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A Cholecystectomy (Removal of the Gallbladder)

A Cholecystectomy (Removal of the Gallbladder)

AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION Surgical Removal of the

Benefits and Risks blocking the cystic of the Operation Gallbladder Benefits—Gallbladder removal will relieve , treat , and, in most cases, stop gallstones from coming back. Possible risks include— leak, bile Gallstones blocking duct , , infection of the the common (), , injury, infection, numbness, raised Gallstones scars, at the incision, complications, puncture of the intestine, and death.1-3 The Condition Risks of not having an operation—The Keeping You Cholecystectomy is the surgical removal possibility of continued pain, worsening of the gallbladder. The operation is symptoms, infection or bursting of the Informed done to remove the gallbladder due to gallbladder, serious illness, and possibly gallstones causing pain or infection. death.1-2 This information will help you understand your operation and Common Symptoms provide you with the skills to ● Sharp pain in the upper right part of Expectations actively participate in your care. the that may go to the back, Before your operation—Evaluation mid abdomen, or right shoulder Education is provided on: usually includes work, a urinalysis, ● Low fever and an abdominal . Your Cholecystectomy Overview...... 1 ● and feeling bloated surgeon and anesthesia provider will Condition, Symptoms, Tests...... 2 discuss your health history, home ● (yellowing of the skin) if stones Treatment Options…...... 3 medications, and pain control options. are blocking the common bile duct1 Risks and The day of your operation—You will Possible Complications...... 4 not eat for 4 hours but may drink clear Preparation Treatment Options liquids up to 2 hours before the operation. and Expectations...... 5 Surgical Procedure1-3 Most often, you will take your normal Your Recovery medication with a sip of water. You will and Discharge...... 6 Laparoscopic cholecystectomy—The need someone to drive you home. Pain Control...... 7 gallbladder is removed with instruments Your recovery—If you do not Glossary/References...... 8 placed into small incisions in the abdomen. have complications, you usually Open cholecystectomy—The gallbladder will go home the same day after a is removed through an incision on the right laparoscopic procedure or in 1 to 2 side under the . days after an open procedure.5 Nonsurgical Procedure Call your surgeon if you have severe ● Stone retrieval by pain, cramping, chills, a high fever (over 101°F or 38.3°C), odor or For Gallstones without Symptoms increased drainage from your incision, ● Watchful waiting for all patients1,4 your skin turns yellow, no bowel ● Increased exercise movements for three days, or and the inability to keep fluids down.

This first page is an overview. For more detailed information, review the entire document.

AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation The Condition, Symptoms, Cholecystectomy and Diagnostic Tests SAMPLE

Common hepatic duct Keeping You Informed Most adults with gallstones do not have Liver symptoms. Eighty percent of people with gallstones go 20 years without symptoms.1,6 Gallbladder Gallstones are more common in 1,7-8 people who: Gallbladder • Are Native American • Have a family history of gallstones

• Are overweight The Condition Symptoms Upper Right Left • Have sickle cell The Gallbladder The most common symptoms of The gallbladder is a small pear-shaped 1 • Are pregnant are: under the liver. The liver makes Right Left • Lose weight rapidly about 3 to 5 cups of bile every day. Bile ●●Sharp pain in the right abdomen • Use to helps in digesting and is stored in the Lower manage gallbladder. When fatty foods are eaten, ●●Low fever the gallbladder squeezes bile out through ●●Nausea and Gallbladder pain or the duct and into the small intestine. biliary is usually ●●Jaundice (yellowing of the skin) may occur temporary. It starts in Gallstones if gallstones are in the common bile duct the middle or the right Gallstones are hardened digestive fluid that can side of the abdomen form in your gallbladder. The medical term for and can last from 30 formation is cholelithiasis. Gallstones Common Tests minutes to 24 hours. The can leave the gallbladder and block the flow of History and Physical Exam pain may occur after bile to the ducts and cause pain and swelling a fatty meal. of the gallbladder. A gallstone in the common Your health care provider will ask you about your pain and any stomach problems. • Acute cholecystitis bile duct is called choledocholithiasis. pain lasts longer Cholecystitis is of the gallbladder, Additional Tests (see Glossary) than 6 hours, and which can happen suddenly (acute) or Other tests may include:1 there is abdominal over a longer period of time (chronic). tenderness and fever. ●●Blood tests, including Gallstone is caused by stones ● • Pain on the right side moving into and blocking the common ● of the abdomen can bile duct, the pancreatic duct, or both. A ●● profile also be from ulcers, cholecystectomy may be recommended.1 ●●Abdominal ultrasound is the most common liver problems, and study for .1-2 You may be Cholecystectomy is the surgical removal of the pain. asked not to eat for 8 hours before the test. gallbladder. Gallstones that cause • Standard treatment of (acute pain in the abdomen caused by ●●Hepatobiliary iminodiacetic acute cholecystitis is or blockage of the cystic or bile duct) are the acid scan (HIDA scan) intravenous (IV) fluids, most common reason for a cholecystectomy. ●●Endoscopic retrograde pain medication, and cholangiopancreatography (ERCP) 9 cholecystectomy. ●●Magnetic resonance cholangiopancreatography (MRCP)

