From the Guidelines
The recommended treatment for symptomatic cholelithiasis is laparoscopic cholecystectomy, which involves surgical removal of the gallbladder. This procedure is considered the gold standard treatment as it eliminates the source of stone formation and prevents recurrent symptoms 1. The surgery typically requires four small incisions and patients usually stay in the hospital for 1-2 days, with full recovery taking 1-2 weeks. For patients who are poor surgical candidates due to comorbidities or who refuse surgery, alternative options include oral dissolution therapy with ursodeoxycholic acid (8-10 mg/kg/day in divided doses for 6-12 months), although this is less effective and has high recurrence rates. Extracorporeal shock wave lithotripsy may be considered in select cases. Pain management during acute episodes includes NSAIDs like ketorolac (30mg IV or 10mg oral) or opioids if needed, and antiemetics such as ondansetron (4mg IV/oral) for nausea. Patients should follow a low-fat diet to reduce symptoms while awaiting definitive treatment. Surgery is recommended because gallstones typically recur if the gallbladder remains in place, and symptomatic stones often lead to complications like acute cholecystitis, pancreatitis, or biliary obstruction if left untreated.
Some key points to consider:
- Laparoscopic cholecystectomy is safe and feasible in elderly patients, with a low complication rate and shortened hospital stay 1.
- 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 1.
- Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery 1.
- Early laparoscopic cholecystectomy should be performed as soon as possible, but can be performed up to 10 days of onset of symptoms, with earlier surgery associated with shorter hospital stay and fewer complications 1.
From the FDA Drug Label
For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients. Watchful waiting has the advantage that no therapy may ever be required. Cholecystectomy For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients.
The recommended treatment for symptomatic cholelithiasis is cholecystectomy, as it offers immediate and permanent stone removal. However, it carries a high risk in some patients, and the decision should be made considering the patient's overall health and age 2.
- Surgery is the preferred treatment for symptomatic gallstones.
- Watchful waiting may be considered for patients with silent or minimally symptomatic stones.
From the Research
Treatment Options for Symptomatic Cholelithiasis
The recommended treatment for symptomatic cholelithiasis is primarily laparoscopic cholecystectomy, as it has become the treatment of choice for patients with symptomatic cholelithiasis 3. This procedure is highly safe and effective, offering less postoperative pain, hospitalization, and recuperation time compared to open cholecystectomy 4.
Management of Common Bile Duct Stones
For patients with suspected common bile duct stones, preoperative endoscopic retrograde cholangiography (ERC) can be performed to confirm the presence of bile duct calculi 5. If common bile duct stones are confirmed, endoscopic sphincterotomy (ES) can be performed to remove the stones 3. Alternatively, combined endoscopic-laparoscopic treatment, which involves laparoscopic cholecystectomy with intraoperative ERC/ES, may be considered as it presents advantages in terms of morbidity, hospital stay, and patient compliance 3.
Alternative Therapies for Complicated Gallbladder Disease
In cases of acute cholecystitis or complicated gallbladder disease, alternative therapies such as percutaneous cholecystostomy, laparoscopic cholecystostomy, or laparoscopic subtotal cholecystectomy may be considered to improve clinical outcomes 6. These alternatives provide the least invasive management to safely temporize or definitively treat the acute condition.
Key Considerations
- Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis 7, 4.
- Preoperative ERC and ES can be used to manage common bile duct stones 3, 5.
- Alternative therapies may be necessary for complicated gallbladder disease 6.
- The choice of treatment should be based on individual patient factors, including the severity of biliary disease and preexisting medical risk factors 6.