Evidence-Based Current Surgical Practice: Calculous Gallbladder Disease

Journal of Gastrointestinal Surgery, Sep 2012

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. 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.

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Evidence-Based Current Surgical Practice: Calculous Gallbladder Disease

Casey B. Duncan Taylor S. Riall 0 ) Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard , Galveston, TX 77555-0541, USA 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. - Gallstone disease is the most costly digestive disease in the USA, with an estimated annual cost of $5 billion.1,2 Approximately 20 million people in the USA have gallstones, leading to over one million hospitalizations and 700,000 operative procedures per year.13 Gallstones are present in approximately 6.5 % of men and 10.5 % of women.3,4 The prevalence of gallstones increases with age. By age 70, 15 % of men and 24 % of women have gallstones, with these numbers increasing to 24 and 35 %, respectively, by the age of 90 (Fig. 1).46 O v e r 7 0 % o f p a t i e n t s w i t h g a l l s t o n e s a r e asymptomatic.3,4,79 The risk of developing symptoms or complications related to gallstones is approximately 14 % per year.7,8 The most common complications of gallstone disease are biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Less common complications include empyema of the gallbladder, liver abscess, gallbladder perforation with bile peritonitis, cholangitis, cholecystoenteric fistula, and gallstone ileus. Biliary colic occurs when the gallbladder contracts against a stone which is transiently obstructing the cystic duct.3 Patients with biliary colic complain of sharp, intermittent, cramping right upper quadrant pain, pain radiating to the right shoulder, nausea, and vomiting. The pain occurs most commonly after a fatty meal and may last for several hours.1,3,7 Acute cholecystitis occurs when the cystic duct becomes obstructed by a gallstone, leading to gallbladder distention, serosal edema, mucosal sloughing, venous and lymphatic congestion, and ischemia. Patients with acute cholecystitis alternative measures in patients who are not fit for surgery. These measures decrease but do not eliminate recurrence of gallstone-related complications. The goal of this paper is to review the evidence-based management of complicated gallstone disease, specifically focusing on controversies in management and advances in surgical technique. The discussion of the symptoms, imaging, and laboratory manifestations of gallbladder disease will be limited. Fig. 1 Prevalence of gallstones by age and gender complain of unresolving right upper quadrant pain, nausea, v o m i t i n g , a n o r e x i a , a n d f e v e r. L e u k o c y t o s i s i s common,3,10,11 while alkaline phosphatase and bilirubin are typically normal.3,1214 Elevated liver function tests (LFTs) are associated with worse outcomes in patients with acute cholecystitis.15 Kimura et al., in a large review of the literature, report mortality and complication rates of acute cholecystitis ranging 010 and 726 %, respectively.3,16 Perforation of the gallbladder occurs in 510 % of cases of acute cholecystitis.3,17 Perforation is caused by necrosis of an ischemic area of the wall of the gallbladder and is associated with a high mortality rate.18 Common bile duct (CBD) stones (choledocholithiasis) are identified in approximately 10 % of patients with cholelithiasis and 518 % of patients undergoing elective cholecystectomy.3,14,1921 Associated signs include jaundice, acholic stools, and dark urine.3,14 Patients with common bile duct stones can present with acute cholangitis, manifested by fever, jaundice, and right upper quadrant pain. Acute cholangitis is a surgical emergency and prompt biliary decompress (...truncated)


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Duncan, Casey B., Riall, Taylor S.. Evidence-Based Current Surgical Practice: Calculous Gallbladder Disease, Journal of Gastrointestinal Surgery, 2012, pp. 2011-2025, Volume 16, Issue 11, DOI: 10.1007/s11605-012-2024-1