Don’t have the gallbladder removed prophylactically just because a check-up found gallstones and you have never had pain

People with stones in the gallbladder who have never had pain stay symptom-free for about eight in ten over nearly nine years. Leave them alone and acute problems such as cholecystitis or pancreatitis run about 1 to 3 per thousand per year. Removing the gallbladder is not zero risk: about 1.5% have bile-duct injury. So European and UK guidelines both say: no symptoms, do not cut yet.

Cost

No money, and you also save one operation under general anesthesia and one hospital stay. What you owe in return is remembering which signals mean go to hospital at once.

Benefit

Italy’s MICOL population survey ultrasound-scanned 11229 people aged 29 to 69. It found 856 with gallstones, of whom 580 had no symptoms, followed a mean 8.7 years. Of those 580, 453 (78.1%) stayed symptom-free, 61 (10.5%) developed mild symptoms, and 66 (11.4%) severe symptoms. Over follow-up there were 189 cholecystectomies, 41.3% of them in people without symptoms. The authors conclude that “expectant management remains an effective approach for most patients” — watch first, no surgery. A U.S. HMO (a managed-care organization) followed 691 people with confirmed gallstones a mean 78±61.6 months. Of 135 without symptoms followed 58±50.2 months (median 46.3 months), only 10% developed gallstone symptoms and 7% had surgery. Of 50 deaths in the whole group, only 2 were biliary-related, both in the symptomatic group. The authors conclude that “patients with silent stones need not be operated on before symptoms appear”; silent stones are stones that stay quiet and do not flare. UK NICE guideline CG188 item 1.2.1 says: for people with a normal gallbladder and biliary tree who have incidentally found asymptomatic gallstones, “reassure them that they do not need treatment until symptoms develop.” The European Association for the Study of the Liver 2016 gallstone guideline puts both sides’ risks together. Asymptomatic people develop symptoms in about 0.7% to 2.5% per year. Acute cholecystitis, acute pancreatitis, obstructive jaundice (blocked bile duct, person turns yellow), or cholangitis run 0.1% to 0.3% per year. After a first colic, complications rise to 1% to 3% per year, so most people hurt once before a major event. On the surgery side, Sweden’s national registry of 51041 cholecystectomies had bile-duct injury in 1.5%. About one fifth of those (0.3%) were partial or complete duct transection. One-year mortality was 3.9% with duct injury versus 1.1% without. The guideline also notes that after surgery 10% to 40% of patients still have discomfort, or it improves then returns. The guideline’s conclusion: operating on asymptomatic people, open or laparoscopic, does not lengthen life, because the death and complication risk of surgery exceeds the risk of not cutting. Waiting for symptoms also costs less overall. A 1983 estimate gave numbers: prophylactic removal in a 30-year-old man meant living 4 days less on average than watching first; at age 50, 18 days less. No randomized trial has yet compared cutting versus not. Prophylactic removal looks worthwhile because of the intuition “it will hurt eventually, better cut once while young.”

Notes

Controversy. China’s 2021 biliary-surgery expert consensus lists some asymptomatic gallstones as surgical indications. A commentary in the same journal states that this is one core of the dispute. The full consensus needs a subscription; which exact situations apply was not verified in the original (TODO: to verify). Another opposing view is small stones: stones within 5 mm relate more to pancreatitis. A Dutch estimate says prophylactic removal in such people may add or subtract life years depending on how common and how deadly pancreatitis is. European guidelines also list exceptions: calcified gallbladder wall (porcelain gallbladder), and a gallbladder polyp 1 cm or larger — both warrant removal. When having another major abdominal operation, concomitant removal may be considered. This item covers only one situation: stones in the gallbladder that have never hurt. Stones in the common bile duct are another matter. The same guideline item 1.3.1 states clearly that common-bile-duct stones, with or without symptoms, need the duct cleared and the gallbladder removed. Go to hospital the same day for any of these; do not tough it out on this conclusion: ongoing colic in the right upper or upper abdomen, fever with chills, yellow whites of the eyes or skin, dark urine. When a doctor who has seen imaging recommends surgery, ask which reason it rests on — duct involvement, a concurrent polyp, abnormal wall. Do not use this conclusion to argue back. It only blocks “no reason at all, cut just because stones were found.” The two studies above followed groups forward without randomized comparison. But they answer “what happens if you leave it alone,” not “which treatment is better,” so they fit here. Also, follow-up was 4 to 9 years; over longer spans the share who develop symptoms will climb.

Sources · 9

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