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https://doi.org/10.1007/s00268- 020- 05637- 5.
Prophylactic Surgery
forGallbladder andBiliary Tract
Pathologies
OsmanNuriDilek andNihanAcar
11
11.1 Introduction
Gallstones are a common health problem and
have been diagnosed since the ancient world.
Today, 20% of the population encounters a biliary tract pathology at some point in their life.
Depending on the age of the patients, gallstones
are detected in 10–33% of the population. Data
on the natural course of gallstones are still controversial [1]. Although 140years have passed
since Langenbuch’s rst recipe for cholecystectomy in 1882, there was not much change in surgical technique. However, biliary tract surgery
has reached very different dimensions owing to
the great advances in laparoscopic, endoscopic,
radiological, and minimally invasive procedures
with ultrasonography, tomography, and magnetic resonance imaging techniques. As a result
of advances in diagnostic tools, many biliary
tract pathologies are detected earlier. On the
other hand, biliary tract traumas have become
more common than ever before as a result of
increasing initiatives with the contribution of
developing technologies. New horizons have
O. N. Dilek (*)
Department of Surgery, Section of
Hepatopancreatobiliary Surgery, Izmir Kâtip Çelebi
University School of Medicine, İzmir, Turkey
e-mail: osmannuri.dilek@ikc.edu.tr
N. Acar
Department of Surgery, Atatürk Education
and Research Hospital, İzmir, Turkey
e-mail: nihan.acar@saglik.gov.tr
been opened in hepatobiliary surgery with threedimensional imaging, navigation techniques,
robotic surgery, and hybrid operating theaters.
With the advances in embolization, stenting, and
drainage techniques, more comprehensive and
more tissue/organ protective procedures have
been started [2].
Prophylactic surgery of the gallbladder and
biliary tract aims to eliminate life-threatening
risks that impair quality of life. Since there are
still many controversial issues in terms of indications, it is vital to follow actual literature and
guidelines. In this chapter, indications, expected
benets, and possible harms of prophylactic surgical interventions of the gallbladder and biliary
tract are going to be consecutively explained.
11.2 Gallbladder
Gallstones have an increasing prevalence worldwide, which has been reported between 10 and
33% [1, 3]. Fortunately, 40–60% of patients
with gallstones have silent gallstones that do
not cause any symptoms. While the others have
complaints in the form of dyspepsia and biliary
colic, and 20% of cases develop gallstone-related
complications. Although we, surgeons, are quite
familiar with the gallbladder disorders and their
management, approach to asymptomatic gallstones has been still controversial. Since only
20% and sometimes fewer gallstones become
symptomatic during the lifetime, prophylactic
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_11
115
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O. N. Dilek and N. Acar
cholecystectomy (PC) is not recommended for
every individual except for several instances
[4–6]. Besides, approximately half of the patients
with uncomplicated gallstones were found to
have cholecystectomy surgery in the future due
to persistent pain or complicated disease [7].
Cholecystectomy is one of the most common
abdominal surgeries. Prophylactic cholecystectomy (PC) can be dened as the removal of the
gallbladder without any further action. Incidental
cholecystectomy (additional, concurrent, simultaneous) can be dened as adding a cholecystectomy to the procedure while performing another
surgery. Indications and risks should be determined in patients with PC.Morbidity and mortality are undesirable. It is performed in the future to
prevent cholelithiasis, acute cholecystitis and its
complications, and second surgery.
It is essential to understand the etiology and
risk factors of the gallbladder disorders leading
to inammation or malignancy to interpret better
and introduce the indications for PC.Therefore,
PC should aim to avoid several probable risks:
a predisposition for severe acute/chronic inammation, predisposition for cancer, hosting bacterial agents (such as Salmonella Typhii), and
a secondary future intervention in patients who
already have a high risk for surgery.
11.2.1 Asymptomatic Gallstones
Prophylactic cholecystectomy in asymptomatic
cholelithiasis has long been a subject of debate.
