Non-Surgical Treatments For Gallstones
Observation
The risks of developing symptoms or complications from gallstones in patients who have no symptoms is on the order of 20% over 20 years. Thus, patients who are older than 40 years of age and have no other indications for gallbladder treatment can be observed. Although there is a risk of having an attack at an inopportune time or developing one of the complications, this is small. However, patients with symptoms or no symptoms in the above mentioned groups should consider treatment.
Drug Therapy
Actigall (Ursodiol) is the primary drug used to dissolve gallstones. It is a naturally-occurring bile acid. This drug has almost no side effects but can rarely lead to increases in cholesterol or diarrhea. This is in marked contrast to other drugs which have been used in the past. These older drugs have been associated with severe diarrhea and abnormalities in liver function.
Actigall is taken two to three times per day and costs about $2.00 per pill. The drug works only in patients who have cholesterol or primarily cholesterol stones (80%). This can be determined by taking an x-ray of the abdomen. The stones are not visible on x-ray if they are cholesterol but are visible if they contain calcium bilirubinate (20%). Patients with cholesterol gallstones who take Actigall for two years have a 20% chance of having their gallstones dissolved. These patients need to continue taking Actigall once per day after the stones dissolve since their gallbladder remains diseased and there is a 30 to 50% chance of recurrence of gallstones in 3 to 5 years without further treatment. While you are on Actigall you will need to get blood tests every 3 months to make sure there are no problems with the treatment.
Lithotripsy
Lithotripsy, or shock wave dissolution of gallstones, is a new procedure that uses a highly focused sound wave to break the stones into tiny particles which then pass through the cystic duct to the common duct and into the intestine.
The procedure, which takes about one hour, is done with general anesthesia or in some cases with mild sedation, and no incision is made. The patient lies flat on a table that has a bath of water beneath it. The physician uses ultrasound to locate the stones, and then focuses shock wave energy to break them up into small pieces. The patient takes the medication Actigall before and after surgery to dissolve the gallstone fragments.
Lithotripsy FAQs
Common questions about lithotripsy include:
No. Patients must have cholesterol gallstones, no history of acute cholecystitis, pancreatitis or common duct stones, not more than three gallstones, total stone size less than 30 mm, a functional gallbladder by oral cholecystogram and no medical contraindications. About 10 to 15 percent of patients with symptomatic gallstones are eligible for lithotripsy.
Some patients experience abdominal pain immediately following lithotripsy, as the stone fragments begin to dissolve. Other side effects can include skin bruising, blood in the urine, upset stomach or fever, diarrhea or constipation, headache or dizziness. Although there is a risk of pancreatitis or common duct stones, it is rare-the chance is less than one percent. The overall treatment is 90 to 95 percent effective.
Yes. After the lithotripsy treatment you need to take Actigall three times per day for about one year to aid in the dissolution of the gallstone fragments. In addition, it is a good idea to continue to take Actigall one time per day to prevent future gallstone formation. You still have a diseased gallbladder, with a 30 to 50 percent estimated chance of gallstone recurrence in 3 to 5 years.
Lithotripsy is a newly-approved procedure which may not be covered by some insurance companies. Check your insurance plan and consult your physician for details.
Laparoscopy
Common questions about laparoscopy include:
Laparoscopy is a means of vision. Rather than making a large incision and looking directly into your abdomen, we make small incisions of 5 to 10 mm (1/5 to 2/5 in.) and use a telescope to see inside your abdomen. The scope is attached to a camera that lets us operate while watching on a television screen.
The actual operation is done the same way but rather than using a 6 to 8 inch incision as for open surgery, we use four small incisions in laparoscopic surgery: two that are 5 mm (1/5 in.) and two that are 10 mm (2/5 in.).We then pass tubes through these incisions to allow access into the abdomen and expand the abdomen with carbon dioxide gas to provide us a space to work in. Our hands never enter the abdomen. Instead, we use long instruments to perform the surgery that we pass through the small tubes. One might compare laparoscopic surgery to open surgery like eating with chop sticks as compared to a knife and fork! Usually, laparoscopic cholecystectomies take about 45 minutes to an hour.
We grab the gallbladder, once it has been disconnected from the liver, and bring it up to the skin. A little bit of your gallbladder will poke out through the small incision in your skin. We then make a small incision in the gallbladder itself and aspirate (suck) the liquid (bile) that is in it. That shrinks your gallbladder to a size that will often come out through the incision. You can imagine this if you think of a balloon that is full of water. If you pull it through a small hole it won't come out because the water stops it. If you take out the water though, it will shrink down and easily come out. Sometimes the stones prevent the gallbladder from coming out. In that case, we take the stones out, one at a time, or break them up into pieces and then take them out. Rarely, we need to make the incision a little large to get your gallbladder out. This most commonly happens when the gallbladder is very inflamed.
Usually there is no spillage of stones or bile into the abdomen. However, when there is, we make sure to clean it up. We remove any stones that have fallen out and we wash the area where the bile was spilled. It is extremely rare for either of these to lead to any problem after surgery.
Yes and no. All patients can have an attempt at laparoscopic cholecystectomy but not all will be completed that way. Overall, about 99% of patients with gallbladder disease will be able to have the procedure completed laparoscopically.
There are a variety of factors which decrease the chance of the surgeon being able to complete the procedure laparoscopically.
These include:
- too much inflammation
- previous surgery
- unclear anatomy
- pregnancy
- common duct stones
- previously unrecognized abnormalities
- an intraoperative problem, such as bleeding
Conversion of a laparoscopic procedure to an open one should not to be viewed as a complication, since some patients simply are unable to be have the surgery performed laparoscopically without undue risk. Our goal is to perform a safe and uncomplicated procedure. Therefore, we will not take unnecessary risks just to complete the procedure laparoscopically.
The major advantage of laparoscopic surgery over open conventional surgery is the significantly shorter recuperative period. This derives from the smaller incisions used. Patients usually go home a few hours after surgery following laparoscopic cholecystectomy. Many patients are able to do normal daily activities that day, such as shopping or going to a movie. However, most people require 2 to 3 days to return to normal. In addition, although some patients return to work in 3 to 4 days, most go back one to two weeks after surgery.
Yes. Laparoscopic cholecystectomy requires general anesthesia. You will be asleep and completely unaware of what we are doing. During the operation, a small tube will be placed into your stomach via your mouth and another into your bladder. In addition, the standard breathing tube will be placed into your windpipe. All these tubes will be removed at the end of the procedure before you are fully conscious.
Like all surgery, there are risks. The first risks are related to the initiation of the laparoscopy. A needle is placed into the abdomen at the belly button. Although precautions are taken to avoid injury, approximately one in 1000 patients will have a resultant injury to the intestine or blood vessel. If this should occur, the surgeon may need to convert the operation to an open one to correct the problem.
In addition to the usual complications of surgery, such as bleeding and infection, injury to the common bile duct is possible. Although rare after open procedures, initial reports suggest that the incidence is greater after laparoscopic cholecystectomies. This finding, however, is related to the experience of the surgeon. The incidence of this injury after the surgeon has performed approximately 30 cases is the same as after open cholecystectomy