Changes in the Biliary System After Cholecystectomy. The Causes of Recurrence of Gallbladder Symptoms

Abstract

IN A recent article, Eiss' discussed some of the after-effects of biliary surgery, and pointed out certain precautionary measures which served to prevent many of the so-called "liver deaths" which too often bring to a fatal termination operations undertaken in full expectation of a perfectly successful outcome. This fatal syndrome would seem to follow traumatization of the ducts during gallbladder operation. Injury to the bile ducts involves biliary obstruction, and this in turn reacts with increased damage to the liver.By way of explanation, the blood supply of the liver is peculiar in that the individual cells of this gland receive their blood supply from the portal vein alone, while the hepatic capsule and the bile ducts are included in the circulation of the hepatic artery. Therefore, any injury to the blood vessels of the biliary tract has an immediate deleterious effect upon liver function, because within the liver cells we do not find an interchange between an arterial and a venous system but a special relation between the portal and the biliary circulation.The contention of the paper referred to is that a meticulous cholecystectomy technic will go far to improve the end-results and lower the operative mortality of gallbladder surgery. But even wheni "'liver deaths" are successfully avoided, the end-results of cholecystectomy often prove most unsatisfactory to patient and surgeon alike. With a technic which is absolutely faultless, there are still many cases where there is recurrence of symptoms, often equaling if not exceeding the violence and gravity of those which originally brought the patient to operation.Despite the popularity of intervention for the extirpation of the gallbladder, there is a steadily increasing protest against it. As far back as I900, the Italian surgeon, Benedetto Schiassi,2 advocated its less extended use, and in its place put forward a form of cholecystotomy, which he termed "cholecystendysis." At the Interniational Congress on Biliarv Lithiasis, held at Vichy in I932, he repeated his assertions made more than thirty years earlier, and discussed at length the reasons for the poor functional results and frequent recurrences of biliary inflammation witnessed after the most technically correct surgery.While many of the surgeons in attendance at this Congress were less outspoken in their condemnation of too frequent resort to removal of the gallbladder, the net result of their discussion was finally drawn up and put on 921