In the 1991 consensus meeting held in France,
PCs under asymptomatic gall stones under elective conditions were not accepted [8]. However,
in persons undergoing laparotomy for other reasons, performing simultaneous cholecystectomy
is more accepted, but controversy continues. The
main reason for the controversy is the emergence
of cholecystectomy-related morbidities [9–12].
Female gender is a risk factor for stone production (the female-to-male ratio is about 4:1
during the reproductive years) and as well as
conversion to the symptomatic disease [5]. Sood
et al. (2015) reported the rates of symptomatic
conversion as 5.36% and 16.83% in males and
females, respectively [
13]. Therefore, males can
be managed expectantly, while PC should be considered in females with asymptomatic gallstones.
Ethnicity is also a determinative for deciding
PC, since some populations have a signicantly
higher risk for both gallstone and cancer development. Those with gallstones have an increased
risk of developing cancer 4–5 times [14]. North
American Indians, the aboriginal populations of
South America, and native Mapuche Indians of
Chile have the highest risks for gallstone production worldwide [15]. In terms of gallbladder cancer, females from Delhi (India), South Karachi
(Pakistan), and Quito (Ecuador) were reported to
have a higher incidence [
16, 17]. PC will be a
reasonable choice in the aforementioned populations, and even the stones stay asymptomatic.
Metabolic syndrome, diabetes mellitus, and
obesity are associated with the increased risk for
gallstone development [15, 18]. Some authors,
in addition, reported that diabetic patients were
more likely to develop complicated disease [14,
19]. However, there are also studies support-
ing that PC for asymptomatic gallstones does
not provide any signicant benets in diabetic
patients but may in fact cause morbidity [20].
Therefore diabetes, alone, is not an adequate factor to recommend PC.
The size of the stones, which is the most considered and known factor, affects the decision of
PC. Both large and small size carry a particular
risk. Stones larger than 3cm are associated with
gallbladder cancer, while stones smaller than
3mm with a patent cystic duct may be considered as a risk factor for symptomatic disease and
biliopancreatic inammation [
21–23]. Besides,
microlithiasis is also associated with metaplastic
and dysplastic lesions which may arise from an
undesirable, prolonged, and diffuse impact on the
gallbladder epithelium [24]. In their prospective
study of 592 cases with asymptomatic and symptomatic gallstones and gallbladder carcinoma,
Csendes etal. (2000) presented that gallbladder
carcinoma cases had signicantly larger stones,
regardless of the number of stones [25]. In addition, they showed that the patients with single
stone were more likely to remain asymptomatic.
These results which lead to the deduction of these
11 Prophylactic Surgery forGallbladder andBiliary Tract Pathologies
117
patients may not require a PC.Irrespective from
the size of the stone, presence of a concomitant
polyp always requires PC [14]. On the contrary,
Choi et al. (2010) suggested that concurrent
gallstones and polyps are not solely adequate
to perform PC, and the criteria such as a thickened gallbladder wall and interval increase in the
size of the polyps should be sought to determine
the candidates for PC [26]. In their study of 180
patients from Karachi, Alvi etal. (2011) reported
that stone size larger than 1cm and solitary stone
are the risk factors for developing gallbladder
cancer [27]. Consequently, using a generalized
cutoff value for the stone size in decision-making is inconvenient since each patient should be
assessed with their own risk factors.
Choledocholithiasis, which is mostly related
to gallbladder stones, can cause jaundice, cholangitis, and/or pancreatitis. Choledocholithiasis
accompanies 10%–20% of the patients with
symptomatic gallstones [28]. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) both have successful
outcomes in terms of diagnosis and treatment
of choledocholithiasis. Most common approach
after the removal of bile duct stones is subsequent
cholecystectomy since there is always a risk of
recurrence as long as the gallbladder stays there
[29, 30]. However, this cannot be accepted as a
standard approach, since a contrary opinion has
emerged in recent years proposing a wait-andsee approach after a successful ERCP [31, 32].
