FIGURE 2.

Statement of informed consent adapted for this study from the one published by Brazilian College of Digestive Surgery - CBCD

What is the gallbladder?

It is a kind of bag that receives and concentrates the bile fluid produced in the liver, functioning as a reservoir for bile. It has the function of helping the digestion of some food, especially fat. Thus, bile is released mainly when we eat these foods and launched in bile duct (common bile duct) which is the tube that carries bile from the gallbladder and liver to the intestine, opening into the intestine along with the pancreatic duct that carries the secretion that comes from the pancreas and helps the digestion of protein foods.

As the stone (calculus) is formed in the gallbladder?

Bile contains several substances, including salts of cholesterol and pigments; so, it has a dark green color. When some of these substances increase in quantity in bile, they can deposit and over the months and years; these deposits come together and form stones (calculi). Other parts of the body such as the kidneys, the bladder and the channels of saliva, tear can also form stones (calculi). But the stones of these locations are different from the gallblader.

How are the stones (calculi)?

The number, size, shape and color of gallstones are quite variable. Some people only have one stone, while others have several . They can also vary in size from tiny, as a grain of sand, to large as an orange.

Who can have stone (calculus) in the gallbladder?

Stone or calculus of the gallbladder is a very common disease. About 10% of people have gallstones. Over 10 million Brazilians have this problem. Anyone can have gallstones, but some are more likely, according to certain variables such as: 1 ) age (the disease can affect even children, but its frequency increases with age and is more common in adults and elderly); 2 ) woman (the gallstones are more common in women than in men, especially in already became pregnant); 3) obesity (fatter, greater is the possibility of having gallstones; however, lean people can also have calculi); 4 ) heredity (the people who have family members with calculi have more chances of having this disease than those without).

Symptoms and complications caused by gallstones

Many individuals who have gallstones have no symptoms. Whether a person has no symptoms or complications depends on the number or size of the stones. Sometimes a single small stone can cause serious complications, as, for example, acute pancreatitis. The presence of gallstones may cause mild, serious or intense symptoms, the most common being : 1) severe pain in the abdomen (belly), usually on the right side or in the region in the stomach; it lasts for minutes to hours, but when longer may indicate complication; in this case, you should seek medical attention urgently; 2) nausea (feeling sick) and vomiting, especially when eating certain foods (fat, eggs, banana, etc.); 3) inflammation or infection of the gallbladder (cholecystitis), in this case, besides the pain other symptoms may appear such as fever, nausea and prostration and severe condition that requires emergency care, because the bladder may even rupture putting your live at risk; 4) jaundice (yellowing of the white parts of the eyes and skin) usually occurs when the tube that carries bile to the intestine (common bile duct) is blocked by stone, then the bile is accumulated in the liver, the blood flows back and makes the skin yellow; 4) acute pancreatitis (inflammation of the pancreas), which is caused by stone that jammed where flow into the biliary and pancreatic channels, causing blockage of both leading to inflammation and infection of the pancreas, which is also a major complication of the disease.

Diagnosis

The best method for diagnosing gallstones is an ultrasound of the abdomen. The scan may not show the stones in many patients.

Treatment

The only form of effective treatment for gallstone or calculus is the surgical removal of the gallbladder (cholecystectomy). Other treatments like lithotripsy (“ break the stone “ with special equipment) and drugs to dissolve the stones, have been tested, but did not give good results and should not be used because only delay proper treatment. Same is said to magic recipes, teas, feeding recommendation done by lay people based on personal experiences, popular beliefs and feeding restriction as they will only delay definitive diagnosis and treatment, which is surgical removal of the gallbladder. The removal of the gallbladder through laparoscopic surgery is possible in most patients (“little holes surgery”). Initially, gas is injected (carbon dioxide) into the abdomen (belly) to create a space where the surgeon can perform the operation safely. After conducting four few millimeters holes, a television camera is placed inside the abdomen through one of the holes so that the surgeon and his team can view the entire abdomen on a TV. The tools to perform the operation (forceps, scissors, suture materials, etc.) are placed through the other holes

All people who have gallstones need to operate?

People who already have symptoms should be operated, due to frequency of complications that in these situations is very high. The people who have yet life expectancy of many years have higher risk of complications, even without symptoms. The elderly and other associated diseases (diabetes, high blood pressure, heart complications) the surgeon and the clinical need to assess the risks and discuss with the patient to make the decision about the operation. Even people who have other diseases, and if they are well controlled, the risk of complications is small. However, under conditions of acute inflammation and infection of the gallbladder (cholecystitis) operation becomes imperative in emergency.

After removal of the gall bladder, will I have any restrictions in my diet?

You do not need to modify your diet after the operation, because the gallbladder have little important function in the body, which is to store bile. It do not produces bile, only helps in storage. The production of bile by the liver remains normal after removal of the gallbladder. No sequel or consequence to the organism exists after removal of the gallbladder. Thus, most people who had intolerance to certain foods, nausea , vomiting, discomfort or pain after eating, with the removal of the gallbladder these symptoms disappear or greatly improve. However, there is a group of people (approximately 20%) in whom symptoms persist after the operation, but the risk of having the aforementioned complications is reduced.

