Symptoms and Diagnosis
Most patients with gallstones do not have symptoms. Natural history studies show that patients with asymptomatic gallstones incidentally discovered will develop symptoms at a rate of approximately 1.5 to 2.0% per year. 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. 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.
Treatment
A surgeon should see the patient within a few weeks 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 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 (common duct stones), and cholangitis require surgical consultation. Patients with recurrent symptoms typical of biliary pain, but without gallstones on ultrasound, should be referred for surgical consultation.
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. Alternative, nonstandard forms of treatment include dissolution of gallstones with oral agents, extracorporeal shock wave lithotripsy, and instilling solvents directly into the gallbladder. Oral dissolution therapy has limited efficacy and is costly. Shock wave lithotripsy and contact dissolution are not approved by the United States Food and Drug Administration (FDA) for definitive treatment of gallstones.
Conversion of Laparoscopic Cholecystectomy to an Open Procedure
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, a thickened gallbladder wall, or acute cholecystitis. The incidence of conversion to an open procedure is about 5%, depending on the patient population.
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 up to 10% 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 unless the patient is a poor operative risk.
Qualifications for Performing Surgery on the Gallbladder
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 laparoscopic and open cholecystectomy. In addition to the standard residency training, qualifications should be based on training, experience, and outcomes.