Schreurs etal. (2004) reported the rate of recurrent biliary symptoms after ERCP as 16% in
patients with gallbladder in situ which was alike
the normal population with silent stones [32].
Yasui etal. (2012) stratied this issue according
to the patient age and concluded that it may not
be necessary to recommend PC after endoscopic
sphincterotomy in very elderly patients, since
there was no signicant difference between cholecystectomized patients and patients with gallbladder in situ, regarding the incidence of overall
biliary complications among the patients older
than 80years [33]. On the other hand, developing a symptomatic choledocholithiasis in the
presence of silent gallbladder stones can be interpreted as a conversion to symptomatic disease,
and it is reasonable to act in this regard while
making a treatment decision.
Medical history of pancreatitis is an important
indication for PC.However, timing of the surgery
and the approach in non-biliary pancreatitis have
been controversial. Deciding when to operate
patients with biliary pancreatitis has not always
been as easy as deciding PC.The risk of developing cholecystitis or cholangitis increases after the
rst episode of biliary pancreatitis and may be
encountered in up to 30% of those patients [34].
Uhl etal. (1999) evaluated the cases according
to the severity of the pancreatitis. Therefore, they
recommended PC after the symptoms relieved
and laboratory tests normalized in mild pancreatitis, while in severe and necrotizing pancreatitis
PC was recommended to be delayed until active
inammation subsided and uid collections
resolved [35]. There are also studies in the literature suggesting that even patients with idiopathic acute pancreatitis benet from PC in terms
of preventing recurrence [36, 37]. Since microlithiasis cannot be excluded in these patients, PC
can be considered in medically t cases.
11.2.2 Hematologic Disorders
Hereditary spherocytosis, sickle cell anemia,
and thalassemia are the hemolytic anemias
that tend to produce gallstones due to increased
bilirubin metabolism. European Association
for the Study of the Liver (EASL) in 2016 and
Working Study Group on Red Cells and Iron of
the European Hematology Association (EHA) in
2017 recommended simultaneous PC in cases
undergoing splenectomy and having asymptomatic gallstones [38, 39].
Morbidity rate related with sickle cell disease
after PC was reported between 4 and 7% [40, 41].
Therefore, PC can be considered in these patients
in order to avoid a catastrophe that may be caused
by the difculties in differentiating an abdominal
pain whether caused by a veno-occlusive incident
or acute cholecystitis. However, routine PC in
absence of gallstones is not recommended since
the risk for developing gallstones is eliminated
with splenectomy [42].
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O. N. Dilek and N. Acar
In terms of thalassemia, although routine PC
is not recommended for silent gallstones, there
are also authors advocating that PC under elective conditions should be considered also in
asymptomatic cases due to the higher perioperative complication rate in these subjects, since
most of them have to undergo surgery following
at least one episode of cholecystitis [43].
11.2.3 Total Parenteral Nutrition
Parenteral nutrition is known to increase the risk
of gallstones, and prolonged parenteral nutrition
has the morbidity rate (associated with biliary
complications) of 57% [44]. Therefore, PC can
be performed during the index abdominal surgery
in suitable patients, if gallstones are detected and
prolonged parenteral nutrition is anticipated.
11.2.4 Short-Bowel Syndrome
Short-bowel syndrome is another issue which is
quite related with parenteral nutrition. The factors, such as the remnant intestine shorter than
120cm, dependency on total parenteral nutrition
and the absence of terminal ileum increase the
risk for gallstones [45]. The incidence of gallstones in patients with type III intestinal failure
(chronic intestinal failure requiring long-term
nutritional support) was reported as 21%, 38%,
and 47% after 10, 20, and 30years of observation, respectively [46]. However, there is no
available data supporting PC in cases without
gallstones. As it is recommended in parenteral
nutrition, concomitant cholecystectomy during
the abdominal surgery (resection or reconstruction) can be considered in these patients by evaluating the stability and life expectancy.
