Ode to One of the ‘Deadliest Organs’

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Surgery to remove the gallbladder is a relatively late intervention. The first laparotomy was performed in 1807 in Danville, Kentucky, and surgeons like Theodor Billroth and Theodor Kocher were removing thyroids and even parts of the esophagus as early as the 1870s — the pricklish gallbladder was not completely excised until 1882.

For years before, the medical and surgical dogma was that the gallbladder was an essential organ and couldn’t safely be removed. Treatment centered around opening the gallbladder and removing the stones or creating a fistula by sewing the opened gallbladder to the skin, like a colostomy (but called a cholecystectomy).

This relieves the infection and gets rid of the stones but leaves the patient with a hole in the belly spilling caustic bile onto the skin, trading pain and misery for lifelong mess and aggravation.

William S. Halsted, MD, often called the father of American surgery, apocryphally performed the first successful cholecystectomy in America — on his mother, on her kitchen table. She lived another year and a half, but repaid him genetically by leaving him with the predilection for forming stones in the gallbladder and common duct.

I think this speaks to the peevish nature of this little gland. Pound for pound, it must be one of the deadliest organs in the human body. Pancreatitis, cholangitis, biliary peritonitis, carcinoma, acalculous and calculous cholecystitis, and torsion are just some of the horsemen of the physiologic apocalypse lashed to the little bile bag in the right upper quadrant — not to mention surgical iatrogenia.

I can just imagine these first operations for cholecystitis with the patients at their wit’s end, having experienced chronic, smoldering, cementitious inflammation and infection. Their gallbladders must have been thickened, scarred, inflamed, and full of pus, white bile, and blood.

Removing these gallbladders would have been difficult for even an experienced, modern-day biliary tract surgeon.

So, it’s easy to understand how the treatment began with a relatively straightforward procedure like simply opening the gallbladder and removing the stones rather than excising the whole bloody thing. But even with this seemingly simple procedure, the mortality rate was around 25%.

Then came Carl Johann August Langenbuch, head of the Lazarus Hospital in Berlin from 1892 to 1901. He was familiar with the 200-year-old literature that found it was safe to remove the gallbladder in animals and agreed with his medical colleagues that the gallbladder itself was responsible for stone formation, an idea that was not universally accepted by surgeons.

Langenbuch worked out the operation in humans in the cadaver lab for several years before trying it out on his first patient in July 1882. The patient was 43 years old, and in a longstanding battle with this aggrieved organ, had lost 80 pounds over 16 years and had become hopelessly addicted to morphine.

Thanks to Langenbuch’s fastidious preparation and — despite his overzealous use of the preoperative bowel preparation, with a 5-day enema-palooza for the poor patient — the operation was a resounding success.

The gallbladder was completely excised with only a minimum of blood loss, in much the same way the procedure is performed today by surgeons who elect to perform it in the conventional, open approach. The patient was sitting up in bed the next day, smoking a cigar, without a right upper quadrant care in the world, except for the occasional twinge of pain from the incision.

The patient might have felt like Lazarus himself, raised from a seeming right upper quadrant death of a thousand calculous calamities. In 6 weeks, he was discharged, gaining weight and without pain, reportedly thumbing his nose at the Lazarus Hospital Utilization Review Committee before discharge.

Like any good surgeon, Langenbuch published his results — 11 of the first 12 patients who had cholecystectomies survived the operation and were free of pain and symptoms. Compared with the 25% mortality associated with simple cholecystectomy, Langenbuch’s open cholecystectomy was a definite win-win.

And thus, a legend was born — well, not really. Langenbuch is not exactly a household or even a surgical on-call room name. He has become a much lesser demigod in the pantheon of surgical heroes, like Billroth, Kocher, or Michael DeBakey, subject to the vagaries of time, technological advancement, or the manuscript of history that relegates brave pioneers of their field to the relative kick-bucket of collegial vindication.

The mortality of cholecystectomy continued to decline, but never, ever will it get to zero. Even in today’s hyper-technologic climate of minimally invasive, robotic surgery, the mortality of cholecystectomy is, in the U.S., conservatively around 0.5%.

That’s great you say; only one in 200 people will die from having their gallbladders removed. But over 500,000 people have their gallbladders removed each year. That sad sack of an organ is still killing over 2,500 patients a year.

Complications from the surgery killed Andy Warhol, Pennsylvania Rep. John Murtha, Jr. (D), and Halsted, to name just a few. And there are likely even greater numbers that die who are either too sick for an operation or never make it to the surgical consultant.

Langenbuch, who pioneered biliary tract surgery, died in 1901, at the ripe old age of 54, of a neglected and perforated appendicitis. Although the details of his death aren’t entirely clear, I suppose denial is a strange cognitive bedfellow and likely played a part in his demise.

Even from the beginning, surgeons, even (especially) pioneers in surgery, have always been horrible patients.

Arthur Williams, MD, is a surgeon and author of The Surgeon’s Obol.

This post appeared on KevinMD.

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