Current estimates show that more than 25 million Americans have gallstones. Each year, about 1 million new cases of gallbladder disease are diagnosed in the United States. Approximately 1.8 million a year will people develop abdominal pain as a result of the disease and seek medical care for treatment. More than 725,000 of these patients ultimately undergo surgery to resolve the problem.
The demand for safer and less-invasive interventions for gallbladder disease continues to promote innovations and new procedures for treatment. “With the recent technological advances in treatment for symptomatic gallbladder disease, it’s important to communicate the potential for new procedures to managing this common disease,” says Todd H. Baron, MD. In a review article published the New England Journal of Medicine, Dr. Baron and colleagues analyzed the pros and cons of five different interventional approaches to treat gallbladder disease.
The most common and well-established intervention that is currently used for treating gallbladder disease is laparoscopic cholecystectomy, according to Dr. Baron. This approach was introduced about 30 years ago as an alternative to traditional open surgery. The laparoscopic approach reduces visible scarring, but can be technically difficult to perform in patients with severe cholecystitis or prior abdominal surgery. “Laparoscopic cholecystectomy remains the gold standard treatment for gallbladder disease and it’s unlikely this will change, even with the new treatments that are emerging,” says Dr. Baron.
For patients who are not suitable candidates for the laparoscopic approach, percutaneous cholecystostomy is another viable option for the treatment of gallbladder disease. With this technique, a catheter is inserted directly into the gallbladder to allow bile to drain. Research shows that percutaneous cholecystostomy effectively resolves cholecystitis in about 90% of recipients. However, the external drainage tubes tend to be uncomfortable for patients, which can reduce quality of life.
Recently, natural orifice transluminal endoscopic surgery (NOTES) has been developed. The procedure involves accessing the gallbladder endoscopically through the mouth, vagina, or anus. The review notes the major advantage to NOTES is that it requires no incision. However, the procedure requires special equipment and is technically difficult to perform. As a result, only a few medical centers in the U.S. are currently offering the procedure, but this may change as more surgeons become skilled in it in the future.
Endoscopic procedures to drain the gallbladder can also be performed using transpapillary or transmural routes. “These are newer procedures that are still evolving, but they could replace percutaneous drainage in many non-operative patients,” says Dr. Baron. In both of these endoscopic techniques, most often performed by gastroenterologists, bile is drained from the gallbladder directly into the patient’s gastrointestinal tract to serve as an aid to digestion. Both approaches eliminate problems that can arise when using external drainage tubes. They can also help with the loss of bile, fluid, and electrolytes.
The transpapillary endoscopic drainage approach has been feasible for years, but it is technically difficult and not currently used in many U.S. medical centers. The transmural drainage approach has emerged more recently. Endoscopic ultrasound guidance is used to puncture the gallbladder through the stomach or duodenum. A self-expandable metal stent is then used to maintain internal bile drainage.
“The transmural approach is an exciting development because it offers an internal, non-operative approach that can be used in patients with gallbladder disease who are not surgical candidates,” Dr. Baron says. “However, it is not yet widely available. Expandable stents available for such use are not yet FDA approved for gallbladder drainage, and we need long-term and comparative outcome data to other approaches, particularly percutaneous therapy.” He adds that, in the future, it may be especially useful for patients who might otherwise be treated with percutaneous drainage because it avoids the need for external tubes.
According to Dr. Baron, the decision on which approach to managing gallbladder disease—be it surgical, laparoscopic, endoscopic, or percutaneous—will depend largely on the patient’s overall medical condition and the local and systemic consequences of the disease (Figure). “When discussing treatment options, clinicians need to think about the severity of the acute illness, the patient’s overall health, and the locally available expertise and technology,” he says. “We should also take a multidisciplinary approach to managing patients. There isn’t always one clear option to choose, and involvement from other specialists can help with treatment decisions. In addition, more than one approach may be needed in an individual patient and the various approaches should be seen as complementary rather than competitive.”
More research is anticipated on the procedures currently available for gallbladder disease, including comparative trials. Data are also needed on recently developed endoscopic methods for gallbladder drainage. These procedures may be useful alternatives to percutaneous cholecystostomy and have been associated with fewer adverse effects, but clinical trials can help assess the short- and long-term outcomes of these emerging interventions.
Readings & Resources (click to view)
Baron TH, Grimm IS, Swanstrom LL. Interventional approaches to gallbladder disease. N Engl J Med. 2015; 373:357-365. Available at: http://www.nejm.org/doi/full/10.1056/NEJMra1411372?query=featured_home.
Tucker JJ, Grim R, Bell T, Martin J, Ahuja V. Changing demographics in laparoscopic cholecystectomy performed in the United States: hospitalizations from 1998 to 2010. Am Surg. 2014;80:652-658.
Yokoe M, Takada T, Strasberg SM, et al. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2013;20:35-46.