Asymptomatic Gallstones RevisitedIs There a Role for Laparoscopic Cholecystectomy?
A. Mark Fendrick, MD;
Sean P. Gleeson, MD, MBA;
Michael D. Cabana;
J. Sanford Schwartz, MD
Arch Fam Med. 1993;2(9):959-968.
Abstract
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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.
Author Affiliations
From the Robert Wood Johnson Clinical Scholars Program (Dr Fendrick); the Leonard Davis Institute of Health Economics (Drs Fendrick and Schwartz); the Department of Health Care Systems, Wharton School of Business (Drs Fendrick, Schwartz, and Gleeson); the Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine (Drs Fendrick and Schwartz); and the University of Pennsylvania School of Medicine (Drs Fendrick, Schwartz, and Gleeson and Mr Cabana), Philadelphia.
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