Gall Bladder Stone

[KannikaP]

10 hours ago, connda said:

$2000 USD if you put it into perspective.  If I had what you have I'd go to CMU Maharaj Hospital here in Chiang Mai.  They did my inguinal hernia and the hospital was top-notch.  Again - best of luck.  Let us know how it shakes out. 

As I posted yesterday, got it all done for Bht 45000, no problems, back to normal. 

[KannikaP]

11 hours ago, Chris Daley said:

Thailand's doctors are just monkeys in a gown, so who knows what they will do.

The doctor who did my gall bladder removal was perfect, and did a good successful job. 

[Sheryl]

@QuantumQuandry

 

It is never the hospital that matters but the doctor.

 

In the case of laparoscopic GB removal,  any general surgeon trained in laparoscopic procedures who has done many of them (i.e. several years and  around 50 procedures or more) would be well able to do this, Cholecystecomies (GB removal) and hernia repair are the "meat and potatoes"  of general surgery.

 

The various hospitals you mention do not differ in medical quality. They do differ greatly in amenities and degree of English spoken especially among nurses etc. Also differ in ease of use, wait time etc.

 

If you want a specific surgeon recommendation at a private hospital that is (compared to other private hospitals) reasonable in cost, I suggest Dr. Narongsak Jongsiri  at Saint Louis Hospital in Bangkok (Sathorn, on the BTS).  https://saintlouis.or.th/en/index

He is very experienced in laparoscopic surgery and also a very nice and sincere man. With excellent English. ST Louis is a solid, "no frills" non-profit private hospital.

Last I heard laparoscopic GB removal there was around 180k.

 

As I have said before, I do not know if lapaorscopic surgery is available at Queen Sirikit.  The only way to find out is to go in person and consult a surgeon. You will have to go in person to get an appointment, waits will be long, a lot of red tape, and other than the surgeon (and even there, no guarantee) little to no English speaking.  However this will certainly be the lowest cost option for you without traveling far afield.

 

As to whether the 5 cm size of your stone precludes laparoscopic approach: not if the doctor is sufficiently skilled and experienced. But there are other factors as well, including your weight (obesity makes laparoscopic more difficult) and whether there are any abdominal adhesions (more likely in people with prior abdominal surgery.)   There is always a possibility that the surgeon may have to switch from laparoscopic to open approach mid surgery if he runs into difficulty, and in that case you still pay the rate for laparoscopic surgery.

 

Best to discuss with surgeon how confident he personally feels about lapaorascopic approach in your specific case all factors considered.

 

Regarding your question about diarrhea as an after effect of the surgery,  the occurrence of any diarrhea after removal of the gallbladder is about 13 - 20%.  The vast majority of this is temporary (days, weeks or less often a few months). Permanent chronic diarrhea affects only  a small percentage of patients, I cannot give an exact number as most studies do not do follow up longer than 6 months but it would certainly be well under 10%.  It is not zero, though.

 

As previously explained the issue with asymptomatic gallstones of >3cm size is that they are more likely to cause blockage of the common bile duct in future than are smaller stones. However the decision to operate on large asymptomatic stones requires an overall assessment of many factors including the specific patients' age , other co-morbidities, whether there are any specific surgical risk factors, and  whether the stone is pigmented  or radioopaque. Also need to consider how readily the patient can access immediate medical care in future if a "wait and see" approach is chosen. 

 

Alternatives to surgery, aside from just "expectant" management, are:

 

1. Oral dissolution therapy:  Medications that medicines that contain bile acids  are used and it takes many months or even 1 year. This works only if the stones are made of cholesterol, which would show up as radiopaque on the ultrasound. that can break up gallstones. It will not work for pigmented stones as these are not made of cholesterol.

 

2. Lithotropsy (shock waves) are rarely used, and only for smaller stones so not an option in your case.

 

You really need to be having this discussion with an experienced surgeon who has access to your full medical history and ultrasound report. 

 

Note that everything I have said assumes the stone size you mentioned (almost 5 cm) is correct and that you did not mean 5 mm.

 

 

 

 

 

[QuantumQuandry]

First, let me thank you for an extensive and knowledgeable response.  I moved here two years ago with my fiance (now wife) and it's been difficult to get quality discussion on medical matters that are Thailand specific (such as Thai hospitals and doctors).  I appreciate your evidence-based approach, as well.

  

1 minute ago, Sheryl said:

It is never the hospital that matters but the doctor.

 

I agree 100%.  However, not knowing a good doctor already and it being a specialist area (compared to a general GP), you kind of end up going with whatever info you have, which is usually the general reputation of the hospital.  Which does not always match personal experiences for reasons that you mentioned.  I am 0 for 3 in having good experiences with BKK-Pattaya hospital, for example, whereas most people recommend them.

