TO OPERATE OR NOT TO OPERATE
ON ASYMPTOMATIC GALLSTONES IN LAPAROSCOPY ERA
DR Fiaz Maqbool Fazili
MBBS. MS; MAMS; FICA; FICS(USA)
Dept of General, Laparoscopy and Endocrine
King Fahad Hospital Medina KSA
President WALS (World Association of
Laparoscopic Surgeons. KSA.)
WALS (World Association of Laparoscopic
Department of General (Endocrine
Surgery) and Gastroenterology,
King Fahad Hospital Medina Munawarh
Kingdom of Saudi Arabia.
The days when the only
means of diagnosis of gallstones was the ever faithful oral
cholecystogram, the gallbladder and its diseases were domains
solely reserved for the surgeons .The policies of management
of its malfunctions, maladies and especially its calculi would
be determined by them –rarely in their agenda was surgery
omitted. The advent of ultrasonography, on the other hand, did
resolve many problems but it also introduced a few of its own.
Thus, not infrequently, surgeons were faced with asymptomatic
gallstones detected by the overzealous internists,
gastroenterologists, general practioners, gynecologists and
cardiologists. This finding undoubtedly lead to the
everlasting controversy of their management. Now with the
establishment of laparoscopic cholecystectomy for initial
treatment of gall stones the incidence of cholecystectomies
has gone high. There seems to be a trend on the part of
surgeons to advise cholecystectomy for all patients with gall
stones irrespective of their symptoms. Present article
discusses the subject of gallstones as regard their
management. Are they to come out despite their seemingly inert
position or should we wait for them to become aggressive
before action is taken?
The presence of gallstones detected incidentally in patients
who do not have any abdominal symptoms or have symptoms that
are not thought to be due to gallstones. The diagnosis is made
during routine ultrasound for other abdominal conditions or,
occasionally, by palpation of the gall bladder at operation.
This definition implies that we know which symptoms are
specific to gallstones
The incidence of
gallstones varies widely, being greatly influenced by dietary
intake, particularly of fat. For example, in Saudi Arabia
gallstone disease was virtually unheard of 50 years ago, but,
with increasing affluence and a Western type diet, gall stones
are now as common there as in many Western countries (2).In
the United Kingdom about 8% of the population aged over 40
years have gall stones, which rises to over 20% in those aged
over 60. Fortunately, 90% of these stones remain
asymptomatatic but cholecystectomy is the most commonly
performed abdominal procedure (1). In United States around
500,000 individuals lose their gallbladders annually. Exactly
how many of those operated upon silent gallstones had is
unknown, although a few reports mention a figure of 4- 7%.
Many of these operations are done for symptoms as vague and
complex as dyspepsia which may not necessarily be due to
stone disease management-------traditional teaching and
Traditionally we were
taught that surgery is indicated in virtually all gallstones
cases. This teaching was based on erroneous concept that
gallstone disease progresses at a fast pace and complications
are very common. These concepts were so much magnified to the
patient that we ended up believing firmly our own magnified
image of the monstrous and mean gallstones. In the old
literature, Moynihan in 1908 and Mayo in 1911 warned of the
consequences of silent stones. Mayo wrote that “the innocent
gall stone is a myth.’).
However, the natural history of gallstone disease indicates
that most patients with gallstones will not require treatment
during the course of their life .Two
thirds of gall
aysmptomatic, and the yearly risk of developing biliary
pain is 1-4%... In
gallstones were detected by ultrasound screening of a
population, which was then followed up for 11 years.
Complication rates (acute pancreatitis, obstructive jaundice,
cholecystitis) are 0.2 - 0.8% per annum (4).
A longitudinal follow – up study of asymptomatic gallstones at
the University of Michigan, showed that over a 20 year period
only 18% developed biliary pain and that the mean yearly
probability of the development of biliary pain is, 2% during
the first 5 years; 1% during the second 5 years; 0.5% during
the third 5 years; 0% during the fourth 5 years. A very
important observation noted in that study, was that no person
ever presented a biliary complication as an initial
manifestation of his biliary disease. None of these
individuals died because of gall stone disease. (5,6) Although
are associated with cancer of the gall
bladder, the risk of developing cancer in patients with
gall stones is <
0.01%—less than the mortality associated with Cholecystectomy.
