The macroscopically non-pathologic gallbladder

The

Macroscopically Non-pathologic Gallbladder GORDON F. MADDING,

M.D.,

HE majority of gaIlbIadders removed contain stones which may or may not produce symptoms. When symptoms are present the patient is improved in go to g5 per cent of cases by choIecystectomy. When there is gross disease of the gaIIbIadder without evident stones, its remova is attended by relief of symptoms in a sIightly smaIler percentage of cases. The care of the third type of gaIIbIadder, encountered on rare occasions, which has previousIy been diagnosed as chronic ChoIecystitis but which at the time of surgery shows none or onIy minima1 evidence of disease, is the probIem to be discussed. At Ieast go per cent of biIiary tract disease is associated with caIcuIi but in most reported series 4 to 6 per cent of a11 gaIIbIadders removed are both non-acute and acaIcuIous. That such a probIem exists has been cIearIy stated by SneII [20] who writes: “It is we11 recognized that al1 symptoms of cholecystic disease incIuding those cIoseIy reSembIing coIic may be present without much visibIe evidence of either infection or ChoIesterosis; yet remova

of the gaIIbIadder not infrequentIy wiI1 reIieve the presenting symptoms.” The probIem of determining whether remova of the gaIIbIadder is in the best interests of the patient when the condition is discovered at operation prompted this study. This is a controversia1 subject and at the outset the probIem to be discussed shouId be cIarified. The macroscopicaIIy non-pathoIogic gaIIbIadder is not synonymous with the normal gaIIbIadder. The gaIIbIadder to be considered is abnorma1 as determined by symptoms, repeat choIecystograms reveaIing impaired or absent function, and histoIogic examination in most cases. CoIcock and McManus [I] reported that 4.2 per cent of the gaIIbIadders removed at the Lahey CIinic from xg5o to 1953 were non-acute and acaIcuIous. Glenn and Mannix [2] reported a series of I 35 patients on whom their group had performed choIecystectomies for non-caIcuIous conditions of the gaIIbIadder not acuteIy invoIved. The 135 patients in their series represent 4.3 per cent of a11 patients treated surgicaIIy on the pavilions of The New York HospitaI for chronic biIiary tract disease during a twenty-two-year period. My study represents an eight-year survey (I948 to 1956) conducted at a IocaI private hospita1, during which period thirty-five choIecystectomies were performed by fifteen surgeons for nbn-acute acaIcuIous gaIIbIadders. (TabIe I.) Cases in which choIecystectomy was performed folIowing previous choIecystostomy have been excIuded. AI1 patients in whom stones were absent in the gaIIbIadder but present in the common duct have been excluded, as we11 as those on whom choIecystectomy was performed during the course of sphincterotomy. In this group of thirty-five patients there were eIeven maIes (31.4 per cent) and twenty-four

T

TABLE I CHOLECYSTECTOMY (1948-1956)

No. of ChoIecystectomies

1948 1949 1950 '951 1952 1953 1954 1955 TotaIs.

No. of Non-acute AIcaIculous GaIIbIadders

68 48 64 74

Per cent

7.3 4.2 9.3 6.7 5.0 5.6

8.0 2.8 567

35

American Journal of Surgery, Volume 98, August, 1959

Burlingame, Culijornia

6.1

276

MacroscopicaIIy

Non-pathoIogic

females (68.6 per cent). The ‘average age was forty-eight and seven-tenths years. Without exception, the clinical history as recorded was compatible with disease involving the gastrointestina1 tract. In less than half the patients a history of biIiary colic was obtained, and in others the symptoms were non-specific and couId have been caused by bihary tract or other intra-abdomina1 conditions. Physical examination was heIpfu1 in approximateIy 40 per cent of the group in whom tenderness was eIicited in the right upper quadrant of the abdomen over the area of the gaIIbIadder. OraI choIecystograms were taken in twentyfive patients (71 per cent of the group). Not a11 the roentgenographic studies were made in the hospita1 where surgery was performed. Of these, twenty-three (85 per cent) revealed pathologic function of the gaIIbIadder. In some the radiologic description varied from no fiIIing or poor filling to faintIy visualized. In others the statement was made that it was impossible to exclude the presence or absence of calculi. OPERATIVE

GaIIbIadders TABLE 11 PATHOLOGIC HISTORY No. of Cases

Histdogy

_.__.___~.

