WeBSurg, the e-surgical reference of Laparoscopic surgery

CHOLELITHIASIS: DIAGNOSIS AND TREATMENT

B Millat , MD , Hôpital Saint Eloi, Montpellier, France
D Mutter , MD , PhD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Introduction

2. Diagnosis

3. Treatment

4. Therapeutic strategy

5. References

1. Introduction

Laparoscopy has revolutionized the field of digestive surgery.
Since the first laparoscopic cholecystectomy performed by P. Mouret in 1987, this approach has become widespread.
Video-assisted procedures are currently being applied to all surgical fields.

From the Consensus Conference of the French Society of Digestive Surgery – 19 to 21 December 1991 and from the recommendations of the National Institute of Health “NIH Consensus Statement: Gallstones and Laparoscopic Cholecystectomy” in 1992.

Figure 1

1.1. Pathophysiology

Cholelithiasis can be defined as the presence of one or more stones in the gallbladder. Today’s extensive use of abdominal sonography, even when performed for reasons other than suspected gallbladder disease, leads to the frequent discovery of biliary stones.
When the stones do not cause biliary symptoms, the term “asymptomatic cholelithiasis” is used. Gallbladder disease declares itself each year in 0.5% to 4% of patients who have stones by an onset of upper right quadrant abdominal pain. Three to four times less often, the disease is discovered due to complications caused by cholelithiasis.
There are 4 main types of cholelithiasis:

pure cholesterol stones (80%);
bilirubin stones;
calcium carbonate stones;
mixed stones containing layers of calcium bilirubinate and of cholesterol.

1.2. Prevalence of cholelithiasis

Gallbladder stones are present in approximately 20% of the population, ranging in age from 20 to 60 years old.
It becomes more frequent with age: approximately 60% of persons over 80 have one or more gallbladder stones.

1.3. Predisposing factors

The incidence of cholelithiasis increases with:

obesity (Body Mass Index of over 30),
diet alterations including low calorie diets, diets rich in polyunsaturated fatty acids and total parenteral nutrition.

On the other hand, a diet which is rich in vegetable fibers can have a preventative effect on the formation of gallbladder stones.
Finally, certain medications (Atromid-S®, estrogens), as well as certain diseases and postoperative conditions (Crohn’s disease, terminal ileal resection or fibrocystic disease) contribute to the occurrence of gallbladder stones.

1. Introduction

2. Diagnosis

3. Treatment

4. Therapeutic strategy

5. References

2. Diagnosis

2.1. Asymptomatic stones

Gallstones are often discovered incidentally: if they give no signs of alert, they are defined as asymptomatic. There are no identifiable risk factors known at present which can predict whether stones will later be the cause of biliary colic or whether they might develop into a complication: neither the patient’s age, gender, medical history and associated treatments, nor the sonographic presentation of the gallbladder or the stones’ characteristics (quantity, size, radiolucency). Monitoring is therefore not justified (clinical, biological nor sonographic) in the presence of a gallbladder stone.

2.2. Biliary pain

Biliary pain or biliary colic is the major sign of cholelithiasis. It is linked to an acute distension of the gallbladder due to the impaction of a stone in the cystic duct.
Biliary pain can be recognized by the following characteristics:

it comes on acutely, with maximum intensity at the onset or very rapidly thereafter;
in 2/3 of cases, it is in the epigastric region and in 1/3 of cases in the right hypochondrium;
the pain often radiates towards the tip of the right shoulder blade or towards the right shoulder;
it lasts from 20 minutes to 5 hours maximum;
the pain is accompanied by respiratory problems and/or nausea in 2/3 of cases and sometimes vomiting.

2.3. Complications of cholelithiasis

Cholelithiasis may be diagnosed following the appearance of its complications. These include:

acute cholecystitis;
compression of the common bile duct by cholecystitis or the Mirizzi syndrome;
stone migration into the common bile duct;
cholangitis;
acute pancreatitis;
and cancer of the gallbladder (see specific chapters concerned).

2.4. Clinical examination

The exam reveals pain in the right hypochondrium, guarding or palpation of an enlarged gallbladder (in less than 10% of cases). The Murphy sign, or the pain produced in the gallbladder region is combined with respiratory inhibition, is not specific.

2.5. Further exams

Biological findings are normal unless there are complications.
The morphologic examination essentially comprises a sonogram. The stones can be seen as hypoechoic images with a non-echogenic zone or a “shadowing” behind the gallbladder. The shadowing may be absent if it is a small stone of less than 2 mm. The stones are usually located in the sloping part of the gallbladder and are mobile when the patient changes positions. The sensitivity of ultrasonography is 98% for detecting gallbladder stones of over 2 mm in diameter.
No other exams are necessary.

Figure 2.5

2.6. Other exams

Other examinations (ie, oral cholecystogram) are no longer indicated for diagnosing cholelithiasis.
Plain radiographs of the abdomen are not necessary. When performed to evaluate non-specific abdominal pain, they may reveal stones whose calcium content is over 4% of their weight. Radio-opaque stones represent 10% to 30% of all stones. Calcification is more frequent in bilirubin stones (50%) than in cholesterol stones (15%).

