What are the treatments for cholelithiasis (gallstones)?

From the Guidelines

Laparoscopic cholecystectomy is generally the preferred treatment for gallstones when intervention is desired, due to its reduced recovery time and lower risk of complications compared to open cholecystectomy, as long as a skilled surgeon is available 1. When considering treatment options for gallstones, several factors come into play, including the patient's overall health, the severity of symptoms, and personal preferences.

• For patients who are good candidates, nonsurgical methods such as oral bile acids or lithotripsy may be considered, especially for those with small, cholesterol-based stones or a solitary radiolucent stone smaller than 2 cm 1.
• The choice between open and laparoscopic cholecystectomy should take into account the potential risk of bile duct injury, particularly with laparoscopic procedures, and the surgeon's experience and qualifications 1.
• Patients should be informed about the potential benefits and risks of each treatment option, including the fact that nonsurgical methods may not reduce the risk of gallbladder cancer 1.
• In cases where surgery is not feasible due to high mortality risks or patient preference, nonsurgical therapy may be a reasonable alternative, with the understanding that it may not be as effective in preventing future complications 1.
• Ultimately, the decision on the best course of treatment should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances, and prioritizing their morbidity, mortality, and quality of life.

From the FDA Drug Label

ALTERNATIVE THERAPIES Watchful Waiting Watchful waiting has the advantage that no therapy may ever be required. For patients with silent or minimally symptomatic stones, the rate of development of moderate-to-severe symptoms or gallstone complications is estimated to be between 2% and 6% per year, leading to a cumulative rate of 7% to 27% in 5 years Presumably the rate is higher for patients already having symptoms. Cholecystectomy For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients. SPECIAL NOTE Gallbladder stone dissolution with Ursodiol Capsules USP, 300 mg treatment requires months of therapy. Complete dissolution does not occur in all patients and recurrence of stones within 5 years has been observed in up to 50% of patients who do dissolve their stones on bile acid therapy. Patients should be carefully selected for therapy with ursodiol, and alternative therapies should be considered.

Treatments for gall stones include:

• Watchful waiting: for patients with silent or minimally symptomatic stones
• Cholecystectomy: for patients with symptomatic gallstones, which offers immediate and permanent stone removal but carries a high risk in some patients
• Ursodeoxycholic acid (PO): for gallbladder stone dissolution, which requires months of therapy and has a recurrence rate of up to 50% within 5 years 2 2

From the Research

Treatment Options for Gallstones

• Laparoscopic cholecystectomy is the procedure of choice for symptomatic gallbladder stones 3
• Open cholecystectomy is advisable in some situations, and natural-orifice transluminal endoscopic surgery is a new technique that has been described recently 3
• Nonsurgical approaches, such as ursodeoxycholic acid (UDCA), have also been used in patients with gallbladder stones 4
• Endoscopic approaches are the most important and commonly used modality for the treatment of common bile duct stones, but surgical removal should be considered if the stones cannot be managed nonsurgically 3, 5

Comparative Analysis of Treatment Approaches

• A comparative analysis of minimally invasive approaches for gallbladder and common bile duct stones found that the combined technology of laparoscopy, choledochoscope, and gastroscope is safe and effective with fast recovery 6
• The study compared the clinical effects of the combined technology with ERCP with laparoscopic cholecystectomy and found that the length of hospital stay and hospital cost were lower in the combined technology group 6
• Another study found that laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones and has become the treatment of choice for many patients 7

Considerations for Treatment

• The treatment of gallstones should be individualized based on the patient's condition and the availability of local expertise 3
• Patients with concomitant gallbladder and common bile duct stones may have various options, depending on the patient's condition and the availability of local expertise 3
• The risk factors for recurrent choledocholithiasis after endoscopic biliary sphincterotomy, such as delayed bile-duct clearance and bactobilia, should be recognized and addressed 5