Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

Abstract

Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.

Before and after COVID‐19 pandemic: impact on hepatobiliary and pancreatic surgical services in a Singapore Tertiary Hospital

“…Thus they had a lower peri‐operative risk of COVID if they visited the hospital. Third, Markov decision tree analysis has shown a high likelihood of asymptomatic gallstones becoming symptomatic and complications, suggesting a cumulative increase in patients with symptoms who are waiting for a cholecystectomy 10 . Finally, the pandemic stress could increase the general population's sedentary behaviour and binge eating 11 .…”

“…Third, Markov decision tree analysis has shown a high likelihood of asymptomatic gallstones becoming symptomatic and complications, suggesting a cumulative increase in patients with symptoms who are waiting for a cholecystectomy. 10 Finally, the pandemic stress could increase the general population's sedentary behaviour and binge eating. 11 The latest Ipsos survey report 12 conducted in January 2022 among a nationally representative sample of 500 adult Singaporeans aged 18 and above showed that 39% of Singaporeans said that they had gained weight since the pandemic, an increase of 9% from the 2020 survey with the average weight gain being 5.7 kg up from 4.8 kg reported in previous surveys.…”

Cracking the silent gallstone code: Wait or operate?

“…Moreover, emergency surgery, particularly for older patients with comorbidities, may significantly increase the risk of morbidity and mortality. Nonetheless, the rarity of complication development without prior symptoms questions the necessity of prophylactic surgery[ 29 ].…”

“…This includes individuals with chronic hemolytic syndromes, those awaiting solid organ transplantation, and those at increased risk of GBC, among others[ 21 - 25 ] (Tables 1 and 2 ). These groups are identified based on research indicating a higher risk of gallstone-related complications, although findings vary[ 29 ]. Nonetheless, the accurate identification of these high-risk categories requires further investigation.…”

Association of cholecystectomy with osteoporosis risk: a prospective study using data from the UK Biobank

“…Cholecystectomy, one of the most common abdominal surgical procedures, is widely performed in patients with chronic symptomatic gallstones and/or cholecystitis (1,2). Currently, some researchers advise expanding indications of early prophylactic cholecystectomy to selected asymptomatic gallstone patients (3). Although laparoscopic cholecystectomy is known to be safe, awareness of perioperative and relatively long-term complications is important in establishing surgical indications.…”