Asymptomatic gallstones revisited. Is there a role for laparoscopic cholecystectomy?
A. M. Fendrick, S. P. Gleeson, M. D. Cabana and J. S. Schwartz
Leonard Davis Institute of Health Economics, University of Pennsylvania School of Medicine, Philadelphia.
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.
