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INVASIVE
Laparoscopic Cholecystectomy
Open Cholecystectomy
ERCP
NON-INVASIVE
ESWL
Oral Dissolution Therapy
Natural Therapy

Laparoscopic Cholecystectomy ("Keyhole" Gallbladder Surgery)

In "keyhole" surgery to remove the gallbladder, four small incisions are made around the abdomen, including one in the navel through which a tube with a tiny video camera is inserted. Guided by the camera images on a video screen, other tiny instruments are inserted through the other incisions and used to:
  • probe the bile ducts to identify the cystic duct.
  • close off the cystic duct and blood vessels to the gallbladder with metal clips.
  • cut the cystic duct to separate the gallbladder.
  • drain the gallbladder of bile through the navel opening.
  • remove the gallbladder also through the navel opening.
"Keyhole" surgery has replaced traditional open surgery as the preferred method to remove the gallbladder, thanks to shorter surgery time, a shorter hospital stay, and a shorter recovery period. Among all the invasive methods of treatment, it offers the fastest relief from gallstone colic.

However, the risks of "keyhole" surgery are inevitably higher simply because it is performed without direct eye and hand contact. The surgeon's visual and tactile judgment is restricted by the myopic "keyhole" camera and the 2D flat video screen, as compared to the direct 3D view and feel of open surgery. The outcome of surgery depends almost entirely on the skill and experience of the surgeon, and to a certain extent the quality of his video equipment.

Risks include cutting the wrong bile duct (fatal and difficult to repair), nicking or puncturing adjacent bile ducts (bile leakage), bowels (fecal leakage), or blood vessels (excessive bleeding), and dropping a clip into the abdominal cavity.

Open Cholecystectomy (Open Gallbladder Surgery)

In open gallbladder surgery, a single large incision is made on the upper right side of the abdomen just below the ribs. The liver is then moved in order to reach the gallbladder. The connecting blood vessels and cystic duct are cut and tied, and the gallbladder removed.

Traditional open surgery has been used to remove the gallbladder long before the emergence of "keyhole" surgery, and will continue to be important as a back-up and repair procedure. Some of the reasons for converting from "keyhole" to open surgery are:

  • accidental injury to any bile duct, blood vessel or organ.
  • unexpected pathology not conducive to "keyhole" management.
  • stones in the common bile duct.
  • excessive bleeding .
  • unclear anatomy.
Open surgery provides the surgeon with a better view and direct feel of the patient's anatomy. The fact that open surgery is used as a back-up to "keyhole" surgery suggests that it is a safer procedure which the surgeon can rely on with greater confidence. However, it remains unpopular because of a longer hospital stay of 3 to 5 days, a slow and painful recovery period of 4 to 6 weeks, and a long ugly scar.

Risks are the same as "keyhole" surgery but significantly lower. With an open view of the anatomy, the risk of cutting the wrong bile duct is almost zero.

Endoscopic Retrograde Cholangiopancreatography (ERCP) and Sphincterotomy (ERS)

  • Endoscope - a hollow, flexible, lighted tube connected to a computer and video monitor, through which other instruments can be inserted.
  • Retrograde - in a direction opposite to the normal flow of bile.
  • Cholangiopancreatography - imaging of the bile ducts (cholangio) and pancreas (pancreato).
To check for gallstones in the bile ducts, ERCP is used before or during gallbladder surgery. After sedation, an endoscope is passed through the mouth, down the esophagus, through the stomach, and into the small intestine. The opening in the small intestine where the common bile duct and the pancreatic duct meet (ampulla of Vater) is identified before it is inserted with a plastic tube (catheter or cannula). Radio-opaque contrast dye is then injected into the common bile duct, and the images observed on the video monitor in order to locate the problem.

ERCP was initially developed as a diagnostic tool to examine abnormalities of the bile ducts, pancreas, and gallbladder. It has since expanded into therapy to treat blockages of the bile and pancreatic ducts. However, it cannot remove stones in the gallbladder.

