WORLD SURGERY Asymptomatic Cholelithiasis ... - Springer Link

World J. Surg. 22, 1119 –1124, 1998

WORLD Journal of

SURGERY © 1998 by the Socie´te´ Internationale de Chirurgie

Asymptomatic Cholelithiasis Revisited Jose´ F. Patin õ, M.D., G.A. Quintero, M.D. Department of Surgery, Fundacio ń Santa Fe de Bogota´, Calle 123 No. 8-20, Bogota ´, Colombia Abstract. Elective cholecystectomy in the asymptomatic patient has elicited considerable controversy, going back to the prelaparoscopy cholecystectomy era. Surgical services often see patients with known or unidentified cholelithiasis who, having been asymptomatic, present with serious complications, potentially lethal, in whom emergency operations are associated with technical difficulties that lead to high conversion rates and significant mortality and morbidity. Elective cholecystectomy is a safe procedure associated with low morbidity and no mortality. Based on an analysis of our experience and a review of the literature, we discuss the indications for elective laparoscopic cholecystectomy in asymptomatic patients at high risk of developing complications of their asymptomatic disease. The following high-risk criteria are proposed for elective cholecystectomy: life expectancy > 20 years; calculi > 2 cm in diameter; calculi < 3 mm and a patent cystic duct; radiopaque calculi; polyps in the gallbladder (GB); nonfunctioning GB; calcified (“porcelain”) GB; concomitant diabetes; women < 60 years; and individuals in geographic regions with a high prevalence of GB cancer.

The matter of elective cholecystectomy in the asymptomatic patient with uncomplicated cholelithiasis has elicited considerable controversy, going back to prelaparoscopic cholecystectomy times. Cholelithiasis is a disease of high prevalence in all nations in the world, with recognized differences according to ethnic and geographic factors. According to a 1992 National Institutes of Health Consensus Conference [1], in the United States it is estimated that 10% to 15% of the population (i.e., about 20 million persons) have gallstones, and that about 1 million new cases are diagnosed yearly. The prevalence is higher in women, associated with multiparity, obesity, rapid weight loss, advanced age, and certain ethnic groups. Some 600,000 cholecystectomies were performed in 1991 in the United States. Gallstones represent the most frequent—and also the most costly— of hospital admissions because of gastrointestinal tract disease, with an estimated yearly cost of US $5000 million. At our institution Botero and Abello [2, 3] found an 8.6% incidence of asymptomatic gallstones in the population who present for regular “executive health checkups.” With the advancement of age, there is an increasing incidence of cholecystitis and of complications. Complications such as choledocholithiasis with associated cholangitis or biliary obstruction, pancreatitis, cholecystoenteric fistula and gallstone ileus, and carcinoma of the Correspondence to: J.F. Patin õ, M.D.

gallbladder tend to be more common in elderly patients who have borne asymptomatic stones for years. When one of these complications is the cause of presentation, surgical treatment becomes associated with significant morbidity and mortality. Most patients with cholelithiasis remain asymptomatic for many years; in fact, they never develop symptoms. “However, the causes of gallstones may be severe, ranging from brief episodes of biliary pain (misnamed ‘colic’) to potentially life-threatening complications, such as acute cholecystitis and pancreatitis, or rarely gallbladder cancer” [1]. According to the 1992 NIH Consensus Conference report [1], 10% of patients develop symptoms during the first 5 years after diagnosis and 20% by 20 years. Considering that many patients develop symptoms before complications set in, it was considered that, with few exceptions, prophylactic surgical treatment is not justified. In contrast, most patients with symptomatic gallstones are candidates for laparoscopic cholecystectomy. The report states that “the availability of laparoscopic cholecystectomy should not expand the indications for gallbladder removal.” Oral dissolution therapy (ODT) with ursodeoxycholic acid, extracorporeal shock-wave lithotripsy (ESWL), and contact dissolution therapy with methyl tert-butyl ether (METB) are treatment options that can be considered in the few well selected cases with co-morbid conditions that preclude a safe laparoscopic cholecystectomy. Poor risk and extremely debilitated patients with acute cholecystitis are best considered for percutaneous cholecystostomy, a procedure that today can be safely performed under ultrasonographic guidance. Surgical services throughout the world often see patients with known or unidentified cholelithiasis that was previously asymptomatic who now present with serious potentially fatal complications. Emergency operations in these patients are associated with considerable technical difficulties that frequently make conversion to laparotomy mandatory, with higher morbidity and mortality rates than with simple elective laparoscopic cholecystectomy. When these patients are incorporated into hospital statistics, they alter the good results of surgical treatment and tarnish the data for cholecystectomy. It is precisely patients with such complex cases that most complications of cholecystectomy occur. Elective cholecystectomy has been demonstrated to be a safe procedure that gives excellent results. It is universally recognized as the gold standard for treatment of cholelithiasis. With the advent of minimally invasive surgery and the important advance-

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World J. Surg. Vol. 22, No. 11, November 1998

Table 1. Incidence of common bile duct (CBD) stones by age at cholecystectomy, according to Hermann [4].

