title: Gallbladder motor function in gallstone patients: sonographic and in vitro studies on the role of gallstones, smooth muscle function and gallbladder wall inflammation. The natural history of cholelithiasis: the National Cooperative Gallstone Study. Postcholecystectomy symptoms. A prospective study of gall stone patients before and two years after surgery. Cost-minimization analysis in a blind randomized trial on small-incision versus laparoscopic cholecystectomy from a societal perspective: sick leave outweighs efforts in hospital savings Is biliary pain exclusively related to gallbladder stones? A controlled prospective study. Prospective audit of the introduction of laparoscopic cholecystectomy in the west of Scotland. West of Scotland Laparoscopic Cholecystectomy Audit Group. Prospective randomized trial using cost–utility analysis of early versus delayed laparoscopic cholecystectomy for acute gallbladder disease Symptomatic, non-complicated gallbladder stone disease. Operation or observation? A randomized clinical study. Comparison of the Rating Scale and the Standard Gamble in Measuring Patient Preferences for Outcomes of Gallstone Disease Pain persists in many patients five years after removal of the gallbladder: Observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial Does routine intraoperative cholangiography prevent bile duct transection? Prevalence of gallstones in a Danish population. From acute to chronic pain after laparoscopic cholecystectomy: A prospective follow-up analysis [Acute cholecystitis: timing of surgery]. A cost utility analysis of treatment options for gallstone disease: methodological issues and results. Pain and quality of life in patients with symptomatic, non‐complicated gallbladder stones: results of a randomized controlled trial Improvement in gastrointestinal symptoms and quality of life after cholecystectomy. Randomized clinical trial of single‐port, minilaparoscopic and conventional laparoscopic cholecystectomy Acute cholecystitis: delayed surgery or observation. A randomized clinical trial. Long‐term gallbladder stone recurrence and risk factors after successful lithotripsy Long term response to gallstone treatment--problems and surprises. Long-term follow-up of a randomized controlled trial of observation versus surgery for acute cholecystitis: Non-operative management is an option in some patients Prevalence of biliary tract disease in India: a sonographic study in adult population in Kashmir. Cholecystectomy: costs and health-related quality of life: a comparison of two techniques. Preoperative prediction model of outcome after cholecystectomy for symptomatic gallstones. [Acute cholecystitis--early or delayed cholecystectomy]. Relationship between persistence of abdominal symptoms and successful outcome after cholecystectomy. Persisting pain after cholecystectomy. A prospective investigation. Expectant management of patients with gallbladder stones diagnosed at planned investigation. A prospective 5- to 7-year follow-up study of 153 patients. Symptomatic and silent gall stones in the community. Prospective evaluation of patients with acute cholecystitis treated with percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Prospective Evaluation of Emergency Versus Delayed Laparoscopic Cholecystectomy for Early Cholecystitis Gray scale ultrasonic cholecystography: a comparison with conventional radiographic techniques. Symptomatic outcome 1 year after laparoscopic and minilaparotomy cholecystectomy: A randomized trial Prevalence of Postcholecystectomy Symptoms: Long-term Outcome after Open versus Laparoscopic Cholecystectomy Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis Randomization to surgery or observation in patients with symptomatic gallbladder stone disease. The problem of evidence-based medicine in clinical practice. A Randomized Controlled Study of Uncomplicated Gallstone Disease with a 14-Year Follow-Up Showed that Operation Was the Preferred Treatment Urgent Laparoscopic Cholecystectomy Is the Best Management for Biliary Colic
abstract: Gallbladder motility was studied by ultrasound in 100 healthy adult volunteers and 150 gallstone patients , in a subgroup of whom gallstone burden , type and number , gallbladder histology and tensiometric responses of gallbladder strips to cholecystokinin octapeptide  were evaluated . Patients were divided into contractors ( n = 108 ) and hypocontractors ( n = 42 ) , according to their gallbladder motility pattern in vivo . Contractors showed slower gallbladder emptying and increased fasting and postpr and ial residual volumes , although the ejected amount of bile was greater than that of controls ( 20.2 + /- SEM 1.1 vs 16.0 + /- 0.7 ml ; p < 0.001 ) . In contrast , hypocontractors exhibited slower and less complete gallbladder emptying than controls with a reduction in the absolute amount of ejected bile . Although gallbladder wall inflammation was mild and comparable in specimens from both groups of patients , the thickness of the muscular layer was greater in hypocontractors than in contractors ( 1073 + /- 76 vs 745 + /- 75 microns , p < 0.01 ) and related inversely to postpr and ial ejected volume ( r = -0.42 ; p < 0.03 ; n = 32 ) but positively to gallstone volume ( r = 0.40 ; p < 0.03 ; n = 32 ) . Compared to contractors , gall-bladder muscle strips of hypocontractors exhibited a decrease in frequency and amplitude of spontaneous contraction and in maximal stress and receptor sensitivity to cholecystokinin octapeptide ( 0.1 nM-1 microM ) . Postpr and ial gallbladder evaculation was unaffected by stone number , and by the presence or absence of stone calcification . Gallstone volume was larger in hypocontractors ( 19.4 + /- 3.0 ml vs 9.6 + /- 0.9 ml , p < 0.001 ) than contractors . The comparison of in vitro contractility patterns between cholesterol , mixed and pigment stone patients showed a more severe defect in patients with cholesterol and mixed stones than in those with pigment calculi . In conclusion , in gallstone patients : ( i ) gallbladder motor dysfunction manifests mainly with increased fasting and postpr and ial residual volumes in contractors and with markedly increased postpr and ial residual volumes and decreased gallbladder emptying in hypocontractors ; ( ii ) gallbladder kinetics seem to be influenced by stone volume and cholesterol content of calculi but not stone number , calcification or mild chronic cholecystitis ; ( iii ) a form of hypertrophic leiomyopathy is observed in gallstone patients with the most impaired gallbladder motor function The National Cooperative Gallstone Study , a double-masked , placebo-controlled , therapeutic trial of chenodiol ( chenodeoxycholic acid ) , provided an opportunity to study the natural history of cholelithiasis in patients who choose nonsurgical management . The major component of the study comprised 916 patients , 305 of whom were r and omly assigned to receive a placebo for 24 months . Among these 305 patients , the probability of having biliary tract pain during the 24 months of prospect i ve evaluation was significantly increased if the patient had had a history of biliary tract pain in the 12 months before entry into the study ( 69 % versus 31 % ) . Thirty-eight percent of patients had stone growth ( greater than 0.5 cm3 ) , and 18 % had a spontaneous decrease in stone volume . Despite the high incidence of biliary tract pain , nonelective cholecystectomy was required in only 4 % of patients during the 24 months The results of cholecystectomy in terms of symptomatic improvement were prospect ively evaluated in 124 unselected gall stone patients interviewed before and two years after elective surgery . Indications for cholecystectomy were biliary pain ( n = 65 ) , previous complications of gall stone disease ( n = 52 ) , and flatulent dyspepsia ( n = 7 ) . At two years 93 patients could be re-evaluated , of whom only 49 ( 53 % ) were completely symptom free . Postcholecystectomy symptoms occurring in the remaining 44 patients were mainly flatulent