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Study of Cholelithiasis After Gastrectomy

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Study of Cholelithiasis After Gastrectomy Kurume Medical Journal, 47,105-108, 2000 Original Article Study of Cholelithiasis after Gastrectomy HISAFUMI KINOSHITA, HIROYASU IMAYAMA, KOTARO HASHINO AND SHIGEAKI AOYAGI Department of Surgery, Kurume University School of Medicine , Kurume 830-0011, Japan Summary: We studied cholelithiasis that occurred after gastrectomy in 52 patients (35 males and 17 females) encountered at our department between January , 1978 and December, 1998. Gastrectomy had been performed for gastric or duodenal ulcer in 35, gastric cancer in 14, gastroptosis in 2, and gastric trauma in 1 of these patients. Reconstruction after gastrectomy was performed by the Billroth II method (B-ll method) in 31 patients, Billroth I method (B-I method) in 17, Roux-en-Y method (Roux-Y method) in 3, and esophagogastrostomy in 1. The period between gas- trectomy and discovery of gallstones was 1-5 years in 9, 5-10 years in 10, and 10 years or longer in 33, or more than 60% of the patients. Gallstones were present in the gallbladder alone in 33 , bile duct alone in 9, gallbladder and bile duct in 10; the percentage of bile duct stones was high . The type of stones was bilirubin-calcium stones in 21, black stones in 12, pure cholesterol stones in 1, combined stones in 4, mixed stones in 12, and others in 2; pigment stones accounted for 63 .5%. Gallstones were symptomatic in 78.8% of the patients, and abdominal pain was the most frequent symptom. Bile was positive on bacterial culture in 68.4%, and Gram-negative bacilli were the most frequently isolated. Lymph node dissection, vagotomy, cholestasis , and biliary tract infection are considered to be related to cholelithiasis after gastrectomy. Key words cholelithiasis after gastrectomy, pigment gallstone, cholangitis tered between January, 1978 and December, 1998 INTRODUCTION . The significance of differences was examined by t- As ultrasonographyhas become a common examina- test at the p •ƒ0.05 level. tion, the incidence of cholelithiasis, which is one of the complications after gastrectomy, has been RESULTS increasing. The frequent occurrence of gallstones after gastrectomy has been indicated for years, but its The patients consisted of 35 males and 17 etiology and pathology remain largely unknown. In females and were aged from 34 to 85 years with a this study, the characteristics of cholelithiasis after mean of 60.7 years. The primary disorder for which gastrectomy and its pathogenic mechanism were gastrectomy was performed was gastric or duodenal evaluated. ulcer in 35, gastroptosis in 2, gastric trauma in 1, and gastric cancer in 14; the disorder was benign in 73.1% of the patients (Table 1). SUBJECTS AND METHODS The procedure of gastrectomy was pyloric gas- The procedure of reconstruction after gastrec- trectomy in 48, total gastrectomy in 3, and cardiac tomy, period until discovery of gallstones, clinical gastrectomy in 1. The procedure of reconstruction symptoms, site and type of gallstones, and frequency was B-‡U in 31, B-I in 17, Roux-Y in 3, and esoph- of bacterial infection of bile were examined in 52 agogastrostomy in 1. Gallstones were observed more patients with cholelithiasis after gastrectomy encoun- frequently after non-physiologic procedures that Received for publication November 24, 1999 106 KINOSIIITA ET AL. TABLE 1. TABLE 4. Primary disorder Clinical symptoms * including duplication finding TABLE 2. TABLE 5. Reconstruction Site and type of gallstones TABLE 3. Period until discovery of gallstones TABLE 6. Bacterial infection rate of bile bypass the duodenum such as B-II and Roux-Y (Table 2). All patients with gastric cancer underwent D1 or more extensive lymph node dissection. The period until discovery of gallstones was 1-5 years in 9 patients, 5-10 years in 10, and 10 years or longer in 33. Gallstones were discovered 10 years or longer after gastrectomy in more than 60% of the patients (Table 3). The period until discovery of each, and malaise in 1 (Table 4). The site of gallstones was the gallbladder alone gallstones was 6,622.8•}3,879.4 days in those who underwent gastrectomy due to benign disorders and in 33, bile duct alone in 9, and gallbladder and bile 3,251.8•}2,270.0 days in those who underwent gas- duct in 10; the frequency of bile duct stones was trectomy due to malignant disorders, with a signif- high. The type of stones was most frequently biliru- icant difference (p •ƒ0.05). bin-calcium stones observed in 21 patients, followed Gallstones were symptomatic in 41 patients by black stones in 12, mixed stones in 12, complex (78.8%) and asymptomatic in 11. Of the symptoms, stones in 4, pure cholesterol stones in 1, and others in abdominal pain was the most frequent, being 2. Pigment gallstones accounted for 63.5% (Table 5). observed in 32 patients (78.0%), followed by back Bacteriological examination of bile was positive in pain in 4, abdominal discomfort and jaundice in 3 13 (68.4%) of the 19 patients, and Gram-negative Kurume Medical