Age (years)

Incidence of CBD stones (%)

31– 40 41–50 51– 60 61–70 71– 80 80 –90

9 9 14 31 48 96

Reproduced from [4], copyright 1989, with permission from Excerpta Medica Inc.

ment of laparoscopic techniques, cholecystectomy has become an almost innocuous procedure, with low morbidity and practically no mortality. When performed on persons of advanced age with co-morbid pathology, however, cholecystectomy is accompanied by significant morbidity and mortality. It is well known that many patients with cholelithiasis never develop complications of their disease. According to Hermann [4] of the Cleveland Clinic, 40% to 60% of persons with cholelithiasis remain asymptomatic, 60% to 70% present with symptoms of chronic cholecystitis (among them 20% have manifestations that are difficult to interpret), 20% develop acute cholecystitis, and 10% develop complicated acute cholecystitis (i.e., cholecystitis accompanied by jaundice, cholangitis, or pancreatitis). Choledocholithiasis is an especially serious complication of cholelithiasis. When it becomes symptomatic or develops complications, such as biliary colic, icterus, cholangitis, or pancreatitis, it demands urgent endoscopic intervention and frequently open operation. In this setting the rate of conversion from laparoscopic cholecystectomy to laparotomy is high, and the operation (whether laparoscopic or open) is associated with higher mortality and morbidity rates. According to Hermann [4], the incidence of choledocholithiasis at the time of cholecystectomy is directly related to age (Table 1). This means a direct relation with the number of years that patients have had cholelithiasis. Of course, again, in patients of advanced age an operation involving choledochotomy exhibits higher morbidity and mortality rates. Our group considers that lithogenic bile (i.e., bile that causes cholelithiasis) is a pathologic entity with the potential of inducing serious consequences, and that the expectant management in the asymptomatic patient with demonstrated cholelithiasis leads to an increasing risk of choledocholithiasis and other complications that may force an emergency surgical intervention, which is more complex and risky than a simple elective cholecystectomy. Asymptomatic calculi, the “silent” or “innocent” stones, have elicited much debate. In 1911 Mayo [5] labeled them a myth. Gracie and Ransohoff [6, 7] have contradicted such view and in 1983 stated that not being a myth they should requiescat in pace. One hundred years ago, Naunyn [8] observed that these calculi do not cease to be dangerous on long-term observation, and Lord Moynihan [9] in 1908 proposed cholecystectomy in all patients with gallstones because they invariably lead to complications if the patient lives long enough. During a surgical residency at Yale, I (J.F.P.) was impressed with the work of Frank Glenn, who came from New York as visiting professor. Truly monumental studies conducted at New

York Hospital–Cornell Medical Center by Glenn’s group [10 –15] and studies by other North American and European authors [16, 17] firmly established that asymptomatic patients tend to become symptomatic with aging if the follow-up is long enough—perhaps as many as 30% to 50%. These studies point to a consideration of prophylactic cholelithiasis before the problem becomes complicated, something that usually occurs at an advanced age. In 1983, before the era of laparoscopic cholecystectomy, Glenn stated: “It is reasonable to strongly recommend an early cholecystectomy for gallstones, whether or not they are causing symptoms, unless there is a contraindication to operation.” Furthermore, “the optimum treatment for asymptomatic cholelithiasis is elective cholecystectomy without undue delay” [12]. Studies conducted in the 1980s [7, 14, 18, 19] indicate that the incidence of the progression of asymptomatic to symptomatic disease is lower, of the order of 10% to 30%. In the study by Ransohoff covering a selected population of 110 men and 13 women (academic faculty members in good health), 18% developed biliary pain during a follow-up of 20 years. On such bases, it has been stated that patients with silent stones should not be operated prior to the onset of symptoms, as most of them can tolerate their symptoms and their condition for prolonged times and may prefer doing that to undergoing cholecystectomy. It must be borne in mind that such reasoning occurred during the era of open cholecystectomy, which is a major operation that produces considerable pain and incapacity. Laparoscopic cholecystectomy, a minimally invasive and minimally traumatic procedure, calls for a reconsideration of prophylactic cholecystectomy as a valid therapeutic option, at least in certain subsets of patients. The natural history of asymptomatic cholelithiasis is uncertain, and recent publications tend to reaffirm its innocuous nature during long-term follow-up [20 –22]. The problem is not simple, however. Even reports emerging from interinstitutional studies, such as the National Cooperative Gallstone Study, provide data that support the concept that cholelithiasis is a potentially dangerous entity. In 1984 Thistle et al. [19] reported on the 2-year follow-up of 305 patients in the National Cooperative Gallstones Study who had remained asymptomatic for the previous 3 months and who had a functioning gallbladder: 13% developed biliary colic, and 4% (n 5 12) required cholecystectomy, four of them for gangrenous cholecystitis. Studies by Friedman et al. [20] on 467 patients, 123 of them asymptomatic and observed over 25 years in a prepaid health plan, revealed that during each 5-year period the patients had serious or mild events (acute cholecystitis, acute biliary pancreatitis, obstructive jaundice, surgery due to continuous but not severe symptomatology) in 6% of patients with mild symptoms or with nonfunctioning gallbladder and in 4% of asymptomatic patients, for a total 10% incidence of events. Speranza [23] and Barbara et al. [24] reported figures indicating that around 10% of asymptomatic patients present with grave complications. Many surgeons have traditionally advocated prophylactic cholecystectomy for the purpose of preventing the transition from asymptomatic to complicated cholelithiasis. Especially it was to prevent the development of acute cholecystitis and choledocholithiasis, which are both potentially serious diseases and demand urgent operations, usually in elderly individuals, with higher risks of morbidity and operative mortality [10 –14, 16]. Operative mortality associated with cholecystectomy has been

