This document provides an overview of alternatives to cholecystectomy for treating cholelithiasis (gallstones). It discusses the history and epidemiology of gallstone disease and outlines various nonsurgical treatment options including dissolution therapy using medications like ursodeoxycholic acid, extracorporeal shockwave lithotripsy to break up stones, and percutaneous techniques to remove stones. While cholecystectomy has long been the standard treatment, this document explores less invasive alternatives that may be suitable for certain patients depending on factors like stone composition and gallbladder function.

1. ALTERNATIVES TO
CHOLECYSTECTOMY FOR
CHOLELITHIASIS
DR Kabir, Abdulkareem

2. OUTLINE
• INTRODUCTION
• HISTORICAL ACCOUNT
• EPIDEMIOLOGY
• PATHOPHYSIOLOGY
• ETIOLOGY
• CLINICAL EVALUATION
• TREATMENT OPTIONS
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Cholelithiasis is one of the most prevalent GI diseases
with a substantial burden to health care systems.
• It is characterized by the formation of gallstones in the
hepatic bile duct, CBD, or gallbladder
• Until in the 1980s, the only therapeutic option for
patients with symptomatic gallstones was surgery
• However, several new and innovative nonsurgical
approaches are currently available.

4. HISTORICAL EVOLUTION
• Gallstones have plagued man since the dawn of time
• One of the earliest English essays on biliary stones was by
Thomas Coe (1757).1
• John S. Bobbs, was the first to offer definitive treatment for
gallstones.1
• He performed an emergency cholecystolithotomy on Mary
E. Wiggins, a 30-year-old female
• J. Marion Sims, a gynecologist is credited with performing
the first elective cholecystolithotomy in 1878.2
• Karl Langenbuch, a German, performed the first
cholecystectomy in 1882.3

5. HISTORICAL EVOLUTION cont..
• William J. Mayo in 1911, promoted cholecystectomy
for both symptomatic and asymptomatic gallstones.
• Cholecystectomy thus became the gold standard
• “Post-cholecystectomy syndrome” & fear of increased
risks of colon cancersearch for alternatives
• Five new treatment alternatives for gallstones have
been introduced over the last half of the 20th century

6. EPIDEMIOLOGY
•The prevalence of cholelithiasis is affected by many
factors; race, gender comorbidities and genetics.
•In the US, 10-20% of adults have gallstones.5
•About 500000 people develop complications
requiring cholecystectomy
•Responsible for about 10000 deaths
•World wide. 5
• the prevalence western countries is similar to that
in the US
• lower in Asia and Africa

7. • In Nigeria, the prevalence has been reported as 2-2.7
% of adults6-7
• In Zaria, gall bladder comprised 0.31% of all general
surgical admissions in between 1980-1999.8

8. ANATOMY

9. PATHOGENESIS
• Gallstones can be classified as either cholesterol,
pigment gallstones or mixed gallstones
• It occurs because certain substances in bile are
present in concentrations that approach the limits of
their solubility.
• When bile is concentrated in the gallbladder, it can
become supersaturated with these substances, which
then precipitate as crystals
• The two main substances involved in gallstone
formation are cholesterol and calcium bilirubinate

10. Illustration copied from;
https://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/pancreas_bil
iary_tract/gallstone_disease.pdf

11. Cholesterol Gallstones:
• The pathogenesis of cholesterol gallstones stems from a
genetic or acquired defect in the hepatic metabolism of lipids
• Normally cholesterol is fully solubilized by bile acids and
lecithin.
•A delicate balance exists in the proportion of cholesterol, Bile
acids and lecithin
• Cholesterol gallstones are formed when bile is super saturated
with cholesterol.

