Gallstone disease - Surgical treatment

In asymptomatic cholelithiasis, as well as in a single episode of biliary colic and infrequent painful episodes, a wait-and-see approach is most justified. If indicated, oral lithotripsy may be performed in these cases.

Indications for surgical treatment of cholecystolithiasis:

• the presence of large and small stones in the gallbladder, occupying more than 1/3 of its volume;
• the course of the disease with frequent attacks of biliary colic, regardless of the size of the stones;
• disabled gallbladder;
• cholelithiasis complicated by cholecystitis and/or cholangitis;
• combination with choledocholithiasis;
• cholelithiasis complicated by the development of Mirizzi syndrome;
• cholelithiasis complicated by dropsy, empyema of the gallbladder;
• cholelithiasis complicated by perforation, penetration, fistulas;
• cholelithiasis complicated by biliary pancreatitis;
• cholelithiasis accompanied by obstruction of the common gallbladder
• bile duct.

Surgical treatment methods: laparoscopic or open cholecystectomy, endoscopic papillosphincterotomy (indicated for choledocholithiasis), extracorporeal shock wave lithotripsy.

Cholecystectomy. It is not indicated for asymptomatic stone carriers, since the risk of surgery exceeds the risk of developing symptoms or complications. However, in some cases, laparoscopic cholecystectomy is considered justified even in the absence of clinical manifestations.

In the presence of symptoms of gallstone disease, especially frequent ones, cholecystectomy is indicated. Preference should be given to the laparoscopic option in the maximum possible number of cases (less severe pain syndrome, shorter hospital stay, less trauma, shorter postoperative period, better cosmetic result).

The question of the timing of cholecystectomy in acute cholecystitis remains controversial to this day. Delayed (6-8 weeks) surgical treatment after conservative therapy with mandatory antibiotics to relieve acute inflammation is considered traditional. However, data have been obtained indicating that early (within a few days from the onset of the disease) laparoscopic cholecystectomy is accompanied by the same frequency of complications, but allows for a significant reduction in treatment time.

The operation removes gallstones and the factors that contribute to their formation. In the United States, about 500,000 cholecystectomies are performed each year, which is equivalent to a multi-million dollar business.

Most patients undergo endoscopic cholecystectomy, which was introduced in the late 1980s and has replaced "open" surgery. Traditional cholecystectomy is used when endoscopic surgery is not possible, so the surgeon must have traditional cholecystectomy skills.

In planned traditional cholecystectomy, the mortality rate in patients under 65 years of age is 0.03%, in patients over 65 years of age - 0.5%. Traditional cholecystectomy is a reliable and effective method of treating cholelithiasis. Revision of the common bile duct, advanced age (over 75 years), emergency surgery, often undertaken for gallbladder perforation and biliary peritonitis, increase the risk of intervention. To reduce the risk, the tactics of early planned surgery for clinical manifestations of cholelithiasis, especially in elderly patients, are proposed.

Successful cholecystectomy requires experienced assistants, convenient access, good lighting, and the ability to perform intraoperative cholangiography. The latter is performed only if there are clinical, radiographic, and anatomical signs of stones in the common bile duct (choledocholithiasis). After opening the common bile duct, it is advisable to perform choledochoscopy, which reduces the likelihood of leaving stones.

Comparative characteristics of various interventions on the gallbladder for cholelithiasis.

Method	Description	Advantages	Flaws
Cholecystectomy	Gallbladder and stone removal	Leads to a complete cure from the disease, prevents relapses, the possibility of developing gallbladder cancer. The method is optimal for the treatment of acute cholecystitis
Endoscopic papillosphincterotomim	Access to the bile ducts through an endoscope inserted through the mouth; using special instruments, sphincterotomy is performed and the stone is removed from the common bile duct	Diagnostic standard for choledocholithiasis; reduced hospital stay; shorter recovery period; can also be used for acute cholangitis
Shock wave lithotripsy	Local application of high energy waves results in crushing of stones	Non-invasive treatment method	Complications: biliary colic, acute cholecystitis, pancreatitis, choledocholithiasis with the development of mechanical jaundice, micro- and macrohematuria. hematomas of the liver, gallbladder

There are practically no absolute contraindications to laparoscopic manipulations. Relative contraindications include acute cholecystitis with a duration of more than 48 hours, peritonitis, acute cholangitis, obstructive jaundice, internal and external biliary fistulas, liver cirrhosis, coagulopathy, unresolved acute pancreatitis, pregnancy, pathological obesity, severe pulmonary heart failure.

Laparoscopic cholecystectomy

Under general anesthesia, after pumping carbon dioxide into the abdominal cavity, a laparoscope and instrumental trocars are inserted.

The cystic duct and gallbladder vessels are carefully isolated and clipped. Electrocoagulation or laser is used for hemostasis. The gallbladder is isolated from its bed and removed entirely. If there are large stones that make it difficult to extract the preparation through the anterior abdominal wall, they are crushed inside the gallbladder.

Efficiency

Laparoscopic cholecystectomy is effective in 95% of patients. In other cases, the operation is completed in the traditional way. This method is most often used in acute cholecystitis (34%), especially if it is complicated by empyema of the gallbladder (83%). In such patients, it is advisable to first perform laparoscopy and then, if necessary, immediately proceed to laparotomy. In acute cholecystitis, a highly qualified endoscopist is required.