___-__ NormaI. . Chronic choIecystitis. Cholesterolosis with or without chronic ChoIecystitis. TotaIs.

..~~~_

18

17.2 5’ .4

II

31.4

6 ;

Per cent

~_

35

100

symptoms to become apparent if they are to occur as a result of removing such a gallbIadder. In the entire group there was one death due to an unreIated disease, and one patient required further surgery a year Iater for the removal of a common duct stone. Complications noted in this group were two cases of wound dehiscence requiring secondary closure and one case of massive atelectasis. There were no hospita1 deaths and al1 patients were discharged in good condition. COMMENTS

FINDINGS

The material for the conclusions presented herein was obtained from three sources: (I) a review of the literature dealing with this problem; (2) correspondence with a number of authorities in this country obtaining their opinions regarding this problem; and (3) information derived from the study I conducted at a IocaI private hospita1. It is fuIIy reaIized how di&uIt it is to evaluate cIinica1 problems statistically, particuIarIy from a series as smaI1 as the one I studied but the results in this group were essentiaIIy the same as those from institutions reporting larger series. Twenty-seven patients have been observed for a period of one and a haIf to eight years and good resuIts (cured or improved) were found to foIIow in 70.3 per cent. There were no immediate postoperative deaths. The immediate morbidity in this group was not significantly greater than that seen in a comparable series of cases in which caIcuIi were present. The resuIts in the six patients having pathologic reports of normat gaIIbIadders is of interest. One was Iost to foIIow-up, one was cIassed as a poor result and four were regarded as good resuIts. The fact that 70 to 75 per cent of patients in most reported series (TabIe III) as we11 as in my study

The surgeons’ operative notes revealed what they considered to be evidence of disease of the gaIIbIadder in 92 per cent of the cases. In this group the pathology described varied from a gaIlbIadder distorted by adhesions or involved by thickening or scarring to one having an abnorma1 cystic duct. PATHOLOGY

On histoIogic examination six of the gallbladders removed were non-pathologic; two of these were described as having abnorma1 cystic ducts. Eighteen showed chronic choIecystitis in varying degrees, and in eleven a diagnosis of choIesteroIosis was made. (Table II.) The cystic duct was specificaIIy mentioned in four cases. In one it was described as narrow, and inanother the mucosa1 folds were felt to be enIarged in the dista1 portion of the gallbladder and couId have periodicaIIy occIuded the cystic duct opening. In two there was a papiIIary infolding of the cystic duct mucosa. In the group of thirty-five patients, twentyseven have been folIowed up for a period of one and a half to eight years. This follow-up period is short and perhaps not Iong enough for 277

Madding TABLE

III

Author

Mackey .................. Schafer. ..................

I934

Doehring .................

I940

Glenn .................... Present study. ............

58.4 74.0 76.2

1936

76.0

1956 I957

1

70.3

obtained good results demonstrates that biliary symptoms can be reIieved in the majority of cases by removing the macroscopically nonpathologic gaIIbladder when it is discovered under the circumstances discussed. What then should we do when confronted with a patient in whom a pathologic galIbIadder was thought to exist from the history and Iaboratory findings, including evidence of impaired function by at Ieast two choIecystographic studies, and in whom fuI1 studies have been made to excIude other pathoIogy, but which on gross examination at the time of surgery appears to be uninvoIved or onIy miIdIy so? A thorough search shouId be made to demonstrate disease of the gaIlbladder and in the absence of this a11 abdomina1 organs, particuIarIy those adjacent to the galIbIadder, shouId be evaIuated in an effort to excIude pathoIogy which might be responsibIe for the symptoms. Babcock and Eyerly [J] found that I .b per cent of their I ,055 patients expIored for gaIIbIadder disease had other conditions, not of the biliary tract, urgentIy in need of surgery. The Iimitations of physica examination in defining disease of the gaIIbIadder must aIso be appreciated. In GIenn’s series of 135 patients, more often than not the surgical pathoIogist believed the gaIIbIadder removed to be within the Iimits of norma or to have onIy minima1 changes. On microscopic examination, however, evidence of chronic choIecystitis was reported in I oo cases (74 per cent). Emptying of the gaIIbIadder by needle aspiration wiI1 aid in our abiIity to paIpate smaI1 stones, poIyps or thickening due to choIesteroIosis. In addition, examination of the aspirated bile can provide heIpfu1 information. An operative choIangiogram performed transvesicaIIy may be helpfu1 in defining any narrowing, stricture, kinking due to a retortuosity, dundant cystic duct or other obstructive factors 278

