Oliver Hall

Okay, it looks like we've all joined. So, good evening, welcome to our webinar on gallbladder problems and treatment.

Presenting this evening is Mr Ahmed Hamouda, our Consultant Surgeon at Benenden Hospital.

This presentation will be followed by a question and answer session, so if you'd like to ask a question during or after the presentation you can do side by using the Q and A icon that's at the bottom of your screen and you can do so with or without giving your name, but please be aware that the session is being recorded so if you do provide your name that will come up in the recording and if you'd like to book a consultation afterwards we'll provide the contact details at the end of the session.

I’ll hand over to Mr Hamouda.

Mr Ahmed Hamouda

Thank you very much, thanks Oli, and thank you very much for joining us today to talk about gallbladder problems. It’s really a very interesting topic but a very common condition and that a lot of people struggle and suffer with and so I will take you through some of the points including the session which is what are the common problems that can happen with with gallstones and gallbladders, what are the symptoms so how how you present basically, what causes them and then the consultation that we have here at Benenden and what we do to diagnose the problem moving on then to management how we treat it and what to expect with your journey through the hospital, what to expect with recovery, living without your gallbladder and how to arrange your treatment, followed by a q and a session.

So let's start off, the gallbladder is a pouch that sits underneath the liver so it's attached to the under surface of the liver it is basically connected to a channel that you can see here the very fine channel here is the main bile duct and that runs from the liver all the way down to the bowel, it takes bile secreted by the liver into the bowel and that has a digestive function. So bile is really a digestive juice, it helps break down fat particles and rich food so what the gallbladder does is during the day it stores bile and then when you have a meal it then gets certain hormone signals to contract and push all the violets in it into the bowel so that you then you have that that digestive capacity to to break down the fat that's in your meal.

So the problems that can happen are obviously forming stones inside the pouch and that will be a precipitation of cholesterol to first of all crystallize and then become bigger and larger over a period of time if you have stones on their own we tend to call it colicthiasis difficult word you don't need to remember it but basically gallstones and the condition that comes with it or the pain that comes with gallstones is called biliary colic so colic related to the the gallbladder and if the the the gallbladder becomes inflamed then that goes into something called cholecystitis which is the pathological word for inflammation if it becomes really badly inflamed and it goes gangrenous then it can perforate and that is a medical emergency so you have to go straight into your local A and E and have that sorted out by drains and operation, antibiotics and fluids and that the stones that are in the gallbladder and move out of the gallbladder and into the bile duct and that migration into the bile duct creates something called bile duct stones or what we call choledocholithiasis, meaning the bile duct and stones and if that happens then you can have jaundice where eyes go yellow, urine turns dark, inflammation of the pancreas or inflammation of the actual bile duct itself and that's cholangitis. These three terms only relate to stones that have passed into the into the bile ducts and represent a much more complex presentation of gallstones so this is something that you would need to go into Hospital any for and be treated quite aggressively.

So the gallstones themselves as mentioned previously sits inside the gallbladder they start off with as very small crystals of cholesterol and they precipitate creating larger stones some people have just one single very large stone some people have what we call sludge or mud and that's in the early process of precipitation and some people have multiple gallstones multiple small gallstones they're very nice they're faceted they sit together and they have sort of very smooth faces facing each other and in that case obviously you can get symptoms with them in the majority of cases we find out about gallstones because you've had a scan for something else so you go into hospital and you have some pain on the left hand side for example you have diverticular disease but they do a scan anyway they pick up that your gallbladder which sits on the right has some gallstones you've never had any symptoms with it we tend not to treat those we just leave them all alone.

It is a very common condition so one in 10 adults in UK is estimated to have gallstones and only a very small proportion of of those of that group of people develop symptoms so what are the symptoms of gallstones so you can have typical symptoms or atypical symptoms now the typical symptoms are classically bloating and crampy tummy pain with after you've had a meal a rich big meal usually with discomfort and pain under the rib cage on the right hand side going into your back and sometimes going up into your shoulder and that is the pain of berry colic it will last a few hours and then it dissipates on its own it can be helped by taking painkillers such as paracetamol or buscopan which is a spasmolytic it breaks down spasms and colic’s and that is called burial colic if it becomes a bit more serious it turns into an infection with inflammation of your gallbladder then the pain can become much more persistent with a high temperature and if we do a blood test so you come into us when we do a blood test we find that you have raised inflammatory markers that's things like the white cell count the CRP and that's when we diagnose that your gallbladder has become inflamed it can also look quite inflamed on an ultrasound scan with a thick wall or any collections around it and then deliver so that again can lead to us diagnosing it as colic cystitis rather than bilicolic so we said about the cause of gallstones it's a high level of cholesterol in the bile precipitating and causing crystallization followed by stone formation.

