564

CHOLECYSTOLITHIASIS

Indications for CholecystectomyAsymptomatic GallstonesSurprisingly, most patients with gallstones, about 65% to 80%, are asymptomatic (see Chapter 30). Studies of the natural history of silent gallstones have shown that symptoms develop in 1% to 2% of patients per year. Among patients with asymptom-atic gallstones, about 10% develop symptoms in 5 years, and about 20% develop symptoms by 20 years. Additionally, most patients experience symptoms for some time before they develop a complication (National Institutes of Health [NIH] Consensus Statement Online, 1992; Stewart et al, 1989; Festi et al, 2010; McSherry et al, 1985). So, the majority of patients with asymptomatic gallstones can be observed, and surgical intervention (laparoscopic cholecystectomy) can be offered if symptoms develop.

Surgical treatment of asymptomatic gallstones is indicated in a number of patient populations for whom prophylactic chole-cystectomy was once recommended. These populations com-prise transplant patients and those with diabetes mellitus, chronic liver disease, sickle cell anemia or other chronic hemo-lytic anemia, patients undergoing bariatric or other gastrointes-tinal operations, and those with a potentially increased risk of gallbladder carcinoma (Table 37.1).

Prophylactic cholecystectomy for asymptomatic cholelithia-sis was previously recommended for patients with diabetes mellitus. Studies in the late 1960s reported a higher mortality following emergency cholecystectomy in diabetic patients. Sub-sequent meta-analysis revealed that diabetes was not an inde-pendent variable; instead, cardiovascular, peripheral vascular, cerebrovascular, or prerenal azotemia were associated with more severe acute cholecystitis (Stewart et al, 1989; Hickman et al, 1988). More recent series have shown similar com-plication rates for acute cholecystectomy among diabetic and nondiabetic patients. Diabetic patients with asymptomatic gall-stones today are managed expectantly.

The incidence of gallstones is twice as high in patients with chronic liver disease. Most of these patients remain asymptom-atic. Operative morbidity and mortality rates for patients with chronic liver disease are also significantly higher. Meta-analyses report no increase in mortality in asymptomatic patients with an expectant management approach (Stewart et al, 1989; NIH Consensus Statement Online, 1992).

Patients undergoing bariatric surgery have a higher inci-dence of cholelithiasis, because obesity is associated with

cholelithiasis, and gallstones may form during rapid weight loss. Studies report a cholelithiasis incidence of 27% to 35% before bariatric operations and a 28% to 71% increase in gallstone formation following bariatric surgery (Wudel et al, 2002). Many surgeons utilize bile salt medications during periods of rapid weight to help prevent cholesterol gallstones. But even if gall-stones form, most are asymptomatic, and elective cholecystec-tomy is safe for symptomatic disease (NIH Consensus Statement Online, 1992).

Several factors must be considered for potential transplant patients with asymptomatic cholelithiasis: cholelithiasis is common, immunosuppression may increase infectious morbid-ity, and morbidity and mortality may be increased with emer-gency surgery. This problem was examined with a recent decision analysis, using probabilities and outcomes derived from a pooled analysis of published studies (Kao et al, 2005). The authors recommended prophylactic posttransplantation cholecystectomy for cardiac transplant recipients with asymp-tomatic cholelithiasis. For pancreas and kidney transplant patients with asymptomatic cholelithiasis, however, expectant management was recommended.

Asymptomatic gallstones found at another gastrointestinal operation should generally be removed if exposure is adequate, if the cholecystectomy can be done safely. Studies of expectant management for patients with asymptomatic gallstones under-going laparotomy for other conditions have shown a high (up to 70%) incidence of symptoms and/or complications from the biliary system, and a significant percentage (up to 40%) of patients require a cholecystectomy within 1 year of the initial operation. Further, no increase in morbidity is associated with concomitant cholecystectomy (Stewart et al, 1989; Klaus et al, 2002).

The management of patients with asymptomatic gallstones undergoing abdominal aortic aneurysm (AAA) repair has recently evolved, especially with the advent of endovascular aortic procedures. In the past, when AAA repair and cholecystectomy were open operations, concomitant cholecystectomy was recom-mended to prevent the higher morbidity associated with the development of acute cholecystitis in the postoperative period. Studies reported no increase in graft infection or morbidity when cholecystectomy was done following closure of the retroperito-neum; however, more recent data show similar mortality rates with or without concomitant cholecystectomy. Today, laparo-scopic cholecystectomy is typically performed after endovascular AAA repair, without increased morbidity (Cadot et al, 2002).

Children with asymptomatic gallstones comprise two main etiologic groups: those with hemolytic anemia (sickle cell

CHAPTER 37

Cholecystolithiasis and stones in the common bile duct: which approach and when?

Mark P. Callery, Norberto J. Sanchez, and Lygia Stewart