Asymptomatic Cholelithiasis: Is Cholecystectomy Really Needed? A Critical Reappraisal 15 Years After the Introduction of Laparoscopic Cholecystectomy

Abstract

Asymptomatic cholelithiasis is increasingly diagnosed today, mainly as a result of the widespread use of abdominal ultrasonography for the evaluation of patients for unrelated or vague abdominal complaints. About 10-20% of people in most western countries have gallstones, and among them 50-70% are asymptomatic at the time of diagnosis. Asymptomatic gallstone disease has a benign natural course; the progression of asymptomatic to symptomatic disease is relatively low, ranging from 10-25%. The majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain ("colic"). In the prelaparoscopy era, (open) cholecystectomy was generally performed for symptomatic disease. The minimally invasive laparoscopic cholecystectomy refueled the discussion about the optimal management of asymptomatic cholelithiasis. Despite some controversy, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management). Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications. Concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions. Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis. An in-depth knowledge of the natural history of gallstone disease is required to select the optimal management option for the individual subject with silent gallstones. Management options should be extensively discussed with the patient; he or she should be actively involved in the process of therapeutic decision making.

Asymptomatic Gallstones (AsGS) – To Treat or Not to?

“…At the age of 65, about 30% of women have GS, and by the age of 80 years, 60% of both males and females have GS. The large majority of these (70-85%) are asymptomatic [4]. In India, Khuroo et al [5] reported a 6.1% (men 3.1% and women 9.6%) prevalence of GS in subjects above 15 years of age from Kashmir in northern India; 94% of these were asymptomatic at the time of diagnosis.…”

“…Factors that have been reported to confer a higher risk of progression from asymptomatic to symptomatic disease and/or complications include age <55 years, smoking, female sex, greater body weight, presence of three or more GS, and presence of floating stones [7,18]. Other workers have observed that life expectancy >20 years, calculi >2 cm in diameter, calculi <3 mm and patent cystic duct, nonfunctioning GB and perioperative detection of incidental stones are the risk factors for progression to symptomatic/ complicated GS disease [4,19] Higher risk of developing GBC has been reported in patients with GS and associated polyps >1 cm, calcified GB (13-22%), large stones >3 cm (10 times risk) [20,21], GB packed with stones [22] and ethnic groups in highincidence GBC areas [21,23,24].…”

Colecistectomia videolaparoscópica em 960 pacientes idosos

“…It is the most common abdominal surgical disease in the elderly, with prevalence of 21.4% for the aged 60 to 69 years and 27.5% in individuals aged over 70 years 2 . The symptoms are absent between 50% and 77% of cases 3,4 , but presentments of worsening and complicated biliary calculi are frequent.…”

Oesophagogastroduodenoscopy in patients with incidental cholelithiasis, its significance and therapeutic value: an observational study

“…perforated gall bladder), choledocholithiasis, other gall bladder pathologies like polyps, those having concurrent hepato-biliary pathology with suspicious/risk for malignancy, porcelain gallbladder, patients with large >3 cm stones, transplant patients and patients with chronic hemolytic conditions were excluded from the study. 5 Pain was evaluated for localization, radiation, severity, intensity alleviating and aggravating factors. The USG findings, endoscopic findings, and histopathology of the patients with gastric/duodenal biopsies findings were evaluated to decide a treatment plan for the patients.…”