Friedman L S, Roberts M S, Brett A S, Marton K I
New England Deaconess Hospital, Boston, Massachusetts.
Ann Intern Med. 1988 Dec 1;109(11):913-9. doi: 10.7326/0003-4819-109-11-913.
The management of asymptomatic cholelithiasis in patients with diabetes is controversial. We used decision analysis to compare expectant management to prophylactic cholecystectomy in asymptomatic diabetic patients. Relevant probabilities were derived from the literature or expert opinion. Hypothetical cohorts of patients were followed for their lifetimes under each strategy. Expectant management was almost always the superior course. For example, a 30-year-old diabetic man gains an average of 6.1 months of life by choosing expectant management over prophylactic surgery. The superiority of expectant management was invariant to changes in age, sex, and the extent to which major surgical complications affect the future quality of life. Prophylactic cholecystectomy was superior only with extremely high estimates of the likelihood of developing symptomatic disease, the probability of requiring emergency surgery after symptoms develop, and emergency surgical mortality rates. However, no single factor had sufficient impact to alter the optimal decision by itself; the probabilities of several untoward events had to be increased simultaneously to favor prophylactic cholecystectomy. Prophylactic surgery for silent gallstones in diabetic patients does not increase life expectancy or quality of life and may in fact reduce it. This result holds over a wide range of basic assumptions.
糖尿病患者无症状胆结石的管理存在争议。我们使用决策分析来比较无症状糖尿病患者的期待治疗与预防性胆囊切除术。相关概率来自文献或专家意见。在每种策略下，对假设的患者队列进行终身随访。期待治疗几乎总是更好的选择。例如，一名30岁的糖尿病男性选择期待治疗而非预防性手术平均可多活6.1个月。期待治疗的优越性不受年龄、性别以及重大手术并发症对未来生活质量影响程度变化的影响。只有在对出现症状性疾病可能性、症状出现后需要急诊手术概率以及急诊手术死亡率的估计极高时，预防性胆囊切除术才更具优势。然而，没有单一因素本身能产生足够影响来改变最佳决策；必须同时提高几种不良事件的概率，才有利于预防性胆囊切除术。糖尿病患者无症状胆结石进行预防性手术并不会增加预期寿命或生活质量，实际上可能会降低。这一结果在广泛的基本假设下都成立。