dyspepsia ( which had relapsed in 22 of 46 patients who suffered it preoperatively ) , dull abdominal pain or diarrhoea . Incisional hernia was present in five patients and one had recurrence of pain because of retained common bile duct stones . Symptomatic cures after cholecystectomy decreased with the duration of the preoperative history . The results reconfirm that cholecystectomy  eradicates specific symptoms and complications of gall stone disease , but they also show that nearly one half of operated patients are dissatisfied with the procedure because of mild but distressing ' postcholecystectomy ' symptoms . These are probably caused by previously undiagnosed functional gut disease associated with , but unrelated to , gall stones . A systemic approach to multisymptomatic patients with gall stones is recommended Background After its introduction , laparoscopic cholecystectomy rapidly exp and ed around the world and was accepted the procedure of choice by consensus . However , analysis of evidence shows no difference regarding primary outcome measures between laparoscopic and small-incision cholecystectomy . In absence of clear clinical benefit it may be interesting to focus on the re source use associated with the available techniques , a secondary outcome measure . This study focuses on a difference in costs between laparoscopic and small-incision cholecystectomy from a societal perspective with emphasis on internal validity and generalisability Methods A blinded r and omized single-centre trial was conducted in a general teaching hospital in The Netherl and s. Patients with reasonable to good health diagnosed with symptomatic cholecystolithiasis scheduled for cholecystectomy were included . Patients were r and omized between laparoscopic and small-incision cholecystectomy .  Total costs were analyzed from a societal perspective . Results Operative costs were higher in the laparoscopic group using reusable laparoscopic instruments ( difference 203 euro ; 95 % confidence interval 147 to 259 euro ) . There were no significant differences in the other direct cost categories ( outpatient clinic and admittance related costs ) , indirect costs , and total costs . More than 60 % of costs in employed patients were caused by sick leave . Conclusion Based on differences in costs , small-incision cholecystectomy seems to be the preferred operative technique over the laparoscopic technique both from a hospital and societal cost perspective . Sick leave associated with convalescence after cholecystectomy in employed patients results in considerable costs to society . Trial registration IS RCT N Register , number IS RCT N67485658 BACKGROUND The uncertainty around true clinical manifestations of gallbladder stone disease is in contrast with the unanimous recommendation that only symptomatic gallstones should be treated . AIM To evaluate the relationship between biliary pain , other gastrointestinal symptoms and gallstones . DESIGN OF STUDY A pragmatic , prospect i ve cohort question naire study . SETTING Seventy-five general practice s in Rotterdam , The Netherl and s. METHOD All patients suspected by their general practitioner ( GP ) to have gallstone disease underwent ultrasound examination of the upper abdomen .  Using a self-administered question naire , the presence of 11 gastrointestinal symptoms was assessed at inclusion and after 1 year . Likelihood ratios ( LRs ) for the presence of gallstones and symptom relief rates after 1 year were calculated . The mean difference in health status at inclusion and after follow-up was calculated for patients without gallstones , for patients with gallstones who were operated on and for patients with gallstones who were not operated on . RESULTS In total , 61 % of the patients with gallstones diagnosed by ultrasound scan reported biliary pain , as did 45 % of the patients without gallstones ( LR = 1.34 , 95 % confidence interval [ CI ] = 1.05 to 1.71 ) . Patients operated on for gallstone disease did not show significant relief of biliary pain compared to patients not operated on for gallstones or patients without gallstones ( 87 % , 63 % and 83 % , respectively ) . Health status improved in all patients . The mean improvement in health status did not differ between the three patient groups . GPs were able to discriminate between patients with high and low probability of gallbladder stones by ultrasound examination ( 53 % versus 23 % ) . This selection , however , did not predict the outcome of cholecystectomy . CONCLUSION Neither biliary pain nor any other gastrointestinal symptom was consistently related to gallstone disease . Therefore , the indication for elective cholecystectomy can not be based on the presence of biliary pain alone . Relief of biliary pain in patients operated on for gallstones should not simply be attributed to a successful cholecystectomy Although laparoscopic cholecystectomy has rapidly developed in the treatment of gall bladder disease in the absence of controlled clinical trial data its outcome parameters compared with open cholecystectomy remain unclear . A prospect i ve audit of the introduction of laparoscopic cholecystectomy in the west of Scotl and over a two year period was carried out to attempt to assess this new procedure . A total of 45 surgeons in 19 hospitals performing laparoscopic cholecystectomy su bmi tted prospect i ve data from September 1990 - 1992 . A total of 2285 cholecystectomies were audited ( a completed data collection rate of 99 % ) . Laparoscopic cholecystectomy was attempted in 1683 ( 74 % ) patients and completed in 1448 patients ( median conversion rate to the open procedure 17 % ) . The median operation time in the completed laparoscopic cholecystectomy patients was 100 minutes ( range 30 - 330 ) and overall hospital stay three days ( 1 - 33 ) . There were nine deaths ( 0.5 % ) after laparoscopic cholecystectomy although only two were directly attributable to the laparoscopic procedure . In the laparoscopic cholecystectomy group there were 99 complications ( 5.9 % ) , 53 ( 3 % ) of these were major requiring further invasive intervention . Forty patients ( 2.4 % ) required early or delayed laparotomy for major complications such as bleeding or bile duct injuries . There were 11 ( 0.7 % ) bile duct injuries in the laparoscopic cholecystectomy series , five were noted during the initial procedure and six were recognised later result ing from jaundice or bile leaks . Ductal injuries occurred after a median of 20 laparoscopic cholecystectomies . In conclusion laparoscopic cholecystectomy has rapidly replaced open cholecystectomy in the treatment of gall bladder disease . Although the overall death and complication rate associated with laparoscopic cholecystectomy is similar to open cholecystectomy , the bile duct injury rate is higher This r and omized controlled trial compared the cost – utility of early laparoscopic cholecystectomy with that for conventional management of newly diagnosed acute gallbladder disease BACKGROUND Cholecystectomy has been recognized as the treatment of choice for symptomatic gallbladder stone disease . Not all patients are cured by an operation and the reason for having the gallbladder removed may rest on common practice rather than evidence -based medicine . The aim was to compare cholecystectomy with observation ( watchful waiting ) in patients with uncomplicated symptomatic GBS disease . Three-hundred- and -thirty-eight patients were considered for participation in the study ; 45 patients were excluded according to predefined criteria and 156 did not join for other reasons . The remaining 137 were r and omized to cholecystectomy ( n = 68 ) or non-operative , expectant treatment ( n = 69 ) . METHODS R and omized patients were contacted regularly and followed for a median of 67 months . All gallstone-related hospital contacts were registered in both r and omized and excluded patients . RESULTS Eight of the patients r and omized to cholecystectomy did not undergo operation , while 35 of the