Page 5 - 05- Cholelithiasis

GENERAL MEASURES
Treat symptomatic cholelithiasis.
Conservative therapy is preferred during pregnancy; surgery in the 2nd trimester if necessary
Prophylactic cholecystectomy for patients with calcified (porcelain) gallbladder (risk for
gallbladder cancer), patients with large stones (≥3 cm), patients with sickle cell disease,
patients planning an organ transplant, and patients with recurrent pancreatitis due to
microlithiasis
In morbidly obese patients, cholecystectomy may be performed in combination with bariatric
procedures to reduce subsequent stone-related comorbidities.
Prophylactic cholecystectomy is recommended for gallstones discovered incidentally during
open abdominal surgery.

Geriatric Considerations
Gallstones are more common in the elderly. Age alone should not alter the therapeutic plan.

MEDICATION
First Line
Analgesics for pain relief
– Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-choice treatment for pain
control which is equivalent to opioid therapy.
– Opioids are an option for patients who cannot tolerate or fail to respond to NSAIDs.
Antibiotics for patients with acute cholecystitis
Prophylactic antibiotics in low-risk patients do not prevent infections during laparoscopic
cholecystectomy (LC) (1)[A].
ISSUES FOR REFERRAL
Patients with retained or recurrent bile duct stones following cholecystectomy should be referred
for ERCP.

SURGERY/OTHER PROCEDURES
Surgery should be considered for patients who have symptomatic cholelithiasis or gallstone-
related complications (e.g., cholecystitis) or in asymptomatic patients with immune
suppression, calcified gallbladder, or family history of gallbladder cancer.
Open and LC have similar mortality and complication rates. LC offers less pain and quicker
recovery and is the current gold-standard treatment.
In well-selected patients, single-incision LC (SILC) and robotic LC are treatments for
symptomatic cholelithiasis. SILC has not been shown to be superior to conventional multiport
LC in terms of pain and risk of complication. Natural orifice transluminal endoscopic surgery
(NOTES) is investigational. Surgery-related complications include CBD injury (0.2%), right
hepatic duct/artery injury, retained stones, duct leak, biloma formation, and bile duct stricture.
Bile spillage during LC has been shown to be a risk factor for surgical site infection.
– Conversion to open procedure is based on clinical judgment. Male gender, previous upper
abdominal surgery, thickened gallbladder wall, and acute cholecystitis increase the
likelihood of need to convert to an open procedure.
– In 10–15% of patients with symptomatic cholelithiasis, CBD stones are detected by
intraoperative cholangiogram (IOC). CBD stone(s) can be removed by laparoscopic CBD
exploration or postoperative ERCP.