Gallstone disease: surgical treatment

In the asymptomatic course of cholelithiasis, as well as with a single episode of biliary colic and infrequent painful episodes, the most justified wait-and-see tactics. If there is evidence in these cases, oral lithotripsy is possible.

Indications for surgical treatment for cholecystolithiasis:

• presence of large and small concrements in the gallbladder, occupying more than 1/3 of its volume;
• the course of the disease with frequent bouts of biliary colic, regardless of the size of the stones;
• disconnected gallbladder;
• cholelithiasis complicated by cholecystitis and / or cholangitis;
• combination with choledocholithiasis;
• gallstone disease, complicated by the development of the Mirizzi syndrome;
• cholelithiasis, complicated by dropsy, empyema of the gallbladder;
• cholelithiasis complicated by perforation, penetration, fistula;
• gallstone disease, complicated by biliary pancreatitis;
• gallstone disease, accompanied by a violation of patency of the general
• bile duct.

Methods of surgical treatment: laparoscopic or open cholecystectomy, endoscopic papillosphincterotomy (shown with choledocholithiasis), extracorporeal shock wave lithotripsy.

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

In the presence of symptoms of cholelithiasis, especially frequent, cholecystectomy is indicated. Laparoscopic variant should be preferred in the maximum possible number of cases (less pain syndrome, shorter hospital stay, less traumatism, shorter postoperative period, better cosmetic result).

The question of the timing of cholecystectomy with acute cholecystitis remains to this day controversial. The traditional deferred (after 6-8 weeks) surgical treatment after conservative therapy with mandatory prescription of antibiotics for relief of acute inflammation. However, evidence has been obtained that early (within a few days after the onset of the disease) laparoscopic cholecystectomy is accompanied by the same frequency of complications, but it allows to significantly shorten the duration of treatment.

As a result of surgery, gallstones and factors contributing to their formation are removed. In the United States, an annual production of about 500,000 cholecystectomies is equivalent to a multimillion-dollar business.

The majority of patients perform endoscopic cholecystectomy, introduced in the late 80's, which replaced the "open" operation. Traditional cholecystectomy is resorted to when endoscopic surgery is not possible, so the surgeon must have the skills of traditional cholecystectomy.

With the planned traditional cholecystectomy, mortality in patients younger than 65 years is 0.03%, in patients older than 65 years, 0.5%. Traditional cholecystectomy is a reliable and effective method of treating cholelithiasis. The revision of the common bile duct, advanced age (over 75 years), an emergency operation, often undertaken around the perforation of the gall bladder and gallstones, increase the risk of interference. To reduce the risk, a tactic of an early planned operation was suggested for clinical manifestations of cholelithiasis, especially in elderly patients.

The success of cholecystectomy requires the presence of experienced assistants, convenient access, good lighting and opportunities for intraoperative cholangiography. The latter is performed only with clinical, radiologic and anatomical signs of stones in the common bile duct (choledocholithiasis). After opening the common bile duct, it is advisable to perform a choledochoscopy, which reduces the probability of leaving stones.

Comparative characteristics of various interventions on the gallbladder in cholelithiasis.

Method	Description	Benefits	Disadvantages
Cholecystectomy	Removal of the gallbladder and stones	It leads to a complete cure of the disease, prevents relapses, the possibility of developing a gallbladder cancer. The method is optimal for the treatment of acute cholecystitis
Endoscopic papillosphincterotomy	Access to the biliary tract through the endoscope, introduced through the mouth; with the help of special tools they perform sphincteromyoma and extraction of the stone from the common bile duct	Diagnostic standard for choledocholithiasis; reduction in the length of stay in the hospital; a shorter recovery period: can also be used for acute cholangitis
Shock-wave lithotripsy	Local summation of high-energy waves leads to the crushing of stones	Non-invasive treatment	Complications: biliary colic, acute cholecystitis, pancreatitis, choledocholysis with the development of mechanical jaundice, micro- and macrohematuria. Hematoma of the liver, gallbladder

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

Laparoscopic cholecystectomy

Under general anesthesia, after injection into the abdominal cavity of carbon dioxide, a laparoscope and instrumental trocars are injected.

The bladder duct and the vessels of the gallbladder are carefully isolated and clipped. For hemostasis, electrocoagulation or a laser is used. The gallbladder is isolated from the bed and removed entirely. In the presence of large concrements, making it difficult to extract the drug through the anterior abdominal wall, they are ground inside the gallbladder.

