store bile. Bile is the digestive juice that's secreted by the liver and stored by the gallbladder. When the bile precipitates out of solution, which has cholesterol, bile acid and bile salts, and if there's no equilibrium at that solution, the cholesterol precipitates out of that solution and it clumps together into gallstones. Gallstones are very problematic because they can cause gallstone disease.

But it's interesting to know this Scott that about 20 million Americans, we know this from previous studies back in the days when they used to do a lot of autopsies, there's about 20 million Americans who do have gallstones found incidentally and have absolutely no problems from the gallstones. Knowing today gallbladder disease is the most common reason patients seek surgery. About 1 million gallbladders are removed in the United States every year. So gallstone disease is very prevalent in Western society.

Scott Steele: Wow. I never heard that particular statistic before, so that's incredible. So what are the common symptoms of a gallstone. Can they be just lurking, as you said? What causes them to create symptoms?

Diya Alaedeen: Most calls don't can be present in the gall bladder without causing any problems. However, when the gallbladder squeezes to secrete the juice that is stored inside of it, if one of those stones obstructs the exit to the gallbladder, that gallbladder becomes obstructed, it can become infected and its causes a lot of pain until the obstruction is relieved.

The most difficult presentation of gallbladder disease is what we call biliary colic, where the patient, after a fatty meal, like a grilled cheese sandwich or a pizza or a hamburger, 20 minutes later, they can experience right upper quadrant pain. That's where the ball better sits. The pain can radiate to the right flank, the right shoulder, and it's often accompanied by nausea and vomiting. And if it's biliary colic, that means one of the stone is obstructing until the stone is dropped down and relieves the obstruction, it can last between one hour to four hours. But if it's an infected gallbladder, that pain usually continues to be more severe and so the patient presents to the emergency room for treatment with either antibiotics or surgery.

Scott Steele: So we're going to transition right now into a little odd game I like to play. It's called Truth or Myth. So Truth or Myth: only adults can develop a gallstone.

Diya Alaedeen: We wish. Used to be the case. We used to think that mostly it's predominant in adults, unfortunately with obesity pandemic, we see gallstones in children. There's also a different type of gallstones, they're called black stones. Those are usually in sickle cell children because they have a high turnover of their blood cells or patients with blood disorders. So gallstones can happen at any age, mostly children in their preteen years and adults.

Scott Steele: Truth or Myth: people who undergo weight loss surgery are more likely to develop gallstones.

Diya Alaedeen: True. We don't understand exactly why, but people who have rapid weight loss, they do have loss of equilibrium in that juice that I mentioned and cholesterol start precipitating out of that juice, they get more cholesterol stones.

Scott Steele: So Diya, can you explain a little bit. Is there any correlation with weight or BMI in the development of gallstones in general?

Diya Alaedeen: Yes. So patients with obesity, they have more cholesterol in their body in general. That's cholesterol as I mentioned is a crystal, those crystals start to precipitate out a solution and they are more prone to having gallstones. So obesity is number one factor to having gallstones. And, an interesting fact to you that you mentioned, some societies in east Africa, like the Maasai tribe, they've never found a case of gallstones in those patients because they're actually very thin, slender and tall. And so, it is predisposed to our diets and our Western lifestyle.

Scott Steele: So Truth or Myth. If I have a gallstone attack just once I won't have another one.

Diya Alaedeen: That is a myth, once you have one attack you have 80% chance of having another attack in your lifetime.

Scott Steele: So Diya, there's a fair number of people who maybe don't get harsh symptoms or maybe are scared of surgery. And so what are the short-term and long-term health concerns of basically not getting your gallbladder out or not doing something about that?

Diya Alaedeen: As you can imagine, a lot of patients actually see us and they have had one or two attacks and then their primary care physician would refer them to get your gallbladder out. And they come to us and say, "Well, my symptoms are mild. I've had one attack. I'm really scared of surgery. Is there anything else to do and do I really need the operation?" Unfortunately, gallstones don't dissolve on their own. They don't go away on their own. And surgery is very safe and effective. With the advancement of dual laparoscopy since the early 2000s, the gallbladder surgery can be done in about 45 minutes. Patients go home recover very well.

If they do not treat their gallstones, there can be ramifications to that and the disease can increase in severity. Not only that they can get coli cystitis, which is infection of the gallbladder, the gallstone can actually exit the gall bladder and get stuck in the bile ducts, which are the drainage of the liver. They can get jaundiced, they can get cholangitis which is a life-threatening disease, which is infection of those bile ducts. And the stone can exit into the small bowel and on its way, it's going to wreak havoc and the patients can get pancreatitis. Because the exit of the biliary tree into the small bowel shares the same exit of the pancreas. And when the tissue becomes edematous, the pancreas can also get inflamed and some patient can present with what we call gallstone pancreatitis, which can also be life-threatening.

So, I always advise my patients, if you had one attack or you have symptomatic gall stones, surgery is very safe, very effective, and it gives you a lifelong relief from dealing with this problem.

Scott Steele: So Diya, you dovetailed nicely into my next question. Let's talk about maybe surgery and some of the other procedures that could be used for this. The first one is just the straightforward cholecystectomy or a lap coli. And the second one is based on what you had mentioned when that gallstone gets stuck in the duct, and that's a ERCP or an endoscopic retrograde collegial pancreastography procedure. So, can you talk about that and how they fit into the treatment of this disease?