We find that the people most at risk of developing gallstones are carrying a bit extra weight or obese but also interestingly enough people who tend to try and lose weight either by crash dieting several times or having a procedure an intervention to lose weight such as a sleeve or a gastric band or a bypass can also develop postal so what's happening there is that the the fat that's being that's being mobilized as a result of the weight loss and creates a higher level of cholesterol in the bile and that in itself will cause the gallstones females are particularly prone to it and especially fertile females and maybe something to do with hormonal change and usually above the age of 40 rather than younger but young people can also developed gallstones especially if they're pigment stones so people who have certain blood diseases where the red blood cells are broken down those pigments can then travel in in the bloodstream go into the bile and again do the same process of crystallization precipitation and stone formation.

So just to go back and mention the atypical symptoms because I did say about typical atypical so the typical was was the one that I talked about with the right-sided tummy pain going to the shoulder, sometimes people come and see us because they've had chest pain for example or they've had some mid tummy pain going to the left side and that can be the pain caused by gallstone pancreatitis for example or it could be associated with reflux and heartburn because those two conditions gallstones and reflux can occur together and so when that is the case and it's atypical then you really need to first of all see a doctor but try and get seen by a specialist to assess your condition. I have a lot of patients who come into clinic to see me and what they've they've been through is that they've developed chest pain and initially the thoughts were this is cardiac something to do with their hearts they've had all of the tests on their heart and the tests are absolutely fine nothing wrong with the heart but then they have an ultrasound scan because their GPA requests it or they go into hospital and they think well let's scan your tummy find out what's going on and lo and behold you have gallstones and that can be the presentation the atypical pain that comes from your gallbladder having stones.

So as I mentioned the gold standard test for a gallbladder condition is an ultrasound scan on the tummy and it can also be diagnosed through a CT scan or an MRI scan better known as an mrck which is a very specific MRI on the gallbladder in the liver and it picks up stones both from the gallbladder but also on the bile ducts so sometimes you'll come and see us at the hospital and we'll look at your ultrasound scan but we think well you know what you've had jaundice in the past or you've had deranged liver functions there is some reason for us to suspect there might be a stone sitting in the common bile duct and that's one will also ask for an MRCP before your surgery because if you were to have a stone sitting in the bile duct before surgery that still needs to be cleared by doing a camera down this way to fish that stone out before you have your surgery if it was left in there then you're more likely to have complications such as phalangitis pancreatitis after you've had your gallbladder operation and that is not unfavourable, it's always best to clear the stone first before you have your gallbladder operation.

So, we talk about obviously diagnosis with an ultrasound scan with blood tests if need be if they're an MRCP if required an ERCP which is the camera if need be and then we talk about surgery itself. So surgery is keyhole it's called the laparoscopic cholecystectomy normally surgeons will use four cuts, some people use three cuts and as you can see there there's four cuts there, a camera through one of the holes in one of the tunnels and then three other holes for instruments to hold the gallbladder dissect and peel it away from the liver and cut away the bile duct sorry the cystic duct and the cystic artery that go into it from from the the main channels and then put it into a bag and take it out through the belly button it is a straightforward and simple procedure to perform but it also has a risk of complications.

Complications usually arise as a result of previous inflammation leading to quite heavy uh in adhesions around the gallbladder so it can stick to the liver it can stick to your mentin which is the bit of fat that we have inside our tummy that protects us or it can stick even worse to the bile duct or to the bowel that's next to it and if it does and it creates a little opening a channel into those structures then it becomes a much more difficult and complex procedure and of course the risk of conversion to an open cut is much higher but if you do have to have an open cut it means your recovery is much longer. You probably will need to have drains put in and left for a period of time and I would have to be honest with you at the Benenden Hospital that's not perhaps the best outcome from having a gallbladder procedure so sometimes we'll say you know what we think that your procedure should probably be done in a hospital that has a lot of backlog facilities to allow for your gallbladder operation to be performed safely or I will sometimes say to people you know I will go in and part of your consent is that if I find it's very difficult to do for any reason or it's stuck to a vital structure around it then I will abandon the procedure and we think about obviously your safety first as paramount and we think about how how we deal with this at a later stage after you've had your surgery and the gallbladder no longer stores bile because it's gone so bile will trickle through the main channel dialect into the bowel and that can lead to you being a bit on the loose side with stools for a few weeks after surgery until your power gets readjusted to the fact that there is a continuous flow of bile going into it and it's no longer being kept and stored in the pouch.

