From the Guidelines
Cholecystectomy is the preferred treatment for symptomatic cholelithiasis, even in elderly patients, as it is a safe and effective procedure with a low complication rate 1.
Diagnosis and Treatment
For symptomatic cholelithiasis, the diagnosis is typically made using a combination of symptoms, signs, and laboratory tests, as no single investigation has sufficient diagnostic power to establish or exclude acute cholecystitis 1. Abdominal ultrasound is the preferred initial imaging technique for elderly patients suspected of having acute cholecystitis due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones 1.
Surgical Approach
The surgical approach for cholelithiasis involves laparoscopic cholecystectomy, which should always be attempted first in elderly patients, except in cases of absolute anesthetic contraindications and septic shock 1. Laparoscopic cholecystectomy is safe, feasible, and associated with a shortened hospital stay in elderly patients 1.
Alternative Treatments
Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery, such as those with ASA III/IV, performance status 3 to 4, or septic shock 1. However, this treatment is typically used as a bridge to cholecystectomy in acutely ill patients deemed unfit for surgery.
Risk Assessment and Treatment
The evaluation of the risk for elderly patients with acute cholecystitis should include mortality rate, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation using frailty scores 1. The treatment should be individualized based on the patient's risk factors and overall health status.
Common Bile Duct Stones
Elevation of liver biochemical enzymes and/or bilirubin levels is not sufficient to identify patients with choledocholithiasis, and further diagnostic tests are needed 1. The visualization of common bile duct stones on abdominal ultrasound is a strong predictor of choledocholithiasis, but indirect signs of stone presence are not sufficient to identify patients with choledocholithiasis 1.
From the Research
Definition and Prevalence of Cholelithiasis
- Cholelithiasis, also known as gallstone disease, affects approximately 15% of the US population 2.
- The condition is more common in women than men, and risk factors include pregnancy, increasing parity, and obesity during pregnancy 2.
Symptoms and Diagnosis of Cholelithiasis
- The classic presentation of cholelithiasis is right upper quadrant pain of the abdomen, often accompanied by referred pain to the right supraclavicular region and/or shoulder, nausea, and vomiting 2.
- Diagnosis is typically made using ultrasonography, which is the gold standard for diagnosis 2.
- Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may also be used to assist in diagnosis 2.
Treatment Options for Cholelithiasis
- Treatment options for symptomatic cholelithiasis include surgery, non-surgical therapies, and pain management strategies in the emergency department 3.
- Laparoscopic cholecystectomy (LC) is a common treatment option, which offers the majority of patients with symptomatic cholelithiasis an improved treatment option, resulting in significantly less postoperative pain, hospitalization, and recuperation time 4.
- For patients with choledocholithiasis, treatment options include endoscopic and surgical approaches, with a debate still existing on how to cure the two diseases at the same time 5.
Management of Cholelithiasis with Choledocholithiasis
- The management of cholelithiasis with choledocholithiasis is a multidisciplinary approach, with therapeutic choices increasing in number with the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques 5.
- Comparison of two-session and one-session treatment approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay and more cost benefits 5.
Cost-Effective Treatment of Cholelithiasis
- The most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible common bile duct stones is laparoscopic cholecystectomy with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE) 6.
- This approach is the most cost-effective across a wide range of probabilities of common bile duct stones, except when the probability is 0%, in which case laparoscopic cholecystectomy alone is the most cost-effective 6.