patients r and omized to observation later had their gallbladders removed . The cumulative risk of having a cholecystectomy seemed to level off after 4 years . Gallstone-related complications occurred in 3 patients in the observation group , 1 in the operation group and 5 of 201 excluded patients . After cholecystectomy , 16 of 222 patients had a major complication and 10 a minor . CONCLUSIONS We found that non-operative expectant treatment carries a low risk of complications . Patients should be informed that watchful waiting is a safe option To estimate patient preferences for gallstone-related treatments and outcomes , and assess how preferences vary by patient characteristics and scaling technique , the authors r and omly assigned 40 patients without gallstones to interviews based on a rating scale ( n = 22 ) and a st and ard gamble ( n = 18 ) . The patients assigned preference values ( possible values 0 to 1 ) to open cholecystectomy ( mean 0.45 by rating scale , 0.78 by st and ard gamble ) , laparoscopic cholecystectomy ( 0.71 , 0.91 ) , extracorporeal shock-wave lithotripsy ( 0.77 , 0.89 ) , acute cholecystitis ( 0.36 , 0.77 ) , lifetime biliary colic ( 0.41 , 0.71 ) , postcholecystectomy syn drome ( 0.43 , 0.79 ) , asymptomatic stone necessitating treatment with bile acids ( 0.76 , 0.96 ) , and surgical scar ( 0.79 , 0.998 ) . Preferences varied little by age , gender , or race . St and ard gamble values were highly correlated with , but significantly greater than , rating scale values . The authors conclude that  patients ' preferences for gallstone-related conditions generally are significantly less than one , and differ markedly by the scaling technique used to derive them . These results should be considered when patient preferences are incorporated into analyses of gallstone treatments . Key words : patient preference values ; rating scale ; stan dard gamble ; gallstones ; cholecystectomy ; lithotripsy . ( Med Decis Making 1994;14:307- 314 After removal of the gallbladder , pain may persist in some patients . To study this condition , 124 patients from two r and omized trials , including those with symptomatic noncomplicated gallbladder stones ( n = 90 ) and acute cholecystitis ( n = 34 ) , were interviewed , while 139 patients ( 90 % ) excluded from both trials responded to a question naire 5 years after the operation . Thirty-four patients ( 27 % ) of those r and omized had pain ; 23 ( 18 % ) had diffuse , steady pain ; and 11 ( 9 % ) had pain attacks resembling their preoperative symptoms . Asignificant dominance of diffuse pain occurred inwomen(P = 0.024 ) , especially those younger than 60 years ( P = 0.004 ) . A tendency for the diffuse type to be dominant was also present in the group of female patients with symptomatic noncomplicated gallbladder stones ( P = 0.052 ) . Of the excluded patients , 18 % ( 25/139 ) had pain , but 88 % of them ( 96 % of the men and 87 % of the women ) were satisfied with the result of the operation . The overall number of patients with postoperative pain was 22 % ( 59/263 ) . We conclude that persisting abdominal pain 5 years after the operation was mainly of a nonspecific type , found mostly in younger women who had had noncomplicated gallstone disease . Eightyeight percent of the excluded patients declared themselves satisfied with the result of cholecystectomy BACKGROUND Patients who undergo endoscopic sphincterotomy for common bile-duct stones , who have residual gallbladder stones , are referred for  laparoscopic cholecystectomy .  However , only 10 % of patients who do not have this operation are reported to develop recurrent biliary symptoms . We aim ed to assess whether a wait- and -see policy is justified . METHODS We did a prospect i ve , r and omised , multicentre trial in 120 patients ( age 18 - 80 years ) who underwent endoscopic sphincterotomy and stone extraction , with proven gallbladder stones . Patients were r and omly allocated to wait and see ( n=64 ) or laparoscopic cholecystectomy ( 56 ) . Primary outcome was recurrence of at least one biliary event during 2-year follow-up , and secondary outcomes were complications of cholecystectomy and quality of life . Analysis was by intention to treat . FINDINGS 12 patients were lost to follow-up immediately . Of 59 patients allocated to wait and see , 27 ( 47 % ) had recurrent biliary symptoms compared with one ( 2 % ) of 49 patients after laparoscopic cholecystectomy ( relative risk 22.42 , 95 % CI 3.16 - 159.14 , p<0.0001 ) . 22 ( 81 % ) of 27 patients underwent cholecystectomy , mainly for biliary pain ( n=13 ) or acute cholecystitis ( 7 ) . Conversion rate to open surgery was 55 % in patients allocated to wait and see who underwent cholecystectomy compared with 23 % in those who were allocated laparoscopic cholecystectomy ( p=0.0104 ) . Morbidity was 32 % versus 14 % ( p=0.1048 ) , and median hospital stay was 9 versus 7 days . Quality of life returned to normal within 3 months after either treatment policy . INTERPRETATION A wait- and -see policy after endoscopic sphincterotomy in combined cholecystodocholithiasis can not be recommended as st and ard treatment , since 47 % of expectantly managed patients developed at least one recurrent biliary event and 37 % needed cholecystectomy . No major biliary complications arose , but conversion rate was high Background The role of routine intraoperative cholangiography is controversial . The aim of this study was to assess the impact of routine intraoperative cholangiography on the incidence of common bile duct injuries , and to evaluate the operative outcome of laparoscopic cholecystectomy carried out in a major teaching hospital and review the literature . Methods Prospect ively collected data on 3,145 laparoscopic cholecystectomies performed mainly by surgical trainees in the period 1990 to 2002 using routine intraoperative cholangiography with fluoroscopy were review ed . Results The mean age of the study sample ( 65.6 % male , 34.4 % female ) was 54 years , and 16.9 % of the patients had clinical acute cholecystitis . The conversion rate to open cholecystectomy was 4.3 % . Intraoperative cholangiography was attempted for 90.7 % of the patients with a 95.9 % success rate . Five patients ( 0.16 % ) had common bile duct injuries . Four injuries had occurred in the first 5 years . One injury ( 0.06 % ) had occurred after 1995 . This injury was identified intraoperatively and repaired laparoscopically . Routine intraoperative cholangiography prevented one definite common bile duct transection . Conclusions In this series using routine intraoperative cholangiography , there was a low rate and severity of common bile duct injuries , with a high intraoperative recognition rate . There was no bile duct transection or major injury requiring common bile duct reconstruction . Although intraoperative cholangiography helped in the immediate identification of injuries and the institution of appropriate therapy , injury was not completely prevented A r and om sample of 4,807 men and women , aged 30 , 40 , 50 , and 60 years , who lived in the western part of Copenhagen County , was drawn from the National Central Person Registry . A total of 226 subjects who were not of Danish origin were omitted . The response rate was 78.8 % ( 3,608/4,581 ) . Each person had his or her gallbladder examined by ultrasonography . The examinations took place between November 1982 and February 1984 . The overall prevalence of gallstone disease ( cases with stones and cholecystectomized cases ) in males aged 30 , 40 , 50 , and 60 years was 1.8 % , 1.5 % , 6.7 % , and 12.9 % , respectively . The corresponding prevalence in females was 4.8 % , 6.1 % , 14.4 % , and 22.4 % , respectively . Differences according to sex were significant in all age groups . Differences between the 40- and 50-year and 50- and 60-year age groups were significant in both sexes . Among subjects with gallstone disease , the disease was unknown to the prob and in the majority of males and in the 30-year-old females , but only