invoIving the cystic duct, as we11 as demonstrating diIation of the common duct secondary to obstruction at the sphincter of Oddi. Hayes and his associates [~g], in a recent clinica study of bile duct anomaIies, found a 47.25 per cent incidence of cIinicaIIy significant deviations from the anatomy hitherto considered normal and so described in anatomic texts. In the Iight of these findings they raise a question regarding the part these anomaIies pIay in the etioIogy of non-caIcuIous as weI1 as caIcuIous cholecystitis because of the disturbance in drainage with consequent stasis. If operative choIangiograms revea1 a normalappearing biliary tree, expIoration of the sphincter of Oddi may be considered. Baker [4] noted that fibrosis of the sphincter of Oddi cannot be ruIed out by operative ChoIangiography, for the duct is not aIways diIated. Stenosis of the sphincter of Oddi is now accepted as a definite entity and one which may produce persistent and severe symptoms in the absence of stones in the common duct or gaIIbIadder. Wangensteen [f] for the past three years has performed common duct expIoration during the course of choIecystectomy for gaIIstones, and in twenty-nine cases (58 per cent) couId not pass a No. 3 Bakes diIator without force. He believes such an ampuIIa is abnorma1 and can cause biIiary stasis which in turn wiII Iead to gaIlstone formation. This beIief is supported by his experimental work which incriminates pancreatic juice activated by biIe and gastric juices as possible agents responsibIe for the narrowing of the sphincter. It wouId seem that after carrying out the diagnostic procedures discussed, without discovering biliary pathoIogy, we are Ieft with five possible courses of treatment: (I) close the abdomen without definitive treatment directed at the biIiary tract; (2) remove the gaIIbIadder but perform no other surgica1 procedure; (3) remove the gaIIbIadder and expIore the sphincter of Oddi for evidence of obstruction such as spasm-or stenosis, and if such is found, perform sphincterotomy; (4) remove the gaIIbIadder and perform sphincterotomy regardIess of the findings; and (5) preserve the gaIIbIadder but perform a short-circuiting procedure by anastomosing it to the smaI1 intestine. The first course wouId seem to be undesirable for we must assume that the clinical and Iaboratory findings strongIy pointed to gaIIbIadder disease and that fulI studies had been

MacroscopicaIIy

Non-pathoIogic

GaIIbIadders

and the resuIting condition may be worse than the original state. The fifth course of treatment seems unwise in view of the lack of necessity for maintaining the gaIIb1adder for possibIe use in a by-pass operation to reIieve jaundice resulting from obstruction of the ampuIIa due to carcinoma of the pancreas or periampuIIary area. The incidence of carcinoma in this Iocation has been noted in less than one-tenth of I per cent of a11 patients admitted to Iarge genera1 hospitals. Of more importance would be the deIay in appearance of jaundice (often the first sign) folIowing obstruction from a carcinoma arising in the aforementioned area were this method used. Thus, such a patient would be denied earlier treatment and possibly any opportunity of cure by resection. Unless the patient’s life expectancy is of short duration, cholecystenterostomy is an undesirable procedure, for the stoma tends to become constricted and stenose. The incidence of duodenal ulcer wouId undoubtedIy be greater in this group as well because of the diversion of the aIkaIine bile from the duodenum. Regardless of the procedure followed, a liver biopsy should be performed. Further study and the patient’s subsequent course may revea1 that the symptoms were due to a liver disturbance such as hepatic biliary obstruction of the cholangitic type (from intrahepatic biliary canaIicuIar obstruction from bile pigment due to Thorazine@ or methyItestosterone) or from an earIy choIangitic cirrhosis. If either of these is found, the added information obtained from the liver biopsy wiII make better treatment possible. .The opinions expressed in the Iiterature by some authors varied regarding the procedure used under these circumstances. Lahey [IO] has expressed the beIief that if symptoms are unrelieved by medica management, the gaIIbIadder shouId be removed regardless of the findings. Glenn [2] states that at The New York HospitaI when it is presumed that a patient has cholecystitis with stones and no stones are found, immediate consuItation at the operating table is requested. The history is reviewed, IocaI findings are evaIuated and a decision is reached concerning choIecystectomy. He [I I] further states, however, that “repeated choIecystograms that revea1 impaired function are an indication for choIecystectomy.” A Ietter was directed to a number of surgeons

