Odd Søreide

Pain persists in many patients five years after removal of the gallbladder: Observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis

After removal of the gallbladder, pain may persist in some patients. To study this condition, 124 patients from two randomized trials, including those with symptomatic noncomplicated gallbladder stones (n = 90) and acute cholecystitis (n =34), were interviewed, while 139 patients (90%) excluded from both trials responded to a questionnaire 5 years after the operation. Thirty-four patients (27%) of those randomized had pain; 23 (18%) had diffuse, steady pain; and 11 (9%) had pain attacks resembling their preoperative symptoms.Asignificant dominance of diffuse pain occurred inwomen(P = 0.024), especially those younger than 60 years (P = 0.004). A tendency for the diffuse type to be dominant was also present in the group of female patients with symptomatic noncomplicated gallbladder stones (P = 0.052). Of the excluded patients, 18% (25/139) had pain, but 88% of them (96% of the men and 87% of the women) were satisfied with the result of the operation. The overall number of patients with postoperative pain was 22% (59/263). We conclude that persisting abdominal pain 5 years after the operation was mainly of a nonspecific type, found mostly in younger women who had had noncomplicated gallstone disease. Eightyeight percent of the excluded patients declared themselves satisfied with the result of cholecystectomy.

Liver and Biliary Tract Symptomatic, Non-Complicated Gallbladder Stone Disease. Operation or Observation?

BACKGROUNDnCholecystectomy has been recognized as the treatment of choice for symptomatic gallbladder stone disease. Not all patients are cured by an operation and the reason for having the gallbladder removed may rest on common practice rather than evidence-based medicine. The aim was to compare cholecystectomy with observation (watchful waiting) in patients with uncomplicated symptomatic GBS disease. Three-hundred-and-thirty-eight patients were considered for participation in the study; 45 patients were excluded according to predefined criteria and 156 did not join for other reasons. The remaining 137 were randomized to cholecystectomy (n = 68) or non-operative, expectant treatment (n = 69).nnnMETHODSnRandomized patients were contacted regularly and followed for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients.nnnRESULTSnEight of the patients randomized to cholecystectomy did not undergo operation, while 35 of the patients randomized to observation later had their gallbladders removed. The cumulative risk of having a cholecystectomy seemed to level off after 4 years. Gallstone-related complications occurred in 3 patients in the observation group, 1 in the operation group and 5 of 201 excluded patients. After cholecystectomy, 16 of 222 patients had a major complication and 10 a minor.nnnCONCLUSIONSnWe found that non-operative expectant treatment carries a low risk of complications. Patients should be informed that watchful waiting is a safe option.Background: Cholecystectomy has been recognized as the treatment of choice for symptomatic gallbladder stone disease. Not all patients are cured by an operation and the reason for having the gallbladder removed may rest on common practice rather than evidence-based medicine. The aim was to compare cholecystectomy with observation (watchful waiting) in patients with uncomplicated symptomatic GBS disease. Three-hundred-and-thirty-eight patients were considered for participation in the study; 45 patients were excluded according to predefined criteria and 156 did not join for other reasons. The remaining 137 were randomized to cholecystectomy ( n = 68) or non-operative, expectant treatment ( n = 69). Methods: Randomized patients were contacted regularly and followed for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. Results: Eight of the patients randomized to cholecystectomy did not undergo operation, while 35 of the patients randomized to observation later had their gallbladders removed. The cumulative risk of having a cholecystectomy seemed to level off after 4 years. Gallstone-related complications occurred in 3 patients in the observation group, 1 in the operation group and 5 of 201 excluded patients. After cholecystectomy, 16 of 222 patients had a major complication and 10 a minor. Conclusions: We found that non-operative expectant treatment carries a low risk of complications. Patients should be informed that watchful waiting is a safe option.

Pain and quality of life in patients with symptomatic, non-complicated gallbladder stones: results of a randomized controlled trial.

Background: Cholecystectomy is intended to relieve symptoms of gallstones, but unfortunately some patients will experience postcholecystectomy symptoms, including pain. There is limited information in the literature on gallstone‐related pain and its influence on quality of life. The aim of this study was to examine how pain and quality of life in patients with symptomatic, uncomplicated gallbladder stones were affected by observation of their condition compared with removal of the gallbladder. Methods: One‐hundred and thirty‐seven patients were randomized to observation (watchful waiting; nu2005=u200569) or cholecystectomy (nu2005=u200568) and answered questionnaires on pain, quality of life (PGWB index and NHP Part II) at randomization and fixed intervals (6, 12 and 60 months). All gallstone‐related events (hospital admission for pain, complications of gallstone disease and cholecystectomy) and crossover between treatment groups were recorded. Results: Of patients randomized to observation, 35 of 69 patients (51%) eventually underwent a cholecystectomy. Significant improvements in quality of life and pain scores were detected regardless of surgical treatment. Patients that subsequently experienced gallstone‐related events had significantly higher pain scores at randomization than patients that did not experience any subsequent events, and this difference was maintained throughout follow‐up. Conclusions: Unexpectedly, in the majority of patients symptoms did abate without any significant differences between groups in pain and quality of life. Patients that had high intensity and frequency of pain at randomization had a higher risk of experiencing subsequent events.

