Gallstones and gallbladder disease
Gallstones are small, hard deposits that form in the gallbladder, a sac-like organ that lies under the liver in the upper right side of the abdomen. They are common in the wealthy countries, affecting 10% to 15% of adults. Most people with gallstones don't even know they have them. But in some cases a stone may cause the gallbladder to become inflamed, resulting in pain, infection, or other serious complications.
Bile and the Gallbladder
The formation of gallstones is a complex process that starts with bile, a fluid composed mostly of water, bile salts, lecithin (a type of phospholipid), and cholesterol. Most gallstones are formed from cholesterol.
Formation of Gallstones (Cholelithiasis)
The process of gallstone formation is referred to as cholelithiasis. It is generally a slow process, and usually causes no pain or other symptoms. The majority of gallstones are either the cholesterol or mixed type. Gallstones can range in size from a few millimeters to several centimeters in diameter.
In adults, about 70% of gallstones are formed from cholesterol. Pigment stones (black or brown) are also very common and account for the remaining 30% of stones. Patients can have a mixture of the two gallstone types.
Although cholesterol makes up only 5% of bile, about three-fourths of the gallstones found in the US population are formed from cholesterol. Cholesterol gallstones typically form in the following way:
Pigment stones are composed of calcium bilirubinate. Pigment stones can be black or brown.
Mixed stones are stones composed of a mixture of cholesterol and pigment.
Choledocholithiasis (Common Bile Duct Stones)
Gallstones can also be present in the common bile duct, rather than the gallbladder. This condition is called choledocholithiasis.
Gallbladder Diseases Without Stones (Acalculous Gallbladder Disease)
Gallbladder disease can occur without stones, a condition called acalculous gallbladder disease. This refers to a condition in which a person has symptoms of gallbladder stones, yet there is no evidence of stones in the gallbladder or biliary tract. It can arise suddenly or be a chronic or persistent problem.
About 90% of gallstones cause no symptoms. There is a very small (2%) chance of developing pain during the first 10 years after gallstones form. After 10 years, the chance for developing symptoms declines. On average, symptoms take about 8 years to develop. The reason for the decline in symptoms after 10 years is not known, although some doctors suggest that "younger," smaller stones may be more likely to cause symptoms than larger, older ones. Acalculous gallbladder disease will often cause symptoms similar to those of gallbladder stones.
Biliary Pain or Colic
The mildest and most common symptom of gallbladder disease is intermittent pain called biliary colic, which occurs either in the mid- or the right portion of the upper abdomen. Symptoms may be fairly nonspecific. A typical attack has several features:
Digestive complaints, such as belching, feeling unusually full after meals, bloating, heartburn (burning feeling behind the breast bone), or regurgitation (acid back-up in the food pipe), are not likely to be caused by gallbladder disease. Conditions that may cause these symptoms include peptic ulcer, gastroesophageal reflux disease, or indigestion of unknown cause.
Symptoms of Gallbladder Inflammation (Acute Cholecystitis)
Between 1% and 3% of people with symptomatic gallstones develop inflammation in the gallbladder (acute cholecystitis), which occurs when stones or sludge block the duct. The symptoms are similar to those of biliary colic, but are more persistent and severe. They include the following:
Anyone who experiences such symptoms should seek medical attention
Acute cholecystitis can progress to gangrene or perforation of the gallbladder if left untreated. Infection develops in about 20% of patients with acute cholecystitis, and increases the danger from this condition. People with diabetes are at particular risk for serious complications.
Symptoms of Chronic Cholecystitis or Dysfunctional Gallbladders
Chronic gallbladder disease (chronic cholecystitis) involves gallstones and mild inflammation. In such cases, the gallbladder may become scarred and stiff. Symptoms of chronic gallbladder disease include the following:
Symptoms of Stones in the Common Bile Duct (Choledocholithiasis)
Stones lodged in the common bile duct can cause symptoms that are similar to those produced by gallbladder stones. But they may also cause symptoms such as:
As in acute cholecystitis, patients who have these symptoms should seek medical help immediately. They may require emergency treatment.
