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Last updated: 30 March, 2020 15:59pm

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Cholecystectomy – Information for GPs

OPCS Codes (for GPs and practices)

J181       Total cholecystectomy and excision of surrounding tissue

J182       Total cholecystectomy and exploration of common bile duct

J183       Total cholecystectomy NEC

J184       Partial cholecystectomy and exploration of common bile duct

J185       Partial cholecystectomy NEC

Y751       Laparoscopically assisted approach to abdominal cavity

Y752       Laparoscopic approach to abdominal cavity NEC

Y755       Laparoscopic ultrasonic approach to abdominal cavity

Background

Gallstones are small stones usually made of cholesterol that form in the gallbladder. The majority of people with gallbladder stones remain asymptomatic and require no treatment. Patients with an incidental finding of stones in an otherwise normal gallbladder require no further investigation or referral1.

This commissioning policy sets out the threshold referral criteria for surgical treatment of gallstones.

Commissioning position

Surgery for asymptomatic gallstones will NOT be routinely commissioned.

Patients with gallstones found incidentally who do not have symptoms relating to gallstones should not be referred to Secondary Care for cholecystectomy.

NHS Scarborough and Ryedale and Vale of York CCGs will only commission elective referral into secondary care for a cholecystectomy assessment if the patient fulfils ANY of the criteria below:

  • Symptomatic gallstones with a thickened gallbladder wall
  • A dilated common bile duct on ultrasound
  • Asymptomatic gallstones with abnormal liver function test (LFT) results
  • Asymptomatic gall bladder polyp(s) reported on ultrasound
  • Symptomatic gall bladder ‘sludge’ reported on ultrasound

Elective cholecystectomy surgery will only be commissioned where the patient fulfils ANY of the criteria below:

  • Symptomatic gallstones
  • Gall bladder polyp(s) larger than 8mm or growing rapidly
  • Common bile duct stones
  • Acute pancreatitis

AND the patient is fit for surgery.

NB: although this policy is not subject to NHS Scarborough and Ryedale and Vale of York CCGs’ Health Optimisation thresholds patients should be encouraged by their GP and surgeon to lose weight prior to surgery and given appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.

GPs can refer patients for a surgical opinion whilst patients lose weight and surgeons (and anaesthetists) can consider the safety of surgery. There is a clinical balance between risk of surgical complications with obesity and with potential complications of gallstones whilst delaying surgery.

Treatment in all other circumstances is not routinely commissioned and should not be referred unless clinical exceptionality is demonstrated and approved by the Individual Funding Request Panel prior to referral.

Further guidance

Cholecystectomy should be performed laparoscopically in patients with an uncomplicated abdomen and in the absence of contra- indications. (The standard laparoscopic approach uses several small incisions in the abdomen).

Cholecystectomy should be offered as a day case procedure in the absence of contra-indications. Routine laparoscopic cholecystectomy does not generally require a consultant outpatient follow up.

If the gall bladder is sent for histological examination, the results should be reviewed by the requesting consultant and communicated to the GP.

Following treatment for CBD stones with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, removal of the gallbladder should be considered in all patients. However, in patients with significant co-morbidities, the risks of surgery may outweigh the benefits1.

Secondary providers offering cholecystectomy must be able to offer intraoperative on-table cholangiography and have arrangements in place for urgent access to ERCP and interventional radiology for the management of postoperative complications1.

Shared decision-making aid should be used, available at cholecystectomy for gallstones.

Patient information leaflets

Patient information leaflets at gallstones leaflet and gallstones diet sheet

Summary of evidence

Cholecystectomy is the surgical removal of the gall bladder. Prophylactic cholecystectomy is not indicated in most patients with asymptomatic gallstones. Possible exceptions include patients who are at increased risk for gallbladder carcinoma or gallstone complications, in which prophylactic cholecystectomy or incidental cholecystectomy at the time of another abdominal operation can be considered. Although patients with diabetes mellitus may have an increased risk of complications from gallstones, the magnitude of the risk does not warrant prophylactic cholecystectomy.

Primary and secondary care discussions with patients should include identifying options (surgery versus no surgery), including the risks and benefits of each.

References

  1. Royal College of Surgeons Commissioning Guide: Gallstone disease October 2013 http://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/gallstones
  2. Ahmed, R., Freeman, J.V., Ross, B., Kohler, B., Nicholl J.P., Johnson, A.G. Long

term response to gallstone treatment – problems and surprises. The European Journal of Surgery 2000 V. 166 (6) pp: 447-54. http://www.ncbi.nlm.nih.gov/pubmed/10890540

  1. British Society of Gastroenterology (January 2017) Guidelines on the management of common bile duct stones

https://www.bsg.org.uk/resource/Updated-guideline-on-the-management-of-common-bile-duct-stones-(CBDS).html

  1. Fazili, FM. (President WALS (World Association of Laparoscopic Surgeons. To operate or not to operate on asymptomatic gallstone in laparoscopy era. May 2010. http://www.wals.org.uk/article.htm
  2. Halldestam-I, Enell-E-L, Kullman-E Borch-K. ’Development of symptoms and complications in individuals with asymptomatic gallstones’. The British Journal of Surgery. 2004.Vol:91(6),Pg. 734-8. http://onlinelibrary.wiley.com/doi/10.1002/bjs.4547/abstract
  3. Meshikhes, A.W. Asymptomatic gallstones in the laparoscopic era. Journal of the Royal College of Surgeons of Edinburgh. 47(6):742-8 2002. http://www.ncbi.nlm.nih.gov/pubmed/12510966
  4. NICE IPG 346 - Single incision laparoscopic cholecystectomy. NICE Interventional

Procedure Guideline (May 2010)

http://guidance.nice.org.uk/IPG346

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