Cholecystectomy for Biliary Dyskinesia: How Did We Get There?

Bielefeldt, Klaus; Saligram, Shreyas; Zickmund, Susan; Dudekula, Anwar; Olyaee, Mojtaba; Yadav, Dhiraj

doi:10.1007/s10620-014-3342-9

Cited by 51 publications

(45 citation statements)

References 200 publications

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“…Cholecystectomy is commonly recommended in these patients based on the finding of an abnormally low gallbladder ejection fraction 1 . Although used commonly in today’s clinical practice, the testing methodology and treatment outcomes pertaining to diagnoses related to the test – specifically biliary dyskinesia (or functional gallbladder disorder, as it is sometimes called) - are controversial and poorly understood by many practicing clinicians, as is the data (or lack thereof) supporting LC as the treatment of choice 2 5. .…”

Section: Discussionmentioning

confidence: 99%

“…Although laparoscopic cholecystectomy (LC) has been widely adopted as the preferred treatment for biliary dyskinesia 1 , this practice remains controversial owing to a lack of high-quality prospective data supporting the practice 2,3,4,5 . To date, only one randomized controlled trial examining the role of cholecystectomy for BD has been published.…”

Section: Introductionmentioning

confidence: 99%

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Pilot Randomized Controlled Trial of Laparoscopic Cholecystectomy vs Active Nonoperative Therapy for the Treatment of Biliary Dyskinesia

Richmond

Grodman

Walker

et al. 2016

Journal of the American College of Surgeons

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Introduction Despite widespread adoption by the surgical community, high-quality prospective data supporting the practice of laparoscopic cholecystectomy (LC) for the treatment of biliary dyskinesia (BD) is lacking. Methods Adult patients meeting criteria for diagnosis of BD (Rome III symptoms, normal ultrasound, gallbladder ejection fraction<38%) were randomized to either LC or a trial of non-operative (NO) therapy with a low-dose neuromodulator (amitriptyline 25mg/day). Patients in the NO arm were allowed to cross over to the surgical arm and remain in the study for any reason. Besides collection of basic demographics and medical/surgical history, patients were administered a standardized quality of life (QOL) assessment (SF-8) and a symptom-specific questionnaire (Rome III criteria) at enrollment and monthly through the study to assess the effect of treatment on biliary symptoms and overall QOL. Results Thirty patients were enrolled over 12 months (15LC, 15NO). In the LC group, 13 underwent LC, 1 refused surgery, 1 withdrew. In the NO group, 14 crossed over to the LC group (of which 13 had LC), yielding 26 patients who underwent LC. SF-8 physical scores (PCS-8) were significantly improved at both the first and last follow-up visits (p<0.0001, p=0.0003 respectively). SF-8 mental scores (MCS-8) were also significantly improved at both the first and last follow-up visits (p=0.0187, p=0.0017 respectively). With median follow-up of 12 months [range 3–14], all 26 reported relief of pain. Conclusions This pilot study raises doubts regarding the feasibility of a randomized trial, presumably due to both clinician and patient bias toward LC and the lack of “gold-standard” non-operative treatments. However, these prospective data indicate that, with careful patient selection (standardized symptom criteria/imaging methodology), LC results in pain relief and significant improvement in QOL in BD patients. Further prospective study of these findings is warranted.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Pilot Randomized Controlled Trial of Laparoscopic Cholecystectomy vs Active Nonoperative Therapy for the Treatment of Biliary Dyskinesia

Richmond

Grodman

Walker

et al. 2016

Journal of the American College of Surgeons

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“…4,5 The uncertainty of contributing causes is reflected in the various names, including gallbladder dyskinesia, gallbladder spasm, acalculous biliary disease, chronic acalculous cholecystitis, chronic acalculous gallbladder dysfunction, and cystic duct syndrome. 6 The Rome III criteria were put forth in 2006 to update and standardize the diagnosis of FGBD. 5 However, the medical literature continues to disagree on the diagnostic validity of the disease, especially because up to 20% of asymptomatic people also have abnormal gallbladder function tests.…”

mentioning

confidence: 99%

“…5 However, the medical literature continues to disagree on the diagnostic validity of the disease, especially because up to 20% of asymptomatic people also have abnormal gallbladder function tests. 6 The relative safety of cholecystectomy and lack of other available treatments has led to the adoption of cholecystectomy as the primary treatment modality for FGBD, [7][8][9] particularly in patients with a low gallbladder ejection fraction; however, high-quality evidence supporting this practice is lacking. 10 Recent research suggests that the rate of cholecystectomy for FGBD is significantly greater in the United States than in other countries and may even be increasing.…”

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confidence: 99%

Functional gallbladder disease: Operative trends and short-term outcomes

Thiels

Hanson

Chawla

et al. 2016

Surgery

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“…However, the value of this test in predicting the outcome of cholecystectomy is controversial, despite numerous studies [2], and there is increasing skepticism about the whole concept of a functional gall bladder disorder [3]. ERCP has no role in this context.…”

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confidence: 99%

The patient with pain; suspected gallbladder and sphincter dysfunction

Cotton

2014

Ercp

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Before the days of sophisticated imaging techniques, ERCP was frequently and effectively used to investigate patients with biliary/pancreatic pain and to diagnose and exclude common diseases such as bile duct stones and chronic pancreatitis. The situation is quite different now.Nowadays, most patients with upper abdominal pain have basic laboratory tests taken and undergo upper endoscopy (after careful clinical enquiry and physical examination). If this is negative, abdominal scanning is indicated, by ultrasound in some countries, more likely by computed tomography (CT) in the United States. If that is negative and suspicion persists, MRCP is recommended. These scans provide excellent information about the biliary tree and pancreas, and should also detect problems in surrounding organs, such as aortic aneurysm and renal tumors. This review concerns patients in whom all of these tests are unrevealing.The appropriate next steps are influenced by clinical features, such as age and the type of pain, and any associated complaints, such as weight loss.Epigastric pain, especially if persistent, is suggestive of a pancreatic origin. The best next step is EUS, which can detect small tumors and less severe cases of pancreatitis. EUS is also valuable in looking for small stones in the gallbladder or bile ducts. If EUS is negative, there is no role for ERCP. The chances of finding anything are less than the risk of causing pancreatitis.Intermittent pain in the right upper quadrant (and/or epigastrium) suggests biliary disease, specifically dysfunction of the gallbladder or sphincter of Oddi, and suspicion is enhanced if the liver tests bump with attacks of pain. This is where the algorithm of investigation gets more controversial, since hard data are scarce [1].Gallbladder dysfunction. It is presumed that incoordination of gallbladder emptying can cause pain. Cholescintigraphy (hepatobiliaryiminodiacetic acid,

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Cholecystectomy for Biliary Dyskinesia: How Did We Get There?

Cited by 51 publications

References 200 publications

Pilot Randomized Controlled Trial of Laparoscopic Cholecystectomy vs Active Nonoperative Therapy for the Treatment of Biliary Dyskinesia

Pilot Randomized Controlled Trial of Laparoscopic Cholecystectomy vs Active Nonoperative Therapy for the Treatment of Biliary Dyskinesia

Functional gallbladder disease: Operative trends and short-term outcomes

The patient with pain; suspected gallbladder and sphincter dysfunction

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