11.2.5 Drugs
Somatostatin analogs which are widely used
in the treatment of neuroendocrine tumors have
an unpleasant effect inducing gallstone forma-
47]. Since symptomatic gallbladder disease
tion [
that may develop during the treatment will cause
disruption of the treatment, simultaneous cholecystectomy can be performed in cases for whom
abdominal surgery is planned [47, 48].
There are various drugs commonly blamed
for causing gallbladder disease such as ceftriaxone, erythromycin, ampicillin, cyclosporin, dapsone, anticoagulant treatment, and narcotic and
anticholinergic medication [49]. However, there
is not any prospective randomized trial or guideline to support PC in case of chronic exposure
to these substances. Hence, utilization of any of
these drugs should be a guide in decision-making
in the presence of other factors leading to PC.
Another risk is chemical cholecystitis which
occurs histologically in almost 100% of the
patients who receive hepatic artery infusion
[
50]. This adverse effect is mostly encountered
following the administration of mitomycin C
and oxuridine/5-uorouracil. Although various
publications from late 1980s recommended PC
in these cases at the time of pump implantation
[50, 51], Carrasco etal. (1983) did not favor this
opinion since the incidence of symptomatic disease was only 0.6% [52].
11.2.6 Transplantation
Transplant patients constitute a special group
in terms of managing asymptomatic gallstones.
These patients are as vulnerable to undergo a surgery as they are at risk because of immunosuppressive therapy which may mask any abdominal
inammatory condition. Graham et al. (1995)
recommended pretransplant PC for all transplant
candidates, since they had a high incidence of
acute biliary complications, and urgent biliary
surgery had signicant morbidity and mortality
due to immunosuppression [53]. On the other
hand, Kao etal. (2005) disagreed with this opinion and they concluded that PC cannot be routinely recommended in all transplant patients
with the current data [54].
Kilic et al. (2013) reported a series of 1687
cases who underwent heart transplantation
11 Prophylactic Surgery forGallbladder andBiliary Tract Pathologies
119
and cholecystectomy, and they strongly recommended performing cholecystectomy after
transplantation in asymptomatic and uncomplicated gallstone patients due to the high risk of
complications [55]. On the other hand, expectant
management (wait-and-see) was recommended
for pancreas and/or kidney transplant recipients
with asymptomatic cholelithiasis by them [55].
Jackson etal. (2005) also showed that morbidity
associated with gallstones did not increase after
renal transplantation [56]. On the contrary, Moray
etal. (2003) recommended to consider PC, with
the concern of encountering complicated disease
during the immunosuppressive treatment, for all
end-stage renal disease patients with gallstones
who are candidates for renal transplantation [57].
Cholecystectomy can be performed safely both
in recipients and candidates [57, 58].
11.2.7 Bariatric Surgery
Higher body mass index (BMI) is associated with
the higher risk for developing gallstones. Among
the cases undergoing bariatric surgery, incidence
of preoperative gallstones is 14–21%. In addition,
rapid weight loss is another risk for gallstone
formation which occurs in 22–71% of the cases
after bariatric surgery [59]. Also, decreased cholecystokinin level after bypass procedures may
lead to gallbladder hypokinesia, bile stasis, and
eventually stone formation [60]. The incidence
of symptomatic gallstones after bariatric surgery
varies between 3.3 and 6.2% [61, 62].
Prophylactic cholecystectomy in bariatric surgery population is controversial in terms of its
necessity and timing. The type of the bariatric
procedure also affects the approach. For example, the future chance to undergo ERCP if needed
remains in sleeve gastrectomy ± bipartition
cases, while Roux-en-Y gastric bypass, mini-gastric bypass, and duodenal switch cases lose this
chance. Morais et al. (2016) reported that only
3.3% of the 653 patients with intact gallbladder
developed symptomatic gallstones and they did
not recommend a routine PC in patients undergoing bariatric surgery [62]. In terms of sleeve
gastrectomy, Raziel etal. (2015) showed that 9%
of patients with asymptomatic sludge or stones
required cholecystectomy after bariatric surgery
due to developing symptomatic disease during
the rst postoperative year [63].
