EXPECTANT MANAGEMENT OR CHOLECYSTECTOMY IN ASYMPTOMATIC CHOLELITHIASIS

It is essential to reevaluate old concepts that, over time, become unquestionable truths. This is particularly important in the treatment of asymptomatic cholelithiasis, where an expectant, non-surgical approach is commonly recommended. We should therefore commend and congratulate the authors of the article “ASYMPTOMATIC CHOLELITHIASIS: EXPECTANT OR CHOLECYSTECTOMY. A SYSTEMATIC REVIEW,” published in the Brazilian Archives of Digestive Surgery (Arq Bras Cir Dig. 2023;36:e1747), for promoting the discussion of one of the most prevalent digestive disorders in the adult population.

Although it is a controversial topic in clinical practice, we agree with the authors’ conclusion that “the majority of evidence points to the safety and feasibility of a conservative (clinical follow-up) management of asymptomatic cholelithiasis”¹. However, we need to consider that some variables are not always taken into consideration in systematic reviews, which can prejudice obtaining more robust conclusions.

It is important to note that there are no clinical trials directly comparing surgical and expectant treatments for asymptomatic cholelithiasis. In most cases, prophylactic cholecystectomy is not recommended due to the low risk of serious complications and the generally mild initial symptoms. The evidence supporting this recommendation, however, largely originates from studies conducted in the 1970s and 1980s, before the advent of laparoscopic surgery. For instance, in 1983, Ransohoff et al.⁷ concluded that conventional prophylactic cholecystectomy decreased patient survival based on a model analyzing the natural history of cholelithiasis. This type of study is now considered outdated considering the advancements in surgical techniques.

The standardization of laparoscopic surgery has drastically reduced the risks and complications associated with cholecystectomy, making it the prime example of the benefits of minimally invasive surgical techniques. Currently, serious complications of laparoscopic cholecystectomy, such as bile duct injuries, bleeding, and inadvertent bowel injuries, have an incidence of less than 0.5%. Surgical wound infection rates are also significantly lower compared to the open technique⁴,⁹. Additionally, the “critical view of safety” approach has been an ally in reducing harm and training new surgeons².