in half of the women aged 40 , 50 , and 60 years . The prevalence of clinical ly diagnosed gallstones was not significantly different between respondents and nonrespondents Objective . The pathogenesis and risk of chronic pain after cholecystectomy are unknown . In this prospect i ve study of 150 consecutive patients undergoing laparoscopic cholecystectomy  , the preoperative clinical data , cold pressor test , state of neuroticism and early postoperative pain intensity were assessed . Material and methods . Follow-up question naires were sent to all patients 1 year after surgery . Patients with moderate/severe chronic pain were interviewed and invited to participate in a structured examination programme . Results . The question naire response rate was 100 % . Twenty patients reported moderate or severe chronic pain . The 1-year in-office interview revealed that two patients without chronic pain had misinterpreted the question naire . Sixteen patients were enrolled for the examination programme . Demonstrable pathology explained the aetiology of chronic pain in 8 patients ( 5 % ) ; another 8 patients with moderate ( n=6 ) or severe ( n=2 ) chronic pain were without pathological findings . In total , 132 patients had no chronic pain . Chronic pain patients suffered significantly more intense acute postoperative pain compared with those without chronic pain ( p≤0.05 ) . The incidence of chronic pain patients was higher in the group of patients with intense acute postoperative pain than in patients with low acute postoperative pain ( p = 0.030–0.063 ) . Development of chronic pain was not statistically related to a preoperative cold pressor nociceptive stimulus , preoperative state of neuroticism or to any other variables examined . Conclusions . The risk of significant chronic pain after laparoscopic cholecystectomy for symptomatic cholecystolithiasis is low but was significantly associated with the intensity of acute postoperative pain . Patients should be carefully examined to exclude somatic causes of chronic pain after laparoscopic cholecystectomy The authors report their own experience about 156 cases of acute cholecystitis observed between January 1991 and October 1992 . The most part of the patients were between 30 and 65 years old ( 84 cases observed ) . In 27 cases , for the positive evolution of the pathology , it was put on practice a non operative treatment . The other 129 cases were treated surgically . The patients with lithiasic cholecystitis were 148 ; those affected by non lithiasic cholecystitis were 5 ; and 3 of them presented an acute cholecystitis as a manifestation of a carcinoma . Between the various diagnostic methods , the echography , executed in emergency , is considered as an indispensable one , for having changed completely the diagnostic approach . It is discussed , particularly , the timing of surgery , an aspect able to influence considerably the therapeutic iter and its results . There are analysed the criteria for whom some authors are favourable to a medical treatment of the acute cholecystitis , postponing the operation , while other of them are favourable to an early surgical treatment . The authors ' casuistry put in evidence 110 operations effectuated in emergency ( < 12 hours ) , 19 operations after an 12 - 72 hours interval , no operations at a long distance ( 1 - 10 months ) . The results are to be considered satisfactory : 1 deceased ( on 129 operated cases , 0.78 % ) ; 10 immediate complications ( 7.75 % ) : 8 suppurations of the wound , 1 biliar fistula and 1 internal hemorrhage after video-laparoscopic operation ; 2 late complications ( 1.55 % ) : they were relapsing gallstones . The aim of this work is to offer a contribution to codification of the treatment of the acute cholecystitis , on the ground of the acquired experience The techniques of cost utility analysis ( CUA ) were used to evaluate the treatment of gallstone disease by open and laparoscopic cholecystectomy and by extracorporeal shockwave lithotripsy ( ESWL ) .  The application of the techniques in this context raised three method ological questions which are not satisfactorily resolved in the literature . The first is whether an ex ante or ex post perspective is best adopted for the measurement of quality of life ( QoL ) . The second is the method for converting a short term deterioration in QoL followed by full health into QALYs and the reliability of the methods available . The third is the issue of indirect costs which , in the context of a temporary disease state , can not be easily avoided . The economic evaluation found laparoscopic cholecystectomy to be generally superior than the competitor technologies ( entailing lower costs and better outcomes ) . However , the results were sensitive to assumptions about the perspective for measuring benefits and the inclusion of indirect costs Background : Cholecystectomy is intended to relieve symptoms of gallstones , but unfortunately some patients will experience postcholecystectomy symptoms , including pain . There is limited information in the literature on gallstone‐related pain and its influence on quality of life . The aim of this study was to examine how pain and quality of life in patients with symptomatic , uncomplicated gallbladder stones were affected by observation of their condition compared with removal of the gallbladder . Methods : One‐hundred and thirty‐seven patients were r and omized to observation ( watchful waiting ; n = 69 ) or cholecystectomy ( n = 68 ) and answered question naires on pain , quality of life ( PGWB index and NHP Part II ) at r and omization and fixed intervals ( 6 , 12 and 60 months ) . All gallstone‐related events ( hospital admission for pain , complications of gallstone disease and cholecystectomy ) and crossover between treatment groups were recorded . Results : Of patients r and omized to observation , 35 of 69 patients ( 51 % ) eventually underwent a cholecystectomy . Significant improvements in quality of life and pain scores were detected regardless of surgical treatment . Patients that subsequently experienced gallstone‐related events had significantly higher pain scores at r and omization than patients that did not experience any subsequent events , and this difference was maintained throughout follow‐up . Conclusions : Unexpectedly , in the majority of patients symptoms did abate without any significant differences between groups in pain and quality of life . Patients that had high intensity and frequency of pain at r and omization had a higher risk of experiencing subsequent events BACKGROUND Laparoscopic cholecystectomy ( LC ) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure . This study assesses the effectiveness of LC on reduction in gastrointestinal ( GI ) symptoms and the impact on quality of life ( QOL ) . METHODS A prospect i ve cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys ( GISS )  and  SF36 QOL surveys . The GISS was developed to quantify the magnitude , severity , and distressfulness of 16 GI symptoms . Surveys were scored and evaluated using paired t tests . RESULTS Fifty-five subjects were included in the final analysis . The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC ( P > .05 ) . Significant improvement was seen in QOL ( P < .01 ) . CONCLUSION This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients ' general QOL This three‐armed r and omized clinical trial , with blinding of patients and outcome assessors , tested the hypothesis that single‐port ( SP ) and /or minilaparoscopic ( ML ) cholecystectomy are superior to conventional laparoscopic ( CL ) cholecystectomy . BACKGROUND The aim of the present study was to compare the risk of observation versus that of cholecystectomy in acute cholecystitis in patients r and omly allocated to delayed operation or conservative treatment . METHODS One-hundred- and -eighty patients were considered for participation in the study ; 71 were excluded according to predefined criteria and 45 did not join for other reasons . The