Prognosis and Complications
Gallstones that do not cause symptoms rarely lead to problems. Death, even from gallstones with symptoms, is very rare. Serious complications are also rare. If they do occur, complications usually develop from stones in the bile duct, or after surgery.
Gallstones, however, can cause obstruction at any point along the ducts that carry bile. In such cases, symptoms can develop.
The most serious complication of acute cholecystitis is infection, which develops in about 20% of cases. It is extremely dangerous and life threatening if it spreads to other parts of the body (a condition called septicemia), and surgery is often required. Symptoms include fever, rapid heartbeat, fast breathing, and confusion. Among the conditions that can lead to septicemia are the following:
Other Complications and Related Biliary Tract Conditions
Gallstones are present in about 80% of people with gallbladder cancer. However, this cancer is very rare, even among people with gallstones. There is a strong association between gallbladder cancer and cholelithiasis, chronic cholecystitis, and inflammation. Symptoms of gallbladder cancer usually do not appear until the disease has reached an advanced stage and may include weight loss, anemia, recurrent vomiting, and a lump in the abdomen.
When the cancer is caught at an early stage and has not spread beyond the mucosa (inner lining), removing the gallbladder can cure many people with the disease. If the cancer has spread beyond the gallbladder, other treatments may be required.
Polyps (benign growths) are sometimes detected during diagnostic tests for gallbladder disease. Small gallbladder polyps (up to 10 mm) pose little or no risk, but large ones (greater than 15 mm) pose some risk for cancer, so the gallbladder should be removed. Patients with polyps 10 to 15 mm have a lower risk. But they should still discuss gallbladder removal with their doctor.
Primary Sclerosing Cholangitis
Primary sclerosing cholangitis is a rare disease that causes inflammation and scarring in the bile duct. It is associated with a lifetime risk of 7% to 12% for gallbladder cancer. The cause is unknown, although it tends to affect younger men with ulcerative colitis. Polyps are often detected in this condition and have a very high likelihood of being cancerous.
Gallbladders are referred to as porcelain when their walls have become so calcified (covered in calcium deposits) that they look like porcelain on an x-ray. Porcelain gallbladders have been associated with a very high risk of cancer, although recent evidence suggests that the risk is lower than was previously thought. This condition may develop from a chronic inflammatory reaction that may actually be responsible for the cancer risk. The cancer risk appears to depend on the presence of specific factors, such as partial calcification involving the inner lining of the gallbladder.
More than 20 million Americans have gallstones, and approximately 1 million are diagnosed each year. However, only 1% to 3% of the population complains of symptoms during the course of a year, and fewer than one half of these people have symptoms that return.
Risk Factors in Women
Women at all ages are much more likely than men to develop gallstones. Gallstones occur in nearly 25% of women in the United States by age 60, and as many as 50% by age 75. In most cases, they have no symptoms. In general, women are probably at increased risk because estrogen stimulates the liver to remove more cholesterol from blood and divert it into the bile.
Pregnancy increases the risk for gallstones, and pregnant women with stones are more likely to develop symptoms than women who are not pregnant. Surgery should be delayed until after delivery if possible. In fact, gallstones may disappear after delivery. If surgery is necessary, laparoscopy is the safest approach.
Hormone Replacement Therapy
Several large studies have shown that the use of hormone replacement therapy (HRT) doubles or triples the risk for gallstones, hospitalization for gallbladder disease, or gallbladder surgery. Estrogen raises triglycerides, a fatty substance that increases the risk for cholesterol stones. How the hormones are delivered may make a difference, however. Women who use a patch or gel form of HRT face less risk than those who take a pill. HRT may also be a less-than-attractive option for women because studies have shown it has negative effects on the heart and increases the risk for breast cancer.
Risk Factors in Men
About 20% of men have gallstones by the time they reach age 75. Because most cases do not have symptoms, however, the rates may be underestimated in older men. One study of nursing home residents reported that 66% of the women and 51% of the men had gallstones. Men who have their gallbladder removed are more likely to have severe disease and surgical complications than women.