The conclusion drawn from the studies that prophylactic
cholecystectomy for asymptomatic gallstones could not be
recommended. (2, 5-7)
Cholecystectomy in Laparoscopy era;
With increasing trend
towards subjecting patients to Laparoscopic Cholecystectomy
for gall stones. The treatment of patients with silent gall
stones must be seen in the context of recent establishment of
laparoscopic Cholecystectomy for gall bladder disease. The
overall mortality risk of cholecystectomy varies from
0.14-0.5% in different series depending on the age and fitness
of the patients. The concern that cholecystectomy leads to a
slightly increased risk of right sided colon cancer in women
after 15 years is still not over. There is also an increase in
gastro-oesophageal bile reflux and of diarrhea after
cholecystectomy (in patients with irritable bowel syndrome and
loose stools). Although Laparoscopic cholecystectomy is
established as first procedure of choice for gall bladder
diseases when performed properly by surgeons skillful with
laparoscopic instruments, the procedure imposes minimal pain
and morbidity. However on a universal scale, the operation at
this time is still associated with same mortality and perhaps
greater morbidity from common bile duct injuries as compared
with standard open cholecystectomy (8).How much justified is
prophylactic cholecystectomy when
stones are discovered incidentally
by radiography or ultrasonography during the investigation of
other symptoms. Doesn’t the risks
of the operation outweigh the complications if the stones are
left .This is another compelling argument against
laparoscopic cholecystectomy for aysmptomatic gallstones (9).
On comparing the cost
of each of the above strategies of treatment it became clear
that the cost of expectant management was almost one fourth
that of prophylactic surgery. The cost of prophylactic
surgery, given the prevalence of gallstones, would be high.
Calculations based on average costs in a British hospital
would be almost £ 4 million / 10,000 patients with
asymptomatic gallstones in
The general recommendation for patients with asymptomatic
gallstones is expectant management unless the patient is at
increased risk for cancer or complications.
However, some groups
are at increased risk, and their management is controversial.
Diabetes mellitus and
asymptomatic gall stones;
diabetes and asymptomatic gallstones, some controversy exists
regarding whether their gall bladder should be removed
It has been stated that diabetic patients are particularly
prone to biliary complications from their stones. This led
some authors to advocate prophylactic
Cholecystectomy in asymptomatic diabetic patients (11-12).
Although there is no evidence, however, that diabetes with
asymptomatic stones are more likely than other patients either
to become symptomatic with biliary colic or to suffer
complications without first becoming symptomatic with biliary
colic However, diabetic patients do
not have an increased morbidity or mortality from stone
disease once other co morbidities such as cardiovascular
disease and renal insufficiency are taken into account (13).
comparing patients with asymptomatic gallstones over time
support this view, showing no difference in the incidence of
symptoms, complications and mortality comparing diabetic to
non-diabetic patients (14).There is no clear benefit to
prophylactic cholecystectomy in diabetic patients with
asymptomatic gallstones. (15, 16).
The incidence of gallstones varies markedly among world
populations. The Pima Indians of the United States, especially
females, have an unusually high incidence of gallstones (17).
Stones develop at a young age and complications requiring
cholecystectomy occur in the majority of those who live for
longer than 50 years. In contrast, the Masai of East Africa
(18) have a very low incidence of cholelithiasis. Gallstone
disease and gallbladder cancer are frequent among the Chilean
(19),. North and South American and
Indian and European –American Indian) admixed population .In
this population, 3-5% of patients with aysmptomatic gall
stones may develop cancer. Hence, in this subgroup,
prophylactic cholecystectomy may be considered. These are
special occasion’s gall stones
develop at an earlier age, and data from numerous studies show
that the risk of symptoms and/or complications (including
gallbladder carcinoma) is cumulative. Indications for
cholecystectomy can therefore be liberalized in these
high-risk populations (12).
ASYMPTOMATIC STONES, GALLBLADDER CARCINOMA AND CALCIFIED
It is very rare to
find gall bladder cancer without stones except in the rare
condition of Adenomatous polyps.