So, it's a general anaesthetic we know that we do small cuts we say four or three we use instruments and keyhole surgery is extremely beneficial it has really changed the way we operate, it's changed the way surgery has been done over the last 15 to 20 years and I think that the recovery time is much quicker. This operation with open surgery meant that you spent four or five nights in hospital, it took about four to five weeks to recover and probably even feel normal up until three four months later, with keyhole surgery you're in and out on the day and you're back to work if you can work from home in the first few days you shouldn't really be driving for two weeks but generally you feel fit and healthy and well in yourself and usually at six weeks you're completely back to normal.

So, with our, or as I was mentioning before because of the keyhole nature of this particular type of surgery it is expected to be a day case procedure so you're in and out. On the day prior to you coming in the pre-assessment nurses will contact you they will go through any fasting instructions what you should bring in your admission time but also there's going to be a pre-assessment appointment where you come and see them in hospital to have your bloods taken to have any swaps done and to make sure that they're quite happy with your medical history and that there's no conditions that will need extra support or you know that you're eligible to have it done at better than any of you that have been to our Hospital know that it's it's a that's a really lovely site, it's a brand new hospital that's only been in operation for last three or four years, all the rooms are individual and you have your own ensuite facilities we expect you to be able to leave the hospital same day after the operation, you will come out to theatre into the recovery area, you spend about half an hour to an hour there until you're ready to go back to your room, a nurse will come come down and pick you up obviously with the bed and then they'll look after you on the wards, get you to eat and drink get out of bed go into the bathroom check that everything is absolutely fine and then arrange for you to go home and usually they will contact you or your next of kin or carers to arrange for them to come and pick you up.

So recovery most people leave the hospital same day, if there's any issues with pain for example retention of urine catheter anything like that then of course we keep you an overnight and after two weeks you're returning to most of your usual activities, you should be driving for this period of time and usually at six weeks we say you're back to normal and that means going back to the gym, it means going and doing your horse riding, your golfing you know anything that you would like to do so without your gallbladder, is there a big difference well yes to a certain extent you can't digest a big rich meal all at once remember when I said about digestive capacity so you haven't got the digestive capacity to have a big a big fry up if you do then it won't kill you but what will happen is you'll get a lot of bloating crampy tummy pain you will feel indigestion proper indigestion because you you know your food is sitting there and it it can't go anywhere until it gets broken down and so it will take a bit of time and then it will obviously pass it is wise to when you've had the surgery to stick to a generally not a completely no fat diet but generally you know Mediterranean healthy diet with as low as low fat as you can or maybe in small amounts rather than having one big fry up.

Any type of surgery has risks so the common risks of surgery is you can react to the anaesthetic, bleeding, infection, clots going out to your lungs from your legs or conversion to an open cut so with specifically a gallbladder operation because the gallbladder comes off the main channel like a leaf of a stem there is the risk of injury to that main channel, we said it was the bile duct or comb bile ducts, there is probably a less than 1 in 5 chance of that happening if it does happen however it can lead to peritonitis and sepsis and you may need another operation to fix it so that's an important one to mention and obviously an important one to know about.

If you want to have treatment for your gallstones then of course you can come in and see us at the hospital, you need to speak to the private patient team and book consultation and of course we've got both private medical insurance, self-pay members coming through as well as society members choosing to book. So having said that, I will hand over again to Oli who's going to talk you through the Q and A session.

Oliver Hall

Thank you, Ahmed. We have had some questions come through. The first one is a patient asks what would be the risks of delaying surgery to remove gallstones be?