Outcomes

Most studies comparing laparoscopic and "mini" cholecystectomy have shown a significant reduction in the length of hospital stay, recovery time, and time to return to normal activity after laparoscopic cholecystectomy. The first two indicators for laparoscopic cholecystectomy were 2-3 days and 2 weeks, respectively, while for traditional surgery they were 7-14 days and up to 2 months. However, in other studies, these indicators for laparoscopic and "mini" cholecystectomy were approximately the same. The cost of the laparoscopic technique is higher, but due to the listed advantages, it is becoming the method of choice. The clinical results for both techniques are the same.

Complications

Complications occur in 1.6-8% of laparoscopic cholecystectomy cases and include wound infection, bile duct injury (0.1-0.9%, 0.5% on average), and stone retention. The incidence of bile duct injury decreases with increasing surgeon skill, although this complication can occur even in experienced surgeons. Mortality with laparoscopic cholecystectomy is less than 0.1%, which compares favorably with that of the traditional technique.

Shock wave lithotripsy is used very limitedly, as it has a fairly narrow range of indications, a number of contraindications and complications.

Gallstones can be fragmented using electrohydraulic, electromagnetic or piezoelectric extracorporeal shock wave generators similar to those used in urology. Shock waves are focused at one point in various ways. The optimal position of the patient and the device so that the maximum energy falls on the stone is selected using ultrasound. The waves pass through soft tissue with minimal energy loss, but the stone, due to its density, absorbs the energy and breaks up. Due to improvements in the design of lithotriptors, general anesthesia is not necessary for a successful procedure. Small fragments are able to pass through the cystic and common bile ducts into the intestine, the rest can be dissolved by oral bile acids. Shock waves cause hemorrhage and edema of the gallbladder wall, which undergo regression over time.

Results

Currently, there are many observations of biliary shock wave lithotripsy, the results of which vary depending on the lithotripter model, the clinic, and the organization of the study. According to reports, only 20-25% of patients met the selection criteria, which include the presence of no more than three radiolucent gallstones with a total diameter of up to 30 mm, a functioning gallbladder (according to cholecystography), characteristic symptoms, and the absence of concomitant diseases. The lithotripter is aimed at the stones using an ultrasound scanner. Lung tissue and bone structures should not be in the path of the shock waves.

In most cases, shock waves are successful in breaking up stones, although some devices, especially piezoelectric devices, may require multiple sessions. However, lithotripsy using a piezoelectric device is better tolerated by patients and can be used on an outpatient basis. With additional oral administration of bile acids (ursodeoxycholic acid at a dose of 10-12 mg/kg per day), the effectiveness of treatment at 6 months increased from 9 to 21%. In other studies, adjuvant therapy with ursodeoxycholic acid or a combination of the two acids was started several weeks before the procedure and ended 3 months after evacuation of all fragments.

At 6 and 12 months after the procedure, the destruction and complete evacuation of stones were achieved in 40-60 and 70-90% of cases, respectively. This figure was even higher for single stones up to 20 mm in diameter, high energy lithotripsy, and additional drug therapy. Normal contraction of the gallbladder after meals (ejection fraction over 60%) was also accompanied by better treatment results. Like cholecystectomy, biliary shock wave lithotripsy does not eliminate dyspeptic disorders (flatulence, nausea). Within 5 years after the end of bile acid therapy, stones reappeared in 30% of cases, and in 70% of cases, relapses were clinically evident. Recurrence of cholelithiasis is associated with incomplete emptying of the gallbladder and a disproportionately high proportion of deoxycholic acid in the bile acid pool.

In some clinics, a rim of calcification on radiographs is not considered a contraindication for lithotripsy, but the effectiveness of the procedure in such cases is lower.

Complications

Complications of biliary shock wave lithotripsy include hepatic colic (30-60%), skin petechiae, hematuria, and pancreatitis (2%) associated with obstruction of the common bile duct by stone fragments.

Extracorporeal shock wave lithotripsy is used in the following cases:

• The presence of no more than three stones in the gallbladder with a total diameter of less than 30 mm.
• The presence of stones that “float up” during oral cholecystography (a characteristic sign of cholesterol stones).
• Functioning gallbladder as demonstrated by oral cholecystography.
• Gallbladder contraction by 50% according to scintigraphy.

It should be taken into account that without additional treatment with ursodeoxycholic acid, the frequency of recurrence of stone formation reaches 50%. In addition, the method does not prevent the possibility of developing gallbladder cancer in the future.

Percutaneous cholecystolithotomy

The method was developed by analogy with percutaneous nephrolithotomy. Oral cholecystography is performed immediately before the manipulation. Under general anesthesia and under fluoroscopy and ultrasound control, the gallbladder is catheterized transperitoneally, after widening the tract, a rigid surgical cystoscope is inserted and the stones are removed, if necessary, destroying them using contact electrohydraulic or laser lithotripsy. The method allows removing stones from a non-functioning gallbladder after its catheterization under ultrasound control. After removing the stones, a catheter with a balloon is left in the gallbladder, which is inflated. This ensures drainage with a minimal risk of bile leakage into the abdominal cavity. The catheter is removed after 10 days.

Results

The method was effective in 90% of 113 patients. Complications occurred in 13%, there were no fatal outcomes. With an average observation period of 26 months, stones recurred in 31% of patients.

Endoscopic papillosphincterotomy is indicated primarily for choledocholithiasis.

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