Gallstones and Gallbladder Disease - Surgery

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Patients should not be shy about inquiring into the number of laparoscopies the surgeon has performed (the minimum should be 40). Obese patients were originally thought to be poor candidates for laparoscopic cholecystectomy, but recent research indicates that this surgery is safe for them.

Open Cholecystectomy

Before the development of laparoscopy, the standard surgical treatment for gallstones was open cholecystectomy (surgical removal of the gallbladder through an abdominal incision), which requires a wide 6 - 8 inch incision and leaves a large surgical scar. In this procedure, the patient usually stays in the hospital for 5 - 7 days and may not return to work for a month. Complications include bleeding, infections, and injury to the common bile duct. The risks of this procedure increase with other factors, such as the age of the patient, or the need to explore the common bile duct for stones at the same time.

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Candidates for whom cholecystectomy may be a more appropriate choice:

• Patients who have had extensive previous abdominal surgery
• Patients with complications of acute cholecystitis (empyema, gangrene, perforation of the gallbladder)

Small-incision or Mini-Laparotomy Cholecystostomy. Mini-laparotomy cholecystostomy uses small abdominal incisions but, unlike laparoscopy, it is an "open" procedure, and the surgeon does not operate through a scope. The surgical instruments used are very small (2 - 3 mm in diameter, or about a tenth of an inch). Comparison with laparoscopic techniques has found little difference in recovery time, mortality or complications.

Older patients. Patients who are over 80 years old are likely to have lower complication rates from open cholecystectomy than laparoscopy, although laparoscopy may also be appropriate in these patients.

Whether or not to insert a drain in the wound after surgery is under debate. Many surgeons implant drains to prevent abscesses or peritonitis. That practice may change. One analysis found that patients who received drains had a dramatically increased risk of wound and chest infection, regardless of the type of drain used.

ERCP with Endoscopic Sphincterotomy (ES)

Reasons for performing the procedure:

• Before gallbladder surgeries, when there is a strong suspicion that common bile duct stones are present.
• At the end of a cholecystectomy, if the surgeon detects stones in the common bile duct (only if there are experts in ERCP present, and equipment is available).
• For patients with gallstone cholangitis (serious infection in the common bile duct). In such cases urgent ERCP and antibiotics are required.
• When acute pancreatitis is caused by gallstones, urgent ERCP, along with antibiotics, may be used. The use of ERCP compared to conservative treatment has been controversial.

The ERCP and ES Procedure. A typical ERCP and endoscopic sphincterotomy (ES) procedure includes the following steps:

• The patient is given a sedative and asked to lie on his or her left side.
• An endoscope (a tube containing fiber optics connected to a camera) is passed through the mouth and stomach and into the duodenum (top part of the small intestine) until it reaches the point where the common bile duct enters. This does not interfere with breathing, but the patient may have a sensation of bloating.
• A thin catheter (tube) is then passed through the endoscope.
• Contrast material (a dye) is injected through the catheter into the opening of the duct. The dye allows x-ray visualization of the biliary tree (the system of ducts through which bile flows, including the common bile duct) and any stones contained in the area.
• Instruments may also be passed through the endoscope to remove any stones that are detected.
• The next phase of the procedure is known as endoscopic sphincterotomy (ES). (It is also sometimes referred to as papillotomy, although this is a slightly different variation.) ES widens the junction between the common bile duct and intestine (the ampulla of Vater) so that the stones can be extracted more easily. With ES, a tiny incision is usually made in the opening of the common bile duct and through the muscles that enclose the lower common bile duct (the sphincter of Oddi).
• One recent alternative to ES is the use of a small inflatable balloon (a procedure known as endoscopic balloon dilation) that opens up the ampulla of Vater to allow stones to pass. This variation does not involve cutting muscles.
• Once the junction has been opened, the stones may pass on their own, or they may be extracted with the use of tiny baskets or balloons.

Complications. Complications of ERCP and ES occur in 5 - 8% of cases, and some can be serious. Mortality rates are 0.2 - 0.5%. Complications include the following:

• Pancreatitis (inflammation of the pancreas) occurs in 3 - 9% of cases and can be very serious. Younger adults are at higher risk than the elderly. The risk is also higher with more complex procedures. The drugs somatostatin or gabexate are sometimes used to reduce the risk, although recent evidence suggests somatostatin may not actually reduce this risk. Gabexate appears to be more effective, although studies are mixed on whether its benefits are significant, particularly with short-term treatment.
• Postoperative infection. Antibiotics may be given before the procedure to prevent infection, although one study reported that they had little benefit.
• Bleeding occurs in 2% of cases. There is an increased risk for bleeding in patients taking anti-clotting drugs, and those who have cholangitis. This complication is treated by flushing the area with epinephrine.
• Perforations (rare)
• Long-term complications include stone recurrence and abscesses.

ERCP and ES are difficult procedures, and patients must be certain that their doctor and medical center are experienced. ERCP can usually be performed successfully by an experienced doctor, even in critically ill patients who are on mechanical ventilators.

ERCP and Gallbladder Removal (Cholecystectomy). ERCP is often performed after gallstones in the common duct are discovered during cholecystectomy.

In some cases, stones in the gallbladder are detected during ERCP. In such cases, laparoscopic cholecystectomy is usually warranted. There is some debate about whether the gallbladder should be removed at the same time as ERCP, or if patients should wait.

Review Date: 06/10/2010
Reviewed By: Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).