Mr Ahmed Hamouda

Right, so it's really important what I said initially about biliary colic, and I differentiated bibliocolic from cholecystitis. If you have biliary colic which means you get sore and uncomfortable and bloated every time you have a rich meal then to a certain extent you can live with the condition as long as you're sticking to a low-fat diet and when I say live with the condition I mean you know waiting until you have your your turn to have surgery. But if you have cholecystitis inflammation quite bad inflammation that's led to persistent pain temperature or having range liver functions because there's been stones that have passed into the bile ducts, then the recommendations to have your surgery as soon as possible, so it's a much quicker pathway to have your surgery. So, it really depends on what the condition of which is better and your gallstones.

Oliver Hall

Great, thanks Ahmed. Another patient asked that they've been told their gallbladder is stuck to their liver and bowel, they've had a failed laparoscopic surgery last year and they've had a recent episode of gallstone pancreatitis their due to have an MRCP next week and they're asking what would be their true options for treatment?

Mr Ahmed Hamouda

Well and I mentioned this in my talk and I said that there can be presentations of gallstones that are quite complex, if you have a connection to surrounding structures your gallbladder is connected to surrounding structures or there's been pancreatitis which has increased the amount of inflammation inside the stomach then there is a chance that keyhole surgery is not going to be successful and that you will need an open operation and that open operation is best performed in a hospital that has all the necessary backup facilities so a possibility to put you into high dependency or intensive care a possibility to do X-rays and CT scans throughout the 24 hours of the day so having you know radiology cover a possibility of uncertain drains under radiological cover possible that can do an ERCP which is a camera down this way to fish the stones out and through the bottom end of the bile duct and that normally is within the context of an NHS Hospital. So, we are very happy to help in looking at your condition doing the scans because we can do the diagnostics but there is a possibility if that is the complexity of your case, we will at the end of the day say it's safer for you to have it done at your local hospital.

Oliver Hall

Great, thanks Ahmed. This next person is asked would they need to have scans after the procedure just to check that it's all gone okay?

Mr Ahmed Hamouda

It is not required and it's not really standard for us to do any scans after procedure. Remember we go in with camera a keyhole operation we have seen everything at the end of the operation we check and make sure everything's all right we look at the liver look at all the structures around it there is no suspicion of us requiring you know any further scans and the only indication for a scan would be if you have persistent temperatures for example or persistent tummy pain that didn't go away two or three weeks later and if we suspected anything then we would ask you to come back and have a scan and ultrasound scan to diagnose the problem but as a standard we do not use scans at all after surgery.

Oliver Hall

Great, thank you and this next person asked they've had an umbilical hernia in the past and they have mesh over the belly button, in fact two meshes, what would be the procedure to remove the gallbladder in this scenario?

Mr Ahmed Hamouda

Yes, so more difficult because of course piercing a hole through the mesh with keyhole surgery can be quite difficult, it is however not impossible, and I've operated on several people who've had mesh before. Unfortunately, because you're puncturing a hole through that mesh the risk of developing another hernia in the future is a possibility so that's something that you will have to consent to. Sometimes we can be quite smart and clever with where we put our our tunnels our keyholes so if the mesh is above we try and go below the belly button if the mesh is below the belly button we try and go above it, but if it's just across the middle of it and there's no way of doing anything apart from going through it and that's what we do and you just have to contend with the fact that you may develop another hernia in the future that may need to be treated.

Oliver Hall

Thank you and the next person asked can you treat a gallbladder without surgery?

Mr Ahmed Hamouda

So remember we talked about people having gallstones without any symptoms, so again you've got this large group of people who have gallstones either diagnosed on scans or haven't at all been diagnosed who are sitting there with no symptoms and that's actually fine we don't need to do anything about it at all and then there's people who've had binary colic so symptoms of pain whenever they've had a rich meal that can't see us it's only happened once in the last say year maybe twice in two or three years and we have a discussion in clinic you know when we talk about it and if they stick to a low-fat diet and they're doing quite well then there's no real indication for us to take out the gallbladder and that's an agreement between doctor and patient however if there is complications as I said before cholecystitis or you're a stone passer and you've passed those into bile duct then it usually is an indication that you will need to have surgery.

Oliver Hall

Great, thank you. This next patient says that they were diagnosed with a large gallstone at the beginning of the year, and they had symptoms of vomiting pain in the back and abdomen, however the pain has stopped since January and they have no symptoms. Should they leave it, and they feel normal, but they're worried about gallbladder cancer.

