Cheickna Diarra, MD, Susana Ho, MS, Jerome Lynsue, MD, Eric M Pauli, MD, Ann M Rogers, MD. Penn State Hershey Medical Center
Biliary dyskinesia, or low gallbladder ejection fraction (GBEF), is a recognized indication for cholecystectomy, as is symptomatic cholelithiasis. However, there is a paucity of literature investigating patients with biliary symptoms, normal gallbladder ultrasounds, and normal or high ejection fraction on Hepatobiliary Iminodiacetic Acid (HIDA) scan. Because abdominal pain is not uncommon after gastric bypass, and because the gastrointestinal anatomy and physiology are altered after this rearrangement, central abdominal pain may be appropriately investigated through surgical exploration. In our series of bypass patients undergoing diagnostic laparoscopy for biliary symptoms but with “normal” preoperative studies, it was the rule to find gallbladder pathology. Based on this series of bypass patients, we then sought to also study this phenomenon in patients with normal anatomy, normal studies, and biliary symptoms.
All gastric bypass and normal anatomy patients who underwent cholecystectomy at a single institution between July 1, 2007 and December 31, 2013 were evaluated by chart review after IRB approval. Patients with abnormal ultrasounds (stones or cholecystitis) or who had low GBEF (<35%) were excluded. 31 patients with biliary symptoms, normal ultrasounds and normal or high GBEF were identified and studied. At our institution, “normal” GBEF is defined as 35% or higher and there is no set range for “hyperkinesia”. We set a “high” GBEF as 65% or higher, based on the few related studies in the literature.
All 31 patients underwent laparoscopic cholecystectomy without postoperative complications. This included single-incision, single-incision robotic, 3-port and 4-port laparoscopic operations. 24 patients had GBEF ≥65 % (mean 86.6%, range 66-98), 6 patients had GBEF between 35% and 65% on HIDA scan (mean 47.8%, range 35-60), and one patient was said to have “brisk” ejection (GBEF is not calculated on in-patients at our institution). Pathology reports were reviewed; only 2 (6.45%) patients had a normal gallbladder, 23 (74%) had chronic cholecystitis without gallstones, and 6 (19.3%) had chronic cholecystitis with unsuspected gallstones. Of the patients reported to have gallbladder polyps on preoperative ultrasound, none were found to actually have polyps. All patients were seen in follow-up 4 to 6 weeks postoperatively. Patients were queried for ongoing pain, and all had complete resolution of symptoms after surgery.
In this series of gastric bypass and normal anatomy patients with biliary symptoms but normal studies, cholecystectomy led to symptomatic relief in 100% of patients. 93.5% also had unexpected pathologic biliary findings. It may be appropriate in patients with symptoms referable to the biliary tract to offer cholecystectomy, even in the face of normal ultrasounds and normal or elevated gallbladder ejection fractions.