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Gallbladder

I had surgery for stomach cancer. Can my gallbladder still be removed laparoscopically?

Previous gastrectomy used to be treated as a reason not to operate through small incisions. The evidence since has not supported that, but the way the stomach was reconstructed does matter.

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Answer

Yes: a Korean multivariable analysis of 58 patients having gallbladder removal after gastrectomy found the laparoscopic approach feasible as the initial approach even where common bile duct stones or acute cholecystitis were present, with one open conversion in the series, and it was independently associated with a shorter hospital stay rather than a longer operation or more complications.

Key takeaways

  • In a Korean series of 58 patients having cholecystectomy after a previous gastrectomy, there was one open conversion, 2.9 percent of the laparoscopic attempts.
  • In that study the laparoscopic approach was not associated with a longer operation and was independently associated with a shorter postoperative stay, with an adjusted odds ratio of 0.057.
  • What did lengthen the operation was exploring the common bile duct, with an adjusted odds ratio of 45.15, and acute cholecystitis, with an adjusted odds ratio of 14.66.
  • Acute cholecystitis was also the factor independently associated with complications, at an adjusted odds ratio of 27.68, while common bile duct exploration and the laparoscopic approach were not.
  • Bile duct stones are substantially more common after gastrectomy: in a Japanese series of 1,104 cholecystectomies, they were present in 33.3 percent of the 51 patients with a previous gastrectomy against 8.6 percent of those without.
  • How the stomach was reconstructed decides whether ERCP can reach the bile duct at all: in one cohort, endoscopic clearance of duct stones succeeded in 81.2 percent of patients after a Billroth I reconstruction but 23.7 percent after Billroth II or Roux-en-Y.
  • The useful thing to know before the consultation is not that you had a gastrectomy, but which reconstruction was used.

Gallstones are more common after the stomach has been operated on, so this question comes up often in a country that performs a great deal of gastric cancer surgery. For a period, a previous gastrectomy was treated as a relative reason not to attempt laparoscopic gallbladder removal: the upper abdomen has been dissected before, adhesions are expected, and the anatomy has been rearranged.

The series published since have not supported that position.

What the Korean data found

Surgeons at Kyung Hee University analysed 58 patients who had a cholecystectomy after a previous gastrectomy, and ran a multivariable analysis against operating time, length of stay and complications. One operation, 2.9 percent, was converted to open.

Independent factors in 58 patients having cholecystectomy after gastrectomy, adjusted odds ratios
FactorOutcomeAdjusted odds ratio
Common bile duct explorationLonger operation45.15 (95% CI 4.53–450.55)
Acute cholecystitisLonger operation14.66 (95% CI 1.46–147.4)
Acute cholecystitisComplications27.68 (95% CI 1.15–666.24)
Laparoscopic approachShorter hospital stay0.057 (95% CI 0.004–0.74)

Read down that table and the previous gastrectomy is not what is driving anything. What lengthens the operation is having to open the bile duct, and inflammation. What causes complications is inflammation. The laparoscopic approach itself was associated with going home sooner.

The duct is the real issue, not the gallbladder

A Japanese series of 1,104 consecutive laparoscopic cholecystectomies included 51 patients, 4.6 percent, who had undergone a previous gastrectomy — 36 for gastric cancer and 15 for ulcer disease. The finding that mattered was not about the gallbladder.

33.3% vs 8.6%

common bile duct stones in patients with a previous gastrectomy against those without, among 1,104 laparoscopic cholecystectomiesSasaki A et al., Surgery Today, 2008

Stones in the bile duct are roughly four times as common in this group, and that is where the reconstruction starts to matter. Clearing duct stones endoscopically means passing a duodenoscope to the point where the bile duct drains, and whether that point is still reachable depends on how the surgeon rejoined the bowel.

Success of endoscopic clearance of common bile duct stones by type of previous gastric reconstruction
ReconstructionERCP success rate
Billroth I81.2%
Billroth II or Roux-en-Y oesophagojejunostomy23.7%

After a Billroth I the route to the duct is close to normal. After a Billroth II or a Roux-en-Y it is long, angled and sometimes impassable, and in that situation a single operation that removes the gallbladder and clears the duct at the same time becomes the more practical plan rather than the more aggressive one.

There is also the situation where both operations are done together. In 400 patients having laparoscopy-assisted gastrectomy for early gastric cancer at a Korean centre, 26 had their gallbladder removed during the same operation, and there were no deaths within 30 days in that group.

So the question to bring to the consultation is a specific one. Not whether a gallbladder can be removed after stomach surgery, which it can, but which reconstruction was performed, whether there are stones in the duct, and if there are, how they are to be cleared.

Sources

  1. 1

    Kim J, Cho JN, Joo SH, Kim BS, Lee SM

    Multivariable analysis of cholecystectomy after gastrectomy: laparoscopy is a feasible initial approach even in the presence of common bile duct stones or acute cholecystitis

    World Journal of Surgery 2012;36(3):638-644

    doi:10.1007/s00268-012-1429-z · PMID:22270995

    https://doi.org/10.1007/s00268-012-1429-z
  2. 2

    Sasaki A, Nakajima J, Nitta H, Obuchi T, Baba S, Wakabayashi G

    Laparoscopic cholecystectomy in patients with a history of gastrectomy

    Surgery Today 2008;38(9):790-794

    doi:10.1007/s00595-007-3726-y · PMID:18751943

    https://doi.org/10.1007/s00595-007-3726-y
  3. 3

    Zhang M, Zhang J, Sun X, Xu J, Zhu J, Yuan W, Yan Q

    Clinical analysis of treatment strategies to cholecystocholedocholithiasis patients with previous subtotal or total gastrectomy: a retrospective cohort study

    BMC Surgery 2018;18(1):54

    doi:10.1186/s12893-018-0388-1 · PMID:30092786

    https://doi.org/10.1186/s12893-018-0388-1
  4. 4

    Kwon AH, Inui H, Imamura A, Kaibori M, Kamiyama Y

    Laparoscopic cholecystectomy and choledocholithotomy in patients with a previous gastrectomy

    Journal of the American College of Surgeons 2001;193(6):614-619

    doi:10.1016/s1072-7515(01)01083-3 · PMID:11768677

    https://doi.org/10.1016/s1072-7515(01)01083-3
  5. 5

    Jeong IH, Choi SU, Lee SR, Kim JH, Park JM, Jin SH, et al.

    Outcomes after combined laparoscopic gastrectomy and laparoscopic cholecystectomy in gastric cancer patients

    European Surgical Research 2009;42(4):203-208

    doi:10.1159/000205974 · PMID:19270458

    https://doi.org/10.1159/000205974