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Gallstone disease

Key sources
The following summarized guidelines for the evaluation and management of gallstone disease are prepared by our editorial team based on guidelines from the Danish Surgical Society (DSS 2022), the World Society of Emergency Surgery (WSES 2020), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the American College of Radiology (ACR 2019), the Japanese Society of Gastroenterology (JSG/JBA/JGES 2017), the North American Neuroendocrine Tumor Society (NANETS 2017), the European Association for the Study of the Liver (EASL 2016), the American Society for Gastrointestinal Endoscopy (ASGE 2015; 2010), the American Academy of Family Physicians (AAFP 2014), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2010).
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Guidelines

1.Diagnostic investigations

History and physical examination: elicit medical history and perform a physical examination to identify characteristic findings of gallbladder stones (episodic attacks of severe pain in the right upper abdominal quadrant or epigastrium for at least 15-30 minutes with radiation to the right back or shoulder and a positive reaction to analgesics).
B
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  • Diagnostic imaging

  • Laboratory tests

2.Medical management

Expectant management: as per DSS 2022 guidelines, consider offering observation as an alternative to laparoscopic cholecystectomy in patients with uncomplicated gallstone disease.
C

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  • Bile acid litholysis

  • Management of pain

3.Therapeutic procedures

Extracorporeal shock wave lithotripsy
As per JSG 2017 guidelines:
Offer extracorporeal shock wave lithotripsy in patients with gallstone disease refusing surgery.
B
Offer extracorporeal shock wave lithotripsy in patients with non-calcified cholesterol gallstones with normal gallbladder function.
B

4.Perioperative care

Perioperative antibiotic prophylaxis: as per EASL 2016 guidelines, do not administer routine antibiotic prophylaxis before elective laparoscopic cholecystectomy.
D

5.Surgical interventions

Cholecystectomy, indications, JBA/JGES/JSG: perform cholecystectomy in patients with cholecystolithiasis presenting with any symptoms.
B

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  • Cholecystectomy (timing)

  • Cholecystectomy (choice of approach)

  • Cholecystectomy (technical considerations)

  • Cholecystectomy (management of postoperative leaks)

6.Specific circumstances

Elderly patients
Perform cholecystectomy in the elderly and in patients with high anesthetic risk with gallstone complications (such as acute cholecystitis, gallstone pancreatitis, or obstructive jaundice) as soon as the general status allows surgery.
B
Do not withhold laparoscopic cholecystectomy solely based on the chronological age.
D

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  • Pregnant patients

  • Patients undergoing bariatric surgery

7.Preventative measures

Primary prevention, lifestyle interventions: consider advising healthy lifestyle and food, regular physical activity, and maintenance of ideal body weight to prevent the formation of cholesterol gallbladder stones and symptomatic gallstones.
C

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  • Primary prevention (pharmacological interventions)

  • Prophylactic cholecystectomy

8.Follow-up and surveillance

Discharge from hospital: consider discharging patients undergoing uncomplicated laparoscopic cholecystectomy on the day of surgery. Ensure adequate control of postoperative pain, nausea, and vomiting for successful same-day discharge.
C

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  • Management of postoperative bile duct injury

  • Management of persistent symptoms