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The asymptomatic patient with gallstones
The Asymptomatic
Patient
with Gallstones*
BENTLEYP. COLCOCK,M.D., Boston, Massachusetts, RICHARDB. KILLEN, M.D., Woodland, California, ANDNEVILLEG. LEACH, BI.D.,London, Englnnd
From the Department of Surgery, Lahey Clinic Foundation, Boston, Massachusetts.
were no symptoms referable to the biliary tract who were submitted to cholecystectomy.
OST SURGEONSbelieve that, with few exceptions, any patient with gallstones should undergo cholecystectomy [l-3]. It is known that the mortality for this operative procedure is low (less than 1 per cent). Moreover, surgeons frequently have been forced to operate upon elderly, poor risk patients because of a complication of cholelithiasis such as acute cholecystitis or jaundice. Many of these patients were known to have had gallstones for years but had not been operated upon because they had no symptoms. Comfort, Gray, and Wilson [4] reported follow-up data on 112 asymptomatic patients with gallstones who were not operated upon; symptoms developed in 50 per cent and were severe in 20 per cent. Lund [5] had an almost 100 per cent follow-up study of five to twenty years in 526 patients with cholelithiasis not operated on. Severe symptoms, complications, or both occurred subsequently in at least a third to a half of his group of patients. The prognosis is approximately the same in patients with or without symptoms. In 1911 Mayo [6] stated, “The innocent gallstone is a myth.” Yet, many physicians and some surgeons are still not convinced that asymptomatic patients with gallstones should undergo operation. We who believe they should must support our positions not by impressions alone but by careful analysis of our experience. It is important to know the mortality and early and late morbidity associated with the removal of the “silent” gallstone. A review is presented of 134 patients with cholelithiasis in whom there
A final diagnosis of asymptomatic cholelithiasis was made in 166 patients treated at the Lahey Clinic between 1950 to 1958. After a careful review of each record the number was reduced to 134. Many of the thirty-two patients omitted from this study had symptoms of belching, flatulence, constipation, and nausea which had been attributed to a concurrent “irritable colon.” Since such symptoms could possibly be related to other gallbladder disease, these patients were excluded. Many patients were seen for primary disease in other systems, or they were referred to the clinic after a thorough examination elsewhere. While the number of cases found on routine physical examination is increasing, most patients were examined because of abdominal symptoms. This is reflected in the incidence of associated disease found with asymptomatic gallstones [7]. Only 22 of the 134 patients (16 per cent) had no symptoms preoperatively. Various gastrointestinal diseases, such as colonic polyps, diverticulitis, hemorrhoids, and irritable colon, were noted in twenty-eight (21 per cent). Patients who had a diagnosis of irritable colon were included only if they had been followed up for several years and a bowel management program had resulted in remission of symptoms. Diabetes was an unsuspected finding in twelve patients (9 per cent), and was a borderline condition in some patients and occult in others. Seven patients (5 per cent) known to have cardiovascular disease had electrocardiographic verification of such disease. Asso-
DATA
M
* Presented at the Seventh Annual Meeting of the Society for Surgery of the Alimentary Chicago, Illinois, June 25 and 26, 1966. 44
Tract,
dmerican Journal of Surgery
Asymptomatic
Patient with Gallstones
ciated disease was also found in the following: skeletal system, ten patients; genitourinary tract, twenty patients; liver, four patients; central nervous system, four patients; all other systems, twenty-seven patients. During the same eight year period (1950 to 1958) 3,112 symptomatic patients were operated for gallstones at the Lahey Clinic [8,9]. The age incidence of both groups was compared and no significant differences were found. No unusual racial distinction was noted, and the ratio of female (ninety-seven or 72 per cent) to male patients (thirty-seven or 28 per cent) is consistent with that observed in symptomatic patients with stones. When disease of the biliary tract was discovered, surgical intervention promptly ensued in most instances. The longest period between diagnosis and treatment was twenty-five years, and this patient was consistently asymptomatic. In three other patients an average of ten years elapsed between diagnosis and surgery. The ages of the patients in this study by decades \vas similar to that of patients with symptomatic gallstones. (Table I.) DIAGNOSIS
Each patient had a detailed history and physical examination which was often repeated when the patient was referred from one section to another. Cardiac evaluation was carefully made. Most patients underwent roentgenologic study of both the upper and lower gastrointestinal tract as well as oral cholecystography. When indicated, opinions of consultants were sought so that each system would be evaluated. Roentgenologic evidence of cholelithiasis was found in 114 patients. In the remaining twenty diagnosis was made at celiotomy performed for other conditions including aortic aneurysm, regional enteritis, and uterine fibroma. Asymptomatic cholelithiasis was noted in three patients on routine pyelograms. Another thirteen cases were discovered during spinal studies and barium x-ray series of both the upper and lower gastrointestinal tract. Survey roentgenograms of the chest and abdomen revealed stones in twelve patients; no additional studies were carried out. Oral cholecystography was performed in eighty-six patients; some patients had two or more negative results on cholecysto,gram during the eight year follow-up period (1958 to 1966) before a third or fourth cholecystogram revealed cholelithiasis.
