What determines the indication for cholecystectomy (gallbladder removal)?

From the Guidelines

The gallbladder should be removed when a patient experiences symptomatic gallstones, acute cholecystitis, or other conditions that significantly impact quality of life, as determined by a combination of clinical, laboratory, and imaging investigations 1. The most common reasons for removal include symptomatic gallstones, which typically cause right upper quadrant pain after meals, especially fatty foods, and acute cholecystitis, which requires urgent removal, usually within 24-72 hours of diagnosis. In elderly patients, cholecystectomy is the preferred treatment for acute cholecystitis, and the evaluation of the risk should include mortality rate, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation 1. The procedure is typically performed laparoscopically with 3-4 small incisions, requiring 1-2 days of hospitalization and 1-2 weeks of recovery, and patients can generally eat a normal diet after recovery, as the liver continues to produce bile that flows directly into the intestine. Some key considerations for determining when to remove the gallbladder include:

• Symptomatic gallstones, which are typically characterized by right upper quadrant pain after meals, especially fatty foods
• Acute cholecystitis, which requires urgent removal, usually within 24-72 hours of diagnosis
• Gallstone pancreatitis, where stones block the pancreatic duct causing inflammation, which necessitates removal once the pancreatitis resolves
• Biliary dyskinesia, where the gallbladder doesn't contract properly, which may warrant removal if the ejection fraction is below 35-40% on a HIDA scan and symptoms align with biliary disease
• Porcelain gallbladder (calcified gallbladder wall), which is often removed due to cancer risk It's worth noting that, according to the guidelines, old age (> 65 years) by itself does not represent a contraindication to cholecystectomy for acute cholecystitis 1, and laparoscopic approach should always be attempted at first, except in case of absolute anesthetic contraindications and septic shock 1.

From the Research

Determining Gallbladder Removal

The decision to remove a gallbladder is typically made based on several factors, including:

• The presence of acute cholecystitis, which is inflammation of the gallbladder, often caused by gallstones 2, 3, 4, 5
• The patient's overall health and risk factors for surgery, such as age and comorbidities 2, 3, 4
• The severity of symptoms and the impact on daily life 6
• The presence of other conditions, such as common bile duct stones 3

Treatment Options

Treatment options for gallbladder disease include:

• Cholecystectomy, which is the surgical removal of the gallbladder 2, 3, 6, 4, 5
• Percutaneous cholecystostomy, which is a minimally invasive procedure to drain the gallbladder 2, 3, 4
• Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which are alternative drainage methods 3
• Medical management, which may include medications and lifestyle modifications to manage symptoms 6

Factors Influencing Decision-Making

Factors that influence the decision to remove a gallbladder include:

• The patient's willingness to undergo surgery and their tolerance for symptoms 6
• The risks and benefits of surgery, including the risk of complications and the potential for symptom relief 2, 3, 4
• The availability and effectiveness of alternative treatments, such as percutaneous cholecystostomy and endoscopic drainage methods 2, 3, 4
• The patient's overall health and quality of life, including their ability to manage symptoms and perform daily activities 6