Asymptomatic gallstones revisited. Is there a role for laparoscopic cholecystectomy?

OBJECTIVE

To compare the mortality effects of prophylactic laparoscopic cholecystectomy with that of expectant management in persons with asymptomatic gallstones.

DESIGN

Decision analytic models of the two clinical strategies using input data from a review of the published medical literature pertaining to the epidemiology, natural history, and treatment outcomes related to gallstone disease.

PATIENTS

Cohorts of men and women aged 30 and 50 years with asymptomatic gallstones.

INTERVENTION

Prophylactic laparoscopic cholecystectomy performed at the time of diagnosis of asymptomatic gallstones or expectant management, defined as therapeutic intervention delayed until gallstone symptoms or complications spontaneously develop.

MAIN OUTCOME MEASURES

Gallstone-related deaths and gallstone-related life-years lost for each age and gender cohort, by strategy. Models were subjected to rigorous sensitivity analysis to test the robustness of the results to changes in individual input variables. Outcomes were calculated with and without discounting nonfinancial benefits.

RESULTS

The prophylactic laparoscopic cholecystectomy strategy led to fewer gallstone-related deaths than the expectant management strategy, but all of the deaths in the prophylactic laparoscopic cholecystectomy group occurred earlier in life. In cohorts older than age 30 years, the expectant management strategy resulted in fewer undiscounted gallstone life-years lost than the prophylactic laparoscopic cholecystectomy strategy. Discounting favored expectant management further because life-years lost were delayed compared with prophylactic surgery. Sensitivity analysis demonstrated the superiority of expectant management over a wide range of input assumptions.

CONCLUSIONS

Prophylactic laparoscopic cholecystectomy should not be routinely recommended for individuals with asymptomatic gallstones.