How to choose the treatment plan for gallstones? Medication or surgery

Gallstones are a common clinical disease, especially in middle-aged and obese women. Many patients have no obvious symptoms, or only mild atypical symptoms, such as upper abdominal pain, bloating, fullness after meals, indigestion, etc. There are also many patients who “accidentally” discover gallstones during physical examinations and B-ultrasound examinations.

Then, a series of questions arise: How to choose the treatment plan for gallstones? Do I need to take medicine or surgery? Can medicine cure it? When should I have surgery and what kind of surgery should I have? Is the surgery traumatic? Will there be sequelae? In addition to surgery, are there other ways to remove stones?

Below, we sort out these questions and answer them one by one:

Question 1

What is the natural course of gallstones and are the consequences serious?

1. Asymptomatic gallstones: Most patients with gallstones have no obvious symptoms for a long time. According to the long-term follow-up observation of some patients with asymptomatic gallstones, this group is a benign disease group with a mild course of disease. Few patients will have severe symptoms and require surgery within 10 to 15 years.

2. Symptomatic gallstones: The “symptoms” here refer to severe gallstone-related symptoms such as biliary colic and acute cholecystitis, and do not include general indigestion symptoms. Symptomatic gallstones not only have a significant impact on the patient’s life, but studies have also shown that this group has a higher risk of acute cholecystitis, pancreatitis, and biliary obstruction.

3. Possibility of developing gallbladder cancer: Gallbladder cancer is the most serious complication of gallstones. But generally speaking, the possibility of occurrence is very small. Large gallstones, American Indians, porcelain gallbladder and abnormal pancreaticobiliary duct junction are considered to be high-risk factors for gallbladder cancer.

Question 2

After confirming gallbladder stones, what are the basis for choosing a treatment plan?

In the past, there was a tendency to “treat everything” for gallstones, especially with the popularization of laparoscopic technology, which has made this tendency more serious. However, given that the gallbladder has many functions such as storing concentrated bile, regulating bile duct pressure, and building the bile duct immune system, whether surgery is needed should be carefully considered in combination with the patient’s specific condition.

Factors that need to be considered when deciding on a treatment plan include: how severe the patient’s symptoms are (are the benefits of surgery great?), whether the gallbladder is functioning normally (how big will the side effects of surgery be?), and whether the gallbladder has inflammation, complications, or malignant changes (other factors that increase the necessity of surgery).

Question 3

What treatment options are currently available? What are the pros and cons of each?

1. Cholecystectomy: It is the most accurate and effective method for treating gallstones, and the technology is mature. However, the disadvantage is that the physiological function of the gallbladder is completely lost, and various complications such as bile duct injury, post-cholecystectomy syndrome, and papillary sphincter dysfunction may occur.

2. Cholecystolithotomy: A method of surgically removing gallstones from the gallbladder while preserving the gallbladder. The advantage is that the function of the gallbladder is preserved, but the biggest problem is that the recurrence rate of gallstones is extremely high in the future. Once the gallstones recur, the surgery is in vain!

3. Drug dissolution: If oral drugs can dissolve stones, that would be ideal. Unfortunately, only ursodeoxycholic acid has this effect, and it is limited to 5% to 15% of stone patients (pure cholesterol stones). Studies have shown that even if the stone is successfully dissolved, the recurrence rate in the future is still as high as more than 50%.

4. Extracorporeal shock wave lithotripsy: It was once used as a minimally invasive method in clinical practice. However, it also faces the disadvantages of limited efficacy, high recurrence rate of stones after surgery, and possible liver damage.

Based on the above information, experts in related fields have reached the following consensus on the treatment of gallstones:

1. The treatment of gallstones should be individualized based on factors such as whether the patient has symptoms, whether the gallbladder is functional, whether there is inflammation, whether there are complications, and whether there are conditions for surgery.

2. Patients with asymptomatic or mildly symptomatic gallstones do not need routine preventive cholecystectomy (so-called expectant management).

3. Prophylactic cholecystectomy may be an option for elderly patients in whom expectant management may significantly increase surgical risks.

4. Patients whose symptoms of gallstones significantly affect their work and life or who have had a history of biliary colic, acute cholecystitis, biliary pancreatitis, etc. should undergo elective cholecystectomy.

5. For patients with gallstones who have high risk factors for gallbladder cancer or suspected gallbladder cancer, surgery should be performed regardless of whether they have symptoms.

6. Cholecystectomy is the standard surgical procedure for the treatment of gallstones. If conditions permit, laparoscopic surgery should be the first choice.

7. The practical value of cholecystolithotomy needs further study. Currently, it is only suitable for emergency treatment under acute conditions and is not recommended as an elective surgical procedure. 

8. The cure rates of drug lithotripsy, stone removal therapy, and extracorporeal shock wave lithotripsy are low and may lead to serious complications. They are not currently recommended for clinical use.