TABLE AGE
\-ears
20-29 3039 40+9 50-59 60-69 TO-X
DISTRIBUTION
I IN
-
DECADES
I’atirnts Sumber
4 8 16 51 44 11
I’CT cent
:i ti 12 38 33 x
Oral cholecystography accounted for ninetyeight diagnoses. One patient had both an oral cholecystogram and an intravenous cholangiogram, and one hospitalized patient had an intravenous cholangiogram only. Cholecystograms were not taken in thirty-four patients, the opaque stones being evident on some other roentgenologic study. Of the fifteen patients in whom the common duct was opened, only one T tube cholangiogram was taken at operation and two T tube cholangiograms were taken postoperatively. By cholecystography and intravenous cholangiography, the gallbladder was visualized in eighty-seven patients (65 per cent). Of these, seventy-one patients had multiple stones and sixteen patients had single stones. On the other hand, the gallbladder in thirteen patients (10 per cent) could not be visualized by oral cholecystography or intravenous cholangiography. In the group of 1,756 symptomatic patients with gallstones reported in 19B3 [Y], the gallbladder was not visualized on roentgenologic examination in 340 patients (19 per cent). Of the 1,172 symptomatic patients operated upon during this period, preoperative x-ray studies proved reliable; only fifteen patients did not have stones. All of the asymptomatic patients showing stones on x-ray study were found to have stones at surgery. OPERATION
The technic of cholecystectomy has been described in a previous report [8]. Only by treating the operation with the respect it merits can this procedure be advocated for both asymptomatic as well as symptomatic patients with gallstones. No patient had injury to the common duct either in this series with cholecystectomies for asymptomatic gallstones or in the entire eight year study of 3,112 cholecystectomies per-
Colcock,
Killen,
formed at the Lahey Clinic between 1950 and 195s. Cholecystectomy was performed in 11’7 patients (87 per cent), and 15 patients (11 per cent) underwent both cholecystectomy and choledochostomy. No stones were found in the common duct in any patient despite the fact that in several the gallbladder contained very small stones. One cholecystostomy was carried out in an elderly patient during an extensive procedure for a condition unrelated to biliary tract disease; cholecystectomy was performed later. Excision of a cystic duct remnant was carried out in one asymptomatic patient in whom stones were present in the remnant. Concomitant operations were performed in 69 of 134 patients (51 per cent) : appendectomy, forty-three patients; liver biopsy, five patients; hiatal herniorrhaphy, one patient; other procedures for disease in the pelvis, intestine, and spleen, twenty patients. That these operations were necessary underlines the need for careful evaluation of all systems, especially the gastrointestinal tract. PATHOLOGIC
FINDINGS
Multiple stones without cholecystitis were found in fourteen patients whereas multiple stones with cholecystitis were found in ninetysix patients. Single stones and cholecystitis occurred in fourteen patients, only one patient having a single stone without cholecystitis. In three patients with subacute or chronic cholecystitis stones were not visualized on the preoperative roentgenogram, and the indication for surgery was a nonfunctioning gallbladder. Hydrops and cholelithiasis were found in one patient, and a polyp and cholecystitis in another. Cholesterolosis was found in four patients. The common duct was explored in 28.6 per cent of the symptomatic patients (503 of 1,756 patients) in our previous study which is in contrast to 11 per cent of ducts explored in asymptomatic patients (15 of 134 patients) reported on herein. No common duct stones were found in this group of asymptomatic patients. MORBIDITY
No postoperative complications were directly related to biliary tract surgery. Five minor wound infections were recorded, occurring in patients who had had concomitant surgical procedures; however, they did not prolong the
