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.
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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)