Don't have your gallbladder removed as a precaution just because a checkup found gallstones when you've never had pain

Cost

Free, and you save an operation under general anesthesia and a hospital stay. In return you owe the work of remembering which signals mean going to the hospital right away.

What you get

The MICOL population survey in Italy gave ultrasound to 11,229 people aged 29 to 69. It found 856 people with gallstones, 580 of whom had no symptoms, and followed them for an average of 8.7 years. Of these 580 people, 453 (78.1%) stayed symptom-free, 61 (10.5%) developed mild symptoms, and 66 (11.4%) developed severe symptoms. During follow-up 189 gallbladder removals were done in all, 41.3% of them in people without symptoms. The authors' conclusion was that “expectant management remains an effective approach for most patients,” where expectant management means watching first and not operating. A U.S. HMO (a kind of managed-care organization) followed 691 people with a confirmed diagnosis of gallstones for an average of 78±61.6 months. Among them, 135 people with no symptoms were followed for 58±50.2 months (median 46.3 months); only 10% developed gallstone symptoms and 7% had surgery. Of the 50 deaths in the whole group, only 2 were related to the bile tract, and both were in the group with symptoms. The authors' conclusion was that “patients with silent stones do not need surgery before symptoms appear”; silent stones are stones that make no noise and cause no attacks. The UK NICE guideline CG188, item 1.2.1, says: “For people with a normal gallbladder and bile ducts in whom asymptomatic gallstones are found incidentally, tell them that treatment is not needed unless symptoms occur.” The European Association for the Study of the Liver's 2016 gallstone guideline puts the risks on both sides together. People with no symptoms develop symptoms at about 0.7% to 2.5% a year. Those who get acute cholecystitis, acute pancreatitis, obstructive jaundice (a blocked bile duct that turns the person yellow) or cholangitis come to 0.1% to 0.3% a year. Only after the first colic does the rate of complications rise to 1% to 3% a year, so most people feel pain once before anything serious happens. On the surgery side, in 51041 gallbladder removals in the Swedish national register, 1.5% injured the bile duct. About one fifth of those (0.3%) were partial or complete severing of the duct. Death within a year was 3.9% in those with a bile duct injury and 1.1% in those without. The guideline also says that after removal 10% to 40% of patients still have discomfort or are better for a while and then it comes back. The guideline's conclusion is that surgery in people with no symptoms, whether open or laparoscopic, does not lengthen life, because the risk of death and complications from the operation itself exceeds the risk of not operating. Dealing with it once symptoms appear is also cheaper overall. A 1983 estimate gave specific numbers: preventive removal at age 30 in a man meant an average of 4 fewer days of life than watching first, and at age 50, 18 fewer days. No randomized trial has ever compared removing and not removing. Preventive removal looks like a good deal because of the intuition that “it will hurt sooner or later, so better to take it all out while young”

Notes

Dispute. The 2021 domestic expert consensus in biliary surgery lists some asymptomatic gallstones among the indications for surgery. An interpretive article in the same journal states that this is one of the core points of dispute. The full consensus requires a subscription, and which specific situations it lists has not been checked against the original (TODO: to be verified). Another opposing view concerns small stones: stones of 5 millimeters or less are more closely linked to pancreatitis. A Dutch estimate said that for this group, preventive removal might lengthen or shorten life, depending on how common and how deadly pancreatitis is. The European guideline also lists exceptions: a calcified gallbladder wall (porcelain gallbladder), and a gallbladder polyp of 1 centimeter or more together with stones; in these two cases it should be removed. When another major abdominal operation is being done, removal can be considered at the same time. This item covers only one situation: the stone is in the gallbladder, and has never caused pain. A stone in the common bile duct is a different matter. Item 1.3.1 of the same guideline clearly states that a common bile duct stone, with or without symptoms, should have the stone cleared from the duct and the gallbladder removed. Go to the hospital the same day if any of the following appear, and don't tough it out with this conclusion: constant colicky pain in the upper right or upper abdomen, fever with chills, yellowing of the whites of the eyes or skin, darker urine. When a doctor has looked at the imaging and recommends surgery, ask which reason it is based on, for example the bile duct is involved, a polyp is present, or the gallbladder wall is abnormal, and don't use this conclusion to argue with them. It blocks only “removing it for no reason other than finding a stone.” Both studies above followed a group of people forward, with no comparison group. But what they set out to answer is “what happens if you leave it alone,” not “which treatment is better,” and they fit that purpose. In addition, these two followed people for 4 to 9 years; with longer follow-up, the share with symptoms would rise

Evidence grade

A : Specific numbers from meta-analyses, large cohorts or randomized trials; for law and policy, the statute or official text.

Sources

1. Festi D, Reggiani ML, Attili AF, et al. (2010). Natural history of gallstone disease: Expectant management or active treatment? Results from a population-based cohort study. Journal of Gastroenterology and Hepatology, 25(4), 719-724. https://doi.org/10.1111/j.1440-1746.2009.06146.x
2. McSherry CK, Ferstenberg H, Calhoun WF, Lahman E, Virshup M (1985). The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Annals of Surgery, 202(1), 59-63. https://doi.org/10.1097/00000658-198507000-00009
3. National Institute for Health and Care Excellence (2014). Gallstone disease: diagnosis and management. NICE guideline CG188，第 1.2.1、1.3.1 条. https://www.nice.org.uk/guidance/cg188/chapter/Recommendations
4. European Association for the Study of the Liver (2016). EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. Journal of Hepatology, 65(1), 146-181. https://doi.org/10.1016/j.jhep.2016.03.005
5. Törnqvist B, Strömberg C, Persson G, Nilsson M (2012). Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ, 345, e6457. https://doi.org/10.1136/bmj.e6457
6. Ransohoff DF, Gracie WA, Wolfenson LB, Neuhauser D (1983). Prophylactic cholecystectomy or expectant management for silent gallstones. A decision analysis to assess survival. Annals of Internal Medicine, 99(2), 199-204. https://doi.org/10.7326/0003-4819-99-2-199
7. Gurusamy KS, Samraj K (2007). Cholecystectomy versus no cholecystectomy in patients with silent gallstones. Cochrane Database of Systematic Reviews, CD006230. https://doi.org/10.1002/14651858.CD006230.pub2
8. 反方：Venneman NG, Buskens E, Besselink MG, et al. (2005). Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy? American Journal of Gastroenterology, 100(11), 2540-2550. https://doi.org/10.1111/j.1572-0241.2005.00317.x
9. 中华医学会外科学分会胆道外科学组, 中国医师协会外科医师分会胆道外科医师委员会 (2022). 胆囊良性疾病外科治疗的专家共识（2021版）. 中华外科杂志, 60(1), 4-9. https://doi.org/10.3760/cma.j.cn112139-20210811-00373（全文需订阅，未取得）
10. 同上 (2022). 《胆囊良性疾病外科治疗的专家共识（2021版）》解读. 中华外科杂志, 60(4), 337-342. https://doi.org/10.3760/cma.j.cn112139-20220119-00031

Translated from the Chinese original. Original book, section 6, tip 20. Content may be out of date and rules differ by place. When you actually deal with an agency, a doctor or a court, follow what local officials, doctors and lawyers tell you. Disclaimer