12. Cholesterol
concentration
Concentration
Bile acids and
phospholipids

13. ⇧ cholesterol
supersaturati
on
• ⇧cholesterol
secretion
• ⇩bile acid production
• ⇧ dietary cholesterol
⇧ cholesterol
precipitation
&crystallizati
on
• ⇧ gallbladder
secretion Nucleation
factorsGel Mucin
Impaired gall
bladder
function
• Poor gallbladder
contractility old age,
post surgical denervation
• Poor gall bladder
emptying TPN.
Pregnancy,
CHOLESTEROL STONE
FORMATION

14. Triangular coordinate relationship of bile constituents
Illustration copied from;
https://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/pancreas_biliary_tract/
gallstone_disease.pdf

15. PIGMENT STONES
•Black pigment stones;
•Form in conditions of high haem turnover
unconjugated bilirubin conc.  formation of
Calcium bilirubinate
•Brown pigment stones;
• Bacteria hydrolyze lecithin to release fatty acids, which bind
calcium and precipitate from the solution.
• The resulting concretions have a claylike consistency and are
termed brown pigment stones.
• Unlike cholesterol or black pigment gallstones, brown
pigment gallstones often form de novo in the bile ducts

16. ETIOLOGY
Cholesterol gallstones:
•Cholesterol gallstones are associated with female
sex, European or Native American ancestry, and
increasing age.
•Other risk factors include the following:
•Obesity
•Pregnancy
•Gallbladder stasis
•Drugs
•Heredity

17. • Black pigment gallstones
• Occur in individuals with high heme turnover as
seen in;
• Haemolytic disorders like SCA, B Thallasemia,
Spherocytosis .
•Cirrhosis.
• Brown pigment gallstones
•Intraductal stasis from strictures or infestations
•chronic colonization of bile with bacteria.

18. CLINICAL EVALUATION
• It is essential to understand the natural history of
gallstone disease to advise patients on the
appropriate management options.
• At one extreme, gallstones can remain silent for years
or even a lifetime.
• At the other extreme, they can cause life-threatening
complications and even death.

19. The lithogenic state
which favors gallstones
formation
Asymptomatic
gallstones
Symptomatic
gallstones,
characterized by
episodes of biliary colic
Complicated
cholelithiasis

20. • Gallstones may be present in the gallbladder without
causing symptoms or complications
• Symptoms of symptomatic cholelithiasis include
•Indigestion
•Dyspepsia,
•Belching,
•Bloating, and fat intolerance

21. • Physical examination;
•Patients with the lithogenic state or asymptomatic
gallstones have no abnormal findings on physical
examination
•In uncomplicated biliary colic,
•The pain is poorly localized and visceral in origin;
•The patient has an essentially benign abdominal
examination without rebound or guarding.
•Fever is absent

22. •Acute cholecystitis
•leads to a well-localized pain in the right upper
quadrant, usually with rebound and guarding.
•A positive Murphy sign
•Fever is often present, but it may lag behind
other signs or symptoms.

23. •INVESTIGATIONS
•Abdominal Xray Black pigment or mixed
gallstones may contain sufficient calcium to appear
radiopaque on plain films
•Abdominal USS Ultrasonography is the procedure
of choice in suspected gallbladder or biliary disease
•Other investigations include; CT scan, MRCP, HIDA
scintigraphy

24. TREATMENT OPTIONS
• Surgery has long remained the exclusive form of therapy
for GD.
• Understanding of the pathogenesis of gallstone formation
has heralded newer, less invasive alternatives.
• CHOLECYSTECTOMY
• Open
• Laparoscopic
• Alternatives to Cholecystectomy;
• DISSOLUTION THERAPY (DT)
• EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY (ESWL)
• ESWL + DT
• PERCUTAENEOUS CHOLECYSTOLITHOTOMY
• ENDOSCOPIC Techniques

25. DISSOLUTION THERAPY
• Also known as litholytic therapy
• Involves administration substances known to dissolve
cholesterol bile stones
• Includes;
•Oral Dissolution Therapy
•Percutaneous Contact litholytic therapy