In their study comparing obese patients who
underwent bariatric surgery (n: 2317) and were
observed without surgery (n: 2331), Chen etal.
(2019) did not nd any difference in terms of
the prevalence of gallstone disease and showed
female gender and restrictive procedures as
only risk factors for developing gallstone disease after bariatric surgery [64]. In contrast,
it was also reported that Roux-en-Y gastric
bypass had higher incidence of cholecystectomy after the index operation compared to
sleeve gastrectomy [61, 65].
Major concerns about simultaneous PC are
the technical difculties caused by visceral obesity and trocar placement, the challenges in the
management of biliary complications in obese
patients, the higher rates of early postoperative
complications, in-hospital mortality, and a longer hospital stay of 0.4 days [66, 67]. On the
other hand, it is also reported that simultaneous
cholecystectomy adds only 15–29min and does
not cause any additional complications [59].
Prophylactic cholecystectomy can be performed
6months after index bariatric surgery in patients
who have asymptomatic gallstones detected preoperatively and 1year after in patients who do
not have gallstones preoperatively but detected
on ultrasonographic examination in postoperative
rst year [68]. These conicting results should
lead surgeons not to confusion, instead to one
certain inference: “Tailored approach.” Tailoring
should be made according to the patient’s clinical
features, preferred surgical technique, surgeon
experience, and facilities of the center. Patients’
individual risk factors should be assessed and the
decision should be made as it is in nonobese population. Cholecystectomy can be quite arduous in
patients with central-type obesity and high BMI,
and we recommend performing it in anatomically appropriate cases. Incidental cholecystectomy may be more appropriate in patients with
peripheral-type obesity or lower BMI.
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11.2.8 Precursors forGallbladder
Cancer
Age, gender, and ethnicity are the most common
unchangeable risk factors for gallbladder cancer.
Besides these factors, there are several lesions of
gallbladder which are closely related with cancer
and have been the subject of many studies in the
literature [69].
Gallbladder polyps are commonly asymptomatic and majority of them are detected incidentally. Size, number, and morphology of
the polyps, the patient’s age, and genetics are
the most signicant factors to decide PC. In
the literature, the rate of cancer development
from polyps has been reported as 0–27% [70].
The guideline for gallbladder polyps published
by European Society of Gastrointestinal and
Abdominal Radiology (ESGAR) in 2017 recommended PC when the size of polypoid lesion is
10mm or greater, the size of polypoid lesion is
between 6 and 9mm but accompanied by a risk
factor, or polyp size increases by ≥2mm [71].
In asymptomatic cases without any gallstones, if
patient has risk factors (age >50years, history of
primary sclerosing cholangitis, Indian ethnicity,
sessile polyp, including focal gallbladder wall
thickening >4mm), PC is considerable according to the same guideline (Fig. 11.1). In terms
of the number of polyps, despite solitary polyp
was once attributed as an indicator for cancer, it
is not accepted as a strong indication for PC in
current studies [72, 73]. Therefore, solitary polyps should be evaluated with the other risk factors for deciding PC [69]. Extraintestinal polyps
in Peutz- Jeghers syndrome are rarely found in
gallbladder. Since, malignant transformation of
extraintestinal polyps has not been reported in the
literature, Peutz-Jeghers syndrome, itself, does
not create a special risk and polyps in these cases
should be managed as in routine [74].
