A study from the University of Texas Medical Branch reveals that many patients with gallbladder disease do not benefit from surgery. The study entitled “The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications”, published in the Journal of the American College of Surgeons was presented at the Southern Surgical Association 126th Annual Meeting that took place in Palm Beach, FL on November 30–December 3, 2014.
Gallbladder disease affects the small organ on the underside of the liver. Its main function is to store the bile produced in the liver, and secrete it into the small intestine. Gallstones may develop in the gallbladder or along the biliary tract when the bile contains too much cholesterol, thus making obesity secondary to a bad diet a risk factor for the development of gallbladder problems. The prevalence of gallstones increases with age, from 8% of people under 40 years, to up to 50% in people 70 years and older. Gallbladder disease is one of the common causes of acute abdominal pain in older patients, and accounts for a third of abdominal procedures in patients older than 65 years.
In patients with symptomatic gallstones, it is recommended they undergo elective cholecystectomy to prevent gallstone-related complications. However, this procedure is associated with increased morbidity and mortality in older patients. Still, without the procedure, older people have an increased risk of severe complications from their gallstones, such as acute cholecystitis with gangrenous cholecystitis, empyema of the gallbladder, gallbladder perforation, or emphysematous cholecystitis. These complications require urgent hospitalization and/or cholecystectomy, thus increasing morbidity and mortality risks.
The team of researchers, led by Taylor S. Riall, MD, PhD, a Professor, and John Sealy Distinguished Chair in Clinical Research, from the Department of Surgery at UTMB, developed a monogram called PREOP-Gallstones (Predicting Risk of Complications in Older Patients with Gallstones) that predicts the 2-year risk of developing acute gallstone-related hospitalization in older patients who present with an initial symptomatic episode of gallstones.
With the objective of examining if the decision to perform cholecystectomy was associated with the risk of 2-year gallstone-related hospitalization, the researchers evaluated 161,568 patients with an incident episode of symptomatic gallstones, and are potential candidates for an elective cholecystectomy. Using their prediction model, the researchers showed that the risk of 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across three distinct risk groups (high, moderate and low risk).
Moreover, in the patients who had surgery after initial symptoms, results revealed that risk was not associated with surgery for gallbladder removal, since 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group. Additionally, in the group of patients without history comorbidities, surgery rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. In patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months following the initial episode
In a recent press release, Dr. Riall said that even though gallbladder removal is recommended for patients with gallstone problems, “Less than a quarter of patients in this study had their gallbladders removed. We sought to determine whether the decision to have the gallbladder removed was actually based on their risk of having gallstone-related complications in the next two years.”
The study concluded that the risk of associated gallbladder symptoms requiring hospital admission has no influence on the decision to perform surgical removal. The team of researchers recommend that using their risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.