Mr Ahmed Hamouda

So there is a fallacy about global blood cancer and I think it's been blown out proportion slightly, again it might be internet it might be social media but gallstones in themselves do not cause gallbladder cancer and so you know in my book if you leave your gallstone that is not putting you at any extra risk, there are people who are diagnosed with gallbladder cancer who have gallstones and that's unfortunate but there is no correlation. You might find a correlation between gallbladder polyps for example and an incidence of gallbladder cancer and but not necessarily stones so I would in this case just again consult and say you know it looks like you're doing quite well with a low-fat diet there's no real urgency or indication to take out your gallbladder leave it a bit longer see how you do in the next six months to a year if you get another severe attack then come back and see us and we can obviously deal with it.

Oliver Hall

Great, thank you. This next patient asks they had a radial nephrectomy and have also had multiple gallstones and their consultant will not operate due to their previous surgery, would there be any other options for them?

Mr Ahmed Hamouda

So radical nephrectomy, if it's on the right side your big scar going across there then of course it can make surgery quite complex to take out your gallbladder if it's on the left side less so of a problem you've obviously seen someone and they've said no we don't want to do it for you but again remember that there is multiple options there's the option of keyhole surgery so if that doesn't work there's an option of open surgery to take out your gallbladder so there's always going to be an option even if you've had previous surgery and it really depends again on your symptoms on how bad the inflamed the gallbladder is because you know if it needs to come out it will need to come out even with an open operation it's just important that you have that operation in a place which can deal with you safely and so again going back to what I said before at the Benenden it's not the best place to have an open procedure on your gallbladder.

Oliver Hall

Great, thank you. This next patient says that they had raised levels of alt and ast after a flare-up of pain and several blood tests later over a period of five weeks they've returned to normal, and they do have a gallstone and they're wondering could this have been caused by the gallstone?

Mr Ahmed Hamouda

Again it's you know difficult to to say but we know that the range lft’s normally happen when there's severe inflammation of the gallbladder affecting the liver and causing inflammation of that area as well and perhaps a very consistent collection which means a collection around the gallbladder or if the stones have passed so you say just one stone and I just wonder if there was another stone that may have passed and caused the raised liver functions again it's important to have a consultation important to have an MRCP to exonerate the common bile duct and look at the condition and then try as best as we can to understand a bit more about whether the stones are causing a problem if they are it looks like they're the culprit then yes you should have your problem.

Oliver Hall

Great, thank you. This next patient says that they've got exceptionally low cholesterol and why would they get gallstones in this case?

Mr Ahmed Hamouda

I don't know about exceptional cholesterol I mean presumably the blood tests have been done and the cholesterol was looked at for one reason or the other if it's in the lower nor if it's in the lower range it doesn't necessarily mean that it's always been low it could have it could have risen at some point the other the other thing to remember is that gallstones aren't necessarily just cholesterol stones you may recall when I did my presentation I was talking about pigment stones but there's also calcium stone so there's there's quite a few things that can cause stones and cholesterol is only is only one of them maybe the most important one of them but not necessarily the only reason for for gallstones I tend to say that gallstones if they're there they're there it doesn't really matter what's caused them you just need to deal with them basically.

Oliver Hall

Great, thank you. Another person asks their gallbladder has been diagnosed as permanently closed with gallstones, what would be the causes and the solution for that?

Mr Ahmed Hamouda

I think what you're referring to is a gallbladder packed full of stones so that's hardly any space for any bile to go into it and that's quite common so you'll find that the gallbladder is completely packaged full of stones so by definition it is non-function another words it's not storing bile anymore and essentially what's happened is that bile is continuously trickling from the liver into the bowel just as if you didn't have a gallbladder so if you do have symptoms and you're uncomfortable with your gallstones then that should be an indication for you to have them taken out in that condition.

Oliver Hall

Great, thank you. Another patient asked they had cholecystitis, and they have a CBD stone and they're due to have a 10-centimetre stent removed as well, what factors would decide if their bladder removal is necessary?

