What is the management of gallstones (cholelithiasis) without acute cholecystitis?

Management of Gallstones Without Acute Cholecystitis

Asymptomatic Gallstones

For truly asymptomatic gallstones discovered incidentally, observation without intervention is the recommended approach, though approximately 30% will develop complications requiring intervention during long-term follow-up. 1, 2

• Cholecystectomy is not indicated in most patients with asymptomatic stones 3
• The risk of developing complications must be weighed against surgical risks on an individual basis 3
• Conservative management is reasonable for patients who are poor surgical candidates 1

Symptomatic Gallstones (Without Acute Cholecystitis)

Laparoscopic cholecystectomy is the definitive treatment of choice for symptomatic gallstones and should be performed early when expertise is available. 1, 2

Timing of Surgery

• Early laparoscopic cholecystectomy should be performed within 7 days of hospital admission and within 10 days from symptom onset 1, 2
• If early cholecystectomy cannot be performed within this timeframe, delayed laparoscopic cholecystectomy should be scheduled beyond 6 weeks from the first clinical presentation 1, 2
• Delaying surgery beyond 4 weeks in patients with mild gallstone pancreatitis increases the risk of recurrent attacks 2

High-Risk Patients

• High-risk patients with symptomatic gallstones should still be considered for laparoscopic cholecystectomy rather than alternative treatments 1
• Risk factors predicting conversion to open cholecystectomy include: age >65 years, male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 2
• Conversion from laparoscopic to open cholecystectomy is not a failure but a valid option when necessary for patient safety 2

Gallstones with Common Bile Duct Stones

For patients with both gallbladder stones and common bile duct stones (CBDS), cholecystectomy is recommended for all patients unless there are specific contraindications. 4

Management Algorithm

• Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction should be performed before or after laparoscopic cholecystectomy 1
• Biliary sphincterotomy and endoscopic stone extraction is the primary treatment for CBDS post-cholecystectomy 4
• Intraoperative cholangiography (IOC) or laparoscopic ultrasound (LUS) can be used to detect CBDS in patients with intermediate to high pre-test probability who have not had the diagnosis confirmed preoperatively 4

Patients with Empty Gallbladder

• Uncertainty exists regarding whether cholecystectomy should be offered to patients with CBDS but an empty gallbladder on imaging 4
• Large observational studies show patients with empty gallbladders have lower risk of recurrent CBDS (5.9-11.3%) compared to those with residual gallbladder stones (15-23.7%) 4
• Surgeons may discuss a wait-and-see approach with patients who have an empty gallbladder following duct clearance 4

Special Considerations

Patients Unsuitable for Surgery

• Despite the benefits of cholecystectomy, for patients at prohibitive operative risk, biliary sphincterotomy and endoscopic duct clearance alone is an acceptable alternative 4
• Age and comorbidity do not appear to significantly impact overall complication rates for ERCP 4
• Biliary stenting as definitive treatment should be restricted to patients with limited life expectancy or those at prohibitive surgical risk 4

Gallstone Pancreatitis

• Following gallstone pancreatitis, early laparoscopic cholecystectomy should be offered to all patients on whom it is safe to operate as the most effective means to prevent recurrent episodes 4
• In mild acute gallstone pancreatitis, cholecystectomy should be performed within 2 weeks of presentation and preferably during the same admission 4
• Patients with pancreatitis of suspected or proven biliary origin with associated cholangitis or persistent biliary obstruction should undergo biliary sphincterotomy and endoscopic stone extraction within 72 hours of presentation 4

Common Pitfalls to Avoid

• Failing to recognize that conservative management of symptomatic gallstones leads to recurrent complications in approximately 30% of patients, with 60% eventually requiring cholecystectomy 2
• Incorrect patient selection for cholecystectomy leads to relatively high failure rates of pain relief 5
• Bile duct injury remains a concern with laparoscopic cholecystectomy, making surgeon experience an important consideration 2
• Spilled gallstones during laparoscopic cholecystectomy can lead to complications in 0.04% to 19% of cases 2