Gallbladder removal with extensive adhesions?

[minookie]

First of all,I'd like to thank you and everyone else who contributes to this forum as it has been extremely helpful. I posted a question last Dec about my mom http://www.medhelp.org/forums/gastro/messages/36941.html
to briefly sum up her condition: 62yrold, current condition is avg/good. 6 yrs ago, colon cancer-surgery; last nov, removal small bowel obstruction/gangrene-surgery; three weeks later, removed severe adhesions of small bowel, condition of sm bowel poor,had to remove 50% SB; fistula formed one week after last operation, from sm bowel to skin. other conditions: abscess-pelvic area; few infections caused by PICC lines=treated succesfully. since surgeries last nov,has been and currently on TPN. in jan. of this year, mom came home still on TPN. her condition greatly improved. we were basically just waiting for her fistula to close. when first formed, it outputted nothing, then few dayslater, all of a sudden just came out. while at home,output slowly started decreasing-with bowel rest. late feb/early march, started to have regular bowel movements while fistula output stopped. docs said she could slowly start eating, started off with purreed foods, then built up to chicken, soft foods. 1 week ago, after some boiled chicken and boiled carrots, mom experienced nausea, heartburn like severe pain (middle of chest), and vomitted. doc suggested maalox- pain subsided. also low-grade fever. along with this, fistula opened up and output increased 200-300cc a day. went into the ER last thurs- not b/c of pain(pain only lasted that one time), but fever persisted, fistula output up. CT scan showed gallbladder inflammed. HIDA scan confirmed duct "closed" (don't know the percent). today's ultrasound also confirmed fluid in gallbladder (doc descrbed as slugde?). docs were hoping that with Zosyn, the inflammation would go down, but it hasnt. she's had no fevers, no pain, fistula output decreased; overall good. they said the best solution would be to remove gallbladder, BUT due to severe adhesions (of intestine, and also near liver, other organs), surgeon doesn't want to go in. so tomorrow morning, radiologist is goign to insert tube to drain fluid from gallbladder. they say this may or may not work. IF this doesn't "open" the GB duct, then what are our options? i've read many other posts on adhesions, and it seems as though many people who've had mutliple surgeries, who also have adhesions have had more surgeries (for various reasons)with ok results (to me is surprising). it is our impression that the second surgery to remove extensive adhesions was quite severe-thus our surgeon DOES NOT want to go back in for fear of the same thing happening. I'd like to know the risks of an open operation to remove the GB. What could happen if we don't? what could happen if we do? how life threatening would another open operation be? could we find a surgeon willing to do this (maybe at a bigger university hospital)? thanks!

[minookie]

Kimbacat, thanks for your reply. I'm glad that you wrote as well. I remember that you posted a comment to my previous question and I've read your other postings too (about your gallbladder surgery). Your situation sounds very similar to my mom's. I don't know if I'm allowed to ask, but you don't by any chance live in California, do you? As I said before, we are hoping that things continue to go well (without surgery), but in case something else happens, I would like to be prepared. In any case, if you do live in California, I'd very much like to speak with you. If you have the time, please email me at ***@****. Thank you all again!

[minookie]

Dear Surgeon, Thank you so much for your comment. I was hoping you would provide some insight, as I've read your other posts and they always seem to be quite helpful. Just to update, my mother actually did have drainage of the gallbladder today and it was successful! i could tell the radiologist was a bit nervous and he reassured me that he took extra care in inserting the tube into the GB. he drained about 30-40cc of dark green/black bile from the GB upon entering. and it is continuing to drain a little now. it looks as though the tube will be kept in for about a week; then more tests to check the GB. and tomorrow night, mom will probably be able to come home, and cont TPN and antibiotics at home. Surgery is pretty much the last resort option and everyone is trying to avoid it by any means. i just wanted to hear the opinion of someone else and get their take on it before we explore other doctors and methods. things are going pretty well, so i just hope they continue. thank you again so much!

[Kevin Pho, MD]

This question has been nicely answered in the comments below, and I agree with its contents with nothing more to add.  I will reprint it here (since comments are not saved):

"Adhesions are very unpredictable. Some people form extensive ones after even minor operations; others form none after the most adhesion-prone situations. They may last a long time, or forever, or dissolve away with time. Going back in early after bowel surgery is the most difficult timing, and to be avoided when at all possible. It's not very likely that the gallbladder explains her recent fistula increase; more likely there was a transient partial obstruction, from adhesions, infection, etc. It sounds, in that regard, as if the trend is favorable, and more time with TPN would be desirable. As to the gallbladder, that's a hard one, too. Draining by the radiologist is often useful, especially if there's indication of infection in it and a reason why operation needs to be avoided. The fact that it's obstructed on the scan does not per se mandate immediate intervention. It's very possible it would resolve on its own without drainage; but if she had pain, fever, tenderness, etc, felt to be related to the gallbladder, then drainage is to be considered. Many people get gallbladder attacks and get over them without intervention. When it's in the context of other illness, and appears to be without stones, then treating "medically" without intervention is sometimes a good idea, with the idea that it may or may not need removal in the future. It's impossible to predict all outcomes of all possibilities: leaving it alone could work out well and avoid surgery. It might become infected and require drainage. Open surgery in the gallbladder area might be surprisingly easy, or it might be very difficult given her past operations. Getting another opinion never is a bad idea. It's hardest of all to give advice without seeing the patient, even with an excellent description as you've provided."

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[kimbacat]

if it gets to the point that she does require surgery, don't necessarily discount laparascopic surgery.  I have extensive abdominal adhesions (including a bunch around my liver) from prior surgeries and ongoing bowel inflammation.  I went to a major university hospital and found a surgeon willing to at least try to remove my gallbladder laparascopically.  she was great.  she explained the benchmarks that she would have to meet in order for her to feel comfortable continuing laparascopically.  she was able to persevere and finish without having to open me up.  the surgery took longer, but I think I benefited greatly by not having to be opened up.  

so, if you can find a surgeon that's willing to try, I think it's worth it to at least discuss it.

[surgeon]

you gave an excellent rendition of a complex situation. Adhesions are very unpredictable. Some people form extensive ones after even minor operations; others form none after the most adhesion-prone situations. They may last a long time, or forever, or dissolve away with time. Going back in early after bowel surgery is the most difficult timing, and to be avoided when at all possible. It's not very likely that the gallbladder explains her recent fistula increase; more likely there was a transient partial obstruction, from adhesions, infection, etc. It sounds, in that regard, as if the trend is favorable, and more time with TPN would be desirable. As to the gallbladder, that's a hard one, too. Draining by the radiologist is often useful, especially if there's indication of infection in it and a reason why operation needs to be avoided. The fact that it's obstructed on the scan does not per se mandate immediate intervention. It's very possible it would resolve on its own without drainage; but if she had pain, fever, tenderness, etc, felt to be related to the gallbladder, then drainage is to be considered. Many people get gallbladder attacks and get over them without intervention. When it's in the context of other illness, and appears to be without stones, then treating "medically" without intervention is sometimes a good idea, with the idea that it may or may not need removal in the future. It's impossible to predict all outcomes of all possibilities: leaving it alone could work out well and avoid surgery. It might become infected and require drainage. Open surgery in the gallbladder area might be surprisingly easy, or it might be very difficult given her past operations. Getting another opinion never is a bad idea. It's hardest of all to give advice without seeing the patient, even with an excellent description as you've provided.