Patin ˜ o and Quintero: Asymptomatic Cholelithiasis Revisited

low. Even before 1932, when antibiotics were not in use and anesthesia had little margin of safety, mortality was 6.5% [15, 25]. In the large series of patients followed by Glenn starting in 1932 (perhaps the most extensive in the surgical literature), which today constitutes a valuable source for comparative studies, mortality rates were 1.8% for the period 1932–1950 and similar, 1.7%, for 1951–1978 [15]. Consolidation of the New York Hospital–Cornell Medical Center 1932–1984 series of 14,232 patients operated on for nonneoplastic biliary tract disease, the global rate of operative mortality was 0.6%. Upon discrimination according to age, it appears that the mortality rate increases with aging: 0.4% in patients , 50 years and 4.5% in those . 65 years [15]. Operative mortality also varies according to the type of pathology: 0.4% among those with chronic cholecystitis and a three times higher rate (1.2%) for those with acute cholecystitis. It is interesting to note that the mortality rate registered in the chenodiol trial in the National Cooperative Gallstone Study was 1.3% [15]. During the last period (1978 –1984) of the New York Hospital– Cornell Medical Center Study, the surgical mortality rate for patients with complicated biliary stone disease was considerably higher than the 0.2% mortality associated with simple cholecystectomy: 10.2% when cholecystostomy had to be performed in high-risk patients unable to tolerate cholecystectomy and 1.2% (nine times higher) when cholecystectomy was accompanied by choledochotomy and exploration [15]. The mortality rate seen with simple cholecystectomy (0.2%) is 6.5 times lower than that recorded in the chenodiol trial. More recent studies conducted during the immediate prelaparoscopic cholecystectomy period also reveal higher mortality among older patients, who were the only ones who died. In the study by Morgensten et al. [26] there was a 1.8% mortality rate for 1200 open cholecystectomies, with all deaths occurring in persons older than 66 years (mean age 80.5 years). In their study the mortality increased threefold when choledochotomy became necessary. The above data support considering elective cholecystectomy for the asymptomatic individual, as cholecystectomy is a safe procedure when performed in an elective manner, whereas when done for complicated cholelithiasis it is associated with significant risk. This conclusion is well documented even in the studies by Gracie and Ransohoff [6, 7], who are the pallbearers in the antiprophylactic cholecystectomy camp: We arbitrarily distinguish between a “simple” cholecystectomy and a “difficult” cholecystectomy. The former denotes an operation performed prophylactically or after an episode of uncomplicated biliary pain. The latter denotes an operation performed after a biliary complication, usually acute cholecystitis or choledocholithiasis, has occurred, even if the acute event has subsided. . . . The mortality rates for “difficult” cholecystectomies are estimated to be four times higher than for “simple” cholecystectomies. . . . Additional comparisons show that the mortality rate of a cholecystectomy performed for acute cholecystitis is two to five times the rate of a cholecystectomy performed electively [7].

Surgeons readily accept the main drawback of cholecystectomy in the asymptomatic patient: the risk of injury to the common bile duct. This injury is a serious, devastating, iatrogenic complication that tends to occur mainly in the setting of the operation for acute cholecystitis [27]. Furthermore, the number of patients who develop acute cholecystitis increases with age, thus making the

