What are the procedures for treating gallstones?

Procedures for Gallstones

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones, with over 95% of gallbladders now removed laparoscopically. 1

Treatment Algorithm Based on Symptom Status

Asymptomatic Gallstones

• Expectant management (watchful waiting) is recommended for patients with asymptomatic gallstones due to their benign natural history and low risk of complications 1
• Exception: Consider prophylactic cholecystectomy for high-risk patients including those with calcified gallbladders, New World Indians, and patients with large stones (>3 cm) 2

Symptomatic Gallstones

• Laparoscopic cholecystectomy is the first-line treatment for symptomatic gallstones regardless of size 1, 2
• Benefits include immediate and permanent stone removal, prevention of gallstone recurrence, and prevention of gallbladder cancer 3
• Mortality rates vary by age, gender, and comorbidities:
  • Low-risk women under 49: 0.054% mortality 4
  • Men have approximately twice the surgical mortality rate of women 4
  • Mortality increases with age and presence of systemic disease 4

Surgical Considerations

Standard Laparoscopic Cholecystectomy

• The Critical View of Safety (CVS) technique is recommended to identify the gallbladder elements and hepatocystic triangle 1
• Only after achieving the CVS should the cystic duct and artery be clipped and divided 1
• Intraoperative cholangiography or laparoscopic ultrasound is suggested for patients with intermediate to high pre-test probability of common bile duct stones 1

Timing of Intervention

• For uncomplicated cholecystitis, early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is recommended 5
• For mild gallstone pancreatitis, perform cholecystectomy within 2-4 weeks, preferably during the same hospital admission 5
• For severe gallstone pancreatitis, delay cholecystectomy until signs of lung injury and systemic disturbance have resolved 5

Non-Surgical Options

For Poor Surgical Candidates

• Oral bile acids (ursodeoxycholic acid) may be considered for select patients who are poor surgical candidates 1, 4

  • Best candidates: Small stones (<0.5 cm), radiolucent (cholesterol-rich) stones that float during oral cholecystography, and patent cystic duct 2, 6
  • Dosage: 10 mg/kg/day, with complete stone dissolution possible in about 30% of patients with uncalcified gallstones <20 mm treated for up to 2 years 4
  • Limitation: Stones recur in about 50% of patients within 5 years of complete dissolution 4, 6

• Extracorporeal shock-wave lithotripsy with adjuvant oral bile acids:

  • Best for solitary radiolucent stones smaller than 2 cm 1, 2
  • Annual dissolution rates are about 80% for single stones 6

• Percutaneous cholecystostomy:

  • For acute cholecystitis in patients with multiple comorbidities unfit for surgery 5
  • Note: Inferior to cholecystectomy in terms of major complications for critically ill patients 5

Special Considerations

Common Bile Duct Stones

• Options for common bile duct stones include:
  • Laparoscopic bile duct exploration (high success rate) 1
  • Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy 5
• For severe gallstone pancreatitis with cholangitis, jaundice, or dilated common bile duct, urgent therapeutic ERCP with sphincterotomy should be performed within 72 hours after onset of pain 5
• After endoscopic clearance of common bile duct stones, cholecystectomy is still recommended if gallbladder stones are present 1

Pregnancy

• Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 2
• Conservative management in pregnancy has a 60% recurrence rate of biliary symptoms 2

Common Pitfalls and Caveats

• Bile duct injury is a potential complication of laparoscopic cholecystectomy - ensure the surgeon is appropriately qualified and experienced 3, 1
• Ambiguous or atypical symptoms (indigestion, flatulence, heartburn, bloating) are less likely to resolve following cholecystectomy 2
• Delaying cholecystectomy beyond two weeks after discharge in gallstone pancreatitis increases risk of potentially fatal recurrent acute pancreatitis 5
• Contraindications to laparoscopic cholecystectomy include empyema of the gallbladder, gangrenous cholecystitis, coagulopathy, portal hypertension, and peritonitis 7
• When the Critical View of Safety cannot be achieved, alternative techniques such as the "fundus-first" approach, subtotal cholecystectomy, or conversion to open surgery should be considered 1