Evidence-based current surgical practice: calculous gallbladder disease

Abstract

Background: Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations.

Discussion: Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.

Figure 1

Prevalence of gallstones by age and gender.

Figure 2

Transabdominal ultrasound demonstrating gallstones (asterisk) with classic acoustic shadowing (short black arrow) and gallbladder wall thickening (short white arrow).

Figure 3

MRCP demonstrating filling defects in the gallbladder consistent with gallstones (long arrow) and a solitary filling defect in the common bile duct (short arrow).

Figure 4

Intraoperative cholangiogram demonstrating lack of flow of contrast into the duodenum consistent with distal obstruction by a small stone.

Figure 5

Intraoperative photograph of port placement in single-incision laparoscopic cholecystectomy.

Figure 6

Management algorithm for acute cholecystitis. Laparoscopic cholecystectomy is preferred in all cases but conversion to open may be necessary and should not be considered a failure in management.

Figure 7

Management algorithm for suspected common bile duct stones. Laparoscopic cholecystectomy is preferred in all cases but conversion to open may be necessary and should not be considered a failure in management.

Figure 8

Management algorithm for gallstone pancreatitis. Laparoscopic cholecystectomy is preferred in all cases but conversion to open may be necessary and should not be considered a failure in management.