What is the recommended management for a stone in the gallbladder neck?

From the Guidelines

The recommended management for a stone in the gallbladder neck typically involves surgical removal of the gallbladder (cholecystectomy), preferably via laparoscopic approach. This approach is supported by guidelines from the American College of Physicians, as outlined in the Annals of Internal Medicine 1. The decision to proceed with surgery should consider the patient's symptoms, treatment goals, and risk factors for gallbladder cancer.

Some key points to consider in the management of gallbladder neck stones include:

• The risk of complications such as acute cholecystitis, gallstone pancreatitis, or gallbladder cancer
• The patient's overall health and suitability for surgery
• The potential benefits and risks of surgical versus non-surgical management
• The importance of prompt intervention to prevent complications and improve outcomes

While waiting for surgery, patients should be managed with:

• Pain control using NSAIDs or opioids if necessary
• Antiemetics such as ondansetron
• NPO (nothing by mouth) status except for medications
• IV hydration
• Antibiotics if infection is suspected

In patients who are poor surgical candidates, alternatives may include:

• Percutaneous cholecystostomy tube placement for drainage
• Endoscopic retrograde cholangiopancreatography (ERCP) if the stone has migrated to the common bile duct

It is essential to prioritize the patient's morbidity, mortality, and quality of life when making management decisions, and to consider the most recent and highest-quality evidence available 1.

From the Research

Management for Stone in Gallbladder Neck

• The management of stones in the gallbladder neck is primarily surgical, with laparoscopic cholecystectomy being the preferred treatment for symptomatic gallbladder stones 2.
• Indications for cholecystectomy are limited to clearly symptomatic gallstones, and contraindications are related to anaesthesiological considerations 3.
• For patients with choledocholithiasis, endoscopic sphincterotomy and endoscopic common bile duct clearance may be performed, either preoperatively or postoperatively 2, 4.
• Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy, and primary outcome measures seem to be equal for the three techniques (laparoscopic, open, and small-incision cholecystectomies) 3.
• Planned perioperative endoscopic retrograde cholangiography and sphincterotomy may be attempted in patients undergoing laparoscopic cholecystectomy with suspected or proven common bile duct stones 5.
• Single-stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography may be beneficial in select patients who may not tolerate a second anesthetic procedure 6.

Treatment Options

• Laparoscopic cholecystectomy
• Endoscopic sphincterotomy and endoscopic common bile duct clearance
• Open cholecystectomy
• Small-incision cholecystectomy
• Planned perioperative endoscopic retrograde cholangiography and sphincterotomy
• Single-stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography

Considerations

• Patient selection and anaesthesiological considerations are crucial in determining the best treatment approach 3.
• The optimal management of common bile duct stones in the era of laparoscopic cholecystectomy is not defined, and different approaches may be suitable for different patients 4, 5, 6.