Risks in Children
Gallstone disease is relatively rare in children. When gallstones do occur in this age group, they are more likely to be pigment stones. The following conditions may put children at higher risk:
Because gallstones are related to diet, particularly fat intake, the incidence of gallstones varies widely among nations and regions. For example, Hispanics and Northern Europeans have a higher risk for gallstones than do people of Asian and African descent. People of Asian descent who develop gallstones are most likely to have the brown pigment type.
Native North and South Americans, such as Pima Indians in the United States and native populations in Chile and Peru, are especially prone to developing gallstones. Pima women have a 70% chance of developing gallstones during their lives, and a majority of native Indian females in Chile and Peru develop gallstones. These populations also have a high incidence of gallbladder cancer. In Chilean women, gallbladder cancer is the most common cause of cancer death, ahead of breast, lung, and cervical cancer.
Having a family member or close relative with gallstones may increase the risk. Up to 33% of cases of painful gallstones may be related to genetic factors.
A mutation in the gene ABCG8 significantly increases a person's risk of developing a certain type of gallstones. A single gene, however, does not explain the majority of cases, so multiple genes and environmental factors play a complex role.
Defects in transport proteins involved in biliary lipid secretion appear to predispose certain people to gallstone disease, but this alone may not be sufficient to create gallstones.
Cholesterol gallstones are more prevalent in people who consume Western diets of high amounts of saturated fats and cholesterol, protein, and refined sugars, and low amounts of fiber as well as a high total calorie count.
People with diabetes are at higher risk for gallstones and have a higher-than-average risk for acalculous gallbladder disease (without stones). Gallbladder disease may progress more rapidly in patients with diabetes, who tend to have worse infections.
Obesity and Weight Changes
Being overweight is a significant risk factor for gallstones. In such cases, the liver over-produces cholesterol, which is delivered into the bile and causes it to become supersaturated.
Rapid weight loss or cycling (dieting and then putting weight back on) further increases cholesterol production in the liver and an increased risk for gallstones.
About 30% of gallstone cases in these situations have symptoms. The risk for gallstones is highest in the following dieters:
Men are also at increased risk of developing gallstones when their weight fluctuates. The risk increases proportionately with dramatic weight changes as well as with frequent weight cycling.
Patients who have either Roux-en-Y or laparoscopic banding bariatric surgery are at increased risk for gallstones. For this reason, many centers request that patients undergo cholecystectomy before their bariatric procedure. However, doctors are now questioning this practice.
Metabolic syndrome is a cluster of conditions that includes obesity (especially belly fat), low HDL (good) cholesterol, high triglycerides, high blood pressure, and high blood sugar. Research suggests that metabolic syndrome is a risk factor for gallstones.
Low HDL Cholesterol, High Triglycerides and Their Treatment
Although gallstones are formed from the supersaturation of cholesterol in the bile, high total cholesterol levels themselves are not necessarily associated with gallstones. Gallstone formation is associated with low levels of HDL (good) cholesterol and high triglyceride levels. Some evidence suggests that high levels of triglycerides may impair the emptying actions of the gallbladder.
Unfortunately, fibrates (drugs that may be used to correct these abnormalities) increase the risk for gallstones by boosting the amount of cholesterol secreted into the bile. These medications include gemfibrozil (Lopid) and fenofibrate (Tricor). Other cholesterol-lowering drugs do not have this problem or may even decrease the risk for gallstones, which is the case for statins.
Other Risk Factors
Prolonged Intravenous Feeding
Prolonged intravenous feeding reduces the flow of bile and increases the risk for gallstones. Up to 40% of patients on home intravenous nutrition develop gallstones within 3 to 4 months, and the risk may be higher in patients on total intravenous nutrition.
Crohn disease, an inflammatory bowel disorder, leads to poor reabsorption of bile salts from the digestive tract and substantially increases the risk for gallbladder disease. Patients over age 60 and those who have had numerous bowel operations (particularly in the region where the small and large bowel meet) are at especially high risk.
Cirrhosis poses a major risk for gallstones, particularly pigment gallstones.