made preoperativeIy to excIude other pathoIogy. In addition GIenn found that when the gallbladder was examined by the pathologist there was a considerabIe error in his ability to diagnose accurateIy disease of the gaIIbIadder macroscopicaIIy. This Iimitation probabIy applies to the operating surgeon as weI1. I believe the second course is the procedure of choice, for approximateIy 70 per cent of the patients in this as we11 as other studies in whom this course was foIIowed obtained satisfactory resuIts. Of the remaining 30 per cent in this study-, only one patient required reoperation flecause of the severity of symptoms; a common duct stone was diagnosed and removed one year later. Even though the gaIIbIadder is not a nuisance organ Iike the appendix, for it does have functions, these can be dispensed with and not produce symptoms. This is evidenced by the fact that at least nine of ten patients who have a diseased gaiIbIadder removed are comfortable thereafter so far as loss of the gallbladder is concerned. The third course seems unjustified in view of the resuIts obtained with the second method. The increased mortaIity and morbidity reIated to the routine exploration of the sphincter would be too great to justify the additiona surgery. We must consider the gaIlbladder, common duct, sphincter of Oddi and pancreas as a reciprocating group associated with much inter-relationship. It is entirely possibIe that as we Iearn more about the sphincter mechanism and its reaction in diseased states, any further improvement we may expect in the therapy of this group wiI1 resuh, in part at Ieast, from the application of the third course. It is in this group in which the gaIIbIadder has been removed for meager findings that most of the dyskinesias wiI1 occur [21]. The fourth course wouId be attended by the same disadvantages as the third. DiIatation of the sphincter of Oddi has been used by some as an alternative to performing sphincterotomy. The dilatation and Iack of sphincter function which foIIow this procedure are only temporary. Branch and his co-workers [6] have shown that in the dog experimental dilatation of the sphincter of Oddi produces no permanent enIargement and is fohowed by actua1 scarring when extensive diIation is carried out. ZoIIinger [7], CatteII [8] and GIenn [9] also beIieve that when the sphincter is forcibIy dilated an undesirable sequence of events can be expected, 279

Madding interested in disease of the bihary tract requesting their procedure when such a gaIlbIadder is encountered. Their rephes are as foIIows: CatteII [12] writes that “if the clinica symptoms strongIy point to gaIIbIadder disease and ful1 studies have been done preoperativeIy one is certainIy justihed in removing the gaIIbIadder if no other pathoIogy is encountered . . . I do not believe that remova of the gaIIbIadder produces gastrointestina1 symptoms.” CoIe [r3] has expressed the folIowing opinion: “The primary error in choIecystography is reIated to a norma choIecystogram when the gaIIbIadder is the cause of the symptoms and when the symptoms wiI1 be obIiterated by choIecystectomy. The expIanation is not diffrcult since I am quite sure that disease of the cystic duct is present which produces a partia1 bIock, but has not yet produced cholecystitis or cholelithiasis. If a patient has delinite symptoms of gaIIbIadder disease, incIuding severe pain in the right upper quadrant I am wiIIing to condemn the gaIIbIadder even though it appears norma at the operating table and concentrates the gaIIbladder media quite we11 . . . I have done this on numerous occasions and aImost invariably symptoms have been reIieved . . . I am quite convinced that remova of a norma gaIIbIadder produces no postoperative gastrointestina1 symptoms . . . if the common duct were not diIated I doubt very much I would open it to expIore the sphincter of Oddi even though I was removing the gaIIbIadder, the dome of which appeared reIativeIy normal. If there has been a history of jaundice or other indications for opening the common duct are present then one has ampIe justification for testing the patency of the sphincter of Oddi. It is my ruIe that if a 6 mm. scoop goes through the sphincter readily it is probabIy not diseased, on the contrary if it does not go through I open the duodenum and actuaIIy look at the sphincter. I cut it whenever there is an obstruction according to the criteria mentioned above.” CriIe [r4] aIso believes that removing a norma1 gaIlbIadder as the onIy surgica1 procedure is not productive of postoperative gastrointestina1 symptoms. He further writes that although it is rare to be presented with a patient having what appears to be a pathoIogic condition of the gaIlbIadder cIinicaIIy yet who at the time of surgery is found to have no gross disease of the biIiary tract, this is occasionaIIy encountered with choIesterolosis of the gaIIbIadder when it can 280

