Assessment

1. Asymptomatic Gallstones

   • Smaller stones more likely to be symptomatic than large stones.
   • Indigestion, belching, bloating and fatty food intolerance may occur but are often not cured by cholecystectomy.
   • Only 2-3% of patients with asymptomatic gallstones will develop symptoms each year.
   • Refer asymptomatic gallstones to the General Surgical Outpatient clinic when:
     • Patient is immunocompromised, is waiting for organ transplantation or has Sickle Cell Disease.
     • Calcified (porcelain) gallbladder.
     • Gallbladder polyp > 10mm in size or showing rapid growth in size.
     • Gallbladder trauma.
     • Patients develop symptoms.

2. Biliary Code Suspected

   • Biliary Tract Disease includes:
     • Biliary colic
       • Occurs when a gallstone obstructs the cystic duct.
       • Pain is usually severe, dull, boring, constant, 1-5hrs duration, starting 30 minutes to hours after a meal, often at night waking the patient and in the epigastrium or RUQ. May radiate to right scapula or back.
       • Nausea and vomiting often occur.
       • Patients tend to move around to seek pain relief.
       • On abdominal examination the patient has epigastric or RUQ abdominal tenderness and guarding. There are no signs of peritonitis.
       • The patient is not jaundiced and vital signs are usually normal.
       • Patients who present with biliary colic may be candidates for Direct Access Gallbladder Surgery.
   • Cholecystitis
     • Occurs when gallstone obstruction of the cystic duct is prolonged (>6hrs). There is initially a chemical inflammation and then a superimposed bacterial infection of the gallbladder.
     • The pain is like that felt with biliary colic but lasting > 24hrs.
     • Patients tend to lie still as movement aggravates the pain.
     • On abdominal examination the patient has epigastric or RUQ abdominal tenderness and guarding and 97% have a positive Murphy sign.
     • Jaundice occurs in < 20% but may occur if the stone in the cystic duct compresses the common bile duct. Choledocholithiasis must be excluded if the patient is jaundiced.
     • The patient's vital signs may become abnormal with fever and tachycardia.
     • Cholecystitis is referred to the Surgical Registrar on call as an emergency.
   • Choledocholithiasis and Cholangitis
     • Occurs when a gallstone passes into the common bile duct.
     • The pain is similar to biliary colic and cholecystitis.
     • Cholangitis is more often associated with fever, jaundice, nausea and vomiting.
     • The patient is unwell with jaundice, fever or rigors, tachycardia and may be hypotensive with a reduced level of consciousness - this is a surgical emergency.
     • The abdominal examination findings are similar to those of cholecystitis.
     • Rigors, RUQ abdominal pain and jaundice (the Charcot triad) is highly suggestive of cholangitis.
     • Cholangitis is referred to the Surgical Registrar on call as an emergency.
   • Asymptomatic gallstones
     • Smaller stones more likely to be symptomatic than large stones.
     • Indigestion, belching, bloating and fatty food intolerance may occur but are often not cured by cholecystectomy.
     • Only 2-3% of patients with asymptomatic gallstones will develop symptoms each year.
     • Refer asymptomatic gallstones to the General Surgical Outpatient clinic when:
       • Patient is immunocompromised, is waiting for organ transplantation or has Sickle Cell Disease.
       • Calcified (porcelain) gallbladder.
       • Gallbladder polyp > 10mm in size or showing rapid growth in size.
       • Gallbladder trauma.
       • Patients develop symptoms.

