Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, June 13, 1995 TAG: 9506130031
SECTION: EXTRA PAGE: 1 EDITION: METRO
SOURCE: JANE BRODY
DATELINE: LENGTH: Long
In the five years since this Band-aid surgical technique was introduced, it has prompted a sharp rise in the number of gallbladders removed each year, in some cases from patients who have no symptoms.
Various studies have shown increases ranging from 22 percent to as much as 57 percent in the frequency of gallbladder surgery during the first few years of the new procedure.
More than 600,000 cholecystectomies are being done each year, 90 percent of them with the new laparoscopic technique. Gallbladder surgery is now about as common as hysterectomy, which is second only to Caesarean sections.
Laparoscopic cholecystectomy, which involves an inch-long incision and three tiny puncture wounds, does not cost any less than the traditional open-abdomen operation that leaves a six-inch scar. But it has significantly eased the trauma of gallbladder surgery, so much so that experts now wonder whether the glamour of the high-tech procedure and the promise of a rapid postoperative recovery are resulting in a lot of needless surgery.
Prospective patients sometimes forget that every operation has its risks, and that the expected benefits from the surgery should justify taking those risks. Such justification may be lacking in most patients with gallstones that cause few or no symptoms.
As health care budgets shrink, it is likely that stricter criteria will be established for the appropriateness of a cholecystectomy and growing numbers of Americans will be told by their insurers, ``No, we will not pay for your gallbladder surgery.''
The gallbladder is a pear-shaped sac about four inches long that stores bile, which is made in the liver and used in the intestines to help digest fat. At least 10 percent of adults, twice as many women as men, form stones in their gallbladders. The incidence rises with age; after the age of 60, 10 to 15 percent of men and 20 to 40 percent of women have gallstones.
The stones can cause inflammation of the gallbladder or they may enter the connecting ducts and cause a blockage and possibly a life-threatening infection.
However, in most cases, absolutely nothing happens, even decades after gallstones have formed. This was shown in studies that followed patients whose gallstones were accidentally discovered during other procedures.
In one study directed by Dr. David Ransohoff of the University of North Carolina at Chapel Hill, only 18 percent of 123 symptomless patients developed symptoms over a 20-year period.
In another study, pain developed in only 1 to 2 percent of symptomless patients annually, and the rate declined with time. Even among patients who once had symptoms, three studies showed that up to 30 percent had no recurrence of gallstone-related pain.
But for those with life-disrupting symptoms and the danger of serious and possibly fatal complications, gallbladder surgery can be an important option. The gallbladder is an expendable organ. After it is removed, bile empties directly into the intestines, and digestion of fats proceeds normally.
For a while in the 1980s, various chemical and mechanical methods were introduced for dissolving gallstones. But in up to half of patients, more stones formed and symptoms recurred. These techniques fell largely into disuse after the laparoscopic cholecystectomy was introduced in this country in 1989.
The risk of recurrence is eliminated when the gallbladder is removed either by open or laparoscopic surgery.
Open cholecystectomy is one of the safest of major operations. It does, however, require general anesthesia, three to five days in the hospital and up to six weeks of recovery before life returns to normal. Postoperative pain is considerable, but the rate of complications and death is very low.
In laparoscopic surgery, a small incision is made near the navel and three puncture holes are made under the rib cage to introduce a lighted scope and video camera and the operating tools.
Carbon dioxide is pumped into the abdomen to separate abdominal muscles and fat from the underlying organs.
Surgeons - ideally, two working together - watch a television monitor as they tie off the duct and artery feeding the gallbladder, free the gallbladder from its perch under the liver and slip the diseased organ out through the umbilical incision.
Most of the carbon dioxide is then sucked out of the abdomen and the wounds are covered with the equivalent of Band-aids.
The patient usually spends just one night in the hospital and can return to normal activities in three to five days, at most a week. The greatest discomfort is likely to be a day or so of abdominal cramps until the residual carbon dioxide is absorbed into the bloodstream.
Simple though it may sound, laparoscopic cholecystectomy is not innocuous. In fact, it has been associated with a higher than usual rate of injury to the bile duct, although this rate is still low - one-tenth to two-tenths of 1 percent.
- New York Times Syndicate
by CNB