Approximately 10-15 percent of the adult population or more than 20 million people in the United States have gallstones. About 1 million new patients are diagnosed annually. Gallstones are more common in women, older patients, and certain ethnic groups, and are associated with multiple pregnancies, obesity, and rapid weight loss. In 1991 approximately 600,000 patients underwent cholecystectomy (removal of the gallbladder).
Gallstones are composed principally of cholesterol. Stones tend to grow for the first 2-3 years, at which point growth tends to stabilize; 85 percent of all gallstones are less than 2 cm in diameter. Most patients with gallstones remain symptom-free for many years and may, in fact, never develop symptoms. However, the consequences of gallstones may be severe, ranging from brief episodes of biliary pain (misnamed "colic") to potentially life-threatening complications, such as acute infections of the gallbladder or pancreas, or rarely gallbladder cancer.
Until a decade ago, the prevailing surgical treatment of symptomatic gallstones was an open operation through an abdominal incision to remove the gallbladder.
Laparoscopic cholecystectomy is a minimally-invasive surgical procedure that is performed using laparoscopic visualization of the gallbladder and surrounding vital structures. This technique requires that only a few small (about half-inch) incisions be made in the abdominal wall. The gallbladder is removed through one of the small incisions, the laparoscope and instruments are removed, and the incisions are closed with sutures and covered with small bandages.
The operation usually requires general anesthesia and is subject to the same risks and complications as open cholecystectomy. However, patients have little pain after the operation, and hospital stays (1-2 days) and recovery (1-2 weeks) are usually shorter than after open cholecystectomy. It is estimated that more than 15,000 surgeons have received some training in the technique of laparoscopic cholecystectomy, and demand for this form of surgery has escalated to the point where probably about 80 percent of cholecystectomies are being performed in this manner.
Q. Which Patients With Gallstones Should Be Treated ?
Symptomatic Gallstones
Once gallstone symptoms appear, they recur in the majority of patients. Furthermore, patients with symptoms secondary to gallstones are more likely (25 percent within 10-20 years) than asymptomatic patients to develop complications. Thus, most symptomatic patients should be treated. Pain from gallstones ('biliary pain') is often severe, episodic, lasting 1 to 5 hours, often waking the patient at night, and located above the bellybutton ('epigastric') or in the right upper quadrant of the abdomen. Biliary pain often flares soon after eating.
Nearly 90 percent of patients with typical biliary pain are rendered symptom free after successful treatment of their gallstones. Those who are too ill to undergo general anesthesia should be managed with nonsurgical therapies.
Q. Which Patients With Gallstones Should Be Treated With Laparoscopic Cholecystectomy ?
Since the advent of laparoscopic cholecystectomy in 1988, this procedure has become the gold-standard for gallbladder removal. Most patients with symptomatic gallstones are candidates for laparoscopic cholecystectomy, if they are able to tolerate general anesthesia and have no serious cardiopulmonary diseases or other coexisting conditions that preclude operation.
Some patients with very serious complications from gallbladder disease may not be eligible for laparoscopic gallbladder removal. In addition, patients in the third trimester of pregnancy should not usually undergo laparoscopic cholecystectomy, because of risk of damage to the uterus during the procedure.
Laparoscopic cholecystectomy in the first trimester of pregnancy remains controversial because of the unknown effects of carbon dioxide on the developing fetus.
Q. What Are the Alternative Surgical Treatments of Gallstone Disease ?
In the past 20 years, a variety of treatment options for gallstone disease have been developed. Open and laparoscopic cholecystectomy have become some of the safer surgical procedures as improved methods of surgical technique, better anesthesia, and management of coexisting diseases have evolved.
Open Cholecystectomy
This operation has been employed for over 100 years and is a safe and effective method for treating symptomatic gallstones. Major complications of open cholecystectomy are infrequent and include injury to the common bile duct, bleeding, biloma, and infections. Open cholecystectomy is the gold-standard against which newer surgical treatments must be compared and remains a safe surgical alternative.
Q. How does Laparoscopic Cholecystectomy compare with Open Cholecystectomy ?
Laparoscopic cholecystectomy is a relatively new operation that provides a safe and effective alternative treatment for patients with symptomatic gallstones. It offers the substantial advantage over open cholecystectomy of markedly decreased pain and disability, without apparent increased mortality or overall morbidity.
Although the rate of common bile duct injury is increased, this rate appears to be sufficiently low to justify the patient's selecting (with the counsel of a physician) this procedure for the treatment of symptomatic gallstones. Laparoscopic cholecystectomy can be performed at a medical treatment cost equal to or slightly less than that of open cholecystectomy, and with substantial cost savings to the patient due to markedly reduced time required for recovery.
However, the results of laparoscopic cholecystectomy are greatly influenced by the skill and experience of the surgeon performing the procedure and reflect a rapid acquisition of appropriate technical skills. Because the conversion of laparoscopic to open cholecystectomy usually reflects sound surgical judgment, it should not be considered a complication of the procedure.
Open cholecystectomy remains a safe and effective procedure for the treatment of patients with symptomatic gallstones. Applicable to almost all such patients, the extensive experience with this time-honored operation makes it the gold-standard with which all other procedures must be compared.
Oral bile acid therapy for dissolution of gallstones, with or without extracorporeal shock wave lithotripsy, provides a useful and safe, but ultimately less effective, alternative therapy for selected patients, especially those whose medical condition and/or personal preference precludes operative cholecystectomy.
Summary
Most patients with gallstones remain asymptomatic. Asymptomatic patients usually develop symptoms before they develop complications. Therefore, with few exceptions, patients with asymptomatic gallstones should not be treated.
Once gallstone symptoms appear, they tend to recur, and such patients are more prone to develop complications. Thus, most patients with typical biliary symptoms and gallstones should be treated.
Because gallstones are so prevalent, they are often present incidentally in patients with other diseases. Patients with gallstones and atypical pain or dyspepsia need further investigation to determine the cause of their symptoms.
Laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones. Indeed, it appears to have become the treatment of choice for many of these patients.
Laparoscopic cholecystectomy provides distinct advantages over open cholecystectomy. It decreases pain and disability, without increasing mortality or overall morbidity. Although the rate of common bile duct injury appears to be increased, this rate is still sufficiently small to justify the use of laparoscopic cholecystectomy in the treatment of symptomatic gallstones.
Laparoscopic cholecystectomy can be performed at a treatment cost that is equal to or slightly less than that of open cholecystectomy, and with substantial cost savings to the patient due to reduced loss of time from work.
The outcome of laparoscopic cholecystectomy is influenced greatly by the training, experience, skill, and judgment of the surgeon performing the procedure.
During laparoscopic cholecystectomy, when the anatomy is obscured, excessive bleeding occurs, or other problems arise, the operation should be converted promptly to open cholecystectomy. Conversion under these circumstances reflects sound surgical judgment and should not be considered a complication of laparoscopic cholecystectomy.
Open cholecystectomy is a safe and effective operation for symptomatic gallstone disease. Because of its wide applicability and low mortality and morbidity, open cholecystectomy remains a standard against which new treatments should be judged.
Oral bile acid therapy, with or without extracorporeal shock-wave lithotripsy, provides a useful and safe, but ultimately less effective, alternative therapy for selected patients. This modality may be indicated for patients whose medical condition and/or personal preference precludes operative cholecystectomy.
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