Gallstones and Gallbladder Disease

Description An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.

Alternative Names Cholecystitis; Choledocholithiasis; Common Bile Duct Stones; Lithotripsy

Surgery The gallbladder is not an essential organ, and even today, only surgical removal of the gallbladder (cholecystectomy) guarantees that the patient will not suffer a recurrence of gallstones. This is one of the most common surgical procedures performed on women and can even be performed on pregnant women with low risk to the baby and mother. The primary advantages of surgical removal of the gallbladder over nonsurgical treatment are both the elimination of gallstones and also the prevention of 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. In fact, about 700,000 people now have their gallbladders removed each year--200,000 more than before the introduction of laparoscopy. Of concern, then, 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 of some significant advantage:

* The patient can leave the hospital and resume normal activities earlier than with open surgery.
* The incisions are small, and there is less post-operative pain and disability than with the open procedure.
* Laparoscopy has fewer complications.
* It is less expensive than open cholecystectomy in the long term. The immediate treatment cost of laparoscopy may be higher than the open procedure, but the more rapid recovery with lap choly and fewer complications translate into shorter hospital stays and fewer sick days and so a greater reduction in overall costs.

Some experts believe, however, that the open procedure still has a number of advantages compared to laparoscopy:

* It is faster to perform.
* It poses less of a risk for bile duct injury, which occurs in only 0.1% to 0.5% of open procedures, compared to about 0.3% to more than 2% with laparoscopy. (It has more overall complications than laparoscopy, however, and laparoscopy bile-duct injury rates are declining.)

The type of surgery performed on specific patients may vary depending on different factors.

Appropriate Surgical Candidates. Candidates for gallbladder removal often have one of the following conditions:

* After a very severe gallstone attack.
* After several less severe gallstone attacks.
* After endoscopic sphincterotomy for common bile duct stones in patients with residual gallbladder stones.
* In patients with cholecystitis (gallbladder inflammation).
* In patients with pancreatitis (inflammation of the pancreas).
* In patients at risk for gallbladder cancer (e.g., patients with anomalous junction of the pancreatic and biliary ducts or patients with certain forms of porcelain gallbladder).
* In some patients with acalculous biliary pain (gallbladder disease symptoms without the presence of gallstones). Best candidates are those with evidence of impaired gallbladder emptying.

Timing of Surgery. Cholecystectomy may be performed within several days to weeks after hospitalization for an acute gallbladder attack, depending on the severity of the condition.

* Emergency gallbladder removal within 24 to 48 hours is warranted in about 20% of patients with acute acalculous cholecystitis . Indications for surgery include deterioration of the patient's condition or signs of perforation or widespread infection.
* The timing and type of surgery in patients with acute cholecystitis whose condition improves and have no signs of severe complications are under debate. Previously, the standard was open cholecystectomy between six and 12 weeks after the acute episode. Some evidence now suggests that early surgery performed between 72 and 96 hours after symptoms have lower complications than surgery performed after that.

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.

* When cholecystectomy is performed as elective surgery, the mortality rates are very low. (Even in the elderly, mortality rates are only between 0.7% to 2%.)
* Emergency cholecystectomy carries a much higher mortality rate (as high 19% in ill elderly patients).

Long-Term Effects of Gallbladder Removal. Although removal of the gallbladder has not been known to cause any long-term adverse effects aside from occasional diarrhea, some researchers have been concerned about its long-term impact on the bodys cholesterol levels.

One study found that within three days of the operation, levels of total cholesterol and LDL returned to their preoperative levels. After three years, however, some types of cholesterol not ordinarily associated with coronary artery disease had risen significantly. These results did not necessarily indicate any increased risk for coronary artery disease, but they did show that the metabolism of cholesterol by the liver had been altered. People who have had their gallbladders removed should have their cholesterol levels checked periodically, as should every adult. Short-term treatment with the cholesterol-lowering known as statins, such as pravastatin (Pravachol), appears to lower cholesterol levels in surgical patients.