Intravenous cholangiography, which had nearly fallen into disuse before the advent of laparoscopy, seemingly became useful again for preoperative explorations prior to cholecystectomies as a means to reveal common bile duct lithiasis or anatomical abnormalities. However, modern imaging techniques (bili-MRI) and the possibility now available to perform intraoperative cholangiography, have replaced this exam. Its weak diagnostic value and the risk entailed by injecting iodized contrast contraindicate its use.

Figure 2.6

1. Introduction

2. Diagnosis

3. Treatment

4. Therapeutic strategy

5. References

3. Treatment

3.1. Treatment of biliary pain (biliary colic)

Analgesics and/or antispasmotics are given either orally or intravenously, depending on the level of pain and nausea.
Intense pain may require the administration of morphine or a morphine derivative, even though these products are believed to increase the pressure in the biliary tract by inhibiting the relaxation of Oddi’s sphincter. This theory has not been proven, however, and morphine derivatives are regularly used today for the management of biliary and pancreatic pain.

3.2. Cholecystectomy

Cholecystectomy was validated as the first-line treatment for symptomatic cholelithiasis, as compared to ultrasound lithotripsy, based on cost efficiency and quality of life criteria, before the advent of laparoscopic cholecystectomy ( Nicholl et al., 1992; Plaisier et al., 1994 ). Today, the laparoscopic approach is considered the gold standard in the treatment of symptomatic CBD stones.
In certain cases, a conventional approach by laparotomy may still be indicated, i.e. when there are contraindications to laparoscopy, or when previous operations make the laparoscopic approach difficult or impossible.

3.3. Laparoscopic cholecystectomy

For open cholecystectomies:

subcostal incisions have proven to be superior to median incisions, in terms of postoperative results ( Garcia-Valdecasas et al., 1988 ),
and right transverse mini-laparotomy gives better postoperative results than a longer transverse incision, without any additional increase in the complication rate ( O'Dwyer et al., 1992; Assalia et al., 1993 ).

Laparoscopy should therefore be compared to mini-laparotomy.

Compared to open cholecystectomy, laparoscopic cholecystectomy offers several advantages:

it maintains the patient’s immune response ( Redmond et al., 1994 );
it decreases the risk of postoperative cardio-pulmonary complications ( Schauer et al., 1993; Putensen-Himmer et al., 1992; Kum et al., 1996 );
the study carried out by Karayiannakis et al., 1997 , demonstrates a lesser degree of elevation of IL6, CRP and glycemia following laparoscopy as compared to laparotomy. However, according to other studies it does not reduce tissue trauma ( Berggren et al., 1994 ) assessed by secondary criteria (interleukins, CRP, adrenalin, cortisol), and does not prevent postoperative catabolic reactions ( Essen et al., 1995 ).

Helium pneumoperitoneum does not have major advantages when compared to CO2 ( McMahon et al., 1994 ). The disadvantages of pneumoperitoneum are not insignificant, however, when compared to cholecystectomies performed under parietal suspension ( Koivusalo et al., 1996 ), but have no significant clinical repercussions under normal circumstances.
Seven trials ( Barkun et al., 1992; Kunz et al., 1992; Tate et al., 1993; McMahon et al., 1994; McGinn et al., 1995; Majeed et al., 1996; Karayiannakis et al., 1997 ) prospectively compared the laparoscopic approach to laparotomy based on clinical criteria. The main conclusions are as follows:

the duration of the procedure was significantly increased in the laparoscopy group ( Barkun et al., 1992; McMahon et al., 1994; McGinn et al., 1995; Majeed et al., 1996 ) except for Kunz et al., 1992 and Karayiannakis et al., 1997 (insignificant difference).
there was less postoperative pain (according to an analogical visual scale) in the laparoscopy group ( Kunz et al., 1992; Tate et al., 1993; McMahon et al., 1994; Karayiannakis et al., 1997 ).
postoperative pain in the right shoulder was worse after laparoscopy ( Tate et al., 1993 ).
hospital stays and convalescence were shorter after laparoscopy ( Barkun et al., 1992; Kunz et al., 1992; Tate et al., 1993; McMahon et al., 1994; Majeed et al., 1996 ) except for McGinn et al., 1995 (identical – for both approaches).
the quality of life / resuming of activities were improved in the laparoscopy group ( Barkun et al., 1992; McMahon et al., 1994 ).
the complication rates were increased in the laparoscopy group (9% as opposed to 3%, p < 0.02) ( McGinn et al., 1995 ) except for Kunz et al., 1992 (17% versus 20%) and Majeed et al., 1996 .
the functional digestive state after one year revealed no differences between the 2 groups ( McMahon et al., 1995 ).

3.4. Other therapeutic options

Biliary dissolvent medication
The only type of stones which respond favorably to dissolvent medication are pure cholesterol stones. The accepted treatment is ursodeoxycholic acid administered orally at a dosage of 10mg/kg/day, or approximately 600 mg/day. To be effective:

the gallbladder must function properly;
the stones must be radiolucent;
the common bile duct must be unobstructed and the treatment must be followed regularly.