and Leach patient’s usual hospital stay. Complications related to associated disease accounted for twelve early postoperative problems. These included : confusion with cerebral arterioscerosis, one patient; symptoms of previous cerebrovascular accident, two; atelectasis in patient with chronic lung disease, three ; Hodgkin’s disease, two; prolapsed hemorrhoids, one; chronic cystitis, two; diabetic-insulin reaction, one. No late complications were related to disease of the biliary tract. Fourteen complications were related to disease that was either concomitant or subsequent to the asymptomatic gallstone. These included ; carcinoma of the lung, one patient; gastric ulcer, one ; carcinoma of the cecum, one; regional ileitis, one; metastatic carcinoma of the rectosigmoid to liver, one; irritable colon (new), one; coronary thrombosis, two; cerebrovascular accident, three; persistent pain, two; incisional hernia (not this operation), one. In two patients, vague abdominal pain developed several months after operation and was not localized to the upper part of the abdomen. Repeated gastrointestinal x-ray studies with barium failed to disclose an organic cause. MORTALITY
Only one postoperative death occurred. The patient was a seventy-eight year old woman with diffuse metastatic carcinoma not diagnosed preoperatively and who had a coronary thrombosis the day after operation. Three late deaths resulted from biliary tract disease which was unrelated to gallbladder surgery. Two patients died from cirrhosis. One aged fiftyseven years died two years after operation from severe viral hepatitis and cirrhosis. The second patient, aged fifty-two years, died five years after surgery from cirrhosis and ascites of unknown cause. The third late death occurred seven years after surgery; this fifty-six year old patient died from carcinoma of the common bile duct. FOLLOW-UP
STUDY
A follow-up study was conducted for eight years from 1958 to 1966. Results were obtained from clinic visits and letters of inquiry to the patient. Of the 134 patients, 115 are alive without symptoms of biliary tract disease including the oldest patient in the study whose diagnosis was made in 1932. Eighteen patients have died since surgery; fourteen without symptoms American
Journal of Surgery
Asymptomatic
Patient with Gallstones
of biliary tract disease died from other causes, one died from an unknown cause, and the three with disease related to the hepatobiliary tract who died are reported as late postoperative deaths. As indicated, these three deaths were not related to cholecystectomy. One patient was lost to follcw-up study. SUMMARY
.4ND CONCLUSIONS
True asymptomatic cholelithiasis is rare. Of 3.112 patients with cholecystitis and cholelithiasis operated upon in an eight year period, only 131 had no symptoms which could be attributed to the gallbladder. Only 11 per cent (15 of 134 patients) had common duct exploration, and no common duct stones were found. Of the 2,978 symptomatic patients operated upon for gallstones during this same period, the common duct was explored in 28.6 per cent, and common duct stones were found in approximately 9 per cent. This suggests that early surgery in patients with cholelithiasis, when these patients are still asymptomatic, may reduce the incidence of common duct disease. If so, it will also reduce the mortality and morbidity associated with disease of the biliary tract. Only one postoperative death occurred in these 134 patients (0.7 per cent). This patient was a seventy-eight year old woman with associated carcinoma who died of coronary thrombosis. No postoperative complications either early or late were related to the operative procedure. On late follow-up study, only three patients had died from biliary tract disease : one from carcinoma, one from cirrhosis, and one from hepatitis; all were unrelated to the operative procedure. Based on our experience, we believe that unless there is a strong contraindication to surgery, such as a recent coronary occlusion, the presence of cholelithiasis, even without symptoms, is an indication for cholecystectomy. REFERENCES 1. METHOD, H. L., MEHN, W. H., and FRABLE, W. J.