2 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Surgical and Cholecystectomy Nonsurgical Treatment

LaparoscopicLaparoscopic versus Open CholecystectomyOpen LaparoscopicCholecystectomy Cholecystectomy Open CholecystectomyCholecystectomy Keeping You Informed • Conversion rates from a laparoscopic to an open technique are less than 1% for young healthy people.

• Conversion rates from laparoscopic to open range from 1.3% to 7.4% in the presence of common bile duct stones.10-11

• The risk of conversion increases up to 30% if you are over 50 years old, are male, and have acute cholecystitis; have had past abdominal operations; or have high fever, high , repeated gallbladder attacks, Surgical Treatment Open Cholecystectomy or conditions that limit your 10-11 A cholecystectomy, or removal of the The surgeon makes an incision approximately activity. gallbladder, is the recommended operation 6 inches long in the upper right side of the for gallbladder pain from gallstones. abdomen and cuts through the and muscle to the gallbladder. The gallbladder is removed, and any ducts are clamped Laparoscopic off. The site is stapled or sutured closed. A small drain may be placed going from the Cholecystectomy inside to the outside of the abdomen. The Cholecystitis in This technique is the most common for drain is usually removed in the hospital. Children simple cholecystectomy. The surgeon will The procedure takes about 1 to 2 hours. Four of 100 gallbladder removals make several small incisions in the abdomen. are done in children.13 Almost Ports (hollow tubes) are inserted into the 70% of children with gallstones openings. Surgical tools and a lighted Nonsurgical Treatment do have symptoms. Symptoms in camera are placed into the ports. The Watchful waiting is recommended if you have children include , abdomen is inflated with carbon dioxide gas gallstones but do not have symptoms.1,4 nausea, vomiting, jaundice, fatty to make it easier to see the internal organs. food intolerance, and fever.18 The gallbladder is removed, and the port About 1 in 5 newly diagnosed patients with openings are closed with sutures, surgical acute cholecystitis who do not have Children also receiving continuous IV clips, or glue. Your surgeon may start with a readmit to the emergency room within about nutrition and those with long-term 4 laparoscopic technique and need to change 12 weeks. use, cystic , , (convert) to an open technique. Gallstones only, without or a family history have a higher The procedure takes about 1 to 2 hours. chance of developing gallstones.14 cholecystitis Nearly 50% of all children with sickle ●●Increase your exercise. Exercising 2 to 3 cell disease develop gallstones and hours a week reduces the risk of should have a screening ultrasound.1,15 11-12 gallstones. Children with cholecystitis confirmed ●●Eat more fruit and vegetables, and eat less by ultrasound, those with severe pain, of foods high in sugars and or those not able to take food or fluids like donuts, pastry, and white bread. should be evaluated for surgery.

3 Cholecystectomy Risks of this Procedure SAMPLE

Risks Based on the ACS Risk Calculator Open Cholecystectomy and Laparoscopic Cholecystectomy from the ACS Risk Calculator – August 2, 2015

Percent for Risks Keeping You Informed Average Patient

Pneumonia: Infection in the Open 1.7% You can decrease your risk by rinsing with mouthwash the morning of Laparoscopic 0.2% your operation (to decrease mouth ), quitting before your operation, and getting up often to walk post-operatively.

Heart : Heart attack Open 0.7% Problems with your heart or lungs can be affected by general or sudden stopping of the heart Laparoscopic 0.1% anesthesia. Your anesthesia provider will take your history and suggest the best option for you.

Wound infection Open 7.6% are not routinely given except for high-risk patients. You Laparoscopic 1% should wash your abdomen with an antimicrobial soap such as dial the night before the operation.