Adenomyomas are hyperplastic nonneoplastic lesions developing from the gallbladder wall. Adenomyomas are the most common
benign polypoid lesions after cholesterol polyps (25%). It is reported that it is mostly seen in
women over 50years old and with a frequency
of 2.5–5% [75]. They are usually located in the
fundus (Fig. 11.2). They may be developed in
generalized (adenomyomatosis), annular, segmentary, and localized forms [70]. It is reported
that segmental adenomyomatous lesions on the
gallbladder wall may be confused with cancer by causing concentric narrowing (hourglass
gallbladder). Although it is generally accepted
that there is no risk of cancer, there are also
studies claiming it to be precancerous. The latest version of National Comprehensive Cancer
Network (NCCN) Clinical Practice Guidelines
in Hepatobiliary Cancers accept adenomyomatosis as a potential risk for developing gallbladder
cancer [76]. Surgery should also be planned in
Fig. 11.1 The MRCP coronal section shows the polyp in
the gallbladder
Fig. 11.2 An adenomyomatosis case originated from the
gallbladder fundus
11 Prophylactic Surgery forGallbladder andBiliary Tract Pathologies
121
segmental adenomyomatosis cases, because they
may be mistaken with cancer. The procedure to
be performed in the treatment of the disease is
laparoscopic cholecystectomy. Prophylactic cholecystectomy is recommended when the risk of
malignancy continues. Due to the risk of cancer,
the specimens should be removed by being put
in an endobag. Open cholecystectomy should be
preferred when cancer is suspected [70].
Our knowledge on the relation between por-
celain gallbladder and gallbladder carcinoma
is based on the studies from the rst half of the
twentieth century. In the literature, its incidence
was given as 0.2%, and carcinoma was detected
in 15% of porcelain gallbladders [77]. Towgh
etal. (2001) changed this infamous statement of
porcelain gallbladder with their study of 10,741
gallbladders reporting that none of the porcelain
gallbladders (0.14%) turned out to be carcinoma
[78]. Therefore, cholecystectomy should not be
routinely recommended in asymptomatic patients
with porcelain gallbladders [79, 80].
Thickness of gallbladder wall should also be
a warning in terms of gallbladder cancer. Seretis
etal. (2014) reported an average gallbladder wall
thickness of 4–5 mm in cases with gallbladder
metaplasia [24]. Gallbladder wall thicker than
3mm was shown as a risk for premalignant epithelial change in the gallbladder mucosa and so,
PC should be considered in these cases [81].
Primary papillary hyperplasia (PPH) of the
gallbladder is a rare precursor lesion for gallbladder cancer. Although PPH mostly lacks from
invasive ndings to the liver, it also demonstrates
a vascular rich, solid tumor as it is in the cancer which makes the differential diagnosis quite
challenging with preoperative diagnostic tests
[82]. In order to obtain a denite diagnosis and
to prevent a malignancy before developing, PC is
recommended in PPH [73]. Frozen section may
be useful to determine the extensiveness of the
surgery.
Pancreaticobiliary maljunction is a rare congenital malformation of biliary tract, which has
the incidences of 1:100,000in Western populations and 1:1000 in Asian populations [83]. It
denes the union of pancreatic and bile ducts outside the duodenum wall. This maljunction creates
a predisposition to cancer by causing bile stasis
and pancreatic reux, which eventually result in
histopathological changes in the epithelium of
biliary system.
Bile duct dilatation, which may occur in 77%
of the cases with pancreaticobiliary maljunction,
is an important indicator to determine the risk
for cancer and treatment option. The incidence
of gallbladder cancer was reported as 13.4–21%
and 37.4–77% in cases with and without biliary
dilatation, respectively [84, 85]. The major challenge is to recognize pancreaticobiliary maljunction before malignant transformation in cases
without biliary dilatation since these are usually
asymptomatic. Takuma et al. (2012) proposed
gallbladder wall thickness on ultrasonography as
an indication for MRCP and EUS for suspected
pancreaticobiliary maljunction without biliary
dilatation [86].