remaining 64 patients were r and omized to cholecystectomy ( n = 31 ) or observation ( n = 33 ) . R and omized patients were contacted regularly and followed up for a median of 67 months . All gallstone-related hospital contacts were registered in both r and omized and excluded patients . RESULTS Gallstone-related complications or emergency admissions for pain occurred in six patients in the operation group ( 19 % ; 95 % CI 5%-33 % ) and in 12 patients ( 36 % ; 9 % CI 20%-53 % ) in the observation group . Twenty-seven of 31 patients r and omized to cholecystectomy had a  cholecystectomy  at a median of 3.6 months after r and omization , and , of these , 3 ( 11 % ; 95 % CI 0%-23 % ) suffered a major and 7 ( 26 % ; 95 % CI 9%-42 % ) a minor complication . Ten patients r and omized to observation later had their gallbladders removed , 1 ( 10 % ; 95 % CI 0%-29 % ) patient had a major and 1 ( 10 % ; 95 % CI 0%-29 % ) a minor complication . We found no mortality after cholecystectomy . CONCLUSIONS We found a certain risk of subsequent gallstone-related events following conservative treatment of acute cholecystitis , but the data also show that cholecystectomy should not necessarily be compulsory after acute cholecystitis Objective The risk of recurrence has limited the acceptability of conservative therapies of gallbladder stones . The aim of the present study was to determine the rate of stone recurrence and its risk factors , after successful shock‐wave lithotripsy . Design Prospect i ve ultrasound follow‐up at yearly intervals or whenever biliary pain was reported . Methods One hundred and fifty‐eight consecutive patients ( single stone , n = 130 ; two or three stones , n = 28 ) were followed up to 70 months ( median , 33 months ) after stone disappearance and discontinuation of ursodeoxycholic acid . Results Forty‐three patients developed recurrent stones . By actuarial analysis , the recurrence rates ( as a percent ) at 1 , 2 , 3 , 4 and 5 years were , respectively : 6 ± 2 , 14 ± 3 , 27 ± 4 , 35 ± 5 , and 44 ± 6 ( observed ± SE ) . Cox 's regression analysis identified high body mass indexes to be a risk factor ( P = 0.02 ) for newly formed stones . Having had a single primary stone did not seem to be protective . Fourteen of the 43 patients ( 33 % ) had early symptoms of recurrence . Thirty‐eight patients ( 89 % ) chose to undergo oral dissolution again , which was complemented by lithotripsy in eight patients ( 19 % ) . Conclusion The 5‐year gallbladder stone recurrence  after lithotripsy and ursodeoxycholic acid is not substantially smaller than that reported by post‐bile acid studies . Obesity is a risk factor for recurrent stones as it is for primary stones . Most patients with secondary stones choose to have conservative therapy again . Gallbladder stone recurrence still is one of the major drawbacks of these treatments and cost‐effective strategies are needed to prevent it . Eur J Gastroenterol Hepatol 12:209‐215 © 2000 Lippincott Williams & Wilkins European Journal of Gastroenterology & Hepatology 2000 , OBJECTIVE To re-evaluate after 5 years the results of a r and omised trial of cholecystectomy and lithotripsy for the treatment of symptomatic gallstones . DESIGN Late follow-up of a r and omised controlled trial . SETTING Teaching hospital , UK . SUBJECTS 144 of the 179 patients originally r and omised . INTERVENTIONS Either elective open cholecystectomy under general anaesthesia or a maximum of 4 sessions of lithotripsy ( up to 3000 shocks/session ) on consecutive days with no anaesthesia or analgesia . RESULTS Of the original 87 patients r and omised to be treated by lithotripsy , 39 ( 45 % ) subsequently underwent cholecystectomy , most of them within 32 months of treatment ( " crossover " group ) . Patients in both main groups had a pronounced reduction in the number of episodes of pain at 5 years and significant reductions in the mean severity scores both on VAS and the McGill rating . Those in the crossover group had the worst scores . Gastrointestinal symptoms improved in the two main groups , but again the crossover group did least well . Quality of life improved significantly over baseline in the two main groups , but was much poorer in the crossover group . CONCLUSIONS Patients who had primary cholecystectomy were more likely to be free of pain than those treated by lithotripsy . Lithotripsy gave good symptomatic results in 55 % of patients , and this was not dependent on clearance of stones . Patients who had a cholecystectomy after lithotripsy had the worst symptomatic results . It is difficult to identify patients who will not benefit from lithotripsy , but the presence of many coexisting symptoms may be an important predictor Abstract Background . Cholecystectomy is routinely recommended to prevent recurrent disease after an initial episode of acute cholecystitis . Therefore , r and omized controlled trials have mainly focused on the timing of surgery , but many patients scheduled for cholecystectomy have deferred surgery with long periods of symptom-free intervals . Our present aim is to examine the long-term feasibility and safety of observation compared with surgery . Methods . Trial of 64 patients with acute cholecystitis previously r and omized to observation or cholecystectomy  , which examined outcome in terms of completed r and omized treatment and appearance of further symptoms and the need for surgical treatment .  Thirty-three patients were r and omized to observation and 31 patients to cholecystectomy .  Median follow-up was 14 years . Results . Of the 33 patients r and omized to observation , 11 ( 33 % ) experienced a new event of gallstone-related disease ( eight ( 24.2 % ) had acute cholecystitis ) and 11 ( 33 % ) were operated . No significant difference ( p = 0.565 ) was found between the two r and omized groups with regard to recurrent disease or complications . Virtually no surgery took place after 5 years of follow-up . The difference in completed r and omized treatment between the groups was not significant ( p = 0.077 ) . Long-term mortality was equal in those operated and in those observed . Conclusions . Twenty-four percent of the patients experienced recurrent cholecystitis , but escalation of disease severity or increased mortality was not observed . Long-term observation after acute cholecystitis was feasible in two-thirds of the patients as the risk for recurrent disease was negligible after 5 years Sonography was used to investigate the prevalence of symptomatic and silent  biliary tract disease , in free living urban population in Kashmir . A r and omly drawn sample of 1695 subjects aged 15 years or above was interviewed by a question naire . Twenty six had previous cholecystectomies , all for gall stones .  Ultrasonography was carried out on 1104 ( 65.1 % ) . The responder rates for  ultrasonography  in men ( 64.3 % ) and in women ( 66.0 % ) were similar ( p greater than 0.2 ) . Gall stones  were detected in 49 adults . Three of these had previous biliary symptoms . The prevalence of gall stones in adult population was 6.12 % ( men 3.07 % and women 9.6 % ) . The prevalence of gall stones rose with age in both sexes to a peak in the sixth decade prevalence of gall stones was significantly higher in age adjusted parous women than in nullipara . There was no correlation with obesity , diet , or socioeconomic status . Five subjects had sonographic appearances of the worm Ascaris lumbricodis in the bile ducts : and had previous biliary symptoms BACKGROUND Outcomes of previous health economic evaluations comparing  minilaparotomy cholecystectomy and laparoscopic cholecystectomy  have been inconsistent . OBJECTIVE To compare costs for minilaparotomy cholecystectomy and laparoscopic cholecystectomy and to study changes in quality of life induced by these operations . DESIGN Single-blind , r and omized controlled trial , run from 1 March 1997 to 30 April 1999 . SETTING One university hospital and four non-university hospitals in Sweden . MAIN MEASURE : Cost and perceived health