Therapy of asymptomatic cholecystolithiasis
After diagnosis of asymptomatic cholecystolithiasis, the risk of developing symptoms is 2-4% per year in the first 5 years and then halves. The risk of biliary complications is only 0.1-0.3% per year [1]. A prophylactic cholecystectomy does not increase life expectancy in asymptomatic stone carriers, as the surgical risk outweighs the probability of developing biliary complications [2]. Various guidelines therefore agree that asymptomatic cholecystolithiasis generally does not represent an indication for surgery [3, 4, 5].
A special case is asymptomatic stone carriers with gallbladder concretions > 3 cm. According to the German S3 guideline 2017, cholecystectomy should be considered in these cases, as the risk of developing gallbladder carcinoma is increased up to 10-fold [6].
Recommendation for asymptomatic stone carriers in the context of obesity surgery
The German S3 guideline 2017 recommends performing a cholecystectomy in the context of obesity surgery only in symptomatic stone carriers [4]. The EASL guidelines 2016 agree with the S3 guideline in this regard, but only at a very low level of evidence [5]. This is reflected in the S3 guideline in a second statement on this topic, according to which a simultaneous cholecystectomy can be performed in asymptomatic patients during major malabsorptive procedures on the small intestine.
Compared to sleeve resection and gastric banding, laparoscopic Roux-en-Y reconstruction has the highest risk of postoperative gallstone formation [7]. The recommendation that simultaneous cholecystectomy should only be performed in symptomatic stone carriers is reflected in a registry study and a meta-analysis [8, 9]. The probability of a secondary cholecystectomy was low in these studies after laparoscopic Roux-en-Y reconstruction at 6.8%, and in 5.3% of cases this was due to symptomatic cholecystolithiasis. The secondary cholecystectomy was performed almost always (95.5%) laparoscopically with a very low morbidity (1.8%).
Therapy of symptomatic cholecystolithiasis
There is a consensus among all professional societies regarding the therapy of symptomatic cholecystolithiasis. Thus, the German S3 guideline 2017 recommends cholecystectomy for uncomplicated cholecystolithiasis with typical biliary pain [4].
The goal of cholecystectomy is to prevent recurrent biliary symptoms and later complications as well as to prevent gallbladder carcinoma. Untreated patients develop colic again in about 70% of cases within the following 2 years, and 4% require acute cholecystectomy [10]. The risk of biliary complications is 1-3% per year. If the patient is symptom-free for 5 years, he is considered an asymptomatic stone carrier again and does not need to undergo cholecystectomy [11]. For gallbladder sludge, the German S3 guideline recommends the same procedure as for symptomatic cholecystolithiasis [4]. Conservative-medical therapy or lithotripsy is obsolete nowadays [3].
Antibiotic prophylaxis in elective cholecystectomy
All of the above guidelines agree that in low-risk patients, no prophylactic antibiotic administration is necessary during elective cholecystectomy. There is no prospective, randomized study with sufficiently large patient numbers to clarify the question, but several meta-analyses, registry data from Germany and Sweden, and a Cochrane review [12, 13].
The SAGES guidelines make the same statement for low-risk patients, elaborating on this point further [14]:
- In high-risk patients (age > 60 years, diabetics, biliary colic within the last 30 days before surgery, jaundice, cholangitis or acute cholecystitis), the administration of antibiotics can reduce the rate of wound infections.
- If antibiotic prophylaxis is performed, it should be done 1 hour before skin incision.
- In open cholecystectomy or conversion from laparoscopic to open procedure, the wound infection rate can be reduced from 15 to 6% [13].
Recommendation for porcelain gallbladder
For the development of gallbladder carcinoma in calcified gallbladders, a risk of up to 62% has been reported in the past. According to newer studies, this number is too high [15, 16]. Nevertheless, it is recommended to prophylactically cholecystectomize asymptomatic patients with porcelain gallbladder [4, 5, 14].
Recommendation for the treatment of gallbladder polyps
The incidence of gallbladder polyps in Germany is about 6% [17]. The frequency of adenomas in these patients is about 5%. Adenomas > 1 cm in size contain carcinoma in up to 50% of cases, which is why these patients should be prophylactically cholecystectomized [18]. In even larger adenomas (1.8-2 cm), the carcinoma incidence increases even further, which is why primary open cholecystectomy should be performed from an oncological point of view [19].
Gallbladder polyps < 1 cm in size have a significantly lower risk of degeneration, so that although immediate cholecystectomy is not necessary, the patients must be regularly monitored sonographically [19]. If the patients develop biliary symptoms or further risk factors (age > 50 years, solitary polyps, gallstones, rapidly growing polyps), the indication for surgery is given [18, 20].
Endosonography is superior to transcutaneous sonography for the diagnosis of gallbladder polyps (87–97% versus 52–76%) [21].
The SAGES guidelines from 2010 recommend laparoscopic cholecystectomy for the treatment of gallbladder polyps in patients with large, singular polyps or in patients with concomitant symptoms. A “wait-and-watch strategy” is recommended for patients with small polyps (< 5 mm) [14].
