The goal of treatment for gallstones is to relieve painful symptoms and prevent serious complications. If gallstones are not causing troublesome symptoms, there is no reason to treat them.
Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones and is generally the treatment of choice when a person is troubled by frequent "attacks." The surgery is called a "cholecystectomy," and about 500,000 Americans undergo the operation each year. In the past, this was major surgery, and so-called open cholecystectomies are still sometimes performed. But minimally invasive laparoscopic techniques have revolutionized treatment for gallstones. A laparoscopic cholecystectomy involves a few small incisions, less pain, usually only a daytime or one overnight hospital stay, and a few days of missed work.
Nonsurgical treatment methods are used for symptomatic gallstone disease when a patient is at too high a risk of surgery because of pregnancy, age, chronic illness, or other factors. Additionally, nonsurgical treatment is the best option when gallstones are trapped in the bile ducts. There are several types of nonsurgical therapies that involve either removing or attempting to dissolve or break up the gallstones. In general, nonsurgical approaches do not permanently eliminate gallstones or attacks.
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Surgery is the treatment of choice for patients with gallstone disease causing symptoms. Laparoscopic techniques have revolutionized gallbladder surgery. In a laparoscopic cholecystectomy, a minimally invasive operation, the surgeon makes several tiny incisions in the abdomen to insert surgical instruments and a miniature video camera. The abdominal muscles are not cut. The video camera sends a magnified image of the organs and ducts from inside the body to a monitor, so the surgeon has a close-up view from inside the body. Guided by the images on the monitor, the surgeon separates the gallbladder from its connections to other organs and the bile ducts, then removes the gallbladder through one of the small incisions. Patients have far less pain and fewer complications than they would after major surgery, generally spend only one night in the hospital or can even leave the same day, and can recuperate over several days at home.
Open cholecystectomy used to be the standard procedure for removing a gallbladder, but it is now used in only about 5 percent of all gallbladder operations. During the operation, the surgeon makes a five-to-eight-inch incision through the abdominal muscles to remove the gallbladder. This is major surgery, requiring a hospital stay of two days to a week and several more weeks of recovery time at home. Open surgery is now done only in cases where there are obstacles to a laparoscopic surgery, such as scarring from past operations or infection.
Sometimes during gallbladder surgery, the surgeon must switch from a laparoscopic procedure to an open cholecystectomy. This may happen in the case of scarring from past surgery, infection, or deviations from the normal human anatomy. The switch is necessary in only about 5 percent of laparoscopic cholecystectomies.
The most serious complication associated with both types of gallbladder removal is injury to one or more of the bile ducts. If a bile duct is injured or cut through completely, a bile leak can cause a painful and potentially dangerous infection. Damage to the ducts during surgery may require additional surgery to repair the problem—though mild injuries can sometimes be treated nonsurgically, through use of endoscopic retrograde cholangiopancreatography or ERCP, an endoscopic procedure that allows the surgeon to visualize, examine, and repair the bile ducts.
Generally speaking, the gallbladder is an organ people can live without. If the gallbladder is removed, bile flows out of the liver through a system of ducts directly to the small intestine, without being stored. Because bile can no longer be stored in the gallbladder, it flows more often into the small intestine, causing diarrhea in about 1 percent of those who have had their gallbladder removed.
Endoscopic retrograde cholangiopancreatography is a technique used to both test for and treat gallbladder disease. It is a nonsurgical procedure and the method of choice to find and remove gallstones that are lodged in the common bile duct. During ERCP, a patient is sedated enough to relax, then swallows an endoscope, a long and flexible lighted tube that is connected to and sends images to a computer and video monitor. The doctor guides the endoscope through the stomach into the small intestine and injects a special dye that allows the visualization of ducts in the biliary system. Once the blocked duct is located, the doctor makes an incision with an instrument inside the endoscope, captures the gallstone in a tiny basket, and then pulls it out through the endoscope. Once the common bile duct stone has been removed by ERCP, the patient should still undergo surgical cholecystectomy to remove the gallbladder in order to prevent future blockages.
Sometimes a person can develop a gallstone in one of the bile ducts even after having his or her gallbladder removed. This can occur long after surgery. The stone is removed with the ERCP procedure.
Possible complications of ERCP include inflammation of the pancreas (pancreatitis) and, less commonly, infection, bleeding, and perforation of the small intestine.
In patients who are unable to undergo surgery, a number of drugs are used to interfere with the development of stones in the gallbladder. Many of these are made from bile acids. One common agent, ursodeoxycholic acid, reduces the production of cholesterol by the liver, thus decreasing the amount of cholesterol in the bile. It also increases the level of bile acids within the bile, since the agent is a bile acid itself. These two factors encourage gallstones to dissolve. However, these drugs are only useful for small, noncalcified cholesterol stones and in patients who have a functional gallbladder—in other words, they work for only about 15 percent of people with symptomatic gallbladder disease. Treatment takes from six months up to two years, and gallstones recur in 50 percent of patients within five years. These drugs can also cause diarrhea.
For patients who cannot have surgery, another option is percutaneous (through the skin) therapy. The gallbladder is accessed through the skin and across the liver using a needle guided by X-rays. The gallbladder is punctured—the small hole seals again on its own—and stones are removed with a cholecystoscope, a hollow tube with a basket that allows the doctor to pull out the stones. Stones that are too large to be removed may be broken up with ultrasound or a tiny laser. A small tube is usually left in the gallbladder to drain the blocked bile through the skin.
This procedure may lead to fewer complications and lower mortality in high-risk surgical patients but is considered to be a very short-term solution and will not permanently cure gallstone disease. Risks of the procedure include infection, bile leak, and perforation.
Patients who cannot have surgery immediately may undergo endoscopic gallbladder stenting. This procedure uses endoscopy to insert a "stent," or a slender, hollow tube, from the gallbladder into the duodenum so bile can flow freely, relieving symptoms of gallstone disease. This procedure is used for high-risk patients and is less invasive than cholecystectomy. If new stones form, the stent acts as another track for the bile to flow, bypassing the blockage caused by the stones. Because there is a risk of blockage inside the stent itself with long-term use, stents are a short-term solution.
Last reviewed on 7/23/09
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