Diya Alaedeen: Absolutely. So for most garden variety gallstones, they're still present in the gallbladder. The treatment is to remove the entire gallbladder. Unfortunately, in the past, they didn't know what the gallbladder depth. They used to open the gallbladder and get the stones out, close it backed up. Unfortunately, we found out that the gallstones would form almost immediately back in the gallbladder. So the treatment for a garden variety gallstones in the gallbladder is to remove that entire organ. This can be done, as I mentioned, laparoscopically through small incisions, fast recovery, fast surgery patients have long-term relief.

If the stones would migrate out of the gall bladder and they cause what we call a biliary obstruction, jaundice or gallstone pancreatitis, sometimes those stones do not exit on their own to the small bowel and they're causing obstruction. The best way to get these stones is something called ERCB. It's an endoscopic procedure where the endoscopist would pass the scope through the stomach into the small bowel, they can locate where the exits of the biliary tree into the small bowel and actually opened that exit a little bigger. They pass the balloon past the stone and retrieved that stone to relieve the obstruction of the biliary tree.

There is risks to this procedure. There's 1% chance of mortality. There's about 10% chance of pancreatitis. So we'd like to actually treat stones when they're still in the gall bladder. We do not like when the patients present late and their disease process and the stones have caused obstruction of the entire biliary tree, but we'd like when it's contained to the gallbladder.

Scott Steele: So, how quickly does a patient recover from gallbladder surgery? Is it a prolonged hospital stay, same day surgery. And then what about afterwards? How do you get back to a quote unquote normal?

Diya Alaedeen: It's a very fast recovery with the advent of laparoscopy. Most patients need a two or three day rest just from having the experience of going under general anesthesia, because this cannot be done without general anesthesia. So usually the recovery from generalist anesthesia, pain is usually minimal. The maximal pain they get at the umbilicus where we actually put the camera and retrieved the organ from the incision, so that's the biggest incision. All the other incisions are about a quarter inch incisions.

I've had patients that wanted to go to Mexico and they were worried because they've had a biliary disease. And they said, "I don't want to get sick when I'm down there." I've had patients who have had their gallbladder removed on a Thursday and traveled to Cancun on a Monday. So the recovery is pretty fast. You can get back into the shower, you can go back to normal activity.

Most patients who do strenuous activity, we usually tell them, wait about a week to recover fully and get back your energy. Most office-based employees, we say we can go back to work within three to four days.

Scott Steele: You mentioned this a little bit before, but just to kind of circle back, are there any non-surgical treatments, medications that you can take for gallstones?

Diya Alaedeen: There is a medication that actually would help put the glycerol back in equilibrium. The problem with that medication, we don't use it that often because one of the side effects to that medication is abdominal pain and cramping. So you're treating one disease with another. So it's not very heavily used. We use it only in patients who are not candidates for surgery. So the side effect of the medication negates the actual symptoms of the gallbladder. So we recommend removing the gallbladder if the patient is a good candidate for the surgery.

Scott Steele: Well, that's all fascinating stuff. As you know, I'd like to ask you some quick hitters. I'm not going to ask you the same ones as before so here's the new ones for you. Tell me about a favorite trip. What's the place that you went to, that you said, "Ah, if you get a chance to go blank, where would that blank be?

Diya Alaedeen: Sedona, Arizona. Magical place.

Scott Steele: The Red Rock, if I believe-

Diya Alaedeen: Yes, absolutely.

Scott Steele: Very pretty. If I was to open up your, in the old days, your cassette player, what would be playing on your iPod if you will?

Diya Alaedeen: I would say classical music. You will notice a lot of classical music and Frank Sinatra.

Scott Steele: For those people who have kind of gotten into a lot of these series on TV here, what's a series that you think is out there that you would recommend?

Diya Alaedeen: There is a series on HBO that I watched recently, it's called The Heads. It's a murder mystery. I think it was fascinating. It's done by European Danish actors. And I think this year is fascinating, well done.

Scott Steele: And finally, what is a hidden talent that you may have?

Diya Alaedeen: I do martial arts. And, part of my stress relievers, I do love boxing about three times a week.

Scott Steele: Well, there you have it and we're very glad about that. Give us a final take home message for our listeners regarding gallstones and cholecystectomy.

Diya Alaedeen: As I mentioned, all better disease and cholecystectomy in particular for the treatment of gallbladder disease is very common. If you need gallbladder surgery, you're one out of million patients in the United States. You're not alone. It's very common. It's very safe. The complication rate of gallbladder surgery is less than 400,000, which putting that in perspective is less than a chance of getting on an accident on the highway. It's very safe. If you need us, call us. If your primary care physician recommends you see a surgeon, by all means, see a surgeon. Take care of this disease before progresses and becomes more severe. It's better to treat it early if you have symptoms than wait and have complications.

Scott Steele: Great advice. And so for more information on gallstones and gallbladder surgery, please visit Cleveland Clinic’s Health Library at clevelandclinic.org/health. That's Clevelandclinic.org/H-E-A-L-T-H. You can also call our Digestive Disease and Surgery Institute at 216.444.7000. That's 216.444.7000.

And finally, please remember that in times like these, it's more important than ever for you and your family to continue to receive medical care. Be rest assured here at the Cleveland Clinic, we're taking every necessary precaution available to sterilize our facilities, protect our patients and our caregivers. Dr. Alaedeen, thank you so much for joining us on Butts & Guts.

Diya Alaedeen: Thank you Scott. Good to be here again.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.