 

9 minutes ago, Sheryl said:

In the case of laparoscopic GB removal,  any general surgeon trained in laparoscopic procedures who has done many of them (i.e. several years and  around 50 procedures or more) would be well able to do this, Cholecystecomies (GB removal) and hernia repair are the "meat and potatoes"  of general surgery.

 

Understood.  However, in my case, due to the size of my stone, I am more concerned about finding a high skill level surgeon.

 

11 minutes ago, Sheryl said:

The various hospitals you mention do not differ in medical quality. They do differ greatly in amenities and degree of English spoken especially among nurses etc. Also differ in ease of use, wait time etc.

 

I have been to Sirikit and I have certainly experienced what you mean, in terms of wait time and ease of use.  My girl needed an endoscopy (which we knew from previous doctors) and it took 3 visits just to get scheduled.  First GP, then Internal Med, then finally the gastroenterologist to schedule it.  And then several months wait time to have it done.  On the upside, being asymptomatic, I am not in a big rush at the moment (knock on wood).

 

14 minutes ago, Sheryl said:

If you want a specific surgeon recommendation at a private hospital that is (compared to other private hospitals) reasonable in cost, I suggest Dr. Narongsak Jongsiri  at Saint Louis Hospital in Bangkok (Sathorn, on the BTS).  https://saintlouis.or.th/en/index

He is very experienced in laparoscopic surgery and also a very nice and sincere man. With excellent English. ST Louis is a solid, "no frills" non-profit private hospital.

Last I heard laparoscopic GB removal there was around 180k.

 

Thank you for the specific recommendation.  It was more than I had hoped for.  What made you decide to use him, in the first place, if I may ask?

 

16 minutes ago, Sheryl said:

There is always a possibility that the surgeon may have to switch from laparoscopic to open approach mid surgery if he runs into difficulty, and in that case you still pay the rate for laparoscopic surgery.

 

That's what I have read.  I am more concerned about the recovery and discomfort than the price but either way, I understand that's a possibility.  A concerning one, for sure.

 

53 minutes ago, Sheryl said:

Note that everything I have said assumes the stone size you mentioned (almost 5 cm) is correct and that you did not mean 5 mm.

 

Understood.  Sadly, unless my Ultrasound from Pattaya Memorial is wrong, it is indeed 4.9 cm (not mm).  An unusual size, I am told.

 

Thank you, again, for the detailed and evidence-based reply.

 

[Sheryl]

3 hours ago, QuantumQuandry said:

First, let me thank you for an extensive and knowledgeable response.  I moved here two years ago with my fiance (now wife) and it's been difficult to get quality discussion on medical matters that are Thailand specific (such as Thai hospitals and doctors).  I appreciate your evidence-based approach, as well.

  

 

I agree 100%.  However, not knowing a good doctor already and it being a specialist area (compared to a general GP), you kind of end up going with whatever info you have, which is usually the general reputation of the hospital.  Which does not always match personal experiences for reasons that you mentioned.  I am 0 for 3 in having good experiences with BKK-Pattaya hospital, for example, whereas most people recommend them.

 

 

Understood.  However, in my case, due to the size of my stone, I am more concerned about finding a high skill level surgeon.

 

 

I have been to Sirikit and I have certainly experienced what you mean, in terms of wait time and ease of use.  My girl needed an endoscopy (which we knew from previous doctors) and it took 3 visits just to get scheduled.  First GP, then Internal Med, then finally the gastroenterologist to schedule it.  And then several months wait time to have it done.  On the upside, being asymptomatic, I am not in a big rush at the moment (knock on wood).

 

 

Thank you for the specific recommendation.  It was more than I had hoped for.  What made you decide to use him, in the first place, if I may ask?

 

 

That's what I have read.  I am more concerned about the recovery and discomfort than the price but either way, I understand that's a possibility.  A concerning one, for sure.

 

 

Understood.  Sadly, unless my Ultrasound from Pattaya Memorial is wrong, it is indeed 4.9 cm (not mm).  An unusual size, I am told.

 

Thank you, again, for the detailed and evidence-based reply.

 

Yes, it is a unusually large gallstone.  Virtually qualifies as a "giant gallstone". there are only a handful of cases in the entire literature of stones >5cm.   Even above 3 cm is rare. Stones of such size carry unusually high risks of serious complications, which is why the usual approach to asymptomatic gallstones (expectant management i.e. wait and see) does not apply.

 

Again, assuming the size estimation is correct.  Not unheard of in my experience for a Thai report  put cm instead of mm (or instead of decimal point cm) so some possibility of error there. Do you have with you the actual ultrasound report and copy of images, either hard copy or on disk? Did the doctor mention it was a very unusually large stone?