26. ORAL DISSOLUTION THERAPY
• Involves the oral administration of bile acid preparations
• Chenodeoxycholic acid (CDCA)
• Ursodeoxycholic Acid (UDCA)
• They act principally by:
• Expanding the bile acid pool
• Inhibiting hepatic HMG-CoAR activity and thus decreasing
the secretion of biliary cholesterol,
• Reducing the duration of secretion of saturated bile.
• Drug therapy is performed long-term (from 6 mo to 2 years
or more),
necessarily with ultrasound guidance every 3 months. 10

27. • Chenodeoxycholic acid (CDCA)
•Its cholelitholitic effect was first demonstrated by
researchers at Mayo clinic in 1960s.9
•Administered in doses 250mg 12 hourly initially for
2/52 then increased to 13-16mg/kg/day
subsequently
•Its use is limited by side effects;
• liver test abnormalities, diarrhea, and increases
in serum LDL cholesterol levels.

29. • Ursodeoxycholic Acid (UDCA)
•Developed and first used in Japan in 1970s
•Safe and equally efficacious
•No significant adverse side effects or signs of
toxicity have ever been reported as a result of UDC
treatment in many of the many studies that have
been published.9
•Administered in 8-10mg/kg/day divided 12hrl, not
to exceed 300mg/dose

31. • Patient Selection for ODT
• For successful litholytic therapy, definite criteria should be met for
selection of patients with cholelithiasis.10:
1. the stone should be cholesterol or mixed;
2. the size of the stones should not be greater than 1.5 cm;
3. the gallbladder should have its functions preserved
4. be packed with stone not more than ¼ of the fasting volume;
5. the cystic duct and common bile duct should have their
patency preserved;
6. enterohepatic circulation of bile acids should be preserved

32. •Draw backs of ODT:
•It has a significant recurrence rate
•Its use is ineffective in pigment stones

33. PERCUTANEOUS CONTACT LITHOLYTIC THERAPY
•A substance that dissolves cholesterol stones is
injected just into the gallbladder or bile ducts
•They are infused transhepatically through a
catheter into the gallbladder lumen or common bile
duct,
•Only cholesterol stones are prone to dissolution
•Methyltretbutyl ether (MTBE)
•monooctanoin
•Dissolution occurs within 4-16 h.10

34. • This procedure is useful in symptomatic or
complicated gallstone disease, especially if the patient
refuses surgery or is a high risk patient.
• Drawbacks:
•MTBE is a toxic, inflammable anesthetic with
considerable side effects

36. EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY
.
•Is the most innovative new approach in the
management of gallstone disease.
•This method employs high-energy sound waves that
produce shock waves.
•Within minutes, stones are pulverized into small
fragments  pass spontaneously out of the
gallbladder or can be further dissolved with oral
dissolution agents.
•The efficacy of ESWL is very dependent on proper
patient selection.

37. • Advantages;
•No general anesthesia is required
•Patient may be managed on an outpatient basis
•Can be used in patients who are poor surgical
candidates

38. • Drawbacks;
•The set up is very expensive
•May require long term ODT
•High recurrence rates in the late period following
lithotripsy
•It has side effects including
•abdominal wall and skin changes (ecchymosis,
petechiae), pain, hematuria, nausea, emesis, and
biliary colic

39. • Patient Selection for ESWL10
1. Single radiolucent cholesterol stones not more
than 3 cm in diameter;
2. Multiple radiolucent stones 1-1.5 cm in diameter;
3. The volume of stones is less than 1/2 of that of the
gallbladder;
4. A functioning gallbladder;
5. Normal bile duct patency

41. PERCUTAENEOUS CHOLECYSTOLITHOTOMY
• Involves puncturing the gallbladder, dilating the tract, and removing
any gallstones with a cholecystoscope under C-arm fluoroscope
guidance
• Small stones (less than 7 mm) may be removed with grasping forceps.
• Larger stones are fragmented with electrohydraulic lithotriptor,
ultrasonic lithotriptor, or laser probes.
• Used in high-risk patients with acute calculous diseases, where
surgical intervention may be associated with increased morbidity and
mortality

42. •The advantages of this procedure are
•Immediate removal of uncrushed gallstones,
•Production of little gallstone debris
•Reduction of danger associated with sludge
entering the cystic duct

44. ENDOSCOPIC SPHINCTEROTOMY+ STONE
EXTRACTION
• Was first reported in 1974
• It employs the use of ERCP apparatus
• It enables extraction of biliary stones by enlarging the
papillary opening
• Stones lodged in the CBD can then be removed by a
basket
• It is commonly used for removal of CBD stones in high risk
surgical patients.