Patients should be informed that when the problem is found, diagnostic ERCP may be converted on the spot to treatment such as:
  • sphincterotomy (ERS) - using an electrified wire (sphincterotome) to cut the sphincter of Oddi, the muscle which controls the opening where the common bile duct and the pancreatic duct meet. This will enlarge that opening through which gallstones are passed or other endoscopic tools inserted.
  • inserting a balloon into the common bile duct, inflating it to stretch the obstructed areas of the duct before withdrawing it to allow the stones to pass.
  • trawling the bile duct with a basket to capture the stones and pull them out.
  • inserting a plastic stent into a narrow area of the bile duct to help drain out the stagnant bile.
Risks include adverse cardiac, respiratory or other reactions to the radio-opaque dye, abrasion along the path of the endoscope leading to inflammation of the bile duct or pancreas, and perforation of the bile duct (bile leakage) or small intestine (bacteria leakage).

Extracorporeal Shock Wave Lithotripsy (ESWL)

ESWL uses high frequency sound waves to shatter cholesterol gallstones into pieces small enough to pass through the bile ducts into the intestines. This treatment is often combined with bile acid therapy to dissolve the fragments. The combination of ESWL and bile acid therapy helps to speed up gallstone clearance faster than either treatment used alone.

ESWL has not gained wide acceptance because of its poor results in relieving gallstone colic. It is useful only to a small percentage of gallstone patients with these conditions:

  • non-calcified cholesterol stones.
  • stones less than 30mm in diameter.
  • three or fewer stones.
  • bile ducts which are not blocked or inflamed.
  • a functioning gallbladder which is not inflamed.
  • a pancreas which is not inflamed.
  • not pregnant.
Many patients do not fulfill all the above conditions, and are therefore not fit for ESWL. For those who do take the treatment, usually with bile acid therapy, the results are slower compared to gallbladder removal.

Risks include shock wave injury to surrounding organs like the kidneys (back pain with or without bloody urine), liver and pancreas (abdominal pain), and stone fragments in the bile ducts (gallstone colic).
Oral Dissolution Therapy (Bile Salt or Bile Acid Therapy)
Because chenodiol (chenodeoxycholic acid) produces strong side effects, ursodiol (ursodeoxycholic acid) has become the main drug used in oral bile acid therapy to dissolve gallstones in the gallbladder. Tradenames for ursodiol include Actigall, Urso, and Urso Forte.

Ursodiol suppresses cholesterol production in the liver, thereby reducing the amount of cholesterol in bile. Low-cholesterol bile reabsorbs the cholesterol that had formed stones in the gallbladder, and gradually reduces the size of the stones.

Ursodiol is used to treat small stones not more than 5mm which float unattached to the gallbladder wall, a condition which can be achieved with the help of ESWL. Since the dissolved stones are passed through the bile ducts into the intestines, ursodiol therapy requires certain conditions similar to ESWL: non-calcified cholesterol stones, a functioning gallbladder, a normal pancreas, and bile ducts which are not blocked or inflamed.

Certain drugs are not compatible and should not be taken together with ursodiol. Antacids containing aluminium reduce ursodiol absorption into the body, while birth control pills and hormone therapy may raise cholesterol levels and negate the effects of ursodiol.

Ursodiol is a slow-acting drug, requiring 6-18 months of therapy and monitoring. If the size or number of stones have not been clearly reduced after 1 year, treatment should be discontinued. On the other hand, gallstones which have been cleared or reduced in size may recur if medication is stopped. It is therefore not surprising that only a small proportion of people with gallstones use bile acid therapy.

Though milder compared to chenodiol, some of the wide-ranging side effects of ursodiol include abdominal pain, nausea, diarrhea, constipation, headache, muscle ache, skin rash, fatigue, cold sweat, fever, cough, dizziness, back pain, bladder pain, difficult urination, bloody urine, swollen lips, tongue or face, difficult breathing and swallowing, chest pain, irregular heartbeat, or simply a general feeling of discomfort.

Home :: Gallstones :: Options :: FAQ :: About Us :: Contact

Disclaimer: This website is intended to provide general information about gallstone disease and management. It is not a substitute for medical advice from a qualified medical practitioner. Please use the information at your own discretion. Yong An Alternative Treatment will not be liable for unsatisfactory results arising from decisions based on the information in this website. Online December 2005.
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