From the Guidelines
Laparoscopic cholecystectomy is the preferred treatment for symptomatic gallstones, as it offers a minimally invasive approach with reduced recovery time, although the potential risk of bile duct injury should be considered 1. When managing cholelithiasis, it's essential to differentiate between symptomatic and asymptomatic patients. For asymptomatic patients, observation without intervention is often recommended, as they may not experience further episodes even after prolonged follow-up 1.
Key Considerations
- Symptomatic patients who opt for expectant management should be aware that the decision between immediate treatment or expectant management may be a matter of personal choice and convenience 1.
- Nonsurgical methods, such as oral bile acids or lithotripsy, may be considered for patients with small stones or specific characteristics, but these methods have limited efficacy and may not reduce the risk of gallbladder cancer 1.
- Patients awaiting surgery or who cannot undergo surgery may benefit from medical dissolution therapy with ursodeoxycholic acid or pain management with NSAIDs, acetaminophen, or opioids, as well as antispasmodics like hyoscyamine to relieve biliary spasms.
Treatment Approach
- The treatment approach should prioritize the patient's quality of life, morbidity, and mortality, with laparoscopic cholecystectomy being the preferred treatment for symptomatic gallstones due to its minimally invasive nature and reduced recovery time 1.
- Open cholecystectomy may be considered if a skilled surgeon is not available for laparoscopic cholecystectomy or if the patient has specific contraindications for laparoscopic surgery.
- Complications like acute cholecystitis, cholangitis, or gallstone pancreatitis require urgent intervention, often including antibiotics, fluid resuscitation, and emergency surgery.
From the Research
Management of Cholelithiasis
The management of cholelithiasis (gallstones) involves various approaches, including surgical and endoscopic methods.
- Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholelithiasis 2, 3, 4.
- For patients with choledocholithiasis (common bile duct stones), a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and LC, or a single-stage procedure such as LC with common bile duct exploration (CBDE) can be used 5, 2, 4.
- Single-stage procedures have been shown to be safe and effective, with a reduced length of stay (LoS) compared to multi-stage management 5, 2, 4.
- The choice of management approach depends on various factors, including the presence of common bile duct stones, the patient's overall health, and the expertise available 3, 4.
Endoscopic and Surgical Approaches
Endoscopic approaches, such as ERCP, can be used to remove common bile duct stones, while surgical approaches, such as LC and CBDE, can be used to remove the gallbladder and common bile duct stones 2, 4.
- Peroperative ERCP with a transcystic guidewire can be a safe and effective approach for managing choledocholithiasis associated with cholelithiasis 2.
- Laparoscopic bile duct exploration and open CBD exploration are other surgical options available for managing choledocholithiasis 2, 3.
Importance of Early Surgeon Involvement
Early surgeon involvement is crucial in the management of symptomatic cholelithiasis, as it can improve the likelihood of receiving standard of care, such as same admission cholecystectomy or elective outpatient cholecystectomy 6.
- Patients who receive a surgery consultation are more likely to receive standard of care, highlighting the importance of early surgeon involvement in the management of symptomatic cholelithiasis 6.