Bone marrow or solid organ transplantation increases the risk of gallstones. The complications can be so severe that some organ transplant centers require the patient's gallbladder to be removed before the transplant is performed.
The following drugs may increase the risk for gallstones:
Chronic hemolytic anemia, including sickle cell anemia, increases the risk for pigment gallstones.
Spinal Cord Injury
People with spinal cord injury have a higher prevalence of gallstones and a higher rate of complications from gallstone disease.
High consumption of heme iron, the type of iron found in meat and seafood, has been shown to lead to gallstone formation in men. Gallstones are not associated with diets high in non-heme iron foods such as beans, lentils, and enriched grains.
Diet may play a role in gallstones. Specific dietary factors may include:
Preventing Gallstones During Weight Loss
Maintaining a normal weight and avoiding rapid weight loss are the keys to reducing the risk of gallstones. Taking the medication ursodiol (also called ursodeoxycholic acid, or Actigall) during weight loss may reduce the risk for people who are very overweight and need to lose weight quickly. This medication is ordinarily used to dissolve existing gallstones. Orlistat (Xenical), a drug for treating obesity, may protect against gallstone formation during weight loss. The drug appears to reduce bile acids and other components involved in gallstone production.
The Effects of Cholesterol-Lowering Drugs
Although it would be reasonable to believe that drugs used to lower cholesterol would protect against gallstones, evidence on gallstone protection from these drugs is mixed. On one hand, fibrates, which increase cholesterol excretion in the bile while decreasing bile salts, promote the formation of cholesterol gallstones and have been shown to increase the need for cholecystectomies. On the other hand, long-term use of statins, which decrease the cholesterol saturation of bile, may reduce the risk of developing gallstones.
The challenge in diagnosing gallstones is to verify that abdominal pain is caused by stones and not by some other condition. Ultrasound or other imaging techniques can usually detect gallstones. Nevertheless, because gallstones are common and most cause no symptoms, simply finding stones does not necessarily explain a patient's pain, which may be caused by any number of ailments.
Ruling Out Other Disorders
In patients with abdominal pain, causes other than gallstones are usually responsible if the pain lasts less than 15 minutes, frequently comes and goes, or is not severe enough to limit activities.
It is sometimes difficult to differentiate between pancreatitis and acute cholecystitis, but a correct diagnosis is critical, because treatment is very different. About 40% of pancreatitis cases are associated with gallstones. Blood tests showing high levels of pancreatic enzymes (amylase and lipase) usually indicate a diagnosis of pancreatitis. Elevated levels of the liver enzyme alanine aminotransferase (ALT) are helpful in identifying gallstone pancreatitis. Imaging techniques are useful in confirming a diagnosis. Ultrasound is often used. A computed tomography (CT) scan, along with a number of laboratory tests, can determine the severity of the condition.
Other Conditions with Similar Symptoms
Acute appendicitis, inflammatory bowel disease (Crohn disease or ulcerative colitis), pneumonia, stomach ulcers, gastroesophageal reflux and hiatal hernia, viral hepatitis, kidney stones, urinary tract infections, diverticulosis or diverticulitis, pregnancy complications, and even a heart attack can potentially mimic a gallbladder attack.
In patients with known gallstones, the doctor can often diagnose acute cholecystitis (gallbladder inflammation) based on classic symptoms (constant and severe pain in the upper right part of the abdomen). Imaging techniques are necessary to confirm the diagnosis. There is usually no tenderness in chronic cholecystitis.
Blood tests are usually normal in people with simple biliary colic or chronic cholecystitis. The following blood test abnormalities may indicate gallstones or complications:
A high white blood cell count is a common finding in many patients with cholecystitis and cholangitis.
Imaging and Diagnostic Techniques
Ultrasound of the Abdomen (Ultrasonography)
Ultrasound is a simple, rapid, and noninvasive imaging technique. It is the diagnostic method most frequently used to detect gallstones and is the method of choice for detecting acute cholecystitis. If possible, the patient should not eat for 6 or more hours before the test, which takes only about 15 minutes. During the procedure, the doctor can check the liver, bile ducts, and pancreas, and quickly scan the gallbladder wall for thickening (characteristic of cholecystitis).