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operation riskier because of concomitant disease or organ dysfunction. Csendes et al. [28], of Santiago, Chile, reported a notorious increment in the incidence of gallbladder cancer in that country, where it has become the most frequent type of malignancy. Since 1970 Csendes has remarked on the close association between carcinoma of the gallbladder and cholelithiasis. In their series, 70% of patients with gallbladder cancer exhibited associated cholelithiasis. For this reason, this respected South American surgeon recommends cholecystectomy in all patients with demonstrated cholelithiasis. Such conduct is recommended in the United States only for selected ethnic groups (American Indians and Mexican-Americans) with cholelithiasis because of a similar high incidence of gallbladder cancer. North American Indian women develop gallbladder cancer with a greater frequency than heavy smokers develop pulmonary cancer. Bedoya and Zun ˜iga [29] recorded a high prevalence of gallbladder cancer in the state of Narin õ, in the southern part of Colombia, with rates similar to those observed in Chile; Bolivia has similar rates. This phenomenon has not been observed in Bogota´ or in other regions of Colombia, where the incidence of gallbladder cancer is low. In our population, the risk of cancer does not, per se, constitute an indication for cholecystectomy. Calcification of the gallbladder (“porcelain gallbladder”) is recognized as an entity associated with the risk of cancer. Cholecystectomy is recommended for those patients [30 –35]. A higher risk of developing acute cholecystitis has been reported in patients with large stones (. 2.0 cm [33] or . 2.5 cm in diameter [36, 37]) and in patients with microlithiasis (calculi , 3 mm in diameter), biliary sludge, or both, who tend to develop acute pancreatitis [38 – 40]. The risk of complicated cholecystitis is admittedly higher when the cystic duct is chronically obliterated. It appears that the risks consequent to a major complication of cholelithiasis and of the corresponding emergency operation are higher in patients with degenerative diseases apt to develop with aging, such as diabetes, cardiovascular diseases, renal insufficiency, or obstructive pulmonary disease. For this reason, many surgeons advocate elective cholecystectomy in such persons bearing asymptomatic gallstones. Contemporary studies have shown that cholelithiasis in diabetics appears to be associated with serious complications, and cholecystectomy results in high morbidity and mortality [41]. Other reports have questioned the value of prophylactic cholecystectomy in diabetics with asymptomatic cholelithiasis [22, 41, 42] unless there is evident risk of developing symptomatic disease and there is a need for emergency operation [22]. One must consider the possibility of the ominous emphysematous cholecystitis, an entity seen most frequent in men older than 60 years (75%). Pellegrini and Way [43] noted that 20% of all patients with emphysematous cholecystitis have diabetes mellitus, although this rate is generally considered to be higher, of the order of 40%. Fortunately, emphysematous cholecystitis represents only about 1% of all acute cholecystitis. It typically produces gangrene of the gallbladder and appears to be associated with high morbidity and mortality. Our surgical group continues to advocate elective cholecystectomy in diabetics with asymptomatic gallstones. According to Way [33], only 30% of persons with gallstones in the United States come to operation. Each year 2% of patients

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Table 2. Analysis of 486 consecutive cholecystectomies: Fundacio ń Santa Fe de Bogota´.

Parameter

Asymptomatic cholelithiasis

First episode in asymptomatic cholelithiasis

No. Women Men Laparoscopic cholecystectomy Open cholecystectomy Hospital stay (days) Morbidity (no. of patients) Mortality (no. of patients)

27 22 5 27 0 1.9 0 0

164 89 75 79 85 5.5–11.2 90 5

with asymptomatic calculi develop symptoms, usually colic, rather than more serious complications. Our policy has been to perform prophylactic cholecystectomy in candidates for organ transplantation, as high complication rates derived from previously asymptomatic cholelithiasis have been reported following kidney and heart transplantation. There is wide acceptance of prophylactic removal of the gallbladder prior to transplant [44 – 47]. The mortality associated with emergency cholecystectomy in patients who have received a heart transplant is high, up to 36% in the review by Begos et al. [44] of Yale. Some authors have reported episodes of acute cholecystitis during periods of maximum immunosuppression or during rejection episodes. “Silent” cholelithiasis often becomes symptomatic following laparotomy performed for an indication other than biliary tract disease, especially in patients who require mechanical ventilation, transfusions, or parenteral nutrition. Most surgeons agree with the policy of cholecystectomy concomitant with such laparotomies [48]. Finally, there is widespread agreement in recommending prophylactic cholecystectomy in children with chronic hemolytic anemia [49]. With the purpose of identifying reasonable evidence to support the policy of advising elective cholecystectomy in asymptomatic patients, our group, under the leadership of Quintero, has completed a retrospective review of the patients who were previously asymptomatic and who presented to our medical center with acute complications of cholelithiasis. Such analysis has shown that there was considerable morbidity and mortality in this group [50]. The study reviewed the records of 486 consecutive patients subjected to cholecystectomy, elective or emergent, during the past year. The patients were classified in three groups: (1) totally asymptomatic, n 5 27; (2) asymptomatic until a first clinical episode made emergency surgery necessary, n 5 164; (3) symptomatic, n 5 295. The latter patients were eliminated from the study. All 27 asymptomatic patients were operated on laparoscopically, with an average hospital stay of 1.9 days; there was no morbidity or mortality. In contrast, the patients in group 2 underwent laparoscopy (48%) or conversion or primary laparotomy (52%). In this group the hospital stay ranged from 5.5 days to 11.3 days. Complications due to cholelithiasis occurred in 55% of the cases, with a mortality rate of 3%. Table 2 summarizes the principal findings. Complications, seen more frequently in men than in women, were secondary to acute cholecystitis of the