3. Investigations

   • Abdominal Ultrasound
     • In patients presenting with suspected biliary disease, the abdominal ultrasound is used:
       • To diagnose biliary disease: Cholelithiasis: 98% sensitive and specific. Cholecystitis: 90-95% sensitive and 78-80% specific.
       • To exclude biliary disease.
       • To exclude alternative causes of the patient's symptoms.
     • For a patient to meet the criteria for Direct Access Gallbladder Surgery, the ultrasound should show a thin walled gallbladder with stones or sludge.
     • Note that false-positive gallbladder wall thickening may be seen in hypoalbuminaemia, ascites, congestive heart failure and carcinoma.
   • Liver function tests
     • Normal in biliary colic.
     • In cholecystitis, Bilirubin, AST, ALT, and ALP levels may be elevated but not always.
     • Significantly elevated Bilirubin, AST, ALT, and ALP levels suggests common bile duct obstruction.
     • A high bilirubin suggests common bile duct obstruction.
   • Amylase
     • Normal in biliary colic.
     • May be elevated up to 3 times normal in cholecystitis.
     • Markedly elevated in pancreatitis caused by pancreatic duct obstruction.
   • Full blood count, Electrolytes, urea, creatinine
     • Normal in biliary colic.
     • A raised white blood cell count is frequently seen in cholecystitis.
   • Serum calcium if there is suspicion of biliary pancreatitis.
   • INR
     • If on warfarin.
     • May be raised in chronic liver disease (cirrhosis) and is useful if operative intervention is being considered in these patients.

4. Assess Suitability for Direct Access Gallbladder Surgery

   • The requirements for Direct Access Gallbladder Surgery
     1. Patient younger than 60 years of age.
     2. Typical symptoms of biliary colic.
     3. BMI < 35.
     4. No history of cholecystitis (no history of admission to hospital for cholecystitis and no gallbladder wall thickening on ultrasound)
     5. Ultrasound confirms a thin-walled gallbladder and stones or sludge.
     6. No medical illness requiring anaesthetic review (excluding well controlled hypertension).
     7. Has a support person to look after them for the first 24 hours after surgery.
     8. Patient is not taking warfarin, clopidogrel or dabigatran.
   • The patient is suitable for Direct Access Gallbladder Surgery if they meet the above requirements and they consent to referral for the procedure. If they do not consent to the procedure, then they may be referred using the traditional pathway.

Management

1. If Direct Access Gallbladder Surgery is suitable, refer patient
   • Please read the Direct Access Gallbladder Surgery protocol.
   • If your patient meets the criteria for Direct Access Gallbladder Surgery, then:
     1. Inform the patient: Provide your patient with the Direct Access Gallbladder Surgery information sheet.
     2. Get consent: Make sure that the patient has read the information sheet above and that they consent to the direct access laparoscopic cholecystectomy pathway (see the surgeon and the anaesthetist on the day of surgery for the first time). They need to complete the consent form attached to the referral form below. The surgeon will consent the patient for the procedure on the day of surgery. To assist the patient in making informed consent they can view this video which shows what will happen during the procedure.
     3. Anaesthetic pre-operative assessment form: Ask the patient to complete this assessment form. Ideally this is completed by the patient before they leave your practice so that it can be sent with the referral. The patient should be able to complete this form by themselves.
     4. Pre-operative blood test: Provide the patient with a form to have FBC, LFTs, Creatinine, K+ and Na+ done if these have not be ordered in the past month.
     5. Refer: Refer the patient using the eReferral system or by completing the referral form.
   • In summary the referral should include:
     • Patient consent
     • Anaesthetic pre-operative assessment form
     • Referral form
2. If referral is not accepted, the patient will be placed on the traditional pathway and graded accordingly.
   • The traditional pathway is a referral to the Department of General Surgery requesting an Outpatient Clinic appointment for the patient. This would either be a faxed paper referral to the Tauranga Hospital Referral Centre, or an eReferral.
   • This referral is graded and, based on the grading, the patient is given an Outpatient Clinic appointment.
3. If Direct Access Gallbladder Surgery is not suitable, the patient will be placed on the traditional pathway and graded accordingly.
   • The traditional pathway is a referral to the Department of General Surgery requesting an Outpatient Clinic appointment for the patient. This would either be a faxed paper referral to the Tauranga Hospital Referral Centre, or an eReferral.
   • This referral is graded and, based on the grading, the patient is given an Outpatient Clinic appointment.

4. If Direct Access Gallbladder Surgery patient referral is accepted, the patient and GP are advised of the expected date for surgery.

