A West Virginia University medical researcher is raising concerns about the widespread practice of gallbladder removal surgeries for biliary dyskinesia, a condition where patients experience gallbladder pain without having gallstones. Dr. Bryan Richmond, chair and professor at the WVU School of Medicine Charleston Campus Department of Surgery, is questioning the increased frequency of this surgery, noting the lack of substantial clinical research supporting its benefits.
Biliary dyskinesia causes pain in the upper right quadrant of the abdomen, typically after consuming a fatty meal. This disorder is the primary reason for gallbladder removal in children and accounts for 10% to 20% of these surgeries in adults in the United States.
“When you see the number of cases of surgery increasing, you just want to make sure that it’s being done for the right indications and that the patients are benefiting, but that’s where there were so many gaps in the data,” Richmond said. “The practice of cholecystectomy for this condition is not embraced in other countries.”
The diagnosis of functional gallbladder disorder involves identifying biliary pain without the presence of gallstones and a low gallbladder ejection fraction, which measures how much bile the gallbladder releases when it contracts. This is assessed using a CCK-HIDA scan, though Richmond warns that this test can be misused.
“The scan itself doesn’t predict the disease because the values that are considered normal versus abnormal are calculated on normal healthy subjects, not patients with pain,” Richmond said. “It has to be considered in the context of the patient’s symptoms.”
Richmond’s invited manuscript, published in the journal JAMA, explores the existing evidence and gaps regarding the surgery’s prevalence and suggests the necessity for future studies. Richmond was asked to write the article after presenting on the topic at the American College of Surgeons Clinical Congress.
He references a 1991 study and a 2016 randomized control trial that both indicated patients with classic gallbladder pain symptoms, no gallstones, and a low ejection fraction were more likely to benefit from surgery. However, Richmond emphasized that these studies are not substantial enough to justify the increasing number of operations.
“The 1991 study had fewer than 30 patients in it — not enough to establish such a dramatic change in practice,” Richmond said. “Our trial, which was published in the Journal of American College of Surgeons, was still a very small study. At the end of the day, we still don’t have large amounts of data to support the practice.”
Richmond advocates for larger studies with more participants to confirm that surgery is the best option based on symptom combination and ejection fraction results.
“My next goal would be to obtain funding for a larger multicenter trial to get enough numbers and standardization of the inclusion criteria and extended follow up to determine success versus failure,” Richmond said.
Currently, there is no treatment for functional gallbladder disorder other than pain medications and avoiding trigger foods. Until further research is conducted, Richmond advises physicians to be cautious when deciding on surgery.
“It’s not a dangerous or progressive condition, it’s a very different disease process than that of gallstone related disease,” Richmond said. “It’s really important that clinicians be honest with their patients about what the implications of this diagnosis are.”
