Asymptomatic cholelithiasis : Is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy

• Published in: Digestive diseases and sciences Vol. 52; no. 5; pp. 1313 - 1325
• Main Authors: SAKORAFAS, George H, MILINGOS, Dimitrios, PEROS, George
• Format: Journal Article
• Language: English
• Published: Heidelberg Springer 01.05.2007; Springer Nature B.V
• Subjects: Abdomen; Asymptomatic; Biological and medical sciences; Cholecystectomy; Cholecystectomy, Laparoscopic; Cholelithiasis - epidemiology; Cholelithiasis - physiopathology; Cholelithiasis - surgery; Disease Progression; Feeding. Feeding behavior; Fundamental and applied biological sciences. Psychology; Gallbladder cancer; Gallstones; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Laparoscopy; Liver, biliary tract, pancreas, portal circulation, spleen; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Medical sciences; Other diseases. Semiology; Patient Selection; Prevalence; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Vertebrates: anatomy and physiology, studies on body, several organs or systems; Sonography; Cholecystectomy; Endoscopic surgery; Carcinoma; Incidental cholecystectomy; Metabolic diseases; Asymptomatic; Malignant tumor; Silent gallstones, Laparoscopic cholecystectomy; Hepatobiliary disease; Biliary tract disease; Cholelithiasis; Abdomen; Porcelain gallbladder; Pain; Treatment; Concomitant cholecystectomy· Gallbladder carcinoma; Echography; Gastroenterology; Digestive diseases; Gallbladder; Biliary colic; Cancer
• ISSN: 0163-2116; 1573-2568
• DOI: 10.1007/s10620-006-9107-3

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.