Evidence-based treatment of gallstone disease.

In response to the evidence-based current surgical practice article by Duncan and Riall, I have some comments about the presentation and the conclusion. The authors want to discuss complicated disease but include asymptomatic and uncomplicated diseases. The name biliary colic has for long been used indiscriminately to characterize clinical gallstone disease. This is unfortunate for several reasons. Even though dictionaries define it as pain originating from a hollow viscus, it is not precise enough to distinguish or describe clinical symptoms associated with gallstone disease. The term should rather be “uncomplicated gallstone disease” as patients with complicated disease also have pain (“colic”) in the initial phase of the disease. Pain elicited from the gallbladder and the common bile duct is indistinguishable. It is further said that the pain radiates to the shoulder and most commonly occur after a fatty meal. In our experience with 500–1,000 patients, this never occurred because shoulder pain is pain of diaphragmatic origin. Instead, pain radiates to the back at the same level, usually beneath the right shoulder blade. A fatty meal may induce pain but not in the majority. The pathology behind pain and inflammation may be debatable. Increased wall tension is a probable cause but we did not demonstrate an obstruction in about 90 % of cases with severe acute cholecystitis. Assumption of stone obstruction should therefore be verified by imaging in the acute phase. The unfortunate lack of a clear distinction between uncomplicated gallbladder disease and complicated disease (acute cholecystitis) was clearly demonstrated in twoCochrane reviews. One dealt with biliary colic. It was defined as RUQ pain lasting for more than half an hour without further description. In another review of acute cholecystitis, no definition was given. However, both reviews alluded to an RCT of acute cholecystitis to describe what may happen to patients waiting for an operation. The evidence-based review by Duncan and Rial fails to mention any RCT, although three are available, two of these with a long-term follow-up. Gallstone disease is a big burden on the health care system in many countries and recent increases in the rate of cholecystectomy has probably been technology driven more than being defined clinically. To stick to old dogma and prescribe cholecystectomy for this disease regardless of emerging evidence of a more diverse attitude does not seem evidencebased nowadays.