Joey Wahler (Host): It's a way of addressing various conditions. So, we're discussing gallbladder surgery. Our guest is Dr. Trey Gunter. He's a general surgeon with Jackson Hospital. This is Vital Signs, candid conversations with providers who care. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Gunter. Welcome to you.

Trey Gunter, MD: Joey, hello. Good to see you. Glad to be here.

Host: Same. We appreciate the time. So first, we're all born with one, as far as I know. But for those unfamiliar, in a nutshell, what is the gallbladder? What's its purpose?

Trey Gunter, MD: The gallbladder's a storage vessel. In its simplest explanation, it stores bile that helps us digest food, and so storage and digestion. Now, the liver makes bile, sends it to the gallbladder. The gallbladder holds it and waits on food to come by, and it sends it into the digestive system, it helps us digest food.

Host: And so, what are some of the conditions people come down with that could lead to gallbladder surgery?

Trey Gunter, MD: The two most common that we take a gallbladder out for or gallbladder surgery is for gallstones or the dysfunction of the gallbladder. And both of those are kind of objective ways we can tell whether they're having those problems and combine those with symptoms. We usually can help them by taking their gallbladder out.

Host: And so, we hear about gallstones. How bad must they be to require surgery as opposed to that not being necessary?

Trey Gunter, MD: And that's a good question because a common misconception is somebody's told they have gallstones. Maybe they had a CT scan for something else and, "Oh, by the way, you got gallstones." And so, having gallstones in themselves is not a reason to get your gallbladder taken out. Having stones in the gallbladder and symptoms we can tie to that, that people usually benefit from taking their gallbladder out.

Host: And so, you led me, Doc, beautifully into my next question. What are some of the common symptoms of gallbladder trouble, whether it be stones or something else?

Trey Gunter, MD: So, stones are by far the most common complaint. And the classic textbook symptoms are right upper quadrant pain. So, your gallbladder's located right under your right side, right under your ribs there. And it's always after I eat, 30 minutes after I eat. Predominantly, it's with a fatty meal. So, you know, I had a cheeseburger. And then, 30 minutes later, right upper quadrant pain, felt like a knife stab wound going to my back. Sometimes nausea or sometimes vomiting. And that's the classic gallbladder presentation. Sometimes it can be as more subtle. It can be right in the middle stomach pain and it gets to be a little harder to tease out is it the gallbladder or is it the stomach. And those photos of gallstones kind of help us. And sometimes we have to do a few other tests to get to that point.

Now, the other common reason we take gallbladders out is what we call bradyskinesia, and that just means the gallbladder doesn't function like it's supposed to. And that's a little harder to diagnose because these people have this baseline of, "I don't feel good. I'm kind of nauseated." Sometimes it gets worse. But it's always there. And the imagings don't show gallstones. And so, they get imagings, ultrasounds, or CT scans that show a normal gallbladder. But the function of the gallbladder is off, and that's the hard part that we have to tease out of there.

 And there's a test that gives us some objective data. It's called a HIDA scan. And it basically fills the gallbladder up with this stuff we can look at with an x-ray machine, watch the gallbladder fill up and then watch it empty. And so, it's not a yes or no test, but it is a test that sort of gives us a range of what we consider normal. And when it doesn't empty in the normal amount of time, it's considered to be bradydyskinesia. And those people benefit from having the gallbladder taken out.

Host: So to backtrack for a moment, a couple of things here, what can people do on their own to prevent gallstones, whether it be regarding diet or what have you?

Trey Gunter, MD: Gallstones in themselves we find are probably genetic. Diet is probably the biggest thing that people could do. Let's talk about what bile is. The stones come from the bile that the gallbladder stores. And so, gallstones are basically the solution of bile, having some of the material come out of there, because there's so much of it. If you take sugar and put it in water and stir it up, it'll disappear. But if you put enough sugar in there, eventually they're going to be some that's going to settle to the bottom. And that's basically what gallstones are. They're primarily made from cholesterol. And so, there's where we get into how you prevent this.