estimation according to the global quality of life instrument EuroQol-5D . RESULTS Of 1719 cholecystectomy patients at five centres , 724 entered the trial and were treated with  minilaparotomy cholecystectomy or laparoscopic cholecystectomy  , 362 in each group . Total health care costs were less for minilaparotomy cholecystectomy than for laparoscopic cholecystectomy ( median values US$ 2428 for minilaparotomy cholecystectomy versus US$ 2613 or US$ 3006 for laparoscopic cholecystectomy with 100 operations per year and reusable trocars or 50 operations per year and disposable trocars , respectively ) . There was no significant difference in total costs ( including costs due to loss of production ) between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with 100 operations per year and reusable trocars in laparoscopic cholecystectomy ( US$ 3731 versus US$ 3649 , respectively ) . However , in calculations assuming 50 operations per year and disposable trocars in laparoscopic cholecystectomy , this technique was more expensive than minilaparotomy cholecystectomy ( US$ 4042 versus US$ 3731 ) . Health-related quality of life was slightly but significantly lower for the minilaparotomy cholecystectomy group 1 week after surgery . One month and 1 year postoperatively no difference between the r and omized groups was found . CONCLUSION Total costs did not differ between minilaparotomy cholecystectomy and laparoscopic cholecystectomy with high-volume surgery and disposable trocars , whereas laparoscopic cholecystectomy was more expensive with fewer operations and disposable trocars . The gain in health-related quality of life with laparoscopic cholecystectomy compared with minilaparotomy cholecystectomy was small and of limited duration BACKGROUND After cholecystectomy for symptomatic gallstone disease 20%-30 % of the patients continue to have abdominal pain . The aim of this study was to investigate whether preoperative variables could predict the symptomatic outcome after cholecystectomy . METHODS One hundred and two patients were referred to elective cholecystectomy  in a prospect i ve study . Median age was 45 years ; range , 20 - 81 years . A preoperative question naire on pain , symptoms , and history was completed , and the questions on pain and symptoms were repeated 1 year postoperatively . Preoperative cholescintigraphy and sonography evaluated gallbladder motility , gallstones , and gallbladder volume . Preoperative variables in patients with or without postcholecystectomy pain were compared statistically , and significant variables were combined in a logistic regression model to predict the postoperative outcome . RESULTS Eighty patients completed all question naires . Twenty-one patients continued to have abdominal pain after the operation . Patients with pain 1 year after cholecystectomy were characterized by the preoperative presence of a high dyspepsia score , ' irritating ' abdominal pain , and an introverted personality and by the absence of ' agonizing ' pain and of symptoms coinciding with pain ( P < 0.000001 ) . In a constructed logistic regression model 15 of 18 predicted patients had postoperative pain ( PVpos = 0.83 ) . Of 62 patients predicted as having no pain postoperatively , 56 were pain-free ( PVneg = 0.90 ) . Overall accuracy was 89 % . CONCLUSION From this prospect i ve study a model based on preoperative symptoms was developed to predict postcholecystectomy pain . Since intra study reclassification may give too optimistic results , the model should be vali date d in future studies INTRODUCTION In our population biliary tract diseases are the most frequent surgical entity . If the diagnosis of acute cholecystitis is relatively clear and the time from onset of the disease does not exceed 72 hours , early cholecystectomy is recommended . The aim of this prospect i ve study was to use certain analytical procedures in order to compare early and late results of early and delayed cholecystectomy . MATERIAL AND METHODS 240 patients were divided into two groups : Group I : patients treated by early cholecystectomy and Group II : patients treated by delayed cholecystectomy .  We compared the following : intraoperative findings , postoperative morbidity and mortality , complications , average number of patient-days and histopathological changes . RESULTS During the investigated period ( 1998 - 1999 ) , 599 ( 35.95 % ) patients with acute and 1.067 ( 64.05 % ) patients with chronic cholecystitis were treated at the Clinic of Abdominal and Endocrine Surgery of the Clinical Center Novi Sad . Out of 599 patients with acute cholecystitis , 489 ( 81.63 % ) patients underwent surgery , whereas 110 ( 18.37 % ) were treated conservatively . In regard to chronic cholecystitis , 963 ( 90.25 % ) patients were surgically treated , and 104 ( 9.75 % ) patients were conservatively treated . All patients from Group I were operated within 24 - 48 hours from onset of the disease or during 24 hours of hospitalization . They were hospitalized due to signs of cholecystitis for the first time , whereas this was the second hospitalization for all patients from Group II , 42 + /- 2.3 days after first hospitalization on average . Regarding sick leave in Group I patients it was calculated as follows : hospital days + home treatment and it made 32 + /- 3.7 days . In Group II it was calculated as follows : first hospitalization + home treatment + second hospitalization + home treatment making 53 + /- 6.7 days . CONCLUSIONS The number and type of early and late complications in Group II patients justifies early cholecystectomy ; in acute cholecystitis , cholecystectomy should be performed within 24 - 48 hours from the onset of the disease ; in regard to late , early cholecystectomies are characterized by significantly shorter period of recovery and sick leave BACKGROUND Patients frequently have persistent abdominal symptoms after undergoing cholecystectomy .  The relationship between abdominal symptoms and biliary dysfunction is often unclear . OBJECTIVES To describe the persistence rate of abdominal symptoms in a large cohort of patients after elective cholecystectomy  , to identify predictors of symptom persistence and operative success , to underst and which symptoms improve after cholecystectomy , and to describe the important determinants of an unsuccessful operation . METHODS Secondary analysis of a prospect i ve , multisite cohort study of 2481 patients undergoing elective cholecystectomy .  RESULTS The mean + /- SD number of abdominal symptoms per patient decreased from 3.1 + /- 2.0 to 1.1 + /- 1.3 ; 27 % of patients who identified a symptom as most bothersome before surgery still had the symptom 6 months after surgery . Symptom persistence rates ranged from 5.6 % ( vomiting ) to 40.2 % ( gas/flatulence ) . A balance score that quantified the abdominal symptom mix between dyspeptic and biliary symptoms shifted after surgery to the dyspeptic category . Predictors of persistence of a most bothersome symptom were dyspeptic symptom category , worse operative risk and self-rated health status , symptom duration longer than 6 months , and no previous episodes of acute cholecystitis . The major correlate of not achieving a very successful outcome ( 15.2 % of patients ) was the presence of postoperative abdominal pain . Other predictors included worse self-rated health status and physical functioning , symptom duration longer than 6 months before surgery , and no previous episodes of acute cholecystitis . CONCLUSIONS Symptoms categorized as dyspeptic were more likely to persist than were biliary symptoms , although all symptoms showed a decrease in prevalence after cholecystectomy . More attention to the rationale for gallbladder removal and clarification of patient expectations for symptom relief might be necessary to improve outcomes after elective cholecystectomy A prospect i ve survey of the short-term outcome  after cholecystectomy  was carried out under circumstances in which the study itself did not influence preoperative