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SSAT Patient Care Guidelines

Treatment of Gallstones and Gallbladder Disease

Introduction
Gallstone disease represents a national health care problem, resulting in more than 750,000 cholecystectomies per year. The overwhelming majority of operations are for symptomatic gallstone disease, and nearly 90% of cholecystectomies are performed laparoscopically. Alternative forms of treatment are palliative rather than curative.

Symptoms and Diagnosis
Most patients with gallstones do not have symptoms. Natural history studies show that only 20% of patients with asymptomatic gallstones incidentally discovered will ultimately develop symptoms. Presenting symptoms of gallstone disease include: biliary colic, cholecystitis (calculous and acalculous), gallstone pancreatitis, and choledocholithiasis (common duct stones). Typical biliary pain due to gallstones is a temporary (between 1/2 hour to 24 hours) epigastric or right upper abdominal pain following meals. The pain may at times radiate to the right flank or back and frequently is associated with nausea. In some patients, the symptoms are mild and consist of vague indigestion or dyspepsia. The diagnosis of gallstones is usually established by ultrasonography. Ultrasound findings of a thickened gallbladder wall and fluid around the gallbladder suggest the presence of acute cholecystitis. Radionuclide scanning is not a useful test for the diagnosis of gallstones but is useful in detecting acute cholecystitis. Patients with biliary dyskinesia present with typical symptoms of biliary pain without radiographic evidence of cholelithiasis. Often they will have a decreased gallbladder ejection fraction (<30%) on cholecystokinin stimulated radionucleide scanning.

Treatment
A surgeon should see the patient within a few weeks of an attack if the acute episode has resolved or symptoms are mild. Patients with significant right upper quadrant tenderness, fever, or elevated white blood cell count should be seen the same day. The presence of gallstones without abdominal symptoms is not an indication for cholecystectomy unless the patient is immunosuppressed or there is a predisposition for malignancy, i.e., the gallbladder wall is calcified or there is a family history of gallbladder cancer. Once a patient with gallstones becomes symptomatic, elective cholecystectomy is indicated. The primary indication for urgent cholecystectomy is acute cholecystitis. Gallstone pancreatitis, choledocholithiasis, and cholangitis require immediate surgical consultation. Patients with recurrent symptoms typical of biliary pain, but without gallstones on ultrasound, should be referred for surgical evaluation. Consideration for cholecystectomy in these patients might be supported by cholecystokinin stimulated biliary scitingraphy, Endoscopic evaluation, and/or gastroenterology consultation. Cholecystostomy tube can be used for patients with chronic cholecystitis to allow for easier laparoscopic cholecystectomy at a later date (after the cooling off period).

Cholecystectomy may be performed by laparoscopic techniques or by laparotomy. The advantages of the laparoscopic approach are less pain, shorter hospital stay, faster return to normal activity, and less abdominal scarring. Oral dissolution therapy has limited efficacy and is costly. Percutaneous cholecystostomy is a viable treatment option for critically ill patients presenting with acute cholecystitis. If the patient subsequently recovers, cholecystectomy should be considered when the inflammatory changes have resolved in the appropriate patient.

Risks
The risks are low in patients undergoing elective cholecystectomy and include: injury to the bile ducts, retained stones in the bile ducts, or injury to surrounding organs. The bile duct injury rate is approximately 0.5% for laparoscopic cholecystectomy. The presence of anatomic variations and/or inflammation contribute to an increased risk of complications, as does the frequent coexistence of serious illnesses in the elderly. The mortality rate in a good-risk patient undergoing elective operation is less than 0.1%. Operative risks usually arise from co-morbid conditions such as cardiac or pulmonary disease. The preoperative degree of coagulopathy, rather than the Child's class, should guide the surgeon's approach and expectations when laparoscopic cholecystectomy is performed in a cirrhotic patient.

The Role of Open Cholecystectomy
Open cholecystectomy may be the proper approach for a certain subset of patients. This may include: cirrhosis, gallbladder mass, suspicion of malignancy, extensive upper abdominal surgery, and late third trimester of pregnancy. Otherwise a laparoscopic approach is feasible in most patients. Conversion to an open procedure may be required because of the presence of adhesions, difficulty in delineating the anatomy, or a suspected complication. Conversion is more often necessary in elderly patients and those with prior upper abdominal operations, or acute cholecystitis. The incidence of conversion to an open procedure is between 2-5%, depending on the patient population.