Sole PC is usually adequate and recommended
treatment option in cases with normal width bile
duct [84, 87]. The approach in case of dilated bile
duct is going to be explained in the prophylactic
surgery for biliary tract pathologies.
11.2.9 Concomitant Surgery
Gastric cancer is one the most compelling issues
in terms of management of asymptomatic gallbladder. Both the vagal cutdown and bypass of
the duodenal passage have effect on the gallstone formation following gastrectomy. In the
literature, the incidence of gallstone formation
after gastrectomy was reported in a wide range
2.2–47 [88–92]. Fortunately, most cases appear
to be asymptomatic, and only 0.5–5 of these
cases reported to require subsequent cholecystectomy [88, 93, 94]. In order to better determine
the indications for PC during the gastric cancer
surgery, many other variables have been evaluated. Regarding the extent of gastrectomy, no
difference was found between total and distal
gastrectomy in terms of the incidence of gallstones [90, 91]. The extent of lymph node dissection is another point that needs attention. The
removal or destruction of nerve system of gallbladder during the dissection around the hepato-
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O. N. Dilek and N. Acar
duodenal ligament disrupts gallbladder function
which may result in gallstone formation. The
incidence of gallstone formation was reported as
8.5–23% and 16.3%–42.1% after D1–2 and D3
dissections, respectively [90, 91]. Cholegas trial
recruiting two groups (undergoing standard gastric surgery with or without PC), 130 patients with
gastric cancer between 2008 and 2012, showed
that nearly all biliary abnormalities found in the
control group were sonographically detected
after 4.5years, the cumulative incidence of gallstones or biliary sludge increased in patients who
were still alive in the fth year of follow-up, and
younger patients affected by symptomatic gallstones were at risk for the subsequent surgery.
The authors of Cholegas trial concluded that concomitant PC during gastric cancer surgery was
safe, although not effective for improving the
natural course of patients and recommended to
consider PC for younger patients with the early
gastric cancer whose life expectancy is high [94].
In conclusion, although PC during gastric cancer surgery is not mandatory, it is a considerable
option in cases undergoing extended lymph node
dissection and with high life expectancy.
Esophagectomy also carries risk for gallstone
formation with the same previously mentioned
mechanism. Routine PC during esophageal can-
cer surgery was found to be safe but unnecessary,
since gallstones occurred in 6.1% of the patients
after esophagectomy and only 6.5% of these
cases required cholecystectomy during followup [95]. Gillen et al. (2010) reported that late
cholecystectomies can be performed safely and
removal of a normal acalculous gallbladder during upper GI surgery cannot generally be recommended [96]. On the other hand, Miftode etal.
(2014) advocated concomitant cholecystectomy
based on the fact of increased surgical mortality
in the cases of late cholecystectomy [97].
Ileal disease or ileal resection have been
reported to be related with gallstone formation in
Crohn’s disease. In their study of 8302 Crohn’s
disease patients with resected ileum, Goet etal.
(2019) displayed that female sex, re-resection,
and a later year of ileum resection were associated with the risk for future cholecystectomy
[98]. In addition, PC in Crohn’s disease was
found to be associated with higher disease activity, lower quality of life, more hospital admissions, and higher risk for colonic dysplasia in the
presence of diseased ileum [99]. Routine PC in
Crohn’s disease is not recommended due to possible undesirable effects, and when it is planned,
individual risk factors should be introduced well.
Concomitant PC during surgery for colorectal
cancer is also controversial. With the widespread
utilization of the imaging tools for preoperative
staging, colorectal cancer cases with gallstones
have been encountered more frequently. Pezzolla
et al. (1993), in their study of 23 patients who
underwent concomitant cholecystectomy during
colorectal cancer surgery and 23 patients who did
not have gallstone, reported that postoperative complications and mortality were more frequent among
the cases who underwent PC [100]. Some more
recent studies showed that the rate of perioperative
biliary complications (0.7%) and PC can be easily
and safely performed during colorectal surgery [9].