Mr Ahmed Hamouda

Yes so going back again to my presentation, if you've had a condition where your gallstones have slipped and gone into the main channel now whether they've been dealt with by an ERCP which is just nicked to the bottom that's called the spirituality they nick the bottom of the duct there's a muscle there and if they open it that's called a sphincterotomy that's just to allow any further stones to pass through if they they slip into the bar that without causing an obstruction or they haven't been able to remove the stone so they put a stent a tube into the pile that to create a channel that can drain bile and avoiding an obstruction by that stone but if you've had any of those conditions where a stone has slipped through then by definition you need to have your gallbladder taken out if it's possible and feasible. The only thing that would stop it is if your health conditions so is so you're very unwell to the point where you can't have adrenal anaesthetic insurgent on your gallbladder in which case, we look at other options.

Oliver Hall

Great, thank you. Another person said that they've heard that there's an option to have the neck of the gallbladder widened so that the stones could pass through, what would be your opinion of this?

Mr Ahmed Hamouda

Yeah so there's there's some of our x-ray doctors are very specialist in going in to the bile ducts from the bottom end and then using a stent which we've just alluded to in our previous question a tube but instead of the tube going into the bile duct it also goes up very so up into the bile duct and then into the cystic duct which is the small very small channel that leads into the gallbladder and again I think that some people do use it to try and drain the gallbladder when there's been passing the gallbladder for example or a severe inflammation to allow the whole thing to settle down I would have to say that the people that specialize in putting those tubes or widening the cystic duct are very small cohort and it's possibly not something that you'll find in your local hospital so by definition my choice would be in this case is to give antibiotics treat the inflammation settle it all down and then go in at the optimal time and do an operation rather than widen the cyst impact.

Oliver Hall

Great, thank you. Another patient asks they have a 23-millimeter stone, and would that be able to be treated with medicine or something like a laser?

Mr Ahmed Hamouda

Yes, so again one of those things that I find a lot of people coming into to consultation with me talk about is melting or dissolving stones and it's all really Chinese medicine that's on the internet and I would not ever recommend that anybody try it I would not recommend a laser or zapping costumes if you think about it what's happening there is you're trying to make the gallstones smaller in size so by definition they are going to be easier to slip through into the main Channel and we said that that was one of the dangerous presentations of gallstones because it can lead to cholecystitis or jaundice so it's not a logical thing to do, I would not advise it at all, I don't think it works I wouldn't advise it.

Oliver Hall

Great, thank you. Another person is asked is ERCP the same as keyhole surgery?

Mr Ahmed Hamouda

No, so keyhole surgery is a general anaesthetic, it's an operation that I do with the four small cuts that I showed you on the diagram to go inside the atomic cavity and peel the gallbladder from the liver and take it out of the body and ERCP is a special camera that goes down the mouth into the gullet stomach and into the first part of the bowel and it can access the lower end of the common bile duct the main channel to move any trapping stones and bring them out the bottom end or to make a cut in the muscle to allow stones to drain through or to put a stent a tube up into the compartment so it's the minimally invasive procedure, it's not surgery and it's only designed to deal with common bile duct stones not the gallbladder.

Oliver Hall

Great, thank you. Someone has asked what does sludge mean and is it dangerous?

Mr Ahmed Hamouda

So the very early stages of stone formation, if you think about it you have to have a nidus a very small little piece of mud gravel or crystal and so if you're forming gallstones and that's you know they do an options kind of a very beginning of you having and forming gallstones that's what they will find they will call it mud or gravel or sand in your in your gallbladder it doesn't look like stones what it looks like is a sediment almost that lies and gravitates towards the bottom of the gallbladder so that's what they're suggesting sludge and some people will say well actually you know I'm not going to treat sludge I'm going to wait until it forms stones, proper stones, bigger stones and but some people will say well actually you know you're going to have stones anyway so why not treat it there and then.

Oliver Hall

Great, thank you. Someone has asked what's the criteria for deciding between keyhole surgery and open surgery.

Mr Ahmed Hamouda

Because keyhole surgery has become the the gold standard for performing gallbladder operations now, I think you would struggle to find a surgeon in the UK or possibly anywhere in Europe that would do an open procedure to start off with. So, we always start with keyhole so in other words we're attempting it with keyhole, but we know that there is probably a five percent, ten percent chance that we need to do an open cut in some people because of the complexity of their presentation, so we then convert to an open procedure. It is quite possible that's you know because of remember we talked about the the person who had a radical nephrectomy before so a big scar to take out the kidney on the right hand side it may be possible that you look at their tummy and you think well you know what I'm never ever going to be able to do keyhole surgery here so I'm going to start with open surgery but the gold standard is you start with a keyhole operation then you convert some open operation a very small percentage of people will need an open operation from the start.