How well ultrasound can help in the diagnosis varies based on the patient's situation:
In an ultrasound variation called endoscopic ultrasound (EUS), the physician places an endoscope (a thin, flexible plastic tube containing a tiny camera) into the patient's mouth and down the esophagus, stomach, and then the first part of the small intestine. The tip of the endoscope contains a small ultrasound transducer, which provides "close-up" ultrasound images of the anatomy in the area. EUS is useful and quite accurate when the provider suspects common bile duct stones. However, if common duct stones are detected, they cannot be removed using this method.
Computed tomography (CT) scans may be helpful if the doctor suspects complications, such as perforation, common duct stones, or other problems such as cancer in the pancreas or gallbladder. Helical (spiral) CT scanning is an advanced technique that is faster and obtains clearer images. With this process, the patient lies on a table while a donut-like, low-radiation x-ray tube rotates around the patient.
Magnetic Resonance Cholangiography (MRCI), or Magnetic Resonance Cholangiopancreatography (MRCP)
A dye is injected into the patient's veins that helps visualize the biliary tract. It is most likely to be useful in a small group of patients who have symptoms that suggest gallbladder or biliary tract problems, but whose ultrasound and other routine tests have been negative. For these patients, performing a MRCP can eliminate the need for ERCP and its side effects. MRCP is extremely sensitive in detecting biliary tract cancer.
Advances in technology have made ultrasonography, CT, and MRI the primary imaging tests for suspected gallbladder disease.
Standard x-rays of the abdomen may detect calcified gallstones and gas. Variations include oral cholecystography or cholangiography.
Cholescintigraphy (also called Gallbladder Radionuclide Scan or HIDA scan)
Cholescintigraphy, a nuclear imaging technique, is more sensitive than ultrasound for diagnosing acute cholecystitis. It is noninvasive but can take 1 to 2 hours or longer. The procedure involves the following steps:
If the dye does not enter the gallbladder, the cystic duct is obstructed, indicating acute cholecystitis. The scan cannot identify individual gallstones or chronic cholecystitis.
Occasionally, the scan gives false positive results (detecting acute cholecystitis in people who do not have the condition). Such results are most common in alcoholic patients with liver disease or patients who are fasting or receiving all their nutrition intravenously.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Endoscopic retrograde cholangiopancreatography (ERCP) was once the gold standard for detecting common bile duct stones, particularly because stones can be removed during the procedure. (See Surgery below for details on the procedure.)
However, this technique is invasive and carries a risk for complications, including pancreatitis. With the technological advancement of noninvasive imaging techniques, ERCP is now generally limited to patients who have severe cholangitis and a high likelihood of common bile ducts stones, which would need to be removed. It may also be used to diagnose biliary dyskinesia.
Acute pain from gallstones and gallbladder disease is usually treated in the hospital, where diagnostic procedures are performed to rule out other conditions and complications. There are three approaches to gallstone treatment:
Expectant Management of Asymptomatic Gallstones
Guidelines from the American College of Physicians state that when a person has no symptoms, the risks of both surgical and nonsurgical treatments for gallstones outweigh the benefits. Experts suggest a wait-and-see approach, which they have termed expectant management, for these patients. Exceptions to this policy are people at risk for complications from gallstones, including those at risk for gallbladder cancer, such as Pima Native Americans and patients with porcelain gallbladder or with stones larger than 3 cm.
Very small gallstones (smaller than 5 mm) may increase the risk for acute pancreatitis, a serious condition.
There are some minor risks with expectant management for people who do not have symptoms or who are at low risk. Gallstones almost never spontaneously disappear, except sometimes when they are formed under special circumstances, such as pregnancy or sudden weight loss. At some point, the stones may cause pain, serious complications, or both, and require treatment. Some studies suggest the younger the patient is at diagnosis, the higher the probability of future surgery.
The slight risk of developing gallbladder cancer might encourage young adults who do not have symptoms to have their gallbladder removed.