“Silent” gallstones. Arch. Surg., 85: 338, 1962. FOSBURG, R. G. Gallstones in young adults. An analysis of 178 patients under thirty years of age. .Im. J. Surg., 106: 82, 1963. 3 CAHOW, C. E., JR. and GLENN, F. Sequelae attributed to delayed surgical treatment of gallstones. .1nn. &rg., 161: 21, 1965. 4. COMFORT, M. W., GRAY, H. K., and WILSON, J. M. Silent gallstone: 10 to 20 year follow-up study of 112 cases. Ann. Surg., 128: 931, 1948. 2
Vol. II.?, January
1967
47
Lucn, J. Surgical indications in cholclithiasi~: prcjphylactic cholelithiasis: prophylactic cholccystcctomy elucidated on the basis of lorlK-trrm follow up on 5’16 nonoperated cases. .lnn. .Yu~x.. 1.51 : IT,:<, 1960. 6. MAYO. W. J. “Innocent” rnllstonc.~ :i myth. J.;I.M..I., 56: 1021. 1911. 7. Downy, (;. S., JR. and WALDRON, G. W. Importance of coexistent factors in biliary tract surgery. An analysis of 2,285 operations. .-1vrh. SUV,~.. XX: 314, 1964. COIXOCK, B. P. and MCMANUS. J. E. Esperienccs with 1,356 cases of cholecystitis and cholclithiasis. surg. Gynec. 6 Ohst., 101: 161. 1955. COLCOCK, B. P. and PEREY. B. The treatment of cholelithiasis. Surg. Gyner. a Obst., 117: X9. 1963. 1i
DISCUSSION
WARREN H. COLE (Chicago, Ill.) : You recall that Dr. Colcock said verv few of these so-called silent stones are actually silent. These patients usually have some minor symptoms which, of course, may develop into more severe symptoms in the \-et-y near future. In our clinic we utilize the principle that if the stones are silent and the patient has a life expectancy of eight or nine years, we advise removing the gallbladder. We have adopted this philosophy because we believe the chance of having one of the several complications mentioned by Dr. Colcock is so great that we believe chances of survival are helter if the stones are removed. The fact that no stones were found in the common duct in Dr. Colcock’s series might, of course, make one think the situation is not so serious and operation is not necessary. The point is that an elective operation will hopefully prevent serious complications from developing later. HARWELL WILSON (Memphis, Term.): I believe that Dr. Colcock has expressed a point of view shared by most surgeons and that more studies of this type should help convince internists and general practitioners of the importance of this point of view. CLAUDE E. WELCH (Boston, Mass.): There was a good deal of speculation a number of years ago on whether the cause of gallbladder disease might be traced to a tight sphincter of Oddi, and a suggestion was made that all cholecystectomies should he accompanied by dilatation of the sphincter. Dr. Colcock’s follow-up study, however, demonstrates that it is unnecessary and that almost surely the cause of gallbladder disease resides in the gallbladder itself. We might say that we have reduced the incidence of cancer of the gallbladder by removing these stones, but here again we may be on rather tenuous grounds. Perhaps the liver secretes some sort of carcinogen that is merely concentrated in the gallbladder, and it may be that after removal of the gall-
Colcock,
Killen,
bladder we will encounter more cases of carcinoma of the common duct or perineum. WILLIAM HERVEY REZXINE(Rochester, Minn.) : Generally, we at the Mayo Clinic are in accord with Dr. Colcock. Whenever we have an asymptomatic patient with gallstones, we usually advise removal of the stones. I am particularly interested in the patient who has other complicating problems. For instance, our internists frequently see patients who have diabetes or a myocardial problem as well as gallstones, and I think it is extremely important to remove the gallbladder in the asymptomatic patient with gallbladder before the other complicating problems can become worse.
and Leach These other problems will become worse, and if the patient has an acute gallbladder attack when the cardiac problem is more severe or when the diabetes is in a difficult state, the gallbladder disease can be a lethal one. BENTLEYP. COLCOCK(closing) : As Dr. Wilson has stated, there are many physicians who are not convinced of what we are so thoroughly convinced of from our experience in the operating room. I do not think for one moment that this paper will change many minds, however, I hope we have added some facts to those which others will add. Someday it will be apparent that serious trouble will be prevented in some patients if gallstones discovered accidentally are removed.