gangrenous type, choledocholithiasis, and pancreatitis; they caused the death of five patients. We concluded that expectant management of asymptomatic patients carries with it the risk of emergency surgery for serious complications of the cholelithiasis at a later date, when the patients are of more advanced age. Moreover, in such a setting, the operation must frequently be done by laparotomy, with significantly higher morbidity and mortality, especially in male patients of advanced age. Cholecystectomy is recommended uniformly throughout Latin America for symptomatic patients. There is need to define the term “symptomatic cholelithiasis.” We believe that the only symptoms that can be attached to cholelithiasis are pain and icterus and that other symptoms (e.g., dyspepsia, flatulence, nausea, or pain outside the right hypochondrium) cannot be considered symptomatic cholelithiasis [51–53]. Our policy has been to recommend cholecystectomy for most symptomatic patients (left upper quadrant pain, icterus, pancreatitis) and for many patients with asymptomatic gallstones who are at high risk of their disease evolving into the symptomatic state or of developing complications [54 –58]. We also believe that not all patients with “silent” stones can be grouped under a single class of “asymptomatic cholelithiasis,” a class in which elective cholecystectomy should be absolutely precluded. We do not agree with such policy, as precluding laparoscopic surgery in many of such patients may be more risky than undertaking an elective operation. Among the asymptomatic patients there are two groups: a low risk group and a high risk group. The low risk patients are those with a functioning gallbladder whose calculi are . 3 mm but , 2 cm in diameter and radiolucent, and who are free of concomitant serious disease. We believe that these patients can be managed with expectant follow-up. The high risk patients are those more likely to develop acute cholecystitis, acute pancreatitis, or other complications of cholelithiasis. Included here are those who have large stones (. 2.0 cm in diameter) [33, 36, 37] and those with small multiple calculi (microlithiasis, stones , 3 mm in diameter), biliary sludge [38, 40], or both. The risk of complicated cholelithiasis is admittedly higher when the cystic duct is chronically obliterated. Patients treated with solvents are candidates for recurrence, as they conserve their lithogenic bile and their diseased gallbladder. We must remember that Langenbuch [59], who performed the first cholecystectomy in Berlin on July 15, 1882, stated that the gallbladder must be removed not for having stones but because it forms them. A report from the University of Bologna, in Italy, showed a 66% recurrence rate in patients not undergoing continued therapy, with a mean interval to recurrence of 5.9 years. Among those who underwent continuing treatment, the recurrence rate at 5 years was 16% in persons younger than 50 years and 60% in those older than age 60 [60]. Evidently, these figures are not satisfactory. In our institution in 1996 we estimated that the yearly cost of oral litholysis was US $1750. We do not perform biliary extracorporeal shock-wave lithotripsy, but the cost of a similar procedure, extracorporeal renal lithotripsy, was US $1435, with US $750 for a repeat treatment. The total cost of laparoscopic cholecystectomy was US $1687.

Patin ˜ o and Quintero: Asymptomatic Cholelithiasis Revisited

Conclusions We classify cholelithiasis into three principal groups: (1) Asymptomatic cholecystitis, for which many do not recommend therapy, either medical or surgical. In this group, we distinguished two classes: (a) a low risk group made up by those who tend to remain asymptomatic and free of complications, for which no therapy is recommended, medical or surgical; and (b) a high risk group, comprising patients who are more likely to develop symptoms and complications, usually late in life, at ages where concomitant disease or loss of organ function is common. (2) Symptomatic cholelithiasis, for which laparoscopic cholecystectomy is recommended as the treatment of choice. (3) Complicated cholecystitis, which usually presents as an acute emergency, for which laparoscopic or open operation is indicated. On the basis of this simple classification, our policy is to recommend elective laparoscopic cholecystectomy for symptomatic cholelithiasis and for asymptomatic cholelithiasis in patients who fulfill the following criteria: Life expectancy . 20 years Calculi . 2 cm in diameter Calculi , 3 mm and patent cystic duct Radiopaque calculi Calcified calculi Polyps in the gallbladder Nonfunctioning gallbladder Calcified gallbladder (“porcelain gallbladder”) Diabetes Severe concomitant chronic disease Women , 60 years (enough life expectancy to develop complications) Individuals living in regions with a high prevalence of gallbladder cancer Of course controversy will persist, at least until we find an effective therapy to prevent or dissolve gallstones or until technologic advances permit performance of a totally safe laparoscopic cholecystectomy, one without the risk of bile duct injury. The procedure could then be labeled truly innocuous. Until then, an editorial by Donaldson of Yale [61] in the New England Journal of Medicine comes to mind, in which he presented a dialogue between physician and patient, a woman whose studies incidentally showed the presence of gallstones. After citing articles and respected textbooks for surgeons and internists about the pros and cons of elective surgery or expectant follow-up, the physician stated: Well Mrs. Gladstone, I’m going to rely on one of the most authoritative textbooks and let you decide for yourself whether to have surgery now or wait for symptoms because ‘it probably doesn’t matter which course is elected since the risks of either are small.’ Once you have symptoms, though, there’s no choice. You must have your gallbladder out right away. Patient: All right. I’ve made up my mind. Physician: And? Patient: Can you refer me to someone for a second opinion?