decision making or surgical procedures . Of 122 consecutive patients , 115 were evaluable . In all cases gallstones were verified preoperatively either by oral cholecystography or by ultrasonography . Follow-up study was 6 - 12 months postoperatively . Ninety-one patients ( 79.1 % ) reported satisfactory outcome in terms of complete relief of preoperative symptoms . Age , sex , preoperative pain characteristics , history of disease , type of surgery , histology , and complications did not predict the surgical outcome . A test for psychic vulnerability was included among preoperative data items . Psychic vulnerability was significantly associated with persisting pain irrespective of the above-mentioned factors . This suggests that psychologic factors influence the outcome after cholecystectomy with regard to pain relief BACKGROUND Few studies have been done on the expectant management of patients with cholelithiasis diagnosed by planned investigation , and results are conflicting . METHODS A prospect i ve 6-year follow-up study of 153 patients with cholelithiasis diagnosed by oral cholecystography  was carried out . RESULTS An acute gallstone complication occurred during the follow-up period in 23 patients (15%)-that is , acute cholecystitis ( n = 18 ) , acute pancreatitis ( n = 2 ) , and jaundice ( n = 3 ) . The annual risk of developing an acute biliary complication was 3.1 % . A history of a gallstone complication predicted further gallstone complications during follow-up . The overall cholecystectomy rate was 20 % during the 1st year but fell to about 3 % during the 5th year of follow-up . Young age and frequent attacks of biliary pain episodes predicted the need for gallstone surgery . CONCLUSIONS Expectant management of patients with electively diagnosed cholelithiasis may be justified , especially in those with only occasional biliary symptoms and no history of gallstone complications The prevalence of gall stone disease in a stratified r and om sample of 1896 British adults ( 72.2 % of those approached ) was established using real time ultrasound . The prevalence rose with age , except in women of 40 - 49 years , so that at 60 - 69 years , 22.4 % of women and 11.5 % of men had gall stones or had undergone cholecystectomy . The  cholecystectomy rate of people with gall stone disease was higher in women than in men ( 43.5 % v 24 % , p less than 0.05 ) . Very few subjects with gall stones had convincing biliary symptoms . In women , 10.4 % had symptoms according to a question naire definition of biliary pain and 6.3 % according to conventional history taking , while no men at all admitted to biliary pain . Nevertheless , cholecystectomy in men had nearly always been preceded by convincing biliary symptoms . The age at cholecystectomy  was , on average , nine years less than the age at detection of silent gall stones in both sexes . It is concluded that either gall stones are especially prone to cause symptoms in younger people or that there are two kinds of cholelithiasis - symptomatic and silent . The lack of symptomatic gall stones in cross sectional surveys is probably due to their rapid diagnosis and treatment BACKGROUND Emergency laparoscopic cholecystectomy has been advocated for the treatment of acute cholecystitis ; however it can be a difficult task , especially in public hospitals , with relatively high conversion and complication rates . Percutaneous cholecystostomy is a simple and effective procedure allowing patients to recover from the acute event and undergo elective laparoscopic surgery at a later stage . METHODS We prospect ively assessed a protocol of initial conservative treatment in patients admitted with acute cholecystitis . Patients who did not respond to medical treatment were treated by percutaneous cholecystostomy .  Following discharge the patients were seen in the outpatient clinic and elective laparoscopic cholecystectomy was considered and scheduled as necessary . The details of the operation were collected with emphasis on complications and conversion rate . RESULTS During a 3-year period , 224 patients who were admitted with acute calculous cholecystitis entered the protocol . Fifty-four patients did not improve under medical treatment and percutaneous cholecystostomy was performed . In spite of adequate drainage , 5 patients still did not improve : 3 patients were successfully operated upon urgently and recovered , while 2 patients who had severe concomitant diseases and multi-organ failure , died . Forty-nine patients were discharged with the catheter and later re-evaluated for elective operation . In 7 patients common bile duct stones were found and were removed by ERCP prior to the elective operation . Twenty-five patients underwent delayed laparoscopic cholecystectomy with a low conversion rate ( 8 % ) , and only minor complications ( 16 % ) . CONCLUSIONS Conservative treatment and delayed operation is still an acceptable choice in the treatment of acute cholecystitis . Percutaneous cholecystostomy is an effective tool , with high success rate and low morbidity , and allows for better pre-operative evaluation of the biliary system and safe interval laparoscopic surgery . Laparoscopic cholecystectomy after drainage of the gall bladder is a low morbidity procedure with relatively low conversion rate Treatment of acute cholecystitis is still under debate . The aim of this study was to evaluate the efficacy of early laparoscopic cholecystectomy ( ELC ) in comparison with conservative treatment followed by delayed laparoscopic cholecystectomy ( DLC ) in the management of acute cholecystitis . This prospect i ve comparative study involved two groups of patients presenting with acute cholecystitis within 72 hours of the onset of symptoms . ELC was performed in 82 consecutive patients , whereas DLC was performed in 87 patients who previously underwent medical treatment .  Surgical variables , hospital stay , and postoperative morbidity were evaluated in both groups . Time of surgery and conversion rate were lower in the ELC group . Postoperative morbidity was similar in both groups . Overall hospital stay was shorter in the ELC group . ELC within 72 hours of the onset of acute cholecystitis is a safe procedure with better results than DLC in terms of surgical timing , conversion rate , and hospital stay A prospect i ve study was design ed to assess the accuracy of gray scale ultrasonography in the evaluation of  cholelithiasis .  A series of 111 patients with nonvisualization on first-day oral cholecystography underwent ultrasonic cholecystography  , and the results were compared with subsequent second-day visualitzation or surgical findings . In 75 cases sufficient data were present to assess the accuracy of the method . Ultrasound correctly diagnosed 68 ( 91 % ) of these cases with regard to gallstones . Only 6 gallbladders could not be visualized ultrasonically and all subsequently proved to have gallstones . It is concluded that improved ultrasonic technique is of considerable value in investigating the nonvisualized gallbladder . Valuable information conderning other upper abdominal pathology was often discovered In a r and omized controlled trial , 299 patients were sent a symptoms question naire 1 year after laparoscopic ( n = 151 ) or minilaparotomy ( n = 148 ) cholecystectomy for symptomatic cholelithiasis . The response rate to the question naire from contactable patients was 86 per cent . In both groups , at least 90 per cent of patients reported that their symptoms were improved , and at least 93 per cent rated the success of their operation as ‘ excellent ’ , ‘ good ’ , or ‘ fair ’ . However , over half the patients reported abdominal pain , a quarter reported flatulence , and a quarter dyspepsia . The only difference between treatment groups was that a higher proportion of patients who underwent minilaparotomy  reported heartburn ( 35 per cent versus 19 per cent , P = 0±005 ) . Patients who reported a ‘ poor ’ outcome were more likely to have suffered a postoperative complication , had lower quality of life scores , and higher anxiety and depression scores . Both laparoscopic and minilaparotomy cholecystectomy result in symptomatic benefit in at least 90 per cent of patients with symptomatic cholelithiasis Abstract . After cholecystectomy a certain number of patients continue to suffer from abdominal symptoms or develop such symptoms postoperatively . The aim of this study was to compare the prevalence of postcholecystectomy symptoms with open cholecystectomy during the prelaparoscopic era and those with laparoscopic cholecystectomy 4 years after introduction of the laparoscopic technique .  