Since the first recognized case of cholelithiasis over 1500 years ago, numerous treatments have been used. These are primarily medical and surgical.
Bile salts taken orally may dissolve gallstones in those with a functioning gallbladder, but the process may take 2 years or longer, and stones may recur after the therapy is discontinued.
Medical dissolution, using both high-dose and low-dose chenodeoxycholic acids (CDCA, chenediol) was an approach investigated in the early 1980s. However, it was successful in only 14% of cases, required a long period of administration and a lifetime of maintenance therapy.
Urodeoxycholic acid (UDCA, ursodiol), a more contemporary medical therapy, is successful in only 40% of cases. Both CDCA and UDCA therapies are useful only for gallstones formed from cholesterol.
Other chemical methods include contact dissolution in which a catheter is passed through the abdominal wall and into the gallbladder and methyl tert-butyl ether, a volatile chemical, is then instilled. This chemical rapidly dissolves cholesterol stones but potential toxicity, stone recurrence, and other complications limit its utility.
Electrohydraulic shock wave lithotripsy (ESWL) has also been employed to treat cholelithiasis. The principal of this method is electromagnetically produced high-energy shock waves focused on a specific point in a liquid medium, producing fragmentation.
This approach was particularly popular in the mid to late 1980s, when some studies found it to clear gallstones in up to 60% of patients. However, its application is limited if there are a large number of stones present, if the stones are very large, or in the presence of acute cholecystitis or cholangitis. It can also be used in association with UDCA to improve its effect.
Despite these medical approaches, modern advances in surgical management have revolutionized the treatment of cholelithiasis. In general, surgery is indicated for symptomatic disease only.
In the past, open cholecystectomy was the usual procedure for uncomplicated cases. This operation necessitated a medium to large abdominal surgical incision just below the right lower rib in order to gain access to the gallbladder. After this operation, a patient typically spent 3-5 days in the hospital recovering.
However, in the early to mid 1980s, a new minimally-invasive technique called laparoscopic cholecystectomy was introduced which used small incisions and camera guidance in order to remove the gallbladder containing the symptomatic stones.
Currently, laparoscopic cholecystectomy is the gold standard for care of symptomatic cholelithiasis and is one of the most common operations performed in hospitals today. Using this approach, a patient with symptomatic cholelithiasis may have their gallbladder removed in the morning and be discharged from the hospital on the same evening or the next morning.
In addition, gallstones blocking the common bile duct may be visualized and removed during the laparoscopic procedure. Because this surgical treatment method has a complication rate of less than 1%, it has supplanted medical approaches to the treatment of gallstones.