Gallstones are the most common cause for emergency room and hospital admissions of patients with severe abdominal pain. Many other patients experience milder symptoms. Results of diagnostic tests and the exam will guide the treatment, as follows:
Normal Test Results and No Severe Pain or Complications
Patients with no fever or serious medical problems who show no signs of severe pain or complications and have normal laboratory tests may be discharged from the hospital with oral antibiotics and pain relievers.
Gallstones and Presence of Pain (Biliary Colic) with No Infection
Patients who have pain and tests that indicate gallstones, but who do not show signs of inflammation or infection, have the following options:
Acute Cholecystitis (Gallbladder Inflammation)
The first step if there are signs of acute cholecystitis is to "rest" the gallbladder in order to reduce inflammation. This involves the following treatments:
People with acute cholecystitis almost always need surgery to remove the gallbladder. The most common procedure now is laparoscopy, a less invasive technique than open cholecystectomy (which involves a wide abdominal incision). Surgery may be done within hours to weeks after the acute episode, depending on the severity of the condition. Preferably, surgery should be performed within the first 72 hours of admission, by surgeons with adequate experience.
Management of Common Bile Duct Stones
Common bile duct stones pose a high risk for complications and nearly always warrant treatment. There are various options available. It is not clear yet which one is best.
Experts are currently debating the choice between laparoscopy and ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice. Still, laparoscopy for common bile duct stones should only be performed by surgeons who are experienced in this technique. In skilled centers, endoscopic techniques are becoming the gold standard.
Oral drugs to dissolve gallstones and lithotripsy (alone or in combination with medication) raised hopes in the 1990s. Due to the low rate of cure, dissolution therapies have lost favor, but may have some value in specific circumstances.
Oral Dissolution Therapy
Oral dissolution therapy uses bile acids in pill form to dissolve gallstones, and may be used in conjunction with lithotripsy, although both techniques are rarely used today. Ursodiol (ursodeoxycholic acid, Actigal, UDCAl) and chenodiol (Chenix) are the standard oral bile acid dissolution drugs. Most doctors prefer ursodeoxycholic acid, which is considered to be one of the safest common drugs. Long-term treatment appears to notably reduce the risk of biliary pain and acute cholecystitis. However, the treatment is only moderately effective because gallstones return in the majority of patients.
Patients most likely to benefit from oral dissolution therapy are those who have normal gallbladder emptying and small stones (less than 1.5 cm in diameter) with a high cholesterol content. Patients with symptoms generally need surgery rather than oral dissolution therapy.
There is some conflicting evidence on its effectiveness as an add-on to biliary stenting.
Only about 30% of patients are candidates for oral dissolution therapy. The number may actually be much lower because compliance is often a problem. The treatment can take up to 2 years and can have a high cost. It is often reserved for patients unwilling or unable to undergo surgery.
Contact Dissolution Therapy
Contact dissolution therapy requires the injection of the organic solvent methyl tert-butyl ether (MTBE) into the gallbladder to dissolve gallstones. This is a technically difficult and hazardous procedure, and should be performed only by experienced doctors in hospitals where research on this treatment is being done. Preliminary studies indicate that MTBE rapidly dissolves stones -- the ether remains liquid at body temperature and dissolves gallstones within 5 to 12 hours. Serious side effects include severe burning pain.
The gallbladder is not an essential organ, and its removal is one of the most common surgical procedures performed, especially 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 cholecystectomy eliminates recurrence of gallstones and prevents gallbladder cancer.
Open Procedures Versus Laparoscopy
Open cholecystectomy involves the removal of the gallbladder through a wide 6 to 8 inch abdominal incision. Small-incision surgery, (mini-laparotomy cholecystectomy), using a 2 to 3 inch (5 to 7.5 cm) incision is a minimally invasive alternative.
Laparoscopic cholecystectomy (commonly called lap choly), which uses small incisions, is the most commonly used surgical approach.
Laparoscopy has largely replaced open cholecystectomy because it offers some significant advantages:
However, some experts believe that the open procedures, including small-incision (mini-laparotomy) cholecystectomy, are a viable alternative 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.
Although cholecystectomy is very safe, as with any operation there are risks of developing 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.