be removed and the patient benefited. Such pathoIogic findings were present in one-third of this series. Dorsey [15] writes, “If a11 other reasonabIe testing is negative and there are recurrent IocaIized findings pointing to the biIiary tract even though choIecystography reports a normaIIy functioning gaIIbladder, Iaparotomy with the intention of doing choIecystectomy is warranted with the patient’s complete knowIedge of the state of affairs.” CoIIer [16] has stated that he wouId remove the gaIIbIadder under the circumstances being discussed if the patient had experienced severe coIicky pain in the right upper quadrant, an episode of which he had witnessed. DoubiIet [r7] has written, “If after opening the abdomen you are unabIe to find any pathoIogic disorder and fee1 impeIIed to remove the gaIIbIadder, you shouId perform sphincterotomy.” Waiters [IS] writes, “If I am uncertain as to whether there is disease in the gaIIbIadder and the patient has a good cIinica1 history of biIiary tract disease, I perform choIecystectomy, but not sphincterotomy.” SUMMARY

A’ND CONCLUSIONS

Discussion of the non-acute acaIcuIous galIbIadder is a sound subject for any group of surgeons to consider, for I am sure that a11 have had experience with it. Emphasis has been made that the chief indication for cholecystectomy is caIcuIous cholecystitis, but one aIso has to consider the symptomatic non-acute acaIcuIous gaIIbIadder, particuIarIy those showing nonfunction with the dye test on at Ieast two occasions. (If the history is fairIy characteristic and al1 other possibilities ruIed out, the dye test is positive and no other cause is found at operation, the gaIIbIadder shouId be removed.) Cholecystectomy eliminates the possibility of future disorders such as acute choIecystitis or choIeIithiasis, or doubt as to the cause of any postoperative symptoms. Any possibIe harm done wiI1 be Iess than the chance of cIearing up the symptomatic condition. The causes of symptoms in the group under study are not we11 understood. How much infection is necessary to produce symptoms, what part stasis and varying biIiary tensions pIay, what are the effects of minor and periodic obstruction of the cystic or common duct, and many other questions are stiI1 to be answered.

MacroscopicaIIy

Non-pathoIogic

GaIIbIadders

tion. As in Dr. Madding’s series, some of these patients had not had the benefit of the Graham-