 Genetics still plays a big role. But diet, exercise, all the things that make you healthy, also lower your cholesterol and make the chance of having too much cholesterol in that bowel sort of precipitate out and form stones. Some of the things you can't change, the genetics. And females seem to have a more predominance of having gallstones

Host: What's the most common line that's crossed that makes someone need it, as opposed to not?

Trey Gunter, MD: That's a great question, because I get many people with stones and some of them are symptomatic. Some of them say, "Six times a year, I have an attack. And it's always when I go eat my grandmother's fried chicken. But when I stay away from that, it doesn't bother me at all." And then, it becomes up-to-them kind of question.

These scenarios are not like cancer, like there's no other option. But surgery, it becomes more of we know what's causing this. If you can stay away from it, the diet part of it, you can keep an avoiding operation. Some people say, "Look, I'm going to eat that fried chicken," or some people say, "Every time I eat, it causes problems." And that's the other edge of that spectrum, is that they can't eat anything without the pain and discomfort. Now, that's the basic gallstone problems. Now, the gallbladder can get more disease infected, get more of a problem, and that becomes less of a choice and more of a need because the disease has gone so far.

Host: How about the different types of gallbladder surgery?

Trey Gunter, MD: Open and laparoscopic are really the two ways these things are done. And what I mean by open, we call it the old-fashioned way, is where you make an incision over the area that the gallbladder's in. So, it's an incision over the right upper quadrant, under the ribs, right where the gallbladder is. Go down, take the gallbladder out, and close it back up. Gallbladder comes out, they get better. It's a bigger operation to recover from. And laparoscopic surgery has progressed over the last 20 years. It is by far more common to do that operation laparoscopic.

Now, laparoscopic means two or three small little incisions about the size of my finger In your abdomen, fill it up with air so we can operate. The gallbladder comes out that way. People recover faster. It's an outpatient process. There's not a big wound to heal. They're back at work in four or five days. And so, both ways are fine.

And there's a need sometimes that laparoscopic is not safe. There are times that there's such a disease process or a body abnormality that you just can't do it safely. And sometimes, even in the operating room, we have to make decisions that we can't do them laparoscopic, we got to do it open. But I'll tell patients, if there's something, if we end up do it open, there's a problem. We've had a problem somewhere. Ninety-nine percent of the ones most surgeons do are laparoscopic.

Host: So, Doctor, generally speaking, what's the success and complication rate of gallbladder surgery? And what complications are there that are possible?

Trey Gunter, MD: Success of an operation is really dependent on patient selection. So if we identified the disease process, we gave them the right operation, the success is usually a hundred percent. Sometimes, they're overlapping problems. Let's say they have some stomach problems and the gallbladder problems. So, we take the gallbladder out, the gallbladder, part of that equation goes away, they still have some stomach problems. And so, that's still a successful operation.

Laparoscopic cholecystectomy is probably the most common operation done by general surgeons. I think that somewhere around a million gallbladders last year taken out in the country, now for various reasons. It's a common operation, but the complications still exists. And predominantly, injuring those ducts that connect the liver to the system. We're taking the gallbladder out, which is a storage vessel, but we still have to have that flow of bile into the digestive system. And those ducts are close in proximity to where we're taking the gallbladder out. So, any injury to that can be a problem. Leakage of that can be a problem. Inadvertently cutting the wrong duct, not knowing what you're looking at and thinking it's something else is always possible. It happens. It's very rare. These are all really rare complications. But when they happen, they can be significant. Bleeding, infection are also risk of operation in general. But otherwise, it's a very low risk to reward operation. People usually feel better immediately. It's one of those satisfying things. They come back and you ask them did we do any good, and they say, "Oh, yes, I feel much better."

Host: So, a few other things, what should people be aware of concerning the procedure itself and the recovery from it? If I'm going in for this, what can I expect?

Trey Gunter, MD: Generally, if everything goes like it's supposed to, predominantly the way this is done, you come in that morning, it's probably a three-hour process. The getting ready to go to sleep and the waking up, total three hours, probably door to door, depending on your facility and depending on how things go. But here at Jackson, we move pretty quickly. The operation can go from 30 minutes to an hour and a half. But again, those things change as we develop situations in the operating room.

