Decision analysis was done to compare the consequences of prophylactic cholecystectomy with expectant management for silent gallstone disease. Probability values were derived from a study of the natural history of silent gallstone disease, published cholecystectomy mortality rates, and life tables. The two strategies were compared by calculating cumulative numbers of person-years lost for hypothetical cohorts of men and women. Prophylactic cholecystectomy slightly decreases survival. A 30-year-old man choosing prophylactic cholecystectomy instead of expectant management would lose, on average, 4 days of life; a 50-year-old man would lose 18 days. Consideration of monetary costs and discounting further disfavors prophylactic cholecystectomy. Sensitivity analysis shows that differences between the two strategies remain small over a broad range of probability values, both for men and women.

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Should persons with symptomatic gallstones (i.e., those that have caused biliary pain) be treated immediately? Or may they be managed expectantly until pain recurs or a biliary complication (i.e., acute cholecystitis or pancreatitis) occurs? To assess the mortality risk of different strategies, we performed a quantitative analysis. For the expectant management strategy that requires surgery only if a biliary complication occurs, the cumulative lifetime probability of gallstone disease death in a 30-year-old man is about 2%, and most deaths occur after age 65. In comparison, elective cholecystectomy has only a 0.1% rate of gallstone disease death, but all deaths occur at age 30. The average amount of life expectancy gained by immediate cholecystectomy compared with expectant management is 52 days, which is reduced to 23 days using 5% discounting. This gain could be increased only slightly by a 100% effective and risk-free therapy such as perfected lithotripsy or medical dissolution. Results are similar for women. The results suggest that, for persons with symptomatic gallstones, the life expectancy gain of immediate cholecystectomy is relatively small and that the potential incremental gain of nonsurgical therapy is also small. For patients and physicians who believe that life expectancy is of primary consideration, the decision about therapy may be made primarily on non-mortality considerations. Some patients and physicians may decide that the risk of symptomatic gallstones is low enough that a policy of expectant management may be acceptable.