With laparoscopy, gallbladder removal is typically performed as follows:
Laparoscopic surgery may be performed using tiny keyhole incisions and 3 to 4 tiny robotic arms. A computerized program guides the arms during surgery. A systematic review comparing robot-assisted and human assisted removal of the gallbladder showed no difference in morbidity, conversion to open surgery, total operating time, or hospital stay. An even newer method involves single-site robot-assisted surgery through the navel. Robot-assisted surgery requires longer overall surgical time and is more costly.
Conversion from Laparoscopy to an Open Procedure
In about 5% to 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 6 to 8 inch incision and leaves a large surgical scar. In this procedure, the patient usually stays in the hospital for 5 to 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:
Small-Incision or Mini-Laparotomy Cholecystostomy
Mini-laparotomy cholecystostomy uses small abdominal incisions but, unlike laparoscopy, it is an "open" procedure, and the surgeon does not operate through a scope. The surgical instruments used are very small (2 to 3 mm in diameter, or about one tenth of an inch). Comparison with laparoscopic techniques has found little difference in recovery time, mortality or complications.
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 for wound and chest infection, regardless of the type of drain used.
ERCP with Endoscopic Sphincterotomy (ES)
Reasons for performing the procedure:
The ERCP and ES Procedure
A typical ERCP and endoscopic sphincterotomy (ES) procedure includes the following steps:
Complications of ERCP and ES occur in 5% to 8% of cases, and some can be serious. Mortality rates are 0.2% to 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 doctor, even in critically ill patients who are on mechanical ventilators.
ERCP and Gallbladder Removal (Cholecystectomy). ERCP may be performed before, during, or after gallbladder removal. 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.
Open or Laparoscopic Common Bile Duct Exploration (Choledocholithotomy)
Laparoscopic Exploration and Cholangiography
Surgeons are now increasingly using laparoscopy with cholangiography instead of ERCP when common duct stones are suspected. Laparoscopy with cholangiography should only be done in centers with expertise in this procedure. This procedure should be done for the following reasons:
The procedure usually involves the following steps:
Experts are debating whether this procedure is better than ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice of treatment. Still, laparoscopy for common duct stones should be performed only by experienced surgeons.
Open Common Bile Duct Exploration (Choledocholithotomy)
Choledocholithotomy, or common bile duct exploration, is used:
In this procedure, the doctor performs open abdominal surgery and extracts gallstones through an incision in the common bile duct. Routinely, a "T-tube" is temporarily left in the common bile duct after surgery and the doctor x-rays the bile duct through the tube 7 to 10 days after surgery, to determine whether any stones remain in the duct.
Extracorporeal Shock Wave Lithotripsy
Gallstone fragmentation by extracorporeal shock wave lithotripsy (ESWL) may be an appropriate therapy for some patients with pain, normal gallbladder emptying and no other complications, but it is no longer widely used. The treatment works best on a single stone that is less than 2 centimeters in diameter. Less than 15% of patients are good candidates for lithotripsy. The typical procedure is performed as follows:
Complications include pain in the gallbladder area and pancreatitis, usually occurring within a month of treatment. In addition, not all of the fragments may clear the bile duct. Adding erythromycin (E.E.S. Granules) to the treatment regimen may help remove these fragments. About 35% of patients who are left with fragments are at risk for further problems, which can be severe. The chance of recurrence after 1 to 3 years is relatively high with this procedure, with up to one quarter or more patients eventually requiring surgery. Older people may have a lower risk for recurrence than younger adults.
Percutaneous cholecystostomy is a procedure that may be used in seriously ill patients with severe gallbladder infection who cannot tolerate immediate surgery. It is also the standard treatment for patients with acalculous cholecystitis (gallbladder inflammation without stones). This procedure uses a needle to withdraw fluid from (aspirate) the gallbladder. A drainage catheter is inserted through the skin and into the gallbladder while the fluid drains out. In some cases, the catheter may be left in place for up to 8 weeks. After that time, if possible, laparoscopy or an open cholecystectomy may be performed. Without a laparoscopy, recurrence rates with this procedure are high.
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