Re´sume´ La cholećystectomie à froid chez le patient asymptomatique a souleve´ d’importantes controverses, meˆme avant l’e`re de la cholećystectomie par laparoscopie. Que la lithiase biliaire soit connue ou pas, on voit toujours des patients, jusqu’alors asymptomatique, se pre´senter pour la premie `re fois avec des complications graves,

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potentiellement fatales. Chez ces patients, l’intervention en urgence est associeé à des difficulte´s techniques amenant souvent à convertir avec une morbidite´ et une mortalite´ éleveés. La chole ćystectomie à froid est une intervention su ˆre, et qui est associeé à une mortalite´ nulle et une morbidite´ re´duite. Base és sur l’analyse de notre expe´rience, et d’apre`s une revue de la litte´rature, nous discutons les indications de la cholećystectomie à froid chez le patient asymptomatique à haut risque de complications. Les crite`res de maladie à haut risque sont une espe´rance de vie .20 ans, un calcul dont le diame`tre .2 cm, un calcul ,3 mm et un canal cystique permeáble, un calcul radio opaque, des polypes de la ve´sicule biliaire, une ve´sicule non-fonctionnelle, une ve´sicule calcifieé («porcelaine»), un diabe `te, le sexe fe ´minin, l’aˆge ,60 ans, ou un habitant d’une re´gion pour laquelle la pre ´valence de cancer de la ve´sicule est éleveé. Resumen La colecistectomıá electiva en pacientes asintoma´ticos ha motivado considerable controversia desde tiempos anteriores a la colecistectomıá laparosco ´pica. En los servicios quiru ´rgicos es frecuente ver pacientes con colelitiasis conocida o previamente no identificada y que, habiendo permanecido asintoma´ticos, se presentan con complicaciones graves, potencialmente letales, de la colelitiasis, en quienes la operacio ń de emergencia se asocia con dificultades tećnicas que conllevan altas tasas de conversio ń y significativas tasas de morbilidad y mortalidad. La colecistectomıá electiva es un procedimiento seguro que se acompan ã de muy baja morbilidad y nula mortalidad. Con base en el ana´lisis de nuestra propia experiencia y en la revisio ń de la literatura, se discuten las indicaciones para colecistectomıá electiva en pacientes asintoma´ticos pero con alto riesgo de desarrollar complicaciones de su enfermedad asintoma´tica. Se proponen los siguientes factores de riesgo como indicacio ń de colecistectomıá electiva: expectativa de vida mayor de 20 an õs; ca´lculos de .2 cm de dia´metro; ca´lculos ,3 mm con canal cı´stico permeable; ca´lculos radioopacos; po ´lipos en la vesıćula biliar; vesıćula biliar no funcionante; vesıćula biliar calcificada (“de porcelana”); diabetes concomitante; mujeres menores de 60 an õs; personas provenientes de regiones donde existe alta incidencia de cańcer de la vesıćula biliar. References 1. NIH Consensus Statement. Gallstones and Laparoscopic Cholecystectomy (Vol. 10, No. 3, September 14 –16, 1992). Bethesda, National Institutes of Health, U.S. Department of Health and Human Services, Office of Medical Applications of Research 2. Botero, R.C., Abello, H.: Frecuencia de los ca´lculos vesiculares asintoma´ticos en un programa de chequeos me´dicos (resumen). Acta Med. Colombia 15:241, 1990 3. Botero, R.C.: Tratamiento me´dico de la enfermedad biliar. Trib. Med. 86:156, 1992 4. Hermann, R.E.: The spectrum of biliary stone disease. Am. J. Surg. 158:171, 1989 5. Mayo, W.J.: “Innocent” gallstones a myth. J.A.M.A. 56:1021, 1911 6. Gracie, W.A., Ransohoff, D.R.: The natural history of gallstones: the innocent gallstone is not a myth. N. Engl. J. Med. 307:798, 1982 7. Gracie, W.A., Ransohoff, D.R.: The silent stone requiescat in pace. In: Controversies in Surgery II, J.P. Delaney, R.L. Varco, editors. Philadelphia, Saunders, 1983, pp. 361–370 8. Naunyn, B.: Treatise on Cholelithiasis. London, New Sydenham Society, 1896, p. 56