Expected Outcomes
The majority of good-risk patients undergoing elective laparoscopic cholecystectomy can usually be discharged the same or next day. High-risk patients and those undergoing emergency operations or open cholecystectomies typically, require longer hospital stays. Hospitalization may be prolonged in patients requiring placement of abdominal drains, exploration of the bile duct, or those with complicated biliary tract disease. Laparoscopic surgery is now proving to be as safe as open surgery in pregnancy, especially in the second trimester.

Nearly 95% of all patients undergoing cholecystectomy experience relief of biliary pain. The remaining 5% have something other than gallstones as the cause of their pain. Cholecystectomy for biliary dyskinesia offers significant symptomatic relief over nonoperative therapy. Patients with dyspepsia or diarrhea before surgery may find that these symptoms persist after operation.

Treatment of Common Duct Stones
Common duct stones may be removed either endoscopically or surgically. The endoscopic approach may be indicated for patients with cholangitis, obstructive jaundice, and in selected patients with gallstone pancreatitis. Endoscopic clearance of common duct stones is an effective treatment, but may be complicated by pancreatitis, bleeding or perforation in approximately 3% of cases. Surgical removal of common duct stones can be performed using open or laparoscopic techniques with appropriate equipment and surgical expertise. Open cholecystectomy with common bile duct exploration is a safe and effective treatment, especially in the acutely ill. Since most common duct stones arise from the gallbladder, cholecystectomy is also indicated.

Costs
Cholecystectomy is cost effective compared to alternative treatments since it definitively treats the disease and reliably alleviates the symptoms.

Qualifications for Performing Surgery on the Gallbladder
The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes. At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for gallbladder disease. Gallbladder surgery should preferably be performed by surgeons with special knowledge, training and experience in the management of gallbladder and biliary tract disorders. These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the gallbladder and biliary tract.

Suggested Readings
Gadacz TR: Update on laparoscopic cholecystectomy, including a clinical pathway. Surg Clin North Am 2000; 80:1127-49

Fletcher DR, Hobbs MST, Tan P, et al. Complications of cholecystectomy: Risks of the laparoscopic approach and protective effects of operative cholangiography: a population based study. Ann Surg 1999; 229:449-457

Traverso LW. Clinical manifestations and impact of gallstone disease. Am J Surg 1993;165:405-409

Barkun JS, Barkun AN, Sampalis JS, et al. Randomised controlled trial of laparoscopic versus mini cholecystectomy. The McGill Gallstone Treatment Group. Lancet 1992; 340: 1116

Memon MA; Hassaballa H; Memon MI Laparoscopic common bile duct exploration: the past, the present, and the future. Am J Surg 2000 ;;179:309-315

Makela JT; Kiviniemi H; Laitinen S: Acute cholecystitis in the elderly. Hepatogastroenterology. 2005 Jul-Aug;52(64):999-1004

Ponsky TA, Desagun R, Brody F; Surgical Therapy for Biliary Dyskinesia: A Meta-analysis and Review of the Literature. J Laparoendosc Adv Surg Tech A. 2005 Oct;15(5):439-42

Society of American Gastrointestinal Endoscopic Surgeons (SAGES) (1998) "Guidelines for laparoscopic surgery during pregnancy." Surg Endosc 12: 189-190

Schiff J, Misra M, Rendon G, Rothschild J, Schwaitzberg S; Laparoscopic cholecystectomy in cirrhotic patients. Surg Endosc. 2005 Jul 21; [Epub ahead of print]

Welschbillig-Meunier K, Pessaux P, Lebigot J, Lermite E, Aube C, Brehant O, Hamy A, Arnaud JP; Percutaneous cholecystostomy for high-risk patients with acute cholecystitis. Surg Endosc. 2005 Jul 14; [Epub ahead of print]


Keywords
gallstones, choledocholithiasis, cholecystitis, cholelithiasis, cholecystectomy, gallbladder disease, acute disease, acalculous cholecystitis, common bile duct stones, guideline, patient

Written 1/96
Revised 1/21/96
Revised 5/5/96
Revised 9/27/96
Revised 10/7/96
Revised 2/5/97
Revised 5/5/97
Revised 5/11/97
Revised 8/21/97
Revised 9/26/99
Revised 10/25/99
Proofed 1/8/00
Revised 10/7/01
Revised 10/02
Board Approved 2/1/03
Revised 5/11/06
Board Approved 5/20/06
Revised & Board Approved 5/6/14

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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