Managing symptomatic gallstone disease

Symptomatic gallstone disease (cholelithiasis) is the classic indication for elective cholecystectomy.1 In addition to relieving symptoms, cholecystectomy reduces the risk of gallstone related complications such as acute cholecystitis, cholangitis, and pancreatitis. Since the late 1980s, when the advent of laparoscopic surgery reduced postoperative morbidity and enabled outpatient surgery,2 the threshold for surgery has been lowered. Today, cholecystectomy has largely replaced alternative interventions such as shock wave lithotripsy and bile salt dissolution treatment,3 and it is now one of the most commonly performed surgical procedures, resulting in high costs for healthcare systems.

The clinical indication for and the timing of surgery, however, remains a grey area. In general, about 20% of patients with a first episode of biliary colic undergo cholecystectomy,4 but some experts argue that all patients with definite symptoms should have their gallbladder removed quickly.5 Furthermore, about one in five patients with symptomatic gallstone disease prefers non-surgical …