Plasma exchange and heart-liver transplantation in a patient with homozygous familial hypercholesterolemia

A female patient born in 1950 underwent plasma exchange and concomitant drug therapy for 20 yr due to homozygous familial hypercholesterolemia. Plasma exchange reduced total cholesterol levels from 25–30 mmol/L (967–1160 mg/dL) before treatment to 9.5 mmol/L (363 mg/dL) with regression of xanthomas and no side effects of long‐term treatment. Due to end‐stage calcific left ventricular outflow tract obstruction not amenable to standard valve reconstructive surgery, a combined heart–liver transplantation was successfully performed in 1996. She is without symptoms and living a normal life 4 yr after transplantation. Total cholesterol value is normal (4.7 mmol/L [182 mg/dL]) using a moderate dose of statins. Selective coronary angiography is without signs of graft vascular disease and the liver function is normal.

The significance of personality in pain from gallbladder stones.

Background: The aim of the study was to investigate the association between personality factors related to coping styles and reported pain due to gallstones. Methods: Personality trait measures were completed by 28 consecutive gallstone patients to provide estimates of positive coping resources (Life Regard Index, Sense of Coherence Scale, Sense of Humor Questionnaire) and negative coping resources (Eysenck Personality Questionnaire on Neuroticism, Tension, and Effort Stress Inventory). An overall index of gallstone-related complaints (pain) over the past 7 days/6 months was also obtained. Ultrasonography confirmed the gallstone condition. Multiple regression analyses tested the hypothesis that pain would be moderated by positive coping resources and mediated by negative coping resources. Results: Reported pain was less severe with positive coping resources (39% of pain variance explained) and more severe with negative coping resources (45% of pain variance explained). Conclusion: The results confirm that mental coping resources have a significant role in pain differences among gallstone patients.

Common pathogenetic mechanisms in symptomatic, uncomplicated gallstone disease and functional dyspepsia: volume measurement of gallbladder and antrum using three-dimensional ultrasonography.

Following cholecystectomy for uncomplicatedgallstone disease (GS) some patients experiencepersistent symptoms suggesting an underlying functionaldisorder. To study this phenomenon, we have comparedsymptomatic GS with functional dyspepsia (FD) patients andhealthy individuals (C) with respect to putativepathogenetic mechanisms. Gallbladder and gastric antrumvolumes were estimated with three-dimensional (3D) ultrasonography before and 10 min afteringestion of 500 ml meat soup in 18 patients with GS.Volume estimation was performed digitally afterinteractive manual tracing and organ reconstruction inthree dimensions. Respiratory sinus arrhythmia (RSA)was calculated to index vagal tone. Abdominal symptomswere assessed by interview. The results were compared topreviously published data in patients with FD and C investigated with the exact samemethods. No significant differences were found betweengroups with respect to fasting gallbladder orgallbladder emptying. Antral volumes both fasting (P< 0.05) and postprandially (P < 0.01) were larger inGS and FD than in C. The soup meal induced dyspepticsymptoms in 2/18 (11% ) of C, 12/18 (67% ) of GS and15/17 (88%) of FD patients (P < 0.001). Compared with C, both GS and FD patients had significantlydecreased vagal tone (P < 0.001). There was nosignificant difference between GS and FD patients withrespect to antral volume, vagal tone, or symptoms. Weconcluded that both gallstone and functional dyspepsiapatients are characterized by dyspeptic symptoms inresponse to ingestion of 500 ml of meat soup, a widegastric antrum, low vagal tone, but normal gallbladder size and emptying. Thus, patients withsymptomatic, uncomplicated gallstone disease andfunctional dyspepsia seem to have common pathogeneticmechanisms.

Diagnosis and management of gallbladder calculus disease

Abstract Background. The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease. Methods. Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research. Results. Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series. Conclusions. Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.

Editorial: How to Report Randomized Controlled Trials. The Consort Statement

(1997). Editorial: How to Report Randomized Controlled Trials. The Consort Statement. Scandinavian Journal of Gastroenterology: Vol. 32, No. 12, pp. 1185-1186.