1124 9. Moynihan, B.: An address on inaugural symptoms. B.M.J. 2:1597, 1908 10. Glenn, F.: Surgical management of acute cholecystitis in patients over 65 years of age and older. Ann. Surg. 193:56, 1981 11. Glenn, F.: Silent gallstones [editorial]. Ann. Surg. 193:251, 1981 12. Glenn, F.: Silent or asymptomatic gallstones. In: Controversies in Surgery II, J.P. Delaney, R.L. Varco, editors. Philadelphia, Saunders, 1983, pp. 356 –361 13. McSherry, C.K., Ferstenberg, H., Calhoun, F., Lahman, E., Virshup, M.: The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients. Ann. Surg. 202:59, 1985 14. McSherry, C.K., Glenn, F.: The incidence and causes of death following surgery for nonmalignant biliary tract disease. Ann. Surg. 191:271, 1980 15. McSherry, C.K.: Cholecystectomy: the gold standard. Am. J. Surg. 158:174, 1989 16. Lund, J.: Surgical indications in cholelithiasis: prophylactic cholecystectomy elucidated on the basis of long-term follow up in 526 nonoperated cases. Ann. Surg. 151:153, 1960 17. Wenckert, A., Robertson, B.: The natural course of gallstone disease. Gastroenterology 50:376, 1966 18. Ransohoff, D.F., Gracie, W.A., Wolfenson, L.B., Neuhauser, D.: Prophylactic cholecystectomy or expectant management for silent gallstones. Ann. Intern. Med. 99:199, 1983 19. Thistle, J.L., Cleary, P.A., Lachin, J.M., Tyor, M.P., Hersh, T., Steering Committe, National Cooperative Gallstone Study Group: The natural history of cholelithiasis: the National Cooperative Gallstone Study. Ann. Intern. Med. 101:171, 1984 20. Friedman, G.D., Raviola, C.A., Fireman, B.: Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organization. J. Clin. Epidemiol. 42:127, 1989 21. Friedman, G.D.: Natural history of asymptomatic and symptomatic gallstones. Am. J. Surg. 165:399, 1993 22. Friedman, L.S., Roberts, M.S., Brett, A.S., Marton, K.I.: Management of asymptomatic gallstones in the diabetic patient: a decision analysis. Ann. Intern. Med. 109:913, 1988 23. Speranza, V.: Changing concepts in biliary stones management: preface. Probl. Gen. Surg. 8:ix, 1991 24. Barbara, L., Sama, C., Labate, A.M.M., Malavolti, M.: Epidemiology and natural history of gallstones. Probl. Gen. Surg. 8:535, 1991 25. Heuer, G.J.: The factors leading to death in operations upon the gallbladder and bile ducts. Ann. Surg. 99:881, 1934 26. Morgenstern, L., Wong, L., Berci, G.: Twelve hundred open cholecystectomies before the laparoscopic era: a standard for comparison. Arch. Surg. 127:400, 1992 27. Cervantes, J.: Iatrogenia en Cirugıá. Mexico DF, Salvat Editores SA de CV, 1991, p. 38 28. Csendes, A., Becerra, M., Morales, E.: Carcinoma de la vesıćula biliar. Trib. Med. (Colombia) 84:131, 1991 29. Bedoya, A., Zun ˜iga, A.: Histomorfologıá de la mucosa vesicular en pacientes jo ´venes con colelitiasis. Rev. Colomb. Cir. 9:67, 1994 30. Polk, H.C., Jr.: Carcinoma and the calcified gallbladder. Gastroenterology 50:582, 1986 31. Gribney, E.J.: Asymptomatic gallstones. Br. J. Surg. 77:368, 1990 32. Way, L.W.: The National Cooperative Gallstone Study and chenodiol. Gastroenterology 84:648, 1983 33. Way, L.W.: Asymptomatic gallstones. In: Current Surgical Diagnosis and Treatment (10th ed.), L.W. Way, editor. East Norwalk, CT, Appleton & Lange, 1994, p. 546 34. Way, L.W.: Biliary tract. In: Current Surgical Diagnosis and Treatment (6th ed.), L.W. Way, editor. Los Altos, CA, Lange Medical Publications, 1983, p. 546 35. Way, L.W.: Cholelithiasis and chronic cholecystitis. In: Surgery of the Gallbladder and Bile Ducts, L.W. Way, C.A. Pellegrini, editors. Philadelphia, Saunders, 1987, p. 235 36. Diehl, A.K.: Gallstone size and the risk of gallbladder cancer. J.A.M.A. 250:2323, 1983 37. Schein, C.J., Hurwitt, E.S., Rosenblatt, M.A.: The significance of


38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55.

56. 57. 58. 59.

