How to manage retained stones in the gallbladder?

Management of Retained Gallbladder Stones

For patients with retained stones in the gallbladder (not the bile duct), laparoscopic cholecystectomy remains the definitive treatment to prevent recurrent biliary complications and reduce mortality. 1

Critical Distinction: Gallbladder vs. Bile Duct Stones

The management approach differs fundamentally based on stone location:

• Gallbladder stones with intact gallbladder: Require cholecystectomy (laparoscopic preferred) to prevent cholecystitis, stone migration, and recurrent biliary events 1
• Common bile duct stones (CBDS): Managed with ERCP, laparoscopic bile duct exploration (LBDE), or advanced endoscopic techniques 1

When the Gallbladder Remains In Situ After Bile Duct Clearance

Prophylactic cholecystectomy significantly reduces mortality compared to watchful waiting (7.9% vs 14.1% mortality; RR 1.78,95% CI 1.15-2.75) over follow-up periods ranging from 17 months to 5+ years. 1

Key Evidence Supporting Cholecystectomy:

• Recurrent biliary events (pain, jaundice, cholangitis) occur significantly more frequently when the gallbladder is left in place after bile duct stone clearance 1
• The mortality benefit persists even in high-risk surgical patients (ASA score 4-5) 1
• In patients over age 70 with coexisting gallbladder stones, elective cholecystectomy after endoscopic duct clearance significantly reduces total biliary events including cholangitis 1

Surgical Approach for Gallbladder Stone Removal

Laparoscopic cholecystectomy is the procedure of choice for symptomatic gallbladder stones, offering superior outcomes compared to open surgery in most patients. 2

When to Consider Open Cholecystectomy:

• Altered anatomy from previous surgery 1
• Inability to safely complete laparoscopic approach 2
• Severe inflammation precluding laparoscopic visualization 2

Non-Surgical Options: Limited Role

Medical dissolution therapy with ursodiol has significant limitations that make it inappropriate for most patients with retained gallbladder stones:

• Requires months of therapy with incomplete dissolution in many patients 3
• Stone recurrence occurs in up to 50% within 5 years after successful dissolution 3
• Only effective for cholesterol-rich, radiolucent stones <6mm with patent cystic duct 4
• Requires functioning gallbladder confirmed by oral cholecystography 5, 4

Appropriate Candidates for Medical Therapy:

Medical dissolution should be restricted to patients who are not surgical candidates due to prohibitive operative risk and who have specific stone characteristics (radiolucent, <6mm, patent cystic duct). 3, 4

Management of Spilled/Dropped Gallstones

If stones were spilled during previous laparoscopic cholecystectomy and subsequently formed an abscess:

• Percutaneous drainage and stone removal by interventional radiology is effective and avoids additional surgery 6, 7
• Stones <1cm can be removed via 30-F sheath by conventional means 7
• Stones >1cm require fragmentation before percutaneous removal 7
• Abscesses from retained stones can develop 4 months to 10 years postoperatively 6

Critical Pitfalls to Avoid

• Do not adopt "watchful waiting" for patients with gallbladder stones after bile duct clearance—the cumulative risk of moderate-to-severe symptoms or complications is 7-27% over 5 years, with significantly higher mortality than prophylactic cholecystectomy 1, 3
• Do not rely on ursodiol as definitive therapy given the 50% recurrence rate within 5 years and requirement for months of treatment 3
• Do not confuse gallbladder stone management with bile duct stone management—the latter has multiple endoscopic options, while gallbladder stones require cholecystectomy for definitive treatment 1, 2