What is the best approach for managing symptomatic gallstones in a patient with multiple comorbidities?

Management of Symptomatic Gallstones in a Patient with Multiple Comorbidities

This patient should proceed with laparoscopic cholecystectomy as planned, as it remains the definitive treatment for symptomatic cholelithiasis even in patients with multiple comorbidities, and her myelodysplastic syndrome with adequate platelet count (96,000) and normal coagulation parameters does not constitute an absolute contraindication. 1

Primary Recommendation: Proceed with Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstone disease and should be offered to all patients unless there are specific prohibitive contraindications. 1, 2 The patient's progressive symptoms (pain escalating from 2/10 to 6-7/10), increasing stone size (now 3 cm), and persistent symptoms despite conservative management over several years make surgical intervention the appropriate choice. 1

Key Supporting Factors for Surgery in This Patient:

• The patient does NOT have absolute contraindications to laparoscopic cholecystectomy. Absolute contraindications include empyema of the gallbladder, gangrenous cholecystitis, severe coagulopathy, portal hypertension, and peritonitis—none of which are present in this case. 3

• Her coagulation parameters are acceptable: PT 15.1s (control 15.2s), INR 1.12, and APTT 32.7s (control 30.6s) are within acceptable limits for surgery. 4

• Her platelet count of 96,000 is adequate for surgery. While thrombocytopenia from myelodysplastic syndrome requires attention, this level is generally sufficient for laparoscopic cholecystectomy, especially given she is on eltrombopag (a thrombopoietin receptor agonist) which suggests her hematologist has optimized her platelet management. 4

Critical Pre-Operative Considerations

Hematologic Optimization:

• Coordinate closely with hematology regarding her myelodysplastic syndrome. Ensure eltrombopag dosing is optimized pre-operatively and consider checking platelet count on the day of surgery. 4

• Verify coagulation parameters immediately pre-operatively given her myeloproliferative disease, even though current values are acceptable. 4

Comorbidity Management:

• Her diabetes mellitus (on Diamicron) and hypertension (on telmisartan/amlodipine) require standard perioperative management but do not increase surgical risk prohibitively. Male gender, emergency surgery, and complexity of disease are stronger predictors of adverse outcomes than comorbidity alone. 5

• The patient's age (59 years) and female gender are actually favorable prognostic factors for laparoscopic cholecystectomy outcomes. 5

Surgical Timing and Approach

Elective laparoscopic cholecystectomy should be performed as soon as feasible given her progressive symptoms and large stone burden (3 cm). 1, 6 The 2020 World Society of Emergency Surgery guidelines support early surgical intervention for symptomatic gallstone disease to prevent complications. 1

Intraoperative Considerations:

• Intraoperative cholangiography (IOC) or laparoscopic ultrasound (LUS) should be considered given the large stone size (3 cm) and intermediate risk of common bile duct stones, though ultrasound shows no bile duct dilatation. 1

• The surgical team should be prepared for potential conversion to open cholecystectomy (occurs in approximately 8.5% of cases), particularly given the large stone size and chronic inflammation from longstanding disease. 6

Risks of Continued Conservative Management

Observation is NOT recommended for this patient. The evidence clearly demonstrates that conservative management leads to poor outcomes:

• Approximately 30% of patients with symptomatic acute cholecystitis who do not undergo cholecystectomy develop recurrent gallstone-related complications over 14 years, compared with only 3% who undergo surgery. 1

• 60% of patients initially managed conservatively ultimately require cholecystectomy anyway, often under less favorable circumstances. 1, 7

• The patient's progressive symptoms (worsening pain from 2/10 to 6-7/10) and increasing stone size (from 2 cm to 3 cm) indicate disease progression that will not resolve without definitive surgical treatment. 1

Alternative Approaches (NOT Recommended for This Patient)

ERCP with sphincterotomy and stone extraction alone is NOT appropriate because:

• This patient has an intact gallbladder with stones, not isolated common bile duct stones. 1
• Cholecystectomy is recommended for all patients with gallbladder stones unless there are specific prohibitive surgical risks. 1
• ERCP alone without cholecystectomy results in significantly higher rates of recurrent biliary complications. 1

Expected Outcomes

Laparoscopic cholecystectomy offers excellent outcomes even in patients with comorbidities:

• Mean postoperative hospital stay of 1 day 2
• Return to normal activities within 1 week 6
• Low complication rates: 4% major complications, 7.2% minor complications 6
• Significantly less postoperative pain compared to open surgery 8, 6
• 36% of patients require no narcotics after leaving the recovery room 6

Common Pitfalls to Avoid

• Do not delay surgery further based on comorbidities alone. The patient's myelodysplastic syndrome with adequate platelet count and normal coagulation does not constitute a prohibitive risk. 3

• Do not pursue ERCP as primary treatment unless common bile duct stones are confirmed, which is not the case here based on ultrasound findings. 1

• Ensure multidisciplinary coordination with hematology for perioperative platelet management, but do not allow this to indefinitely postpone necessary surgery. 4

• Do not underestimate the risk of emergency presentation if surgery is further delayed—emergency surgery carries significantly higher conversion rates and complication rates than elective surgery. 5