American
Journal
of Surgery
Patient
with Gallstones*
BENTLEYP. COLCOCK,M.D., Boston, Massachusetts, RICHARDB. KILLEN, M.D., Woodland, California, ANDNEVILLEG. LEACH, BI.D.,London, Englnnd
From the Department of Surgery, Lahey Clinic Foundation, Boston, Massachusetts.
were no symptoms referable to the biliary tract who were submitted to cholecystectomy.
OST SURGEONSbelieve that, with few exceptions, any patient with gallstones should undergo cholecystectomy [l-3]. It is known that the mortality for this operative procedure is low (less than 1 per cent). Moreover, surgeons frequently have been forced to operate upon elderly, poor risk patients because of a complication of cholelithiasis such as acute cholecystitis or jaundice. Many of these patients were known to have had gallstones for years but had not been operated upon because they had no symptoms. Comfort, Gray, and Wilson [4] reported follow-up data on 112 asymptomatic patients with gallstones who were not operated upon; symptoms developed in 50 per cent and were severe in 20 per cent. Lund [5] had an almost 100 per cent follow-up study of five to twenty years in 526 patients with cholelithiasis not operated on. Severe symptoms, complications, or both occurred subsequently in at least a third to a half of his group of patients. The prognosis is approximately the same in patients with or without symptoms. In 1911 Mayo [6] stated, “The innocent gallstone is a myth.” Yet, many physicians and some surgeons are still not convinced that asymptomatic patients with gallstones should undergo operation. We who believe they should must support our positions not by impressions alone but by careful analysis of our experience. It is important to know the mortality and early and late morbidity associated with the removal of the “silent” gallstone. A review is presented of 134 patients with cholelithiasis in whom there
A final diagnosis of asymptomatic cholelithiasis was made in 166 patients treated at the Lahey Clinic between 1950 to 1958. After a careful review of each record the number was reduced to 134. Many of the thirty-two patients omitted from this study had symptoms of belching, flatulence, constipation, and nausea which had been attributed to a concurrent “irritable colon.” Since such symptoms could possibly be related to other gallbladder disease, these patients were excluded. Many patients were seen for primary disease in other systems, or they were referred to the clinic after a thorough examination elsewhere. While the number of cases found on routine physical examination is increasing, most patients were examined because of abdominal symptoms. This is reflected in the incidence of associated disease found with asymptomatic gallstones [7]. Only 22 of the 134 patients (16 per cent) had no symptoms preoperatively. Various gastrointestinal diseases, such as colonic polyps, diverticulitis, hemorrhoids, and irritable colon, were noted in twenty-eight (21 per cent). Patients who had a diagnosis of irritable colon were included only if they had been followed up for several years and a bowel management program had resulted in remission of symptoms. Diabetes was an unsuspected finding in twelve patients (9 per cent), and was a borderline condition in some patients and occult in others. Seven patients (5 per cent) known to have cardiovascular disease had electrocardiographic verification of such disease. Asso-
DATA
M
* Presented at the Seventh Annual Meeting of the Society for Surgery of the Alimentary Chicago, Illinois, June 25 and 26, 1966. 44
Tract,
dmerican Journal of Surgery
Asymptomatic
Patient with Gallstones
ciated disease was also found in the following: skeletal system, ten patients; genitourinary tract, twenty patients; liver, four patients; central nervous system, four patients; all other systems, twenty-seven patients. During the same eight year period (1950 to 1958) 3,112 symptomatic patients were operated for gallstones at the Lahey Clinic [8,9]. The age incidence of both groups was compared and no significant differences were found. No unusual racial distinction was noted, and the ratio of female (ninety-seven or 72 per cent) to male patients (thirty-seven or 28 per cent) is consistent with that observed in symptomatic patients with stones. When disease of the biliary tract was discovered, surgical intervention promptly ensued in most instances. The longest period between diagnosis and treatment was twenty-five years, and this patient was consistently asymptomatic. In three other patients an average of ten years elapsed between diagnosis and surgery. The ages of the patients in this study by decades \vas similar to that of patients with symptomatic gallstones. (Table I.) DIAGNOSIS