The EASL guidelines from 2016 elaborate on the recommendations [5]:
- Cholecystectomy in patients with gallbladder polyps > 1 cm regardless of symptoms and independent of the presence of gallstones
- Cholecystectomy in patients with primary sclerosing cholangitis and gallbladder polyps
- No cholecystectomy in asymptomatic cholecystolithiasis and small polyps (< 5 mm)
The German S3 guideline recommends cholecystectomy only in patients with cholecystolithiasis and gallbladder polyps ≥ 1 cm independent of symptomatology [4].
Recommendation for laparoscopy in liver cirrhosis Child-Pugh A and B
Patients with liver cirrhosis are predisposed to the development of cholecystolithiasis. Studies have shown acceptable morbidity (9.5-23%) and mortality (0-6.3%) for laparoscopic cholecystectomy in Child-Pugh A and B patients. A prospective randomized study showed superiority of the laparoscopic technique over the open one [22]. Laparoscopic cholecystectomy is not recommended for Child-C patients.
The above guidelines agree on this with different levels of evidence and grades of recommendation.
Recommendations for the therapy of acute cholecystitis
The most common complication of cholecystolithiasis is acute cholecystitis, which in > 90% of cases is caused by a transient or permanent outflow obstruction due to concretions in the cystic duct. In these cases, laparoscopic cholecystectomy is performed as standard.
The recommendations of the various guidelines on the optimal timing of cholecystectomy after diagnosis of acute cholecystitis are as follows:
- German S3 guideline [4]
Acute cholecystitis is an indication for early laparoscopic cholecystectomy. This should be performed within 24 h after hospital admission.
- EASL [5]
An early cholecystectomy (preferably within 72 h after admission) should be performed by an experienced surgeon.
- SAGES [14]
Early cholecystectomy (within 24–72 h after diagnosis) can be performed without an increased conversion rate to an open procedure and without an increased risk of complications and can reduce both hospital costs and length of stay.
- Tokyo [23]
Determination of the therapy strategy after determining the severity of acute cholecystitis. For both grade I (mild) and II (moderate), laparoscopic cholecystectomy should ideally be performed promptly after onset of symptoms if the patient tolerates surgery. In case of severe inflammation (grade III), organ function should first be secured.
The Tokyo Guidelines from 2013 have been criticized by many professional societies as too conservative and not up-to-date [24,25]. Based on the current literature, immediate cholecystectomy within 24–48 h is associated with a clear benefit for the patient, which is withheld from grade II patients according to the treatment recommendations of the Tokyo Guidelines 2013.
Recommendation for gallbladder carcinoma, carcinoma in situ (Tis) and mucosal carcinoma (T1a)
Incidental gallbladder carcinomas are found in less than 1% of cholecystectomy specimens. For further therapy, the T stage is decisive, which is why the German S3 guideline, in agreement with the SAGES guidelines, states that removal of the gallbladder is sufficient for carcinoma in situ (Tis) or mucosal carcinoma (T1a) [5, 14].
In the aforementioned early tumor stages, there is neither lymphatic nor perineural spread [26]. Thus, liver partial resection or lymphadenectomy is not indicated. For all tumor stages ≥ T1b, oncological re-resection should be performed with curative intent (wedge resection with 2-3 cm liver cuff resection). If R0 status is achieved, the results after 4 years are very good [26].
Recommendation for laparoscopic cholecystectomy in pregnancy
Gallstones and sludge form in about 5% of all pregnant women with about 1% gallstone-associated complications still during pregnancy [27]. If conservative management is used, 92% of patients in the first trimester experience recurrent symptoms, 64% in the second trimester, and 44% in the third trimester. Fetal lethality due to biliary complications is 12-60% and thus significantly higher than due to indicated laparoscopic cholecystectomy (1.2%). Regarding fetal mortality or preterm birth rate, the current study situation shows no significant differences between open or laparoscopic cholecystectomy (5% vs. 4%) [28].
The German S3 guideline recommends regarding laparoscopic cholecystectomy during pregnancy that the procedure can be performed in any trimester if there is an urgent indication. Furthermore, patients who have already become symptomatic in the 1st trimester should be operated on early electively due to significant risk of recurrence in the further course of pregnancy [5].
This statement is confirmed by the SAGES guidelines on diagnosis, treatment and use of laparoscopy during pregnancy:
- For acute abdominal processes, diagnostic laparoscopy is also a safe and effective option during pregnancy.
- Laparoscopic cholecystectomy is the treatment of choice for pregnant patients with gallstone disease regardless of trimester.
- The same indications for laparoscopic treatment of acute abdominal diseases apply to pregnant patients as to non-pregnant ones.
- Laparoscopy can be performed safely in any trimester.
Recommendation for access techniques of laparoscopic cholecystectomy
A laparoscopic operation is generally the standard procedure for cholecystectomy. Both the German S3 guideline and the EASL and SAGES guidelines make recommendations for the type of laparoscopic access. While the SAGES guideline makes rather vague statements, the S3 and EASL guidelines are specific in that laparoscopic cholecystectomy should be performed in a 4-trocar technique [4, 5, 14].
Currently, there are no large, randomized studies that demonstrate an advantage for single-incision (SILS) or natural orifice transluminal endoscopic surgery (NOTES), so these techniques cannot currently be recommended as standard. Operative time and complication rate depend heavily on the surgeon's experience, and postoperative pain is not significantly reduced by either the SILS technique or the NOTES procedure [29, 30].