Not Time to Abandon Cholecystectomy for Symptomatic Cholelithiasis

Abstract

To the Editor We commend Comes et al 1 for recognizing the challenges of conducting randomized trials. They reported longterm follow-up while assessing a "restrictive" approach for symptomatic cholelithiasis on postoperative pain, 2 concluding that cholecystectomy can be safely avoided. However, we do have some concerns.It cannot be understated that 70% or more of the patients in both arms required cholecystectomy at 6 weeks, highlighting that symptomatic cholelithiasis remains a surgical disease and most patients require short-interval elective cholecystectomy.The primary outcome was a pain scale developed for chronic pain in chronic pancreatitis. It might be argued that reported pain rates are not valid, and most patients were satisfied with their care, likely a more important measure. Furthermore, common conditions that might account for persistent pain (eg, inflammatory bowel disease, irritable bowel syndrome, endometriosis) were not considered. With 80% receiving cholecystectomy, and nearly 80% achieving a pain score of 4 points or lower on a visual analog scale, surgical management seems to achieve excellent outcomes.Both arms reported similar surgical and biliary complications. However, it might equally be concluded that the operative approach introduced no greater risk. Moreover, there were a surprising number of surgically preventable biliary complications (cholecystitis, choledocholithiasis) in the standard cohort. 3 Subanalysis among operative patients was not reported, so the causes cannot be assessed.Watchful waiting may beget additional costly testing in an already-strained US health care system, whereas cholecystectomy is exceedingly safe and relatively inexpensive. 4 The follow-up cost-effectiveness analysis noted marginal cost savings. 5 However, this ignores potential immortal-time bias variant, where the additional workup encouraged in restrictive pathway occurred during an unreported preoperative period. The standard approach simply involved cholecystectomy, we suspect without additional workup. We welcome clarification if additional data are available.Finally, the authors did not consider health disparities. Access to elective surgical care remains a significant challenge for socially vulnerable communities in the US. Recommending that more than 60% have additional testing, consulta-