Treatment

Surgical Therapy In asymptomatic gallstone patients, the risk of developing symptoms or complications requiring surgery is quite small (in the range of 1 to 2% per year). Thus a recommendation for cholecystectomy in a patient with gallstones should probably be based on assessment of three factors: (1) the presence of symptoms that are frequent enough or severe enough to interfere with the patient's general routine; (2) the presence of a prior complication of gallstone disease, i.e., history of acute cholecystitis, pancreatitis, gallstone fistula, etc.; or (3) the presence of an underlying condition predisposing the patient to increased risk of gallstone complications (e.g., calcified or porcelain gallbladder and/or a previous attack of acute cholecystitis regardless of current symptomatic status). Patients with very large gallstones (over 2 cm in diameter) and patients having gallstones in a congenitally anomalous gallbladder might also be considered for prophylactic cholecystectomy. Although age under 50 years is a worrisome factor in asymptomatic gallstone patients, few authorities would now recommend routine cholecystectomy in all young patients with silent stones. Laparoscopic cholecystectomy is a minimal-access approach for the removal of the gallbladder together with its stones. Its advantages include a markedly shortened hospital stay as well as decreased cost, and it is the procedure of choice for most patients referred for elective cholecystectomy.

From several studies involving over 4000 patients undergoing laparoscopic cholecystectomy, the following key points emerge: (1) complications develop in about 4% of patients, (2) conversion to laparotomy occurs in 5%, (3) the death rate is remarkably low (i.e., 0.1%), and (4) bile duct injuries are unusual (i.e., 0.2 to 0.5%). These data indicate why laparoscopic cholecystectomy has become the "gold standard" for treating symptomatic cholelithiasis.

Medical TherapyGallstone Dissolution UDCA decreases cholesterol saturation of bile and also appears to produce a lamellar liquid crystalline phase in bile that allows a dispersion of cholesterol from stones by physiochemical means. UDCA may also retard cholesterol crystal nucleation. In carefully selected patients with a functioning gallbladder and with radiolucent stones 10 mm in diameter, complete dissolution can be achieved in about 50% of patients within 6 months to 2 years with UDCA at a dose of 8 to 10 mg/kg per day. The highest success rate (i.e., 70%) occurs in patients with small (5 mm) floating radiolucent gallstones. Probably no more than 10% of patients with symptomatic cholelithiasis are candidates for such treatment. However, in addition to the vexing problem of recurrent stones (30 to 50% over 3 to 5 years of follow-up), there is also the factor of taking an expensive drug for an indefinite period of time. The advantages and success of laparoscopic cholecystectomy have largely reduced the role of gallstone dissolution to patients who wish to avoid or are not candidates for elective cholecystectomy.

Gallbladder stones may be fragmented by extracorporeal shock waves. While such shock wave lithotripsy combined with medical litholytic therapy is safe and effective in carefully selected patients with gallbladder calculi (radiolucent, solitary stone 2 cm in well-contracting gallbladder), the procedure is employed infrequently because of the emergence of laparoscopic cholystectomy as the procedure of choice for symptomatic cholelithiasis, the recurrence of gallstones in 30% of patients within 5 years after lithotripsy combined with medical litholytic therapy, and the cost of taking UDCA for a variable period after the procedure.