REFERENCES

I. COLCOCK, B. and MCMANUS, J. E. Experiences with 1,356 cases of choIecystitis and choIeIithiasis. Sura., Gynec. c~ Obst., IOI: 161-172, 1955. 2. GLENK, F. and MANNIX, H. The acalculous galIbladder. Ann. SW-~., 144: 670-680, 1956. 3. BABCOCK, J. and EYERLY, R. A five year survey of 1,055 consecutive patients with extrahepatic biliary tract diseases. Surg., Gynec. c~ Obst., ro4: 711-716, 1957, 4. BAKER, J. Operative cholangiography. Surg., cynec. r~ Obst., IOO: 763-765, 1955. 5. WANCENSTEEN. 0. Discussion of oaoer bv LARGE. A. Regurgitation choIecystitis w&h choI&thiasis: Ann. Surg., 146: 607-618, 1957. 6. BKANC~, C. D., BAILEY, 0. and ZOLLINGER, R. Consequences of instrumentaI dilatation of the papilla of Vater. An experimental study. Arch. surg., 38: 358-371, rg3g. 7. ZOLLIN~ER, R. Discussion during symposium on surgery of gaIIb!adder and bile- ducts. Bull. New York Acad. Med., 34: 495-524, 1958. 8. CATTELL, R. Discussion during svmposium on surgery of gaIIbIadder and bile c&s. &ll. New York Acad. Med., 34: 495-524, 1958. 9. GLENN, F. Discussion during symposium on surgery of gallbladder and biie ducts. Bull. New York Acad. Med., 34: 495-524, 1958. IO. LAHEY, F. Cited by DOEHRING, P. C. MacroscopicaIIy nonpat hologic gaIIbIadder. Arch. Surg., 42: 665-680, yg4r. 1 I. GLENU, F. SurgrcaI treatment of nonmaIignant disease of the bi1iar.y tract. S. Clin. North America, 38: 471,485, 1958. 12. CA~EI L, R. Personal communication. ‘3. COLE, W. Persona1 communication. ‘4. CRILE, G. Personal communication. 15. DORSE~ , J. Personal communication. 16. COLLER, F. Persona1 communication. 17. DOUBILET, H. Personal communication. 18. WALTERS, W. Persona1 communication. ‘9. HAYES, M., GOLDENBERG, F. and BISHOP, C. The developmental basis for biIe duct anomalies. Surg., Gynec. ti Obst., I IO: 447-456, 1958. 20. SNELL, A. Chronic noncaIcuIous choIecystic disease. In: Diseases of the GaIlbIadder and Bile Ducts bv W. Walters and A. SneII. PhiIadeIphia, ,940. W. B. Saunders Company. 21. SNELI., A. Persona1 communication.

CoIe test. In addition to these eighteen stoneIess, chronic cases, there were fourteen acuteIy infIamed gallbladders, two of which had frank empyema, and live with gangrene, all without stones, certainly attesting to the fact that function may be lost and disease ensue independentIy of the formation of stones. Gross stricture of the cystic duct was convincingly recorded in onIy one of these cases. It is interesting that ascariasis was Present in the common duct

of one patient.

I think it shouId be emphasized that in Dr. Madding’s concIuding recommendation for choIecystectomy he has cIearIy stated he refers to the gaIIbfadder that is suspect on the basis of symptoms and has faiIed to function on at Ieast two cholecystograms. I do not beIieve Iaparotomy shouId be performed in such cases soleIy on the basis of a poorIy functioning gaIIbIadder, but onIy after the repeated tests show no function. In the absence of other Iesions to expIain the patient’s symptoms we would then concur on choIecystectomy and would emphasize a few points from our experience. (I) Doubling the dose of the TeIepaque@’ when the test was repeated did not enhance its value in our experience. In 90 per cent of those

patients

with repeated

tests

showing non-function, the gaIIbIadder was found to have stones at operation. PathoIogic Iesions of the gaIlbladder, incIuding poIyps, choIesterosis or cancer, were discovered in most of the remaining IO per cent. (2) Repeatedly, we have been convinced that the surgeon, by paIpation of the distended or partiaIIy distended gaIIbladder, cannot rule out small stones. In one case a stone was demonstrated by the Graham-CoIe test yet neither I nor my two assistants could demonstrate this stone by careful and repeated palpation until the gallbladder had been aspirated. (3) In the series of our 500 cases just cited, there were two with normal acaIcuIous gallbIadders in which a stone was recovered from the common bile duct. In Dr. Madding’s series there was one case in which a common duct stone was recovered a year later. For this reason I wouId Iike to ask him if he would consider and discuss a sixth aIternative recommendation to the five he has reviewed, that is, to remove the gaIlbladder in these bizarre cases, as he concluded, but to make use of the cystic duct for an operative cholangiogram at the same time. This may be a controversia1 subject but I personaIIy believe it has a definite pIace in

