BY NORM TOLLINSKY
The high incidence of gallbladder disease in northwestern Ontario has led general surgeon Dr. Eric Touzin to advocate for an endoscopic retrograde cholangiopancreatography (ERCP) capability at the Sioux Lookout Meno Ya Win Health Centre.
The two surgeons at the Meno Ya Win Health Centre perform upwards of 200 laparoscopic cholecystectomies annually, but between 10 and 14 per cent of their patients have to be flown to Thunder Bay or Winnipeg for an ERCP prior to the removal of their gallbladder.
The ERCP combines the use of endoscopy and fluoroscopy to detect and remove stones in the biliary ducts.
“The ducts have to be clear of any stones before the gallbladder is removed,” explained Touzin, who co-authored a paper entitled Gallbladder disease in northwestern Ontario: the case for Canada’s first rural ERCP program, in the Spring 2011 issue of the Canadian Journal of Rural Medicine.
Research conducted by Touzin shows that the incidence of gallbladder disease in the Sioux Lookout catchment area is at least twice the provincial average and that the incidence of ERCP procedures is three times the provincial average.
“When I moved to Sioux Lookout, I quickly realized there was a very high incidence of gallbladder disease,” said Touzin. “We decided to look into crunching some numbers to see whether our intuition was correct, and indeed the numbers are much, much higher than the rest of the province and most of North America.”
40-50 cases
With referrals from the nearby communities of Dryden, Kenora and Fort Frances, Touzin is confident of achieving a volume of 40 to 50 cases annually to justify an ERCP program for the region.
The estimated initial cost for acquiring the equipment and training nurses would be between $200,000 and $250,000, but having the capability to perform ERCPs in Sioux Lookout would dramatically reduce the cost of transporting patients to Thunder Bay and Winnipeg, said Touzin.
“Transportation for ERCP services in our region is very expensive,” the article in the Canadian Journal of Rural Medicine points out. “Simply eliminating five of the six medevacs our 17 ERCP patients each incurred in the past two years could have saved more than $272,000. The potential savings on 40 or 50 of the 89 ERCPs done on patients from our region would be greater.”
The Sioux Lookout Meno Ya Win Health Centre serves a population of 30,000, of which 82 per cent is First Nation.
The risk factors associated with gallbladder disease include obesity, poor nutrition, high cholesterol and a high fertility rate, all of which are prevalent in the First Nation community, said Touzin.
Data for laparoscopic cholecystectomies performed in Sioux Lookout between 2007 and 2009 show a female to male ratio of three to one and a mean age of 32.2 years.
Golf ball
Gallstones can be as small as a grain of sand or as large as a golf ball and are composed of cholesterol, bile pigments or a combination of the two. They can cause acute cholecystitis, an inflammatory condition characterized by the retention of bile in the gallbladder, as well as secondary infections.
Patients are referred for an ERCP based on clinical presentation and results from blood work and ultrasound tests.
“People can live a completely normal life after having their gallbladder removed,” said Touzin. “They will be able to eat absolutely anything they want – even foods that would trigger their attacks previously.”
Two adaptive processes occur following gallbladder removal. The bile duct itself grows and dilates and, following a few weeks of mild diarrhea, the intestine adapts to the higher volume of bile.
A healthy diet including fresh fruits and vegetables is generally recommended for lowering the risk factors associated with gallbladder disease.