 

re Dr. Narongsak, I originally found him about 10 - 15 years ago when a distant relative needed a hernia repair.  Coming from Cambodia so government hospital not very practical, yet cost was a consideration so looked at St Louis and reviewed qualifications, selected him based on training, experience  and publications. I was very favorably impressed when we then met him. Since then over the years I have referred many board members to him with continued good feedback.  He is very experienced and competent, open to questions and patient concerns, unassuming and kind.

 

 

 

 

[QuantumQuandry]

12 minutes ago, Sheryl said:

Again, assuming the size estimation is correct.  Not unheard of in my experience for a Thai report  put cm instead of mm (or instead of decimal point cm) so some possibility of error there. Do you have with you the actual ultrasound report and copy of images, either hard copy or on disk? Did the doctor mention it was a very unusually large stone?

 

I do have the report on paper and images on a disk (not that I actually have a disk drive to access the images).

 

The doctor didn't mention it being unusual.  I asked about surgery vs. wait and see.  The doc said if I was going to travel a lot in places without good medical care, I should do the surgery but otherwise, it's more or less '50/50' on what I should do.

 

I hope a mistake was made.  At least if it is that large, though, I will have a paperweight with a very interesting story.

 

20 minutes ago, Sheryl said:

re Dr. Narongsak, I originally found him about 10 - 15 years ago when a distant relative needed a hernia repair.  Coming from Cambodia so government hospital not very practical, yet cost was a consideration so looked at St Louis and reviewed qualifications, selected him based on training, experience  and publications. I was very favorably impressed when we then met him. Since then over the years I have referred many board members to him with continued good feedback.

 

Sounds like an excellent recommendation.

 

[Sheryl]

2 hours ago, QuantumQuandry said:

 

I do have the report on paper and images on a disk (not that I actually have a disk drive to access the images).

 

The doctor didn't mention it being unusual.  I asked about surgery vs. wait and see.  The doc said if I was going to travel a lot in places without good medical care, I should do the surgery but otherwise, it's more or less '50/50' on what I should do.

 

I hope a mistake was made.  At least if it is that large, though, I will have a paperweight with a very interesting story.

 

 

 I am really starting to think maybe there is just a misplaced  decimal point or "cm" where it should have been "mm" as  surely any doctor would mention it if size was really 4.9 cm.  That is larger than a golf ball!!!

 

A 4.9mm gallstone on the other hand, is unremarkable and in an asymptomatic patient can certainly e managed expectantly i.e. no need for surgery until/unless symptoms arise.

 

Bring the CD with the ultrasound to a surgeon and let him review it.  Or, return to same hospital and ask for clarification.

 

 

[QuantumQuandry]

On 11/15/2023 at 6:41 PM, Sheryl said:

 I am really starting to think maybe there is just a misplaced  decimal point or "cm" where it should have been "mm" as  surely any doctor would mention it if size was really 4.9 cm.  That is larger than a golf ball!!!

 

A 4.9mm gallstone on the other hand, is unremarkable and in an asymptomatic patient can certainly e managed expectantly i.e. no need for surgery until/unless symptoms arise.

 

Bring the CD with the ultrasound to a surgeon and let him review it.  Or, return to same hospital and ask for clarification.

 

Investigating further, it appears you were right to question it.  Unfortunately, it's still not as small as 4.9mm but it turns out it is 2.9 cm rather than 4.9 cm.  One paper said 4.9, one said 2.9 but after calling them, it looks like 2.9 is correct.

 

So...better...but still an issue, perhaps? :)

[Sheryl]

4 hours ago, QuantumQuandry said:

 

Investigating further, it appears you were right to question it.  Unfortunately, it's still not as small as 4.9mm but it turns out it is 2.9 cm rather than 4.9 cm.  One paper said 4.9, one said 2.9 but after calling them, it looks like 2.9 is correct.

 

So...better...but still an issue, perhaps? :)

3.0 cm (virtually your size) is considered large (not giant, but large)  and associated with an increased incidence of gall bladder cancer. 

 

Is it opaque or translucent? 

[QuantumQuandry]

5 hours ago, Sheryl said:

Is it opaque or translucent? 

 

The report didn't mention that (though there might be more info on the actual disk, not sure).  Had some stuff about kidney stones, lots of other stuff that looked 'normal' and, on the gall bladder:

 

"GB is normally distended, with containing a 2.9cm gallstone.  No thickened wall of GB.  No pericholecystic fluid.".

 

And then at the end, it says:

"Impression: A 2.9cm, gallstone without evidence of acute cholecystitis.

Suspected a 7mm calyceal stone at mid part of left kidney.  No hydronephrosis of both kidneys.

Few small benign-appearing cysts in both kidneys, size up to 1cm.".

 

So yeah...looks like my body loves to make stones.