Between July 1988 and June 1989 a total of 163 consecutive patients with elective open cholecystectomy and between September 1994 and August 1995 a total of 234 consecutive patients with elective laparoscopic cholecystectomy  were prospect ively evaluated using a st and ard question naire about preoperative symptoms , diagnostic modalities , and intraoperative findings . After a minimum of 12 months the patients were interviewed by telephone . Since the introduction of the minimal invasive technique the number of cholecystectomies performed at our institution increased . There was no significant difference in the prevalence of postcholecystectomy symptoms found after the open procedure compared with laparoscopic cholecystectomy : 90 % of patients after open and 94 % after laparoscopic cholecystectomy had no or only minor symptoms The aim of this prospect i ve r and omized study was to define the optimum management between early and delayed laparoscopic cholecystectomy for patients with acute cholecystitis BACKGROUND The description and underst and ing of gallbladder stone disease in the medical literature are difficult because an assessment of the natural course of this symptomatic disease , with separation of patients in strictly defined groups , is generally lacking . METHOD A multicenter study was carried out with patients r and omized to either surgery or conservative , expectant treatment to examine optimal treatment and natural history in well-defined groups of symptomatic gallbladder stone disease with pain , episodes only ( study group 1 ) or acute cholecystitis ( study group 2 ) . The patients were between 18 and 80 years of age and had right upper quadrant or midline epigastric pain and ultrasonographic evidence of gallbladder stone , with or without acute cholecystitis . Medical treatment was ordinated on the basis of signs and symptom severity . Patients r and omized to surgery  were placed on the hospital 's waiting list and electively operated on with cholecystectomy as soon as conveniently possible . Preliminary results of follow-up are based on question naires mailed at regular intervals and consultations if required by the patients ' symptoms . Quality of life and freedom from pain are study end points for evaluation . RESULTS Five hundred and one patients were considered for the study , 318 patients ( 63.5 % ) belonging to group 1 and 183 ( 36.5 % ) to group 2 . One hundred and eighty-four patients ( 36.7 % ) were r and omized , 120 ( 24 % ) in group 1 and 64 ( 12.7 % ) in group 2 . Three hundred and seventeen patients ( 63.3 % ) , with an equal proportion from each study group , were excluded , the largest number of patients because of incapacitating pain or serious presenting symptoms ( 26 % ) . More women ( 81 % ) than men ( 19 % ) had pain alone ( group 1 ) , but the sex ratio was reduced , 56 % women and 44 % men , in patients with acute cholecystitis ( group 2 ) , with a highly significant difference ( P = < 0.001 ) between the two groups . A significant difference in patient withdrawal from r and omized treatment was registered , with 24 % from observation and 12 % from surgery ( P = 0.032 ) , but with an equal distribution in the two study groups . CONCLUSIONS A r and omized trial of this nature is feasible but extremely difficult to perform because of the heterogeneous nature of gallbladder stone disease , leading to exclusion of many patients and difficulties in measuring and evaluating outcome variables Background / Aims : Cholecystectomy is considered the treatment of choice for symptomatic gallstone disease . Some patients abstain from surgery and provide the opportunity to study the natural history of cholelithiasis . The aim of the present study was to examine the feasibility and safety of observation after extended long-term follow-up in a r and omized controlled trial . Methods : A total of 137 patients ( 40.5 % of those assessed ) were r and omized to observation or cholecystectomy and followed up for 14 years . The prevalence of symptomatic events or major complications after treatment was the primary end point . A secondary end point was completion of r and omized treatment . Results : There were no differences in outcome between the observation group and the surgical group ( p = 0.298 ) . Virtually no  cholecystectomy  was performed after 5 years of follow-up , and no clear escalation in the severity of the disease was observed . A total of 50.7 % of patients from the observation group and 88.2 % from the surgical group underwent surgery . The group r and omized to surgery completed their design ated treatment significantly more often ( p < 0.001 ) , especially among patients younger than 70 years of age ( p = 0.005 ) . Conclusion : Cholecystectomy was the preferred treatment after extended long-term follow-up , but conservative management for symptomatic gallstone disease is an alternative to surgery in the elderly Background / Aim : Delay of laparoscopic cholecystectomy after the diagnosis of biliary colic may increase the probability of recurrent emergency admission while awaiting elective cholecystectomy . The aim of this study was to compare the possible advantages and safety of urgent laparoscopic cholecystectomy ( ULC ) with elective laparoscopic cholecystectomy ( ELC ) in patients with biliary colic . Patients and Methods : Between 2001 and 2003 , 75 patients with biliary colic were included in this study . The patients were classified into following two groups : patients who had ULC in 24 h were in group I ( n = 28 ) and patients who had ELC ( mean interval 4.22 ± 1.42 months ) were in group II ( n = 35 ) . Conversion to open cholecystectomy , operative time , postoperative hospital stay , costs , and complications were evaluated . Results : In group II , 9 patients made a total of 13 return visits to the emergency department with recurrent attacks of biliary colic or complications of gallstone disease . Mean operative time increased from 35.1 ± 6.74 min for urgent laparascopic cholecystectomy to 49.9 ± 6.12 min for ELC ( p > 0.05 ) and hospital stay time increased from 1.06 ± 0.4 to 2.31 ± 2.36 days ( p < 0.05 ) . Conversion to open cholecystectomy increased from 0 % in group I to 17.2 % in group II ( p < 0.05 ) . Discussion : ULC for biliary colic may be the most medically efficacious and cost-effective treatment
target: The results of the economic evaluation suggest that , on average , the surgery strategy costs £ 1236 more per patient than the conservative management strategy but was , on average , more effective .
  An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy .
  The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people .
  However , approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people .
background: BACKGROUND Approximately 10 - 15 % of the adult population suffer from gallstone disease , cholelithiasis , with more women than men being affected .
  Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones .
  However , some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis .
  As most of the current research focuses on the surgical management of the disease , less attention has been dedicated to the consequences of conservative management .
  OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of  cholecystectomy  compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones ( biliary pain ) or cholecystitis .