Urinary tract infection: Infection of Open 1.5% A Foley is placed during surgery to drain the . Let your the bladder or kidneys Laparoscopic 0.5% surgical team know if you have trouble urinating after the tube is removed—this is more common in older men or if an epidural is used for pain.

Blood clot: A blood clot in the legs Open 1% Longer surgery and bed rest increase the risk. Walking 5 times/day and can travel to the Laparoscopic 0.2% wearing support stockings reduce the risk.

Renal () failure: Kidneys Open 0.9% Pre-existing renal problems, Type 1 , being over 65 years old, no longer function in making urine Laparoscopic 0.1% and other medications may increase the risk. and/or cleaning the blood of

Return to surgery Open 3.3 % Bile leakage or a retained stone may cause a return to surgery. Your Laparoscopic 0.8% surgical team is prepared to reduce all risks of return to surgery.1

Death Open 0.8% Your surgical team will review for possible complications and be Laparoscopic 0.1% prepared to decrease all risks.

Discharge to nursing or Open 5.4% Pre-existing health conditions can increase this risk. rehabilitation facility Laparoscopic 0.6%

Bile Duct Injury/Leakage*1,16 0.5% Injury can happen between 1 week to 6 months after the operation from fever, pain, jaundice, or bile leakage from the incision. Further testing and surgery may be needed.1,17

Retained common bile 4% to 40% A gallstone may pass after surgery and block the bile from draining. duct stone*1 The stone should be removed because of an increased risk of biliary obstruction or inflammation of the pancreas or bile duct.1

Pregnancy Complications, Fetal loss 4% Most pregnant women with gallstones will have no symptoms during premature labor and fetal loss* (uncomplicated removal) . If you have or pancreatitis, gallbladder up to 60% if pancreatitis removal will be offered to reduce maternal complications.18

1% means that 1 of 100 people will have this complication *Results from the last 10 years of literature

The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org.

4 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Expectations: Cholecystectomy Preparing for Your Operation

What to Bring Preparing for Your Operation ●●Insurance card and identification Questions Home Medication ●●Advance directives (see Glossary) to Ask Bring a list of all of the medications and ●●List of medicines About my that you are taking, including blood thinners, ●●Loose-fitting, comfortable clothes , or NSAIDS, and inform your surgical team. operation: Some medications can affect your recovery and ●●Slip-on shoes that don’t require that you bend over • What are the risks response to anesthesia and may have to be adjusted and side effects of ●●Leave jewelry and valuables at home before and after surgery. Most often, you will general anesthesia? take your morning medication with a sip of water. What You Can Expect • What type of Resources about medications can be found at procedure will be www.facs.org/patienteducation/medications.html. An identification (ID) bracelet and bracelet with your name and hospital/ used to remove Anesthesia clinic number will be placed on your wrist. the gallbladder— laparoscopic Let your anesthesia provider know if you have These should be checked by all health team or open? , neurologic disease (epilepsy, stroke), heart members before they perform any procedures disease, stomach problems, lung disease (asthma, or give you medication. Your surgeon will • Ask your surgeon emphysema), endocrine disease (diabetes, thyroid mark and initial the operation site. how frequently they perform this conditions), or loose teeth; if you smoke, drink , Fluids and Anesthesia use drugs, or take any herbs or vitamins; or if you have procedure? a history of nausea and vomiting with anesthesia. An intravenous line (IV) will be started • What are the risks of to give your fluids and medication. For this procedure for If you smoke, you should let your surgical team know, general anesthesia, you will be asleep myself or my child? and you should plan to quit. Quitting before your and pain-free. A tube will be placed down surgery can decrease your rate of respiratory and • What level of pain your throat to help you breathe during the should I expect wound complications and increase your chances of operation. For spinal anesthesia, a small staying smoke-free for life. Resources to help you and how will it needle with medication will be placed be managed? quit may be found at www.facs.org/patienteducation/ in your back near your spinal column. quitsmoking.html. • How long will it After Your Operation be before I can Length of Stay You will be moved to a recovery room return to my normal If you have a laparoscopic cholecystectomy, you where your heart rate, breathing rate, activities—work, will usually go home the same day. You may stay oxygen saturation, , and driving, lifting? overnight if you had an open removal of the urine output will be closely watched. Be gallbladder, a laparoscopic repair with a longer sure that all visitors wash their hands. anesthesia time, post-anesthesia issues such as severe nausea and vomiting, or you are unable Preventing and Blood Clots to pass urine. Movement and deep breathing after your operation can help prevent postoperative complications such as blood clots, fluid in The Day of Your Operation your lungs, and pneumonia. Every hour, ●●Do not eat for 4 hours or drink anything but clear take 5 to 10 deep breaths and hold each liquids for at least 2 hours before the operation. breath for 3 to 5 seconds. ●●Shower and clean your abdomen and When you have an operation, you are at area with a mild antibacterial soap. risk of getting blood clots because of not ●●Brush your teeth and rinse your mouth moving during anesthesia. The longer and out with mouthwash. more complicated your surgery, the greater the risk. This risk is decreased by getting up ●●Do not shave the surgical site; your surgical team will clip the hair nearest the incision site. and walking 5 to 6 times per day, wearing special support stockings or compression boots on your legs, and, for high-risk patients, taking a medication that thins your blood. 5 Cholecystectomy Your Recovery and Discharge SAMPLE

