Gallstones

Abstract

Gallstones are extremely common in the UK and have a major effect on healthcare resources. Presentation depends on whether the stones occlude the cystic duct or the common bile duct. Treatment for symptomatic gallstones is laparoscopic cholecystectomy as a day case. Conversion rates to open surgery should be <10% overall; many series report much lower rates. Stones in the common bile duct should be suspected and diagnosed preoperatively and may be removed by preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the young, an attempt should be made to preserve the biliary sphincter, and stones diagnosed preoperatively may be managed by ERCP and stenting followed by laparoscopic exploration, or directly by laparoscopic exploration. Laparoscopic cholecystectomy may be accompanied by selective or routine cholangiography. Stones discovered at elective laparoscopic cholecystectomy during on-table cholangiography may be managed by laparoscopic transcystic exploration or laparoscopic choledochotomy with bile duct exploration. On-table combined perioperative ERCP is another option and this technique may be enhanced by combined procedures to carry out a sphincterotomy or to place a biliary stent. Failure of these options may be followed by open exploration of the bile duct or postoperative ERCP. The treatment of acute gallstone disease is conservative, with subsequent elective laparoscopic cholecystectomy or urgent laparoscopic cholecystectomy. Urgent surgery is more economical, with a low conversion rate to open surgery in specialist hands.