Not Time to Abandon Cholecystectomy for Symptomatic Cholelithiasis—Reply

Abstract

COMMENT & RESPONSEIn Reply We thank Wehrle and colleagues for their comments and advocacy that routine cholecystectomy for gallstone disease should remain the standard of care, with nonoperative management being the exception. The conclusion from the long-term follow-up of the SECURE trial was that the restrictive strategy is as disappointing as usual care in achieving a pain-free state after cholecystectomy. 1 Additionally, treatment satisfaction and the rate of biliary and surgical complications between usual care and the restrictive strategy showed no significant difference. These results should not be interpreted as a reason to abandon cholecystectomy for symptomatic cholelithiasis, but rather as an opportunity to reconsider the indication when the a priori likelihood of achieving a pain-free state is low, surgical capacity is limited, and the burden of surgery is substantial. While the majority of surgically treated patients were operated on within 6 weeks, 26.3% of patients in the restrictive arm required no surgical treatment over a period of 5 years. 1 We agree that cholecystectomy is the definitive surgical solution for complicated cholecystolithiasis, but we argue that it is not the solution for all patients with abdominal pain in the presence of gallstones. The C-GALL trial reinforces that symptomatic cholecystolithiasis is not exclusively a surgical disease. 2 After 2 years of follow-up, only 25% of patients in the conservative arm required surgery. Importantly, at the end of followup, outcomes related to quality of life, abdominal pain, and biliary or surgical complications were similar between both groups. 2 Two recent randomized clinical trials clearly show that a restrictive strategy or even conservative management is safe and feasible, demonstrating that not all patients with symptomatic cholecystolithiasis require surgery. Irritable bowel syndrome and dyspepsia are common causes of persistent pain and should be excluded prior to surgery. 3 Second, the relationship between gallstones and metabolic syndrome highlights a broader, systemic issue that calls for a more holistic approach. Simply performing a cholecystectomy without addressing the underlying metabolic factors or functional disorders is short-sighted and can lead to suboptimal long-term outcomes. A more comprehensive management strategy, which considers lifestyle, dietary factors, and metabolic health, may be more effective in treating the root causes of symptomatic cholecystolithiasis and preventing other sequelae of metabolic syndrome.We acknowledge that it could be debated whether the Izbicki pain score, originally developed for pancreatitis, is the right instrument to evaluate persistent pain after surgery. However,