First day at home, it's going to be uncomfortable. Those little incisions are small, we go through those muscles. You laugh and cough and move, and so they can be uncomfortable two or three days. Sutures are on the inside, so there won't be sutures should take you out. There'll be what looks like a little glue on the outside so you can shower that evening. You can eat whatever you want to eat. Do whatever you feel like doing. I tell folks don't plan on having any responsibilities for four or five days. Send you home with a prescription for some pain medicine. A lot of people don't need it more than that night or the next day. And usually, if you have to be back at work, you could be back at work in a week.

Host: I like how you said, door to door, three hours door to door. Like calling an Uber, right, Doc?

Trey Gunter, MD: Well, when they ask me how long the operation takes, I tell them 30 minutes. Because that's what it takes, you know, my part of the operation. They want to know when am I getting home. And so, I had to start thinking through that whole process, door to door. That's back home.

Host: That definitely sums it up. How about the fact that clearly we can live without our gallbladder upon having this procedure. So once it's over with, what does one need to do to compensate, if you will, and be healthy from then on? Is medication needed for the rest of one's life or not necessarily?

Trey Gunter, MD: Generally speaking, taking the gallbladder out doesn't precipitate or indicate that you need anything after that. It's a mechanical thing. We're eliminating the storage vessel that's creating these stones, and it's the act of these stones or the bile sitting in the gallbladder waiting to do its job that actually helps it precipitate out. You don't get gallstones-- it's rare, you don't get gallstones formed in the pathways by themselves. Most of the time, if they are, they're coming from the gallbladder, but it's just this area that holds this stuff and it gives it the opportunity to precipitate out and become stones. So, taking the gallbladder out doesn't set you up for any medical maintenance afterwards.

Now, it does bring up that the reason we form the stone, if it was because of cholesterol diet and those kind of things, those things affect more than just gallstones, and they're certainly worth remembering. So, we don't forget just because the gallbladder's gone, those may not be an issue somewhere else. But from a gallbladder standpoint, most folks don't miss the gallbladder. It's not something that they have to compensate for.

The only thing that I will say is that because we have that flow bile into the system straight now, right, coming from the liver into the digestive system, not stopping and holding it, sometimes people say they get a little loose in their bowels initially. And it's really just that bile that's now flowing directly into the system. Now, the system is kind of set up to when it gets down to the colon at the end, that bile circulates back to the liver. Eventually, the liver figures out I got more of this coming back than I need to make. And so, it quits making as much. They are reported in rare cases that not happening. And there are some medicines that we can use to reduce the flow of bile or the production of bile.

Host: And finally, Doctor, in summary, what would you say is the most important thing for those joining us to know about good general gallbladder health?

Trey Gunter, MD: Health of the gallbladder, I would say, probably depends on what you're putting in your body. Each organ has its effects on what you're eating, your exercise, and those kinds of things.

So if I had to answer good gallbladder health, I'd say it has to do with just good health in general. Again, the stuff that kicks the gallbladder off and makes it unhappy are typically fatty foods, fatty meals that we all going to have. The things that make gallstones are typically things that are showing up in the gallbladders, being an excess of cholesterol and excess of something else.

Diabetes does funny things to organs that people who don't have controlled diabetes, their blood sugars are out of control. Gallbladders and stomachs don't work like they usually do. And so, maintaining those kind of things, but again, that sort of circles around to do the things that we all know are good for us. And I think the gallbladder tags along just fine.

Host: Certainly makes perfect sense to me. Well, folks, we trust you're now more familiar with gallbladder health and gallbladder surgery. Dr. Gunner, keep up all your great work and thanks so much again.

Trey Gunter, MD: I enjoyed it, Joey. Thanks.

Host: Same here. And for more information, please do visit jacksonclinic.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks so much again for being part of Vital Signs, candid conversations with providers who care.