Surgical treatment

Postoperative recovery: Most patients stay in the hospital only one day and can return to work and to all activities, including sports, in a week or two. Complete and final resolution of the disease: In some people the symptoms remain. Little pain in the postoperative period: As laparoscopic operation is minimally invasive and almost doesn’t damage the tissue around the bladder, pain in the postoperative period is discrete and improves with common analgesics. Minimal surgical scar: Are performed only four holes whose scars may disappear after sometime Risk of infection and complications: When the operation is done on a scheduled basis (elective), the risk of infection and other complications is small, around 0.1%. However, when performed in emergency and due to complications (cholecystitis) , the risk is higher (up to 3%) and hospitalization time and recovery will also be longer. Risk of death: It is very low. Even in elderly individuals the risk of death related to the transaction is less than 0.5%. However, if the operation is done in emergency, infection or other complications, the risk of death rises to 1%.

Is the operation 100% safe?

Although the results of surgical treatment are excellent, some patients may have complications, as with any surgical procedure. The most common are: viscera injury, infection, bleeding and anesthetic risk (low). If you cannot perform the operation by laparoscopic technique (“holes technique”), you may need to make a larger incision (cut) in your abdomen to complete the operation. The risks of the operation are more common in patients who have severe disease or complications such as inflammation of the gallbladder, jaundice, acute pancreatitis at the time of operation. In these situations, the operation is generally more difficult to achieve and should be done as emergency.

Comorbidities (accompanying diseases)

As the disease affects more frequently the older people and some of them favor the formation of gallstones, there are common associated diseases. Among them the most common are obesity, diabetes and dyslipidemia (high cholesterol) . But also high blood pressure, heart problems and osteoarthrosis are common diseases in the elderly. All these associated diseases should be adequately controlled before surgery. In these cases, the set of a clinical medical care with the surgeon and the anesthesiologist will ensure good control of associated diseases before operation, ensuring maximum patient safety.

Anesthesia and pre-anesthetic evaluation

Many people are afraid or apprehensive and anxious before the anesthesia. Most of the time it is generated by ignorance of the subject, bad reports of relatives, friends or even by the press and broadcast media. Long time anesthesia is procedure completely safe for the patient; the medications and anesthetics had advances. There is no reason to think that you will be subjected to anesthesia and “will not wake-up “ as some argue. Your whole body is monitored during the anesthetic doctors team, nurses and technicians. Pressure, breath and heart rate are carefully monitored by the team and devices with automatic alarms. Furthermore, some believe which during anesthesia dreams, nightmares and unpleasant memories occur is fantasy. None of this happens. You sleep relaxed and wake-up as if nothing had happened, rested. An appropriate pre -anesthetic assessment will bring peace and security to you, to surgical and anesthesia teams. In this pre-anesthetic consultation, you can talk with the anesthesiologist, explain your fears and concerns and he will know guide you, answer your question and everyone will be safer during the procedure. Many studies have identified the major fears or concerns related to anesthesia, they are: fear of not sleeping; feeling pain during the operation; feeling cold and shivering; feel something and not be able to communicate; surprising the environment of the operating room; fear that anesthesia finishs before the end of the operation; fear of having “allergy” and “anesthetic shock”; fear of not waking-up after anesthesia and fear of postoperative pain. Of all these, the only real risk is having to allergic reaction to the medication, but that is very rare and can happen to any medication you use. The difference is that by being in the presence of a medical team and all their vital signs monitored, you will have chance to be attended to immediately and with less risk. Cholecystectomy, the operation you need to do, requires general anesthesia. Before entering the operating room, you may have already received slee -inducing drug that has fast action. General anesthesia prevents you from feeling pain. After the operation you receive another medicine that makes you wake-up and everything goes like you slept peacefully in that period. Don’t doubted it: during the entire period of the operation you are being carefully controlled by the anesthesiologist.

Postoperative guidance

The recovery is usually very fast and most people return to their normal activities within a few days. The guidelines should be followed so that you have little discomfort and recovery occurs uneventfully. It has no special diet. You can eat or drink any food you want, including solid foods. Some patients may possibly have nausea and vomiting on the first day after surgery due to drugs and anesthetics received. If you have nausea and vomiting, ingest only liquids in small quantities at a time. These symptoms usually disappear within one or two days after the organism to eliminate drugs received in a hospital. If nausea and vomiting persist after this period, see your doctor. Shoulder pain is common after this type of operation. It is caused by the gas injected into the abdomen and it irritates a nerve diaphragm which lies between the abdomen and thorax. It is not due to twist or sprain in the shoulder. Shoulder pain usually disappears in a few hours or days. If it is severe, take analgesic (pain medication) prescribed by your doctor. The cuts (holes) will be closed with stitches and covered with simple dressing (micropore). It is common to have bruises (“blue” or “purple”) or minor bleeding. This is normal and you should not worry. Do not remove the micropore unless your doctor the tells you to do. You can take a full bath and wet the micropore. Dry the belly with a towel. Usually, the patient carries on without the need for special care on the cuts. However, if it has the appearance of infection (red with pain, discharge of pus or strong-smelling), contact your doctor. Breathe deeply three times every hour to best expand your lungs and avoid complications, such as fever and pneumonia. Avoid staying long lying down or sitting. Try to walk several times a day. If you can, walk, climb stairs or even run. There is no danger on doing that. Once you’re moving fast and with little pain, you are able to drive. You can lift up to 20 kg in the first month and after this time, you have no more limitations.