Treatment

Treatment of gall stones

Surgery

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.) Each year more than 500,000 Americans have gallbladder surgery. The surgery is called cholecystectomy.

The standard surgery is called laparoscopic cholecystectomy. For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a closeup view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions.

Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. Recovery usually involves only one night in the hospital, followed by several days of restricted activity at home.

If the surgeon discovers any obstacles to the laparoscopic procedure, such as infection or scarring from other operations, the operating team may have to switch to open surgery. In some cases the obstacles are known before surgery, and an open surgery is planned. It is called "open" surgery because the surgeon has to make a 5- to 8-inch incision in the abdomen to remove the gallbladder. This is a major surgery and may require about a 2- to 7-day stay in the hospital and several more weeks at home to recover. Open surgery is required in about 5 percent of gallbladder operations.

The most common complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes be treated nonsurgically. Major injury, however, is more serious and requires additional surgery.

If gallstones are in the bile ducts, the surgeon may use ERCP in removing them before or during the gallbladder surgery. Once the endoscope is in the small intestine, the surgeon locates the affected bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope. This two-step procedure is called ERCP with endoscopic sphincterotomy.

Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the bile ducts weeks, months, or even years after the surgery. The two-step ERCP procedure is usually successful in removing the stone.

Nonsurgical Treatment

Nonsurgical approaches are used only in special situations such as when a patient's condition prevents using an anesthetic and only for cholesterol stones. Stones recur after nonsurgical treatment about half the time.

• Oral dissolution therapy. Drugs made from bile acid are used to dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix), work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs cause mild diarrhea, and chenodiol may temporarily raise levels of blood cholesterol and the liver enzyme transaminase.
• Contact dissolution therapy. This experimental procedure involves injecting a drug directly into the gallbladder to dissolve stones. The drug methyl tert butyl can dissolve some stones in 1 to 3 days, but it must be used very carefully because it is a flammable anesthetic that can be toxic. The procedure is being tested in patients with symptomatic, noncalcified cholesterol stones.
• Extracorporeal shockwave lithotripsy (ESWL). This treatment uses shock waves to break up stones into tiny pieces that can pass through the bile ducts without causing blockages. Attacks of biliary colic (intense pain) are common after treatment, and ESWL's success rate is not very high. Remaining stones can sometimes be dissolved with medication.