Over 70% of patients developing gallbladder carcinoma have
gallstones (20). The risk of developing carcinoma is estimated
to be0.3% - 1% of calculous
gallbladders 20 years (21). The risk of developing
cancer in patients with aysmptomatic
stones is < 0.01%—less than the mortality associated
with cholecystectomy. A higher incidence of carcinoma has been
reported in patients with larger stones than 3cm size (22).
Because it would take at least 100 cholecystectomies to
prevent one death from gallbladder carcinoma, most authors do
not recommend prophylactic cholecystectomy in patients with
asymptomatic gallstones as a measure of preventing the
development of gallbladder cancer (23). The American Indian
women and the Chilean Hispanic and Indian population with
gallstones represent the only exceptions to this rule.
Because of the early onset of gallstones in that population,
there is an increased risk of gallbladder carcinoma and
prophylactic cholecystectomy appears to be justified (17, 19).
Patients with porcelain gall bladder (a rare occurrence
of a calcified gall bladder wall)
associated with carcinoma in 13–22% of patients
(23).Prophylactic cholecystectomy is indicated in these cases
even in the absence of symptoms because of the elevated
risk of malignancy.
OTHER RISK FACTORS-Warranting prophylactic Cholecystectomy;
Patients with other
hemolytic anemia's are also at risk for gallstone development
many of whom will become symptomatic (24). Several arguments
stand in favor of elective cholecystectomy in patients with
hemolytic anemias. Biliary complications and vaso-occlusive
crisis both present similarly (nausea, abdominal pain, fever,
leucocytosis and cholestatic jaundice) and differentiation is
not easy. The onset of gallstones at a young age in
sickle-cell disease raises the lifetime risk of biliary
complications. Cholecystectomy following the diagnosis of
asymptomatic gallstones in patients with sickle-cell disease
is therefore advisable (25).
Sometimes, consideration is given to perform an incidental
cholecystectomy in addition to the planned operation in
patients with asymptomatic gallstones. The purpose would be to
prevent postoperative cholecystitis or the later development
of symptoms. Of course the addition of one procedure should
bear no added risks for the patient. Several investigators
have tried to address this question. Several studies have
confirmed a high incidence of biliary symptoms following
laparotomy for unrelated conditions. Juhasz and
colleagues studied patients with asymptomatic cholelithiasis
who underwent operation for colorectal disease. One hundred
and ninety-five (4%) had an incidental cholecystectomy while
110 (36%) did not There was no increase in operative morbidity
in the cholecystectomy group. A
total of 20 patients required cholecystectomy during a median
follow up of 6 years in non
operative group. The cumulative probability of needing a
cholecystectomy at 2 and 5 years after the initial surgery was
12 and 22 %( 26). The authors therefore recommend incidental
cholecystectomy in patients with asymptomatic gallstones who
undergo operation for colorectal diseases. Simple
cholecystectomy is now widely accepted as a concomitant
procedure during the course of laparotomy for unrelated
conditions. Its purpose is not only to prevent immediate
postoperative biliary complications but also to reduce the
risk of later biliary symptoms. If the gallstones are
discovered preoperatively, as is most often the case,
cholecystectomy should be discussed with the patient
preoperatively. The discussion should emphasize the safety and
the purpose of the procedure and not dismiss the possible
complications—as with any additional surgical procedure.
Clinical judgment and caution as to the appropriateness of the
procedure remain paramount in each specific case of incidental
careful analysis of hepatobiliary and systemic risk factors
should precede any decision regarding cholecystectomy for
asymptomatic gallstones. The procedure cannot be recommended
for the vast majority of the population. Because the risk
factors for symptoms and possibly the
complications of gallstones are cumulative
(2% per year), prophylactic cholecystectomy may be considered
in some populations in asymptomatic patients with genetically
determined early development of gallstones and risk for
gallbladder cancer. Whether patients with a life expectancy of
several decades should undergo prophylactic cholecystectomy is
debatable (12). At this point there is no data to support it.
