Percutaneous Cholecystolithotomy: A Logical Progression of Endourologic Techniques

What should I do about my patient's gall stones?

The problem of benign biliary disease is one that causes significant morbidity and social economic strain in the western world. The classical treatment, cholecystectomy, has been challenged by various medical and surgical techniques in a seemingly random nature. The development of the treatment of gall stone disease is reviewed by analysis of published studies over the last 20 years. The advantages and disadvantages are discussed as an overview and summary of the current management of gall stone disease in the light of our knowledge of its malignant potential.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a newly developed technique for removing the gallbladder. Its future is very promising and this operation will probably become the preferred method of cholecystectomy for most patients. However, the limitations of laparoscopic cholecystectomy should be realized and great care must be taken to avoid technical complications. If laparoscopic cholecystectomy is associated with a much higher incidence of injuries to the bile duct than is traditional open cholecystectomy, its promise of decreasing pain, disability, and costs to patients undergoing cholecystectomy will be unfulfilled. The practicing general surgeon should learn laparoscopic techniques, since much of the future of abdominal surgery will ultimately reside in applying "less invasive" methods to perform standard operations. When embarking on a new procedure such as laparoscopic cholecystectomy, it is imperative that the surgeon remember the basis of his or her craft, primum non nocere.

Percutaneous endoscopic treatment of cholelithiasis

Surgical management of gallstones was first performed successfully in 1878. Over the past decade, several new treatment alternatives have evolved that challenge the supremacy of traditional surgical cholecystectomy. Two endoscopic alternatives, e.g., percutaneous cholecystolithotomy (PCCL) and laparoscopic cholecystectomy (LC) are the latest additions to the growing armamentarium. Our initial experience with PCCL and LC as compared with our traditional cholecystectomy experience shows a 57% reduction in hospital days, a 58% reduction in postoperative analgesic dose, and 50% or more reduction in disabling convalescence in favor of the endoscopic alternatives. A review of the efficacy and morbidity of traditional surgery, peroral drug chemolysis (PDC), shockwave lithotripsy plus PDC, and percutaneous transhepatic lavage with methyl terbutyl ether suggests that the endoscopic alternatives are less morbid than traditional surgery and more efficacious and perhaps less morbid than other non-invasive or minimally invasive alternatives. Both original data and a literature review are presented.