DISCUSSION JOEL W. BAKER (SeattIe, Wash.): Dr. Madding has anaIyzed a prohIem that wiII occasionahy confront every surgeon performing abdomina1 surgery. There appears to be an irreducibIe minimdm of from 3 to 6 per cent in a11 reported choIecystectomy series in which the gaIIbIadder is grossIy if not also microscopically normaI. SeveraI years ago Dr. Gibbons and I found eighteen (3 per cent) of 542 gaIIbIadders removed at the Virginia Mason Hospita1 to be grossIy normal, and thirteen of the eighteen were equivoca1 aIs on microscopic examina-

this unusua1 situation. The choiangiogram pIus the Iiver biopsy he has suggested, reinforced by a most carefu1 expIoration of the esophageal hiatus, the pancreas, stomach, duodenum and other abdominal viscera, as he has mentioned, should resuIt in fewer patients suffering from unexpIained persisting symptoms. It is in just such equivocal cases that the more compIete picture afforded by operative

281

Madding cholangiography becomes of obvious vaIue in reducing unnecessary secondary operations on the biIiary tract. Since the gaIIbIadder is but part of the biliary system, it might seem that preoperative symptoms sufhcient to justify the remova of a grossIy norma galIbIadder wouId also speak for this visuaI information about the rest of the tract. It would ehminate the question of unnecessary instrumental opening of the common duct in these borderline cases. It would provide a permanent record of the size and emptying of the intra- and extrahepatic ducta systems. In summary, we wouId not operate for vague gastrointestina1 symptoms without First having at least two reIiabIe, positive Graham-CoIe examinations. At operation we would not depend upon paIpation of the fasting, distended gaIIbIadder to rule out the presence of small stones. If no other expIanation of symptoms is found within the abdomen, we wouId remove the gaIIbIadder and also take an x-ray of the bile duct. Those who have served on HospitaI Tissue Committees wiI1 agree that in the operative record shouId be carefuIIy Iisted the reasons justifying the remova of a grossIy normal organ. I am indebted to Dr. Madding for bringing this probIem into focus and offering a rationa method of dealing with it. He has supported his recommendations by the opinions of a number of authorities. KIRK H. PRINDLE (San Mateo, CaIif.): It does not seem to me that one can argue with removing an innocent-Iooking gaIlbladder when no stones are found, especiaIIy after adjacent possibiIities for the cause of the symptoms have been eIiminated. However, I wouId like to make two points: First, fifteen surgeons found gross evidence of disease in 92 per cent of the thirty&e cases that Dr. Madding caIIed macroscopica1Iy non-pathoIogic. This was in the nature of adhesions about the gaIIbIadder, thickening and scarring. Eighty-three per cent of the thirty-Iive cases had microscopic evidence of inflammation. These figures do not seem to justify

a category of macroscopicaIIy non-pathologic disease. Second, the author, in his review of the records, states that a11 of the thirty-five cases cIassiIied as macroscopicaIIy non-pathoIogic had a history of gastrointestina1 disease, yet more than haIf had no tenderness in the right upper quadrant and no history of biliary colic. Ten of the thirty-five patients had no choIecystograms; twenty-three of the thirtyfive had some evidence of impaired fiIIing. There was no mention of repeat choIecystograms in these cases under discussion or other specia1 studies such as double-dose dye, etc. AI1 of this suggests to me that the indications for surgery in this group were not always clear-cut, and I wonder if Dr. Madding would not agree. CHARLES E. MACMAHON (Seattle, Wash.): I wouId Iike to caI1 attention to the fact that a11 pain in the right upper quadrant is not of intra-abdomina1 origin, and cite as evidence two unfortunate cases of my own. In one year at Swedish Hospital we had three patients with congenita1 absence of the gaIIbIadder. (I treated two of them and Dr. John Duncan one.) They a11 had Graham-Cole tests which obviously showed a non-functioning gaIIbIadder since it was absent. In my two cases the cause of the pain in the right upper quadrant was the prodrome of right heart failure as was demonstrated in the immediate postoperative period to our great distress. GORDON F. MADDING (closing) : The 6. I per cent of cases of cholecystectomy falling into the nonacute and acaIcuIous group is too high. A more compIete study of some patients in this group shouId have been made from a roengenographic standpoint. With present methods of study, approximateIy 2 to 4 per cent of a11 gaIIbIadders removed wiI1 faI1 into the non-acute and acaIcuIous category. UntiI our knowledge is greater concerning a11 causes of biIiary tract dysfunction and discomfort, this shouId remain an acceptabIe figure.

282