60. 61.

calculus size in determining the indication for elective cholecystectomy. Gastroenterology 29:377, 1955 Houssin, D., Castaing, D., Lemoine, J., Bismuth, H.: Microlithiasis of the gallbladder. Surg. Gynecol. Obstet. 157:20, 1983 Lee, S.H., Burhenne, H.J.: Gallbladder surgery following cholecystlithotripsy: suggested guidelines for treatment. Br. J. Surg. 77:1268, 1990 Lee, S.P., Nichols, J.F., Park, H.Z.: Biliary sludge as a cause of acute pancreatitis. N. Engl. J. Med. 326:589, 1992 Landau, O., Deutsch, A.A., Kott, I., Rivlin, E., Reiss, R.: The risk of cholecystectomy for acute cholecystitis in diabetic patients. Hepatogastroenterology 39:437, 1992 Aucott, J.N., Cooper, G.S., Bloom, A.D., Aron, D.C.: Management of gallstones in diabetic patients. Arch. Intern. Med. 10:153, 1993 Pellegrini, C.A., Way, L.W.: Acute cholecystitis. In: Surgery of the Gallbladder and Bile Ducts, L.W. Way, C.A. Pellegrini, editors. Philadelphia, Saunders, 1987, p. 161 Begos, D.G., Franco, K.L., Baldwin, J.C., Lee, F.A., Revkin, J.H., Modlin, M.I.: Optimal timing and indications for cholecystectomy in cardiac transplant patients. World J. Surg. 19:661, 1995 Girardet, R.E., Rosenbloom, P., DeWeese, B.M.: Significance of asymptomatic biliary tract disease in heart transplant recipients. J. Heart Transplant. 8:391, 1989 Graham, S.M., Flowers, J.L., Schweitzer, E., Bartlett, S.T., Imbembo, A.: The utility of prophylactic cholecystectomy in transplant candidates. Am. J. Surg. 169:44, 1995 Sekela, M.E., Hutchins, D.A., Young, J.B., Noon, G.P.: Biliary surgery after cardiac transplantation. Arch. Surg. 126:571, 1991 Bragg, L.E., Thompson, J.S.: Concomitant cholecystectomy for asymptomatic cholelithiasis. Arch. Surg. 124:460, 1989 Pappis, C.H., Galanakis, S., Moussatos, G., Keramidas, D., Kattamis, C.: Experience of splenectomy and cholecystectomy in chlidren with chronic hemolytic anemia. J. Pediatr. Surg. 24:543, 1989 Quintero, G.A., Patin õ, J.F., Garcıá-Herreros, L.G., Sua´rez, J.F.: Asymptomatic cholelithiasis: thirteen years of experience at Fundacio ń Santa Fe de Bogota´. Submitted 1997 Patin õ, J.F.: Litiasis biliar: aspectos quiru ´rgicos. In: Enfermedades Digestivas (Vol. IV), F. Villardel, editor. Madrid, Ediciones CEA, SA, 1990, p. 2503 Patin õ, J.F.: Tratamiento actual de la colelitiasis. Trib. Med. (Colombia) 86:155, 1992 Patin õ, J.F.: Conveniencia de la colecistectomıá laparosco ´pica en el paciente con litiasis asintoma´tica. Cirug Cirujanos (Mexico) 64:29, 1996 Patin õ, J.F.: Conveniencia de la colecistectomıá laparosco ´pica en el paciente asintoma´tico. Acta Gastroenterol. Latinoam. 26:187, 1996 Patin õ, J.F., Escallo ń, J., Zundel, N., Eidelman, N., Cadena, M.: La colecistectomıá laparosco ´pica. In: Anuario 1991. Comite´ de Investigaciones y Publicaciones Biome´dicas. Fundacio ń Santa Fe de Bogota´, H. Cuervo, E. Matijasevic, G.A. Quintero, editors. Bogota´, Ediciones AMC, 1991, pp. 67–75 Patin õ, J.F., London õ, E., Garcıá-Herreros, L.G.: La colecistectomıá minitrauma´tica o “minicolecistectomıá.” Rev. Colomb. Cir. 6:70, 1991 Patin õ, J.F., Escallo ń, J., Zundel, N., et al. La colecistectomıá laparosco ´pica. Trib. Med. (Colombia) 85:237, 1992 Patin õ, J.F., Quintero, G.A.: Colecistectomıá electiva en el paciente asintoma´tico. Presented at Conferencia Marcelo Royer, Asociacio ń Argentina de Gastroenterologıá, Buenos Aires, 1994 Langenbuch, K.: Ein Fall von Extirpation der Gallenblase wegen chronischer Cholelithiasis. Berl. Klin. Wochenschr. 18:725, 1882 (Este artıćulo aparecio ´ traducido al idioma ingle´s: Ammon HV, Hofmann AF. The Langenbuch paper. I. An historical perspective and comments of the translators. II. A translation. Gastroenterology 85:1426, 1983) Roda, E., Barbara, L., Bazzolli, F.: Recurrence after medical therapy. Probl. Gen. Surg. 8:673, 1991 Donaldson, R.M.: Advice for the patient with “silent” gallstones. N. Engl. J. Med. 307:815, 1982