   • GP Pre-Operative Visit
     • One to two weeks prior to surgery, the patient visits their GP who checks that:

     1. 1. The patient has received and read the Gallbladder Surgery information.
        2. The patient has given their consent for the direct access laparoscopic cholecystectomy pathway (see the surgeon and the anaesthetist on the day of surgery for the first time) and they have completed the consent form (usually done at the time of referral and is attached to the referral form).
        3. The patient has had recent FBC, Creatinine and Liver Function Tests.
        4. There are no medical concerns that could affect anaesthesia or surgery and the anaesthetic form has been completed.
   • Day of Surgery
     1. Patient admitted to Surgical Admissions Unit (SAU) at 07:00.
     2. Patient is seen in SAU at 07:30-08:30 by surgeon and anaesthetist.
     3. If appropriate for direct access surgery, Consent to perform the operation is completed.
     4. If inappropriate for direct access surgery, the patient is rebooked for OPD clinic.
     5. Surgery performed.
     6. Post operatively, the patient is transferred to SAU.
     7. Patient seen post operatively by surgical team before discharge.
     8. Patient discharged on the same day.
     9. Discharge medications:
        • Paracetamol 1g PO QID X 2/52
        • Brufen 400mg PO TDS X 2/52
        • Oxynorm 5mg X 3 doses, maxalon 10 mg TDS X 3 doses
   • GP Follow Up
     • One to two weeks post-surgery, the patient sees their GP to review histology and to make sure that there are no postoperative complications.

Information

• For patients
  • Direct Access Gallbladder Surgery information sheet.
  • Video of a laparoscopic cholecystectomy: https://www.youtube.com/watch?v=4Be7Ce2dLNw (Sign in necessary)
• For providers
  • Protocol for Direct Access Gallbladder Surgery

    Scope: This pathway outlines the care for direct access laparoscopic gallbladder surgery

    Length of stay: Expected day-stay.

    Associated resources:

    • Patient Information
    • Consent and referral form
    • Anaesthetic Pre-Op form

    
    Before Surgery:

    The GP is to identify a suitable patient. In general these are young fit patients with typical symptoms, who are likely to have uncomplicated surgery. Therefore, the inclusion criteria include:

    • Younger than 60 years of age
    • Typical biliary symptoms
    • BMI <35
    • Has not had cholecystitis (admission to hospital for cholecystitis or thick wall gallbladder on ultrasound) 
    • Ultrasound confirming a thin walled gallbladder and stones or sludge
    • No medical illness requiring anaesthetic review (excludes well controlled hypertension)
    • Has a support person to look after them for the first 24 hours after surgery
    • Medications excluded Warfarin, Clopidigral, Dabigatran
      
      

    Patients are referred on the pro forma and if suitable, the patient and GP are advised of the expected date for surgery. If unsuitable, the patient will be placed on the traditional pathway and graded accordingly.

    One to two weeks prior to surgery, the GP checks the anaesthetic questionnaire and patient consent form has been completed and there are no medical concerns, ensures up to date FBC, creatinine and LFT results are available and surgery has been discussed with the patient. GP has provided the guide to laparoscopic cholecystectomy patient information booklet and consent info, ensuring patient is happy to be involved in the process.

    Day of Surgery:

    1. Patient admitted to Surgical Admissions Unit (SAU) at 07:00
    2. Patient is seen in SAU at 07:30-08:30 by surgeon and anaesthetist.
    3. If appropriate for direct access surgery, Consent to perform the operation is completed.
    4. If inappropriate for direct access surgery, the patient is rebooked for OPD clinic
    5. Surgery performed.
    6. Post operatively, the patient transferred to SAU
    7. Patient seen post operatively by surgical team before discharge

    Discharge medications:

    Paracetamol 1g PO QID X 2/52, Brufen 400mg PO TDS X 2/52,
    Oxynorm 5mg X 3 doses, maxalon 10 mg TDS X 3 doses

    Post operation

    Patient discharged on day of surgery. GP follow up within 2 weeks post operatively to check patient is doing well and review histology.

  • Referral form
  • Anaesthetic pre-operative assessment form
• Acknowledgements

  Pathway developed with the following:

  Title	Name
  Project Manager	Wendy Carey
  GP liaison	Joe Bourne
  Surgeon Clinical lead	Jeremy Rossaak
  CNS Upper GI	Sharon Hilton

   

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.