Besides, gallstones were reported to increase general risk of colorectal cancer [101, 102] Therefore,
PC during the index operation for colorectal cancer
may also be considered as a preventive for future
recurrence or metachronous colorectal cancer.
However, actual data is not adequate to recommend
a concomitant PC for colorectal cancer surgery.
On the other hand, this approach may be different in benign colorectal disorders such ulcer-
ative colitis and ischemic colitis. Cholecystitis
may occur during or after ischemic colitis due
to increased intra-abdominal pressure and/or
splanchnic vasoconstriction. Moszkowicz etal.
(2013) recommended PC in patients undergoing
surgery due to ischemic colitis in order to prevent acute acalculous, with a low level of evidence [103]. They proposed this opinion, since
a secondary operation may be catastrophic and
challenging in unstable and fragile patients.
However, operation time and surgical morbidity
are also vital in these patients, especially the ones
undergoing emergency surgery, so benet and
loss should be carefully evaluated when deciding
PC.In terms of ulcerative colitis, unlike Crohn’s
disease, the risk for developing gallstones was
not different than general population [104].
However, there have also been studies opposing
11 Prophylactic Surgery forGallbladder andBiliary Tract Pathologies
123
this inference. Ha etal. (2015) presented a prevalence of gallstone almost four times higher in
patients with ulcerative colitis than normal population [105]. Risk factors for gallstone formation
were indicated as elder age, multiple hospitalizations, hypertension, diabetes mellitus, and colectomy [106, 107]. These conicting results require
further investigation in order to determine the criteria for recommending PC in ulcerative colitis.
Simultaneous cholecystectomy of the asymptomatic gallbladder with curative resection of
hepatocellular carcinoma in the left lateral
section or Spiegel lobe resulted in higher postoperative complications. Consequently, the gallbladder should be preserved except in cases of
gallbladder stones or polyps [108]. Besides, concomitant cholecystectomy is recommended in
cases where right or common hepatic artery is
ligated or embolized, in order to avoid gallbladder necrosis [109].
Cytoreductive surgery which aims to excise
macroscopic disease by removing all the affected
peritoneal surfaces and adjacent organs has been
used widely in both primary and secondary malignancies (metastasis) of peritoneum [110]. As a part
of omental bursectomy, cholecystectomy is also
a component of cytoreductive surgery. In addition, PC may be required in cases who undergo
diaphragmatic peritonectomy, excision of disease
from the porta hepatis and liver’s capsule [111].
In their study of 1257 cases who underwent
open heart surgery due to coronary artery disease, valvular disease, and severe aortic stenosis, Charokopos etal. (2007) reported that they
performed concomitant cholecystectomy in nine
patients and concluded that these two procedures
can be performed safely in selected patients at the
same session [112]. However, all patients in that
study had symptomatic disease.
Multiple gallbladders are rare anatomical variations and divided into four subgroups according
to which step organogenesis was affected. Their
association with cancer is not clearly reported in
the literature, so the indications for PC are vague.
Type II multiple gallbladders were reported
to have similar appearance with Todani type II
bile cyst [117] Therefore, PC can be considered
in these cases even if they are asymptomatic,
since preoperative differential diagnosis is nearly
impossible. Furthermore, supernumerary or the
accurate number of the gallbladders is mostly
discovered during the surgery which is being performed due to a symptomatic disease [118]. In
this case, it should be emphasized that diseasefree gallbladder(s) should also be removed to
avoid any biliary complications.
Bilobed and hourglass-shaped gallbladders can also be encountered on preoperative
imaging or during the surgery (Fig. 11.3).
11.2.10 Anatomical Variations
Anatomical variations of biliary system are seen
in 7.3–47% of the population, and manifest as
supernumerary structures, atypical shapes, atypical localization and/or atypical joint of ductal
structures [113–116].
Fig. 11.3 An hourglass gallbladder that can mimic choledochal cysts is the specimen of our case
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