Nonsurgical management of gallstones.

Nonsurgical management of gallstones has made considerable progress within the past 20 years. More than 95% of all patients with bile duct stones can be treated successfully by peroral endoscopic or percutaneous techniques. In the case of very large or impacted calculi, intracorporeal or extracorporeal lithotripsy is available (Figure 9-10). Mortality from these approaches is low (in the range of 1%) despite the fact that most patients are elderly and frail, and open surgery is rarely required. While nonsurgical management of bile duct stones is commonly accepted, there is disagreement as to whether gallbladder stones should be managed nonsurgically, especially in view of the introduction of laparoscopic cholecystectomy. For patients in good general health who are willing to undergo surgery, removal of the gallbladder is the treatment of choice. However, there are some patients in whom a nonsurgical procedure ought to be considered. These are patients with a patent cystic duct, a functioning gallbladder, and symptomatic, radiolucent stones who can be scheduled for elective treatment. In patients with small floating stones, solitary radiolucent stones or even multiple large stones with a CT density lower than 50 HU, the chance of complete clearance of the gallbladder ranges between 80% and 90% using oral dissolution therapy, direct contact dissolution, or a combination of extracorporeal lithotripsy and dissolution. Each method has its ideal candidates (Table 9-1). The overall percentage of patients with gallstones for these nonsurgical therapeutic options is probably not higher than 20%. Therefore, the impact on surgery is still minor. Controlled clinical comparisons of the different therapies are lacking at the moment. However, these approaches have already stimulated further research into the pathogenesis of gallbladder stone disease and will no doubt undergo further improvement. Drugs that, in addition to ursodeoxycholic acid, further reduce cholesterol saturation in bile such as 3-hydroxymethyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors are already under investigation for oral treatment of gallstones in combination with bile acids. Further studies will also clarify the influence of gallbladder motility and certain bile constituents, such as proteins, on clearance of gallstones and recurrence after successful nonsurgical management. Thus, nonsurgical options, which obviate the necessity for general anesthesia and eliminate the risk of bile duct injury, will certainly continue to play a role in the management of gallbladder stones.