46. ENDOSCOPIC USS GUIDED GALLBLADDER
STENTING
• Endoscopic gallbladder stenting is useful in high-risk patients.
• It uses ERCP to insert a stent from the gallbladder to the
duodenum to relieve biliary symptoms and complications in high-
risk patients.
• A hydrophilic wire is passed from the ampulla of Vater into the
common bile duct and into the gallbladder through the cystic
duct.
• A trans-gastric or trans-duodenal gallbladder puncture is
performed under the EUS guidance
• lumen apposing metal stents (LAMS) is then introduced
through the puncture site

48. •Advantages
•It is less invasive than cholecystectomy
•Patients may be discharged quickly.
•Unlike other procedures that leave the gallbladder
intact, further stone formation does not hinder the
effectiveness of endoscopic stenting.

49. CONCLUSION
• Given the risks associated with cholecystectomy- both open and
laparoscopic, advances in the understanding of cholepoisis as well as
ultrasonic technology has led to the development of safer and non
invasive alternatives.
• The surgeon thus have an array of options to consider to tailor his/her
patient’s needs.

50. REFFERENCES
1. Cutter IS. Landmarks in surgical progress: John Stough
Bobbs and lithotomy of the gallbladder. Int Abstr Surg. 192847:409-411
2. Sims JM. Remarks on cholecystotomy in dropsy of the gallbladder. Br Med J. 1878. 1: 811 - 815
3. Langenbuch K. EinFall vonExstirpation der Gallenblasewegen
chronischerCholelithiasis. Heilung.BerlKlinWochenschr. (1882) 19:725
4. Mayo WJ. "Innocent" gallstones: a myth. JAMA. (1911) 56:
i021-1024
5. Halldestm I, Kullman E, Borch K, Incidence of and Poetential for Gallstone Disease in a general
population sample. Br J Surg. 2009 Nov. 96(11): 1315-22
6. Charles UE, Emanuel EE, Christpher CO. Prevalence of Cholelithiasis Among Igbo Adult Subjects
in Nnewi, Nigeria: A community- Based Sonographic Study. Journal of Diagnostic Medical
Sonography. 2017.
7. Akuto OO, Marinho AO, et al, Prevalence of Galllstones in a group of antenatal women in
Ibadan Nigeria. Afr J Med Med Sci. 1999; 28(3-4).

51. REFERENCES
8. MM Dauda, Yusufu LMD, Attah MM. Cholecysitis and Cholelithiasis in Adults in Zaria. Tropical
Doctor 2005;35 243-245
9. Albert MB, Hans F. Nonsurgical alternatives in the management of gallstones. J Intensive Care
Med. 1989;4:3-10.
10. Reshetnyak VI. Concept of the pathogenesis and treatment of VI. Concept of the pathogenesis
and treatment of of the pathogenesis and treatment of cholelithiasis. World J Hepatol 2012(2): 18-
3; Available from: URL: http://www.wjgnet.com/1948-5182/full/v/i2/18.htm DOI:
http://dx.doi.org/10.25/wjh.v.i2.18
11. Donald PG, Pedro AR, Malachy JG. Percutaneous endoscopic treatment of cholelithiasis. Surg
Endosc (1990)4" 141- 149
12.https://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/pancreas_biliary_tract/g
allstone_disease.pdf
13. Douglas MH. Gallstones (cholelithiasis). Medscape Article; updated Apr 2019