Keeping You Your Recovery Informed and Discharge Thinking Clearly High-Fiber Foods If general anesthesia is given or if you are Foods high in fiber include beans, taking narcotic pain medication, it may cause Handwashing Steri-Strips® bran cereals and whole-grain you to feel different for 2 or 3 days, have Wound Care breads, peas, dried fruit (figs, difficulty with memory, or feel more fatigued. apricots, and dates), raspberries, You should not drive, drink alcohol, or make ●●Always wash your hands before and blackberries, strawberries, any big decisions for at least 2 days. after touching near your incision site. sweet corn, broccoli, baked ●●Do not soak in a bathtub until your stitches, potatoes with skin, plums, pears, Nutrition Steri-Strips®, or staples are removed. apples, greens, and nuts. ●●When you wake up from the anesthesia, You may take a shower after the second you will be able to drink small amounts postoperative day unless you are told not to. of liquid. If you do not feel sick, you ●●Follow your surgeon’s instructions on can begin eating regular foods. when to change your bandages. ●●Continue to drink about 8 to 10 ●●A small amount of drainage from the glasses of water per day. incision is normal. If the dressing is ●●Eat a high-fiber diet so you don’t strain soaked with blood, call your surgeon. while having a bowel movement. ●●If you have Steri-Strips in place, Activity they will fall off in 7 to 10 days. ●●If you have a glue-like covering ●●Slowly increase your activity. Be sure over the incision, just let the to get up and walk every hour or so glue to flake off on its own. to prevent blood clot formation. ●●Avoid wearing tight or rough clothing. ●●Patients usually take 1 to 3 weeks to It may rub your incisions and make return comfortably to normal activity.16 it harder for them to heal. ●●You may go home the same day after ●●Your scars will heal in about 4 to 6 a laparoscopic repair. If you have other weeks and will become softer and health conditions or complications such continue to fade over the next year. as nausea, vomiting, bleeding, or difficulty passing urine, you may stay longer. Bowel Movements ●●Persons sexually active before the Anesthesia, decreased activity, and pain operation reported being able to return medication (narcotics) can contribute to to sexual activity in 14 days (average). . Avoid straining with bowel Work and Return to School movements by increasing the fiber in your diet with high-fiber foods or over-the-counter ●●You may usually return to work 1 week medicines (like Metamucil® and FiberCon®). after laparoscopic or open repair, as Be sure you are drinking 8 to 10 glasses of fluid long as you don’t do any heavy lifting. each day. Your surgeon may prescribe Discuss the timing with your surgeon. Do not lift anything a stool softener if necessary. ●●Do not lift items heavier than 10 over 10 pounds. Pain A gallon of milk pounds or participate in strenuous weighs 9 pounds. activity for at least 4 to 6 weeks. The amount of pain is different for each person. The new medicine you will need after your operation is for pain control, and your doctor will advise how much you should take. You can use throat lozenges if you have sore throat from the tube placed in your throat during your anesthesia.

