Management of Asymptomatic Gallstones

Few predictive factors for symptomatic progression of gallstone disease:
- Bariatric surgery - 30% develop gallstones
- post-colectomy - 20% will develop symptoms within 5 years
- prolonged TPN use

Despite these risk factors, there are few indications for prophylactic cholecystectomy:
- Expectant Management of Cholelithiasis is the accepted treatment despite low morbidity of lap chole
- Diabetes is not an indication for prophylactic chole.  Diabetics do not have any significant difference in prevalence, presentation or complications compared to nondiabetics

Post-Transplantation:
- Cyclosporine leads to gallstone formation.
- Need for prophylactic chole has been shown to be of benefit in cardiac transplant patients if screening u/s shows stones (Milas et al, Mayo clinic)
- in renal transplant patients, majority (~90%) remain asymptomatic

Hemoglobinopathies:
- at risk of developing pigmented stones.
- sickle cell: 70% of pts
- hereditary spherocytosis: 85%
- thalassemia: 24%
- Gallstones in sickle cell patients can pose a problem. ~50% will become symptomatic within 3-5 years. Presence of gallstones can be diagnostically challenging due to possibility of abdominal sickling crisis.
- Hemoglobinopathies are an indication to perform prophylactic lap chole, lap chole should also be performed if doing a lap splenectomy

Bariatric Surgery:
- incidence of gallstone formation after rapid weight loss:
- general population: 10-20%
- bariatric surgery population: 30-40%
- if gallstones documented at time of bariatric surgery - lap chole recommended
- Ursodiol - can decrease incidence if patient compliant (prevents cholesterol absorption, expensive (~$1.50/d), BID). Suggested for patients undergoing bariatric surgery without prior evidence of stones.

Incidental Cholecystectomy - Controversial:
- During AAA: controversial due to the presence of graft material.  Review of incidental chole - shown to be safe as long as performed after retroperitoneum is closed
- Other abdominal surgeries: One study (Watemberg et al) showed that in pts >70 yo with cholelithiasis, M&M was higher if you DO NOT do incidental chole during laparotomy for other reasons.... yet we do not routinely do this in practice - why?
- most were small studies - only Watemberg was larger study