A 6-month treatment for stones of less than 5 mm results in a complete dissolution in 70% to 80% of cases. For larger stones, of less than 15 mm, a 2-year treatment successfully dissolves the stones in 40% to 60% of cases.

After stopping the treatment, a recurrence of stones after five years occurs in 10% to 50% of cases. This medical treatment may be indicated in cases involving a contraindication or a high risk to surgery.

Extracorporeal lithotripsy
This technique focuses shock waves on the stones in order to dissolve them. It must be combined with a biliary dissolvent drug therapy. It may only be proposed to patients whose stones are radiolucent, few in number (less than three stones) and less than 3 cm in diameter. This method successfully gets rid of single stones of less than 20 mm in 70% to 80% of cases. The treatment is effective in only 25% to 50% of cases for patients with larger or more numerous stones. Complications, which are linked to the migration of the stone fragments, are rare - they can include acute cholecystitis, obstruction of the common bile duct or acute pancreatitis.
Proposed in the early 1990s, this method has fallen into disuse since the general acceptance of laparoscopic cholecystectomy.

Litholysis and direct contact lithotripsy
Both litholysis, achieved by injecting methyl ter butyl ether (MTBE), and direct contact lithotripsy involve a direct approach to the stones in the gallbladder. They are favorably replaced by a removal of the gallbladder and are therefore no longer indicated.

1. Introduction

2. Diagnosis

3. Treatment

4. Therapeutic strategy

5. References

4. Therapeutic strategy

The currently accepted indications for treating cholelithiasis are straightforward:

when the lithiasis has become symptomatic (presence of pain or complications), the indication for cholecystectomy is indisputable.
surgery may be proposed for asymptomatic patients who are exposed to a potential risk of complications:
candidates for an organ transplant;
candidates for heart surgery;
patients treated for chronic kidney failure;
patients treated for sickle cell anemia.

These prophylactic cholecystectomies are justified by the high rate of mortality, which has been observed when emergency cholecystectomies have to be performed in these patients for complications. No scientific assessment has been carried out on this subject, however.
Non-surgical treatments (dissolvents, extracorporeal lithotripsy) may be prescribed for patients who cannot or do not want to undergo surgery.

4.1. Objective of surgical treatment

The objective of surgery is to remove gallbladder stones in order to prevent painful attacks from recurring and complications from arising in patients with symptomatic lithiasis. This is currently achieved by cholecystectomy, which is ideally performed by laparoscopy.

4.2. Intraoperative antibiotic prophylaxis

Intraoperative antibiotic prophylaxis is recommended for many surgical procedures.
A meta-analysis carried out by Meijer et al. in 1990 grouping together 42 controlled randomized trials (4129 patients) is strongly in favor of antibiotic prophylaxis which reduced the number of parietal infections by 9%. It was not proven beneficial for laparoscopic cholecystectomies, however, in the 2 available randomized trials ( Higgins et al., 1999; Tocchi et al., 2000 ).
In order to reduce costs, antibiotic prophylaxis is therefore not recommended for “simple” laparoscopic cholecystectomies.

Table 1: Comparison of the efficacy of two antibiotics versus placebo ( Higgins et al., 1999 )

N=450	Cefalotan N=137	Cefazolin N=140	Placebo N=135	p
ASA 1/2/3 Operative time (min.)	37/89/10 69 +/- 31	37/91/12 64 +/- 29	35/81/18 64 +/- 25
Infections Wound & Deep	2.2%	4.3%	3%	NS

Table 2: Comparison of the efficacy of one antibiotic versus placebo ( Tocchi et al., 2000 )

N=84	Cefotaxim N=44	Placebo N=40	p
ASA 1/2/3	38/4/2	37/2/1
Operative time (min.)	88 +/- 19	91 +/- 15
Infected bile	18 (41%)	9 (22.5%)
Infections Wound & Deep	5 (11.3%)	7 (17.5%)	NS

4.3. Contraindications to surgical treatment

Except when performed in emergency situations, the contraindications to a laparoscopic approach to gallbladder removal are rare.
Contraindications are essentially those which apply to all laparoscopic procedures (see chapter on anesthesia for laparoscopic surgery). Relative contraindications include:

major portal hypertension due to the risk of intraoperative bleeding;
uncorrected coagulation disorders;
suspicion of gallbladder cancer due to the risk of neoplastic dissemination.

1. Introduction

2. Diagnosis

3. Treatment

4. Therapeutic strategy

5. References

5. References

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Essen P, Thorell A, McNurlan MA, Anderson S, Ljungqvist O, Wernerman J et al . Laparoscopic cholecystectomy does not prevent the postoperative protein catabolic response in muscle. Ann Surg 1995;222:36-42.
Garcia-Valdecasas JC, Almenara R, Cabrer C, de Lacy AM, Sust M, Taura P et al . Subcostal incision versus midline laparotomy in gallstone surgery: a prospective and randomized trial. Br J Surg 1988;75:473-5.
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