Editorial

 

Cholelithiasis and gastroesophageal reflux disease

 

Gastroesophageal reflux disease has been connected with cholelithiasis for years. Saint’s triad (1), a well-known association of hiatal hernia with cholelithiasis and colon diverticula that was much in fashion during the 1980’s, represented a paradigmatic expression of westernization-induced gastrointestinal disturbances. In this issue of Revista Española de Enfermedades Digestivas, Pozo et al. (2) bring forward two of the components in that much debated Saint’s triad: gastroesophageal reflux disease and cholelithiasis. The truth of the matter is that questions posed are many, and all of them entail an immediate clinical impact.

The first question is: is there really an association of cholelithiasis with gastroesophageal reflux disease? Should such an association exist beyond mere chance, then we should actively seek the accompanying condition in those who suffer from either of the aforementioned diseases, and provide a joint solution to this problem or, at least, consider the need to do so.

Both are common conditions in our country. Ten percent of the population has ultrasonographically demonstrated cholelithiasis (4), and 30% of the population suffers from reflux symptoms, 10% of these on a weekly basis (5). Chances are high that a patient with one condition will have the other simply because of their frequency; however, they are even higher when the fact that overweight is a risk factor for both is brought to our attention. If no association exists beyond mere chance (3), considering an active diagnostic approach in the absence of supporting clinical data is an unreasonable choice.

When both conditions coexist, therapeutic aspects are interesting. Statements such as “as he has these two things, let’s operate and fix them both” or “while we are at it with this one, let’s operate the other, it’ll just take a few minutes more” are relatively commonplace. To which extent are these statements wise?

The mere coexistence of both conditions does not represent a combined surgical indication, and each of them should be individually assessed. Of course, if surgery is not indicated for either condition, its consideration in view of their association seems devoid of any logic. Therefore, the problem is broken down into two circumstances: should we perform a cholecystectomy when fundoplication is indicated? And viceversa: should we carry out a fundoplication when a cholecystectomy is to be performed? Surprisingly, the literature provides only few answers.

The performance of cholecystectomy during laparoscopic fundoplication is a topic that has been recently raised in the literature by the Mayo Clinic team at Jacksonville. With an extensive series of successive procedures, Klaus et al. (6) demonstrate that the performance of cholecystectomy in patients undergoing fundoplication results in no increased morbidity and no prolonged hospital stay, and has no significant impact on antireflux surgery outcomes. The authors recommend this approach, but the study’s retropective nature and Ron Hinder’s extensive experience in such procedures should lead us to carefully assess our setting and each subject before adopting such recommendation.

Not much information is there either on the reverse situation: should fundoplication be performed in patients where cholecystectomy is indicated? To find a study answering this question one must date back to 1980, when Stahlgreen et al. (7) showed the difference between performing a cholecystectomy and associating or not a fundoplication in those with demonstrated GERD. A considerable difference exists regarding morbidity, with 1 versus 8%, respectively. Despite this, authors advise that fundoplication be performed in patients with GERD without waiting for medical therapy to fail, although the fact that medical treatment effectiveness was scarce during the 1970’s weighed heavily on it (8).

In this issue of Revista Española de Enfermedades Digestivas (2), a team from Asturias’ Central Hospital offers readers a study focused in the latter problem, which somehow updates results reported by Stahlgreen et al. by using the laparoscopic approach and basing the indication of associated fundoplication upon not only an objective study of GERD, but also inadequate symptom control from medical treatment. Results show that the addition of fundoplication prolongs (duplicates) surgery duration and slightly lengthens work resumption times (by almost one day), but is not associated with increased morbidity or hospital stay. Surgical team experience (no conversion to laparotomy in 442 procedures) is probably a decisive factor for such good results.

Should we recommend the combined procedure? A consequence of this study is that performing an associated fundoplication in patients with indicated cholecystectomy is a safe option provided the following two conditions are met: a clinical indication for fundoplication and the presence of an experienced surgical team. It is under such conditions that we should offer a patient undergoing cholecystectomy a choice to either stick to antireflux medical therapy or have fundoplication performed within the same surgical procedure.

E. Rey

Service of Digestive Diseases. Hospital Clínico San Carlos. Madrid, Spain

 

References

1. Burkitt DP, Walker ARP. Saint’s triad: confirmation and explanation. S Afr Med J 1976; 50: 2136.

2. Pozo F, Giganto F, Rodrigo L. Colelitiasis no complicada asociada con ERGE: resultados de la cirugía laparoscopica combinada en pacientes con bajo riesgo quirúrgico. Rev Esp Enferm Dig 2004; 96 (4): 237-45.

3. Avidan B, Sonnenberg A, Schell TG, Sontag SJ. No association between gallstones and gastroesophageal reflux disease. Am J Gastroesnterol 2001; 96: 2858-62.

4. Martínez de Pancorbo C, Carballo F, Horcajo P, Aldeguer M, Villa I, Nieto E, et al. Prevalence and associated factorsfor gallstone disease: results of a population survey in Spain. J Clin Epidemiol 1997; 50: 1347-55.

5. Díaz-Rubio M, Moreno-Elola-Olaso C, Rey E, Locke III GR, Rodríguez-Artalejo F. Symptoms of gastro-oesophageal reflux: prevalence, severity, duration and associated factors in a Spanish population. Aliment Pharmacol Ther 2004; 19: 95-106.

6. Klaus A, Hinder RA, Swain J, Achem SR. Incidental cholecystectomy during laparoscopic surgery. Am Surg 2002; 68: 619-23.

7. Stahlgreen LH, Pagana TJ, Constantino GN. Funduplication for major reflux in patients with gallstones. Surg Gynecol Obst 1980; 150: 875-7.

8. Rey E, Díaz-Rubio M. Enfermedad por reflujo gastroesofágico: un siglo de historia. Rev Esp Enferm Dig 2003; 95 (extraordinario): 18-24.