Journal Vol. 47, No. 2, 2000 CHOLELITHIASIS AFTER GASTRECTOMY 107 bacilli were often isolated. Escherichia coli (E. coli) stomach. However, the reduction in the gallbladder was isolated from 7 patients, Klebsiella pneumoniae contractility appears relatively early, i.e. 1-2 weeks (K. pneumoniae) from 5, Enterobacter cloacae, aero- after operation, reaches a nadir about 1 month after genes (E. cloacae, aerogenes) and Clostridium per- operation, and recovers gradually to the preoperative fringens (C. perfringens) from 3 each, Bacteroides level in 6 months to 1 year [4,10,11 ] . Sapala [12] distasonis (B. distasonis), Pseudomonas aeruginosa observed that the incidence of gallstones was only (P. aeruginosa), Citrobacter freundii (C. freundii), 6% after gastrectomy alone but was markedly and Enterococcus faecalis (E. faecalis) from 1 each increased to 21% after gastrectomy accompanied by (Table 6). vagotomy and suggested the importance of gall- bladder dyskinesia due to vagotomy. On the other hand, Shimayama et al. [4], Tajima [11], and Usui et DISCUSSION al. [ 13] emphasized the role of changes in the bile The frequency of detection of gallstones after composition including bacterial infection. Concerning gastrectomy has increased due to the improvements the primary disorders, mostly patients with gastric or in imaging diagnostic modalities such as ultrasonog- duodenal ulcer were evaluated in many earlier stud- raphy, and cases have been reported from a number ies, but recent studies have included more patients of institutions. However, the pathology and etiology with gastric cancer. Lymph node dissection is com- of the condition remain largely unknown. The inci- monly performed in surgical resection of gastric dence of gallstones after gastrectomy varies from a cancer with inevitable vagotomy and separation of few percent to 40%, but it is often reported to be nerves of the hepatoduodenal ligament, presumably about 20% [1-9]. resulting in a high incidence of gallstones. The period between gastrectomy and discovery Characteristics of gallstones after gastrectomy of gallstones is often long, and the incidence of are predilection for males, high frequencies of silent gallstones increased a long period after surgery stones, bile duct stones, and pigment stones, and a according to the nation-wide statistics by Tajima et high frequency of complication by biliary tract infec- al. [10]. However, gallstones were reported to have tions. However, many of our patients were sympto- occurred relatively early after gastrectomy in some matic, probably because they were often referred to recent reports based on ultrasonographic follow-up. us from other institutions after they had developed After resection of gastric cancer, gallstones were attacks of cholelithiasis. reported to have been detected mostly within 5 years Concerning the reconstruction procedures, the by Sugiyama et al. [3], within 4 years by Mizuta et incidence of gallstones after gastrectomy is consid- al. [8], and within 3 years by Ito et al. [6]. Of the ered to be high by non-physiologic procedures such cases that we encountered, gallstones were detected as B-h and Roux-Y compared with .B-I. Although 10 years or longer after gastrectomy in more than Sugiyama et al. [3] reported that there was no differ- 60%, probably because many of them had benign ence in the incidence of gallstones between non- diseases. The time of detection of gallstones was physiologic reconstruction procedures and B-I, it was earlier' in patients with malignant diseases than in higher after non-physiologic procedures than after B- those with benign diseases with a significant dif- I in our patients ference. Part of the reasons that gallstones were . The possibility of bacterial proliferation in the detected earlier in patients with malignant diseases is duodenum after gastrectomy due to reduced concen- the difference in the manner of follow-up, i.e. they tration of gastric acid has been suggested, and the are examined more frequently at the outpatient clinic. bacterial count in the duodenum has been confirmed Dyskinesia of the gallbladder and changes in the to increase significantly in the bypassed duodenum bile composition have been suggested as 2 major after non-physiologic reconstruction. In this state, an causes of gallstones after gastrectomy. Dyskinesia of increase in the duodenal pressure and cholestasis are the gallbladder is considered to be related to a reduc- considered to induce biliary tract infection, which tion in the tone of the gallbladder wall and an greatly affects formation of gallstones. Ise et al. [14] increase in the gallbladder capacity due to vagotomy, observed that the serum bile acid level and bile acid a reduction in the sensitivity of cholecystokinin composition change after gastrectomy and that receptors in the gallbladder wall due to separation of duodenum-bypassing reconstruction, in particular, preganglionic fibers, and disturbance of ejection of prepares conditions favorable for formation of pig- gastric contents due to dyskinesia of the residual ment stones.
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