Efficiency

Laparoscopic cholecystectomy is effective in 95% of patients. In other cases, the operation is terminated in the traditional way. This method is more often used for acute cholecystitis (34%), especially if it was complicated by empyema of the gallbladder (83%). In such patients, it is advisable to perform laparoscopy first and then, if necessary, go directly to laparotomy. At an acute cholecystitis the high qualification of the endoscopist is necessary.

Outcomes

Most studies comparing Laparoscopic and "mini" -cholecystectomy showed a significant decrease in hospital stay, duration of recovery, and the timing of recovery of normal activity after laparoscopic cholecystectomy. The first two parameters for laparoscopic cholecystectomy were 2-3 days and 2 weeks, respectively, in the traditional operation - 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 thanks to the advantages listed above, it becomes a method of choice. Clinical results in the application of both methods are the same.

Complications

Complications are observed in 1.6-8% of cases of laparoscopic cholecystectomy and include wound infection, damage to the bile ducts (0.1-0.9%, 0.5% on average) and the abandonment of stones. The frequency of damage to the bile ducts decreases with the surgeon's skills, although this complication can occur in an experienced surgeon. Mortality with laparoscopic cholecystectomy is less than 0.1%, favorably differing from that in the traditional method.

Shock-wave lithotripsy is used very narrowly, since it has a rather narrow spectrum of indications, a number of contraindications and complications.

Gallstones can be fragmented by electro-hydraulic, electromagnetic or piezoelectric extracorporeal shock wave generators, similar to those used in urology. In different ways, shock waves are focused at one point. The optimal position of the patient and the device, so that the maximum energy is on the stone, is selected with the help of ultrasound. Waves pass through soft tissues with minimal energy loss, but the stone, by virtue of its density, absorbs energy and is crushed. Thanks to the improvement 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 duct into the intestine, the rest can be dissolved by oral bile acids. Shock waves cause hemorrhage and edema of the gallbladder wall, which eventually undergo reverse development.

results

At present, many observations of biliary shock-wave lithotripsy have been accumulated, the results of which vary depending on the model of the lithotriptor, 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 X-ray-negative 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 lithotriptor is guided to the stones with an ultrasound scanner. On the path of shock waves, there should not be pulmonary tissue and bone structures.

In most cases, shock waves successfully destroy rocks, although using certain devices, especially piezoelectric ones, may require several sessions. At the same time, lithotripsy using a piezoelectric device is more easily tolerated by patients and can be used in outpatient settings. With an additional oral intake of bile acids (ursodeoxycholic acid at a dose of 10-12 mg / kg in knocking), the efficacy of treatment at 6 months was increased from 9 to 21%. In other studies, adjuvant therapy with ursodeoxycholic acid or a combination of two acids started several weeks before the procedure and ended 3 months after the evacuation of all fragments.

At 6 and 12 months after the procedure, 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 with a diameter of up to 20 mm, high energy of lithotripsy and additional drug therapy. The normal contraction of the gallbladder after eating (the ejection fraction more than 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 therapy with bile acids in 30% of the cases stones appeared again, and in 70% of cases the relapses manifested clinically. Recurrence of cholelithiasis is associated with incomplete evacuation of the gallbladder and a disproportionately high proportion of deoxycholic acid in the bile acid bile.

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

Complications

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

Extracorporeal shock-wave lithotripsy is used in the following cases:

• The presence in the gallbladder of not more than three stones with a total diameter of less than 30 mm.
• The presence of concrements, "pop up" during oral cholecystography (a characteristic sign of cholesterol stones).
• Functioning gall bladder according to oral cholecystography.
• Reduction of the gallbladder by 50% according to scintigraphy.

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

Percutaneous cholecystolithotomy

The method was developed by analogy with percutaneous nephrolithotomy. Immediately before manipulation, oral cholecystography is performed. Under general anesthesia and under the supervision of fluoroscopy and ultrasound, the gallbladder is catheterized, after the stroke is extended, a hard surgical cystoscope is inserted and the stones removed, if necessary, by destroying them with the help of electro-hydraulic or laser lithotripsy. The method allows you to remove stones from a dysfunctional gallbladder after its catheterization under the supervision of ultrasound. After removing the stones in the gallbladder, leave a catheter with a can, which is inflated. This provides drainage with a minimal risk of leakage of bile into the abdominal cavity. After 10 days, the catheter is removed.

results

In 90% of 113 patients the method was effective. Complications arose in 13%, there were no lethal outcomes. With an average follow-up of 26 months, stones recurred in 31% of patients.

Endoscopic papillosphincterotomy is indicated primarily in choledocholithiasis.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]