If a stone is located at the gallbladder (GB) neck, is an Endoscopic Retrograde Cholangiopancreatography (ERCP) necessary or can a cholecystectomy alone resolve the issue?

Management of Gallbladder Neck Stones: Cholecystectomy Alone is Sufficient

For patients with stones located at the gallbladder neck, cholecystectomy alone is sufficient and ERCP is not routinely necessary unless there is evidence of common bile duct stones or obstruction. 1

Decision Algorithm for Managing Gallbladder Neck Stones

Initial Assessment

• Evaluate for signs of common bile duct (CBD) obstruction:
  • Abnormal liver function tests (LFTs)
  • Dilated bile duct on ultrasound
  • History of jaundice or pancreatitis
  • Signs of cholangitis

Management Pathway

1. Gallbladder neck stone WITHOUT evidence of CBD stones:

   • Proceed directly to laparoscopic cholecystectomy
   • Intraoperative cholangiography (IOC) may be considered for patients with intermediate to high pre-test probability of CBD stones 1

2. Gallbladder neck stone WITH suspected CBD stones:

   • Options include:
     • Preoperative ERCP followed by cholecystectomy
     • Laparoscopic cholecystectomy with intraoperative cholangiography and either:
       • Laparoscopic bile duct exploration if expertise available
       • Postoperative ERCP if stones are detected during surgery

Evidence Supporting This Approach

The 2017 British Society of Gastroenterology guidelines clearly state that cholecystectomy is the treatment of choice for gallbladder stones, including those at the neck 1. ERCP should be reserved for patients with confirmed or highly suspected common bile duct stones.

Studies have shown that performing unnecessary ERCP increases procedural risks without benefit. In patients with both normal biliary sonogram and LFTs, 97.6% had negative ERCP findings, indicating that ERCP is not necessary before laparoscopic cholecystectomy in these patients 2.

Special Considerations

When to Consider ERCP

• Elevated liver function tests
• Dilated common bile duct on imaging
• Jaundice or history of pancreatitis
• Cholangitis
• Failed IOC or inability to clear stones during laparoscopic exploration

Risk Factors for CBD Stones

• Stones at the gallbladder neck may increase risk of migration into the CBD, but this alone is not an indication for ERCP
• The presence of stones at the gallbladder neck may cause Mirizzi syndrome (compression of the common hepatic duct), which requires careful surgical management but not necessarily ERCP

Potential Pitfalls and How to Avoid Them

1. Unnecessary ERCP:

   • ERCP carries risks including pancreatitis, bleeding, and perforation
   • Reserve ERCP for patients with clear evidence of CBD stones 1, 2

2. Missed CBD stones:

   • Consider IOC during cholecystectomy to detect unsuspected CBD stones
   • If IOC is not available, careful preoperative assessment of LFTs and imaging is essential

3. Mirizzi Syndrome:

   • When a stone at the gallbladder neck compresses the common hepatic duct
   • May require modified surgical approach but not necessarily ERCP

Long-term Outcomes

Cholecystectomy alone for gallbladder neck stones (without CBD stones) provides excellent outcomes with low morbidity and mortality. The 2017 guidelines emphasize that cholecystectomy is the definitive treatment for symptomatic gallstones, preventing recurrent biliary events and improving quality of life 1.

For patients with prohibitive surgical risk, biliary sphincterotomy and endoscopic duct clearance may be considered as an alternative, but this approach should be reserved for those who cannot undergo surgery 1.