An Indian surgeon's perspective on management of asymptomatic gallstones

INTRODUCTION

Cholelithiasis is widely prevalent in India, with a majority of patients being asymptomatic while a small proportion experiencing mild complications. In the laparoscopic era, the rate of cholecystectomies has increased owing to early recovery and fewer complications. In asymptomatic patients, the risk of complications must be balanced against the treatment benefit. Recent guidelines suggest no prophylactic cholecystectomy in asymptomatic patients. We aimed to find out the Indian surgeons' perspective on asymptomatic gallstone management.

METHODS

A cross-sectional e-survey was conducted of practicing surgeons, onco-surgeons and gastrointestinal-surgeons in India. The survey had questions regarding their perspective on laparoscopic cholecystectomy and treatment modalities in asymptomatic gallstones.

RESULTS

A total of 196 surgeons responded to the survey. Their mean age was 42.3 years. Overall, 111 (57%) respondents worked in the private sector. Most surgeons (164) agreed that the rate of cholecystectomy has increased since the advent of laparoscopy; 137 (70%) respondents agreed that they would not operate on patients without risk factors. Common bile duct stones, chronic hemolytic diseases, transplant recipients, and diabetes mellitus were the risk factors. Majority of the participants agreed on not performing a cholecystectomy in patients with asymptomatic gallstones.

CONCLUSION

There exists a lack of consensus among Indian surgeons on asymptomatic gallstone management in India. Where the majority of cases are asymptomatic and do not require surgery, certain comorbidities can influence the line of treatment in individual patients. Currently, the treatment guidelines for asymptomatic patients need to be established as cholecystectomies may be overperformed due to the fear of development of complications.

Risk factors of gallbladder cancer in Karachi-a case-control study

BACKGROUND

Gallbladder carcinoma (GC) is a relatively rare malignancy worldwide but is the second commonest gastrointestinal cancer in Pakistani women. Gallstones have a positive association with GC but other factors also influence in causation.

METHODS

This is a retrospective case control study over a period of 19 years. The cases (Group A) were patients with histopathological proven carcinoma gallbladder (N = 60) and controls were patients with cholelithiasis but no carcinoma gallbladder on histopathology (N = 120). Multivariate regression analysis was done to calculate the odds ratio, 95% confidence interval and P-Value. A positive relationship was found between size of stone > 1 cm, solitary stone, age > 55 years and multi-parity in women.

RESULTS

There were 60 patients in Group A and 120 patients in Group B. mean age of diagnosis in Group A patients was 57 ± 2.4 years while mean age of diagnosis in Group B patients was 48 ± 1.35 years. Sixty seven percent of cancer group patients were female as compared to 78% females in non-cancer group. In Group A, 69% of female patients were multiparous (parity of more than 5) while 43% of group B patients were multiparous. For body mass index (BMI), both groups were not very different in our study population i.e. around 78% patients in each group has BMI of more than 23 Kg/m2. In Group A, 37% (n = 22) have solitary stones as compared to 15% (n = 18) in group B. similarly Group A patients has larger stone size as compared to Group B i.e.59% (n = 36) patients in Group A have stones of more than 1 cm when compared to 35% (n = 41) patients in Group B. After using multivariate regression analysis, age more than 55 years (OR - 7.27, p value- < 0.001), solitary stone (OR - 3.33, p value - 0.002) and stone of more than 1 cm (OR - 2.73, p value - 0.004) were found to be independent risk factors for development of gallbladder cancer.

CONCLUSION

Most of the patients (78%) with GC were female, and the statistically significant risk factors were older age, solitary stones and stones size more than one centimeter. A case can be made for prophylactic cholecystectomy in such a high risk group. However a population based study is required to calculate the true incidence of GC in Karachi and a prospective multi center study is needed to produce strong evidence for screening and prophylactic cholecystectomy.

TRIAL REGISTRATION

As this was a retrospective review of medical records, as per institution policy, its gives waiver from any registration (ethical/trial).