An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.
Cholecystitis; Choledocholithiasis; Bile duct stones
The gallbladder is not an essential organ, and its removal is one of the most common surgical procedures performed on women. It can even be performed on pregnant women with low risk to both the baby and mother. The primary advantages of surgically removing the gallbladder over nonsurgical treatment are that it can eliminate gallstones and prevent gallbladder cancer.
Open Procedures Versus Laparoscopy. Until the early 1990s, open cholecystectomy (the removal of the gallbladder through a wide abdominal incision) was the standard treatment. Now, laparoscopic cholecystectomy (commonly called lap choly), which uses small incisions, is the most commonly used surgical approach. First performed in 1987, lap choly is now used in most cholecystectomies in the United States. Of concern is a significant increase in its use in patients who have inflammation in the gallbladder but no infection or gallstones, and in those who have gallstones but no symptoms.
Laparoscopy has largely replaced open cholecystectomy because it offers some significant advantages:
Some experts believe, however, that the open procedure still has a number of advantages compared to laparoscopy:
The type of surgery performed on specific patients may vary depending on different factors.
Appropriate Surgical Candidates. Candidates for gallbladder removal often have, or have had, one of the following conditions:
The best candidates are those with evidence of impaired gallbladder emptying.
Pregnant women who have gallstones and experience symptoms are also candidates for surgery.
Timing of Surgery. Cholecystectomy may be performed within days to weeks after hospitalization for an acute gallbladder attack, depending on the severity of the condition.
General Outlook. Although cholecystectomy is very safe, as with any operation there are risks of complications, depending on whether the procedure is done on an elective or emergency basis.
Long-Term Effects of Gallbladder Removal. Removal of the gallbladder has not been known to cause any long-term adverse effects, aside from occasional diarrhea.
The Procedure. With laparoscopy, gallbladder removal is typically performed as follows:
Risk Factors for Conversion from Laparoscopy to an Open Procedure. In about 5 - 10% of laparoscopies, conversion to open cholecystectomy is required during the procedure. The rate of conversion to open surgery is higher in men than in women. This may be due to the higher rate of inflammation and fibrosis in men with symptomatic gallstones. Other reasons for conversion from laparoscopic to open surgery include:
Complications and Side Effects of Surgery
Patients should not be shy about inquiring into the number of laparoscopies the surgeon has performed (the minimum should be 40). Obese patients were originally thought to be poor candidates for laparoscopic cholecystectomy, but recent research indicates that this surgery is safe for them.
Before the development of laparoscopy, the standard surgical treatment for gallstones was open cholecystectomy (surgical removal of the gallbladder through an abdominal incision), which requires a wide incision and leaves a large surgical scar. In this procedure, the patient usually stays in the hospital for 5 - 7 days and may not return to work for a month. Complications include bleeding, infections, and injury to the common bile duct. The risks of this procedure increase with other factors, such as the age of the patient, or the need to explore the common bile duct for stones at the same time.
Candidates for whom cholecystectomy may be a more appropriate choice:
Older patients. Patients who are over 80 years old are likely to have lower complication rates from open cholecystectomy than laparoscopy, although laparoscopy may also be appropriate in these patients.
Whether or not to insert a drain in the wound after surgery is under debate. Many surgeons implant drains to prevent abscesses or peritonitis. That practice may change. One analysis found that patients who received drains had a dramatically increased risk of wound and chest infection, regardless of the type of drain used.
Reasons for performing the procedure:
The ERCP and ES Procedure. A typical ERCP and endoscopic sphincterotomy (ES) procedure includes the following steps:
Complications. Complications of ERCP and ES occur in 5 - 8% of cases, and some can be serious. Mortality rates are 0.2 - 0.5%. Complications include the following:
ERCP and ES are difficult procedures, and patients must be certain that their doctor and medical center are experienced. ERCP can usually be performed successfully by an experienced surgeon, even in critically ill patients who are on mechanical ventilators.
ERCP and Gallbladder Removal (Cholecystectomy). ERCP is often performed after gallstones in the common duct are discovered during cholecystectomy.
In some cases, stones in the gallbladder are detected during ERCP. In such cases, laparoscopic cholecystectomy is usually warranted. There is some debate about whether the gallbladder should be removed at the same time as ERCP, or if patients should wait.
Afdhal NH. Diseases of the Gallbladder and Bile Ducts. In: Goldman L, Ausiello D. (eds.). Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007.
Chambrlain RS, Sakpal SV. A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg. 2009 May 2 [Epub ahead of print].
Chari RS, Shah SA. Biliary system. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 18th ed. St. Louis, MO: WB Saunders;2007:chap 54.
Dray X, Joy F, Reijasse D, et al. Incidence, risk factors, and complications of cholelithiasis in patients with home parenteral nutrition. J Am Coll Surg. 2007;204(1):13-21.
Gurusamy, KS, Samraj K. Cholecystectomy versus no cholecystectomy in patients with silent gallstones. Cochrane Database Syst Rev. 2007;(1):CD006230.
Ito K, Ito H, Whang EE. Timing of Cholecystectomy for Biliary Pancreatitis: Do the Data Support Current Guidelines? J Gastrointest Surg. 2008 Jul 18 [Epub ahead of print].
Konstantinidis IT, Deshpande V, Genevay M, Berger D, Fernandez-del Castillo C, Tanabe KK, et al. Trends in presentation and survival for gallbladder cancer during a period of more than four decades. Arch Surg. 2009;144(5):441-447.
Liu B, Beral V, Balkwill A, Green J, Sweetland S, Reeves G, et al. Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women. BMJ. 2008;337:a386. Doi: 10.1136/bmj.a386.
Portenier DD, Grant JP, Blackwood HS, et al. Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007; 3(4):476-479.
Rosing DK, de Virgilio C, Yaghoubian A, et al. Early cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay. J Am Coll Surg. 2007;205(6):762-766.
Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-2811.
Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc. 2008;67(2):235-244.
Verbesey JE, Birkett DH. Common bile duct exploration for choledocholithiasis. Surg Clin N Am. 2008;88(6):1315-1328.
Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7):1004-1021.
© 2011 University of Maryland Medical Center (UMMC). All rights reserved.
UMMC is a member of the University of Maryland Medical System,
22 S. Greene Street, Baltimore, MD 21201. TDD: 1-800-735-2258 or 1.866.408.6885