Oliver Hall

Great, thank you. and we've had a couple of people ask about recommendations for diet, nutrition any supplements they could take that would reduce the effects of gallstones?

Mr Ahmed Hamouda

So, gallstones are not necessarily related to any institutional deficiencies apart from the fact that you perhaps maybe not able to digest fat as well as you should do so a general multivitamin would would probably cover you for you know things like vitamin K etc but generally we don't tend to recommend the multivitamins for people with gallstones unless you take them you know as a standard.

Oliver Hall

Great, thank you. I think we have one of potentially your previous patients on here and they've asked, I think they asked the previous question about the mesh because they had a hernia and they're saying if they had surgery would a third mesh need to be installed?

Mr Ahmed Hamouda

So this is where we've done the gallbladder procedure puncture to hold through the mesh and on you know at the end of the operation we stitch that hole as well as we can but then we are speculating that the person has had a recurrence of the hernia in that position and then again this is all speculative and it doesn't necessarily mean that you need to have a further hernia you know present or repaired but if that was the case in the worst case scenario you have another hernia after you've had two previous mesh repairs then it's very likely that you will need another mesh repair for you.

Oliver Hall

Great, thank you. Someone's asked that they've they've had a CT scan showing stones in the gallbladder and they're a bit worried waiting for results of their MRI because they've still got pain in their stomach. Should they be worried while they're waiting for the results?

Mr Ahmed Hamouda

I don't think so. I think that you know depending on your presentation how your gallstones have presented if it's biliary colic again where it's just pain and discomfort I relate to meals then you're quite safe if you've had cholecystitis before and you've been to hospital for IV and antibiotics then of course you know that there could be another attack so I would stick to painkillers and low-fat diet if you've had a stone pass through then and you're waiting for an MRCP then you probably need to have an ESP soon after if they do discover that there's a stone in a compound left so it really depends on the presentation but generally you know most people with stones are quite safe to to wait a bit longer.

Oliver Hall

Great, thank you. Someone has mentioned a medicine and they're wondering if that's available in the UK if that's something that we would potentially use, and does it break up the stones?

Mr Ahmed Hamouda

So I think they're referring to eurozone deoxycholic acid which is the the scientific name for it and I think it is it is available but it may need to be prescribed and again I go back to what I said before which is I I do not believe that breaking down gallstones is either safe, effective or necessary and you're only trying to make the stone smaller you at least at a higher risk of the stone slipping into the main channel and causing even further trouble and I don't think that the the the the medication actually does work.

Oliver Hall

Great, thank you. I've got a last question here. What would be what could be done if someone is too weak to have an operation for gallstones?

Mr Ahmed Hamouda

Yes and sometimes that happens some people are quite frail and weak to have a general anaesthetic to have surgery and if that's the case then what we sometimes decide to do is do an ERCP and create a sphincterotomy which is to nick the bottom part of the bile duct so that in the unlucky event that a stone which slip into the main channel it would just pass through the bottom end and not cause the more serious presentations of gallstones such as cholangitis pancreatitis or jaundice which I talked about previously so really that would be probably the definitive management there's another way of managing uh gallbladder problems especially cholecystitis which is putting a drain through the skin into the gallbladder that's called the cholestatic tube and that drains and pus that may be in the gallbladder to help the inflammation settle and again we use that if we can't do an operation in hospital.

Oliver Hall

Great, thank you. That looks like all the questions we've had come through, but if we didn't answer your question we'll do so after the event if you've provided your name and if you'd like to book a consultation with Mr Hamouda or anyone at the hospital, our Private Patient team are available to take your calls and that's between 8am and 6pm Monday to Friday and that's with the contact details on the screen and we're offering a small discount for this session and that's with the terms of the bottom of the screen, so that'll be 50 percent off your initial consultation.

You'll receive a short survey at the end of this as well, we'll be really grateful if you could spare a few minutes and just so we can have your feedback and it helps us put on future events and see what topics and things you'd be interested in.

Our next webinars include hip and knee surgery and cataract treatment, and you can visit our website to sign up for those. So, on behalf of our team at Benenden Hospital and Mr Hamouda I'd like to say thank you for joining us today and I hope you have a good evening. Thank you and goodbye.