6 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Cholecystectomy

Non-Narcotic Pain Medication When to Contact Most non- are classified Your Surgeon as non-steroidal anti-inflammatory drugs Contact your surgeon if you have: (NSAIDs). They are used to treat mild pain and inflammation or can be combined with ●●Pain that will not go away narcotics to treat severe pain. Possible side ●●Pain that gets worse effects of NSAIDs are stomach upset, bleeding ●●A fever of more than 101°F or 38.3°C in the digestive tract, and fluid retention. ●●Continuous vomiting These side effects usually are not seen with short-term use. Let your doctor know if ●●Swelling, redness, bleeding, or you have heart, kidney, or liver problems. bad-smelling drainage from Examples of NSAIDs include ibuprofen, your wound site Motrin®, Aleve®, and Toradol® (given as a shot). ●●Strong or continuous abdominal pain or swelling of your abdomen Pain Control without Medicine ●●No bowel movement 2 to 3 days Splinting your stomach by placing after the operation a pillow over your abdomen with firm pressure before coughing or movement can help reduce the pain. Pain Control Distraction helps you focus on other activities Splinting Your Stomach Everyone reacts to pain in a different way. A instead of your pain. Listening to music, scale from 0 to 10 is used to measure pain. playing games, or other engaging activities At a “0,” you do not feel any pain. A “10” is can help you cope with mild pain and anxiety. the worst pain you have ever felt. Following Guided imagery helps you direct and a laparoscopic procedure, pain is sometimes control your emotions. Close your eyes felt in the shoulder. This is due to the gas and gently inhale and exhale. Picture inserted into your abdomen during the yourself in the center of somewhere procedure. Moving and walking help to beautiful. Feel the beauty surrounding decrease the gas and the right shoulder pain. you and your emotions coming back to Extreme pain puts extra stress on your body your control. You should feel calmer. at a time when your body needs to focus on healing. Do not wait until your pain has reached a level “10” or is unbearable before OTHER INSTRUCTIONS: telling you doctor or nurse. It is much easier to control pain before it becomes severe. Distraction Common Medicines to Control Pain Narcotics or are used for severe pain. Possible side effects of narcotics are sleepiness, lowered blood pressure, FOLLOW-UP APPOINTMENTS heart rate, and breathing rate; skin rash WHO: and itching; constipation; nausea; and difficulty urinating. Some examples of narcotics include and . DATE:

PHONE:

Guided imagery

7 Cholecystectomy More Information SAMPLE

For more information on tests and procedures, please go to the National Institutes of Health website at www.nlm.nih.gov/medlineplus/encyclopedia.html. GLOSSARY REFERENCES Abdominal ultrasound: A handheld Endoscopic retrograde The information provided in this brochure is chosen from transducer, or probe, is used to project cholangiopancreatography recent articles based on relevant clinical research or trends. The and receive sound waves to determine (ERCP): A tube with a light and research listed below does not represent all of the information the location of deep structures in the a camera on the end is passed that is available about your operation. Ask your doctor if he or body. A gel is wiped onto the patient’s through your mouth, stomach, and she recommends that you read any additional research. skin so that the sound waves are not intestines to check for conditions of 1. Jackson PG, Evans S. Biliary System. In: Townsend CM Jr, Beauchamp RD, distorted as they cross through the skin. the bile ducts and main pancreatic Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. duct and to remove gallstones. Philadelphia, PA: Saunders Elsevier; 2012:chap 55. Advance directives: Documents signed by a competent person giving Gallstones: Hardened deposits 2. Gurusamy KS, Davidson BR. Surgical treatment of gallstones. direction to health care providers of digestive fluid that can Gastroenterol Clin N Am. 2010 Jun;39(2):229-44, viii. about treatment choices. They give form in your gallbladder. 3. Duca S, Bala O, Al-Hajjar N, et al. Laparoscopic cholecystectomy you the chance to tell your feelings incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB (Oxford). 2003;5(3):152–158. about health care decisions. Hepatobiliary iminodiacetic acid scan or gallbladder 4. Mestral C, Rotstein O, Laupacis A, et al. A population-based analysis Adhesions: A fibrous band or (HIDA): A scan that shows images of the clinical course of 10, 304 patients with acute cholecystitis, scar that causes internal organs of the liver, gallbladder, and discharged without cholecystectomy. Trauma Acute Care Surg. to adhere or stick together. bile ducts following injection 2012;74(1):26-30. of a dye into the . 5. American College of Surgeons. ACS Risk Calculator. Bile: A fluid produced by the liver http://riskcalculator.facs.org. Last accessed August 2015. and stored in the gallbladder which Intraoperative cholangiogram: 6. NIH Consensus Development Panel on Gallstones and Laparoscopic helps in the of fats. During surgery to remove the Cholecystectomy Gallstones and laparoscopic cholecystectomy. gallbladder (cholecystectomy), JAMA. 1993;269:1018-1024. Biliary colic: Sudden pain in the a small tube called a catheter is abdomen caused by spasm or 7. Nakeeb A, Cumuzzie AG, Martin L, et al. Gallstone: genetics versus inserted into the cystic duct, which environment. Ann Surg. 2002;235:842-849. blockage of the cystic or bile duct drains bile from the gallbladder to lasting for more than 30 minutes. 8. Weinsier RL, Wilson LJ, Lee J. Medically safe rate of check for remaining gallstones. for the treatment of obesity: a guideline based on risk of gallstone Bilirubin: A yellow breakdown Magnetic resonance formation. Am J Med. 1995;98:115-117. product of the red blood cells. cholangiopancreatography 9. Leitzmann MF, Giovannucci EL, Rimm EB, et al. The relation of High levels may indicate (MRCP): A physical activity to risk for symptomatic gallstone disease in men. of the liver or gall bladder. technique that uses magnetic Ann Intern Med. 1998;128:417-425. Complete blood count (CBC): A CBC resonance imaging to visualize the 10. Sakpal SV, Bindra SS, Chamberlain RS. Laparoscopic cholecystectomy conversion rates two decades later. JSLS. 2010 Oct-Dec;14(4):476-483. measures your red blood cells (RBCs) biliary and pancreatic ducts. and white blood cells (WBCs). WBCs 11. Clayton ES, Connor S, Alexakis N, et al. Meta-analysis of endoscopy increase with inflammation. The normal and surgery versus surgery alone for the with the gallbladder in situ. Br J Surg. 2006;93:1185-1191. range for WBCs is 5,000 to 10,000. 12. Leitzmann MF, Rimm EB, Willet WC, et al. Recreational physical activity and the risk of cholecystectomy in women. N Engl J Med. 1999;341:777-784. DISCLAIMER 13. Schwarz S, Hebra A, Miller M. Pediatric cholecystitis. Medscape This information is published to educate you about your specific surgical procedure. It reference, 2011. Available at: http://emedicine.medscape.com/ is not intended to take the place of a discussion with a qualified surgeon who is familiar article/927340-overview. Accessed December 6, 2011. with your situation. It is important to remember that each individual is different, and the 14. Dellacorte C, Falchetti D, Nebbia G, et al. Management of reasons and outcomes of any operation depend on the patient’s individual condition. cholelithiasis in Italian children; a national multicenter study. World J Gastroenterol. 2008;14(9):1383-1388. The American College of Surgeons (ACS) is a scientific and educational organization 15. Gumiero AP, Bellomo-Brandao MA, Costa-Pinto EA. Gallstones in that is dedicated to the ethical and competent practice of surgery. It was children with followed up at a Brazilian founded to raise the standards of surgical practice and to improve the quality center. Arq Gastroenterol. 2008;45(4):313-318. of care for the surgical patient. The ACS has endeavored to present information 16. Nawaz H, Papachristou GI. Endoscopic treatment of post- for prospective surgical patients based on current scientific information; there cholecystectomy bile leaks: updates and recent advances. is no warranty on the timeliness, accuracy, or usefulness of this content. Ann Gastroenterol. 2011;24(3):161-163. Open access at www.annalsgastro.gr/index.php/annalsgastro/article/view/988/718. Originally Reviewed 2009 by: Revised 2013 and 2015 by: 17. Society for Surgery of the Alimentary Tract (SSAT) Patient Care Patricia Lynne Turner, MD, FACS Kathleen Heneghan, RN, MSN Committee. SSAT Patient Care Guidelines: Treatment of gallstone Kathleen Heneghan, RN, MSN Nancy Strand, MPH, RN and gallbladder disease. J Gastrointest Surg. 2004 Mar-Apr; 8(3):363-364. Available online at http://ssat.com/guidelines/ Mark Malangoni, MD, FACS Nicholas J. Zyromski, MD, FACS Gallstone-and-Gallbladder-Disease.cgi. Accessed August 13, 2015. Stephen Richard Thomas Evans, MD, FACS 18. Chiappetta P, Napoli E, Canullan C, et al. Minimally invasive management of acute disease during pregnancy. HPB Surg. 2009;2009:829020. doi: 10.1155/2009/829020. Epub 2009 Jul 12.

8 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation