ALTERNATIVE THERAPIES
Watchful Waiting
Watchful waiting has the advantage that no therapy may ever be required. For patients with silent or minimally symptomatic stones, the rate of development of moderate-to-severe symptoms or gallstone complications is estimated to be between 2% and 6% per year, leading to a cumulative rate of 7% - 27% in 5 years. Presumably the rate is higher for patients already having symptoms.
Cholecystectomy
For patients with symptomatic gallstones, surgery offers the advantage of immediate and permanent stone removal, but carries a high risk in some patients. About 5% of cholecystectomized patients have residual symptoms or retained common duct stones. The spectrum of surgical risk varies as a function of age and the presence of disease other than cholelithiasis.
Mortality Rates for Cholecystectomy in the U.S.
(National Halothane Study, JAMA 1966; 197:775-8)
27,600 Cholecystectomies
(Smoothed Rates)
Deaths/1000 Operations***
Figure 1
Mortality Rates for Cholecystectomy in the US |
Low Risk Patients*
|
Age (yrs)
|
Cholecystectomy
|
Cholecystectomy Common Duct Exploration
|
Women |
0-49 |
.54 |
2.13 |
| 50-69 |
2.80 |
10.10 |
Men |
0-49 |
1.04 |
4.12 |
| 50-69 |
5.41 |
19.23 |
High Risk Patients**
|
|
|
|
Women |
0-49 |
12.66 |
47.62 |
| 50-69 |
17.24 |
58.82 |
Men |
0-49 |
24.39 |
90.91 |
| 50-69 |
33.33 |
111.11 |
* In good health or with moderate systemic disease.
** With severe or extreme systemic disease.
*** Includes both elective and emergency surgery.
Women in good health or who have only moderate systemic disease and are under 49 years of age have the lowest surgical mortality rate (0.054); men in all categories have a surgical mortality rate twice that of women. Common duct exploration quadruples the rates in all categories. The rates rise with each decade of life and increase tenfold or more in all categories with severe or extreme systemic disease.
INDICATIONS AND USAGE
- Ursodiol is indicated for patients with radiolucent, noncalcified gallbladder stones < 20 mm in greatest diameter in whom elective cholecystectomy would be undertaken except for the presence of increased surgical risk due to systemic disease, advanced age, idiosyncratic reaction to general anesthesia, or for those patients who refuse surgery. Safety of use of ursodiol beyond 24 months is not established.
- Ursodiol is indicated for the prevention of gallstone formation in obese patients experiencing rapid weight loss.
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