Choledochoscopic Gallbladder-Preserving Cholecystolithotomy Alternative to Cholecystectomy

While it does not replace cholecystectomy, choledochoscopic gallbladder-preserving cholecystolithotomy (CGPC) provides a safe and efficacious treatment alternative that preserves the gallbladder while removing gallstones in select patients with gallstones, according to findings published in Surgery.

During CGPC, surgeons remove gallstones, stone debris, biliary sludge, benign lesions of the gallbladder wall, and polyps from the gallbladder and cystic duct under choledochoscopy. Surgeons must visualize free flowing bile from the cystic duct into the gallbladder prior to closing the incision with absorbable sutures. This procedure improves gallbladder function and bile circulation while preserving the gallbladder.

Only patients who present with normal gallbladder shape, size, and morphology without acute cholecystitis are suitable candidates for CGPC. Patients with more severe gallbladder atrophy and dysfunction, abnormal morphology, acute cholecystitis, or possible gallbladder carcinoma require cholecystectomies.

Researchers in China conducted a retrospective study analyzing postoperative outcomes of 4340 patients with gallstones who underwent CGPC between February 1992 and December 2011 at Peking University Department Shougang Hospital. Clinical data of interest included postoperative complications and recurrence rates following CGPC. The researchers successfully reassessed 3511 (80.9%) of the 4340 patients until December 2015.

Acute postoperative complications included bile leakage, intra-gallbladder hemorrhage, acute cholecystitis, and residual gallstones, requiring 13 of the 4340 patients who underwent successful CGPC to return for complete cholecystectomies.

During the follow-up period for 3511 patients, 4 developed colon cancer (3 in the ascending colon and 1 in the descending colon). Additionally, 52 patients developed common bile duct stones. Six developed simple common bile duct stones, while the remaining 46 also developed recurrent gallstones.

At the 1-year follow-up, patients experienced a 0.83% gallstone recurrence rate. Cumulative gallstone recurrence increased with time, peaking at a rate of 7.94% after 14 years; however, no further recurrence occurred between 14 and 23 years postoperatively. Most patients with gallstone recurrence either presented with mild symptoms or were asymptomatic.

After analyzing cumulative recurrence rate by subgroups divided by age, gender, gallstone number, and gallstone size, the researchers discovered that gallstone recurrence occurred at significantly higher rates in the 14- to 20-year-old age group compared with other age groups (P <.05). Gallstone recurrence also occurred at significantly higher rates in patients presenting with multiple gallstones compared with those with a single gallstone (P <.05). Therefore, patient age and gallstone number independently predicted risk for gallstone recurrence after CGPC.

“Through long-term observational studies of patients after endoscopic minimally invasive cholecystectomy, it could be confirmed that CGPC is a safe and effective surgical technique,” the study authors wrote. “Although it cannot replace cholecystectomy, it provides a treatment that preserves gallbladder function and can be used for patients with gallstones with a good gallbladder condition.”

Study limitations include lack of prospective control, long follow-up time, and less comprehensive follow-ups considering only gallstone recurrence and postoperative complications.