Cholecystectomy for asymptomatic gallstones is indicated in
all patients with calcified gallbladder and in young patients
with sickle-cell disease, patients with rapid weight loss,
weight cyclers.Patients who are known to have gallstones and
may be living in a part of the world that is very remote from
medical treatment, should they get a complication. Patients
with immune suppression e.g. after transplantation. These may
have a far higher risk should they develop a complication such
as cholangitis. But also cyclosporine A and tacrolimus (Prograf/FK
506) are prolithogenic because of decreased bile salt export
pump function (BSEP).
Exceptions to this
policy – of not operating on asymptomatic gallstones – may
depend on whether the patient is scheduled for another
abdominal operation or whether an operation is carried out
specifically for the presence of gallstones...
Patients with insulin-dependent diabetes do not have a higher
prevalence of stones, Diabetic patients should be evaluated
for cholecystectomy with the same criteria as the general
population; prophylactic cholecystectomy cannot be supported
but when an elderly, have a higher risk of ischaemia of gall
bladder should they develop inflammatory complications.
Provided that the exposure is adequate and there are no
associated hepatobiliary risk factors (abnormal liver function
tests, dilated bile ducts, cirrhosis, a shrunken or scarred
gallbladder), incidental cholecystectomy can be carried out
safely as part of another abdominal procedure. There are
individual considerations or exceptions as mentioned before
like gall stones in sicklers and gall stones in children,
have a relative indication for cholecystectomy even if their
gall stones are aysmptomatic .The chances of developing
complications on long term is high .Similarly accidental
discovery of gall stones at laparotomy some controversy
continues regarding the management amongst proponents of
prophylactic cholecystectomy and those who believe that
combining surgery for a aysmptomatic disease increases
morbidity. Reports are conflicting regarding both the
incidence of biliary symptoms after surgery in patients in
whom the gall bladder is not removed and the incidence of
longer recovery time and perioperative complications in
patients who do have cholecystectomy en passant currently. A
role for prophylactic treatment for aysmptomatic stones
discovered at major abdominal surgery remains to be
demonstrated. Cholecystectomy en passant currently is clearly
indicated only in symptomatic patients. It is contraindicated
when vascular grafts are to be simultaneously placed in the
Conclusion; Despite wishful
thinking, gall stones seldom disappear spontaneously.
Statistics show that every year thousands of people have their
gallbladders removed. Even today, only surgical removal of the
gallbladder (laparoscopic/open cholecystectomy is treatment
of choice) guarantees that the patient will not suffer a
recurrence of gall stones. The advantages of surgical removal
of the gallbladder over non-surgical treatment are the
elimination of gallstones, and the prevention of gallbladder
cancer. Issue of the development of carcinoma of the gall
bladder in patients with long standing gall stones comes up
frequently. Suffice it to say, the incidence of gall bladder
cancer is infrequent enough that this argument in favor of
prophylactic cholecystectomy is without merit. Patients
with silent gall stones must be carefully evaluated in the
context of their age, symptoms, and associated conditions in
order to arrive at a decision for the optimal treatment of
their calculous disease. In general, most patients with
aysmtomatic calculi are best managed by continued observation-
and not cholecystectomy.
Majority of people with gallstones never experience any
Others remain aysmptomatic (without symptoms) for at least
two years after the stone formation begins.
symptoms do occur, the chance of developing pain is about
2% per year for the first ten years after the stone
formation, after which the chance for developing symptoms
Risk of bile duct injury with laparoscopic cholecystectomy
is around 0.2%
Asymptomatic gall stones do not require treatment.
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Links to useful websites
Society for Surgery of the
Treatment of gallstone
and gallbladder disease. Inc.. 1998 Jun 3 (revised 2000 Jan).
Society of American
Gastrointestinal Endoscopic Surgeons
Guidelines for the
clinical application of laparoscopic biliary tract surgery.
1990 (updated 1999). 3 pages.
Optimed Medical Systems Clinical
(revised 2000). The software includes over 19 menus and
requires user to spend 2-5 minutes depending on the clinical
American College of Radiology
Criteria for evaluation of patients with acute right upper
quadrant pain. 1996 (revised 1999). 5 pages.
National Guidelines Clearing House
At the NGC site type 'cholelithiasis' in the searchbox for an
overview of all guidelines which mention
Dr Fiaz Maqbool Fazili
PoBox; 5147 Medina munawarah KSA.