Each patient had a detailed history and physical examination which was often repeated when the patient was referred from one section to another. Cardiac evaluation was carefully made. Most patients underwent roentgenologic study of both the upper and lower gastrointestinal tract as well as oral cholecystography. When indicated, opinions of consultants were sought so that each system would be evaluated. Roentgenologic evidence of cholelithiasis was found in 114 patients. In the remaining twenty diagnosis was made at celiotomy performed for other conditions including aortic aneurysm, regional enteritis, and uterine fibroma. Asymptomatic cholelithiasis was noted in three patients on routine pyelograms. Another thirteen cases were discovered during spinal studies and barium x-ray series of both the upper and lower gastrointestinal tract. Survey roentgenograms of the chest and abdomen revealed stones in twelve patients; no additional studies were carried out. Oral cholecystography was performed in eighty-six patients; some patients had two or more negative results on cholecysto,gram during the eight year follow-up period (1958 to 1966) before a third or fourth cholecystogram revealed cholelithiasis.
TABLE AGE
\-ears
20-29 3039 40+9 50-59 60-69 TO-X
DISTRIBUTION
I IN
-
DECADES
I’atirnts Sumber
4 8 16 51 44 11
I’CT cent
:i ti 12 38 33 x
Oral cholecystography accounted for ninetyeight diagnoses. One patient had both an oral cholecystogram and an intravenous cholangiogram, and one hospitalized patient had an intravenous cholangiogram only. Cholecystograms were not taken in thirty-four patients, the opaque stones being evident on some other roentgenologic study. Of the fifteen patients in whom the common duct was opened, only one T tube cholangiogram was taken at operation and two T tube cholangiograms were taken postoperatively. By cholecystography and intravenous cholangiography, the gallbladder was visualized in eighty-seven patients (65 per cent). Of these, seventy-one patients had multiple stones and sixteen patients had single stones. On the other hand, the gallbladder in thirteen patients (10 per cent) could not be visualized by oral cholecystography or intravenous cholangiography. In the group of 1,756 symptomatic patients with gallstones reported in 19B3 [Y], the gallbladder was not visualized on roentgenologic examination in 340 patients (19 per cent). Of the 1,172 symptomatic patients operated upon during this period, preoperative x-ray studies proved reliable; only fifteen patients did not have stones. All of the asymptomatic patients showing stones on x-ray study were found to have stones at surgery. OPERATION
The technic of cholecystectomy has been described in a previous report [8]. Only by treating the operation with the respect it merits can this procedure be advocated for both asymptomatic as well as symptomatic patients with gallstones. No patient had injury to the common duct either in this series with cholecystectomies for asymptomatic gallstones or in the entire eight year study of 3,112 cholecystectomies per-
Colcock,
Killen,
formed at the Lahey Clinic between 1950 and 195s. Cholecystectomy was performed in 11’7 patients (87 per cent), and 15 patients (11 per cent) underwent both cholecystectomy and choledochostomy. No stones were found in the common duct in any patient despite the fact that in several the gallbladder contained very small stones. One cholecystostomy was carried out in an elderly patient during an extensive procedure for a condition unrelated to biliary tract disease; cholecystectomy was performed later. Excision of a cystic duct remnant was carried out in one asymptomatic patient in whom stones were present in the remnant. Concomitant operations were performed in 69 of 134 patients (51 per cent) : appendectomy, forty-three patients; liver biopsy, five patients; hiatal herniorrhaphy, one patient; other procedures for disease in the pelvis, intestine, and spleen, twenty patients. That these operations were necessary underlines the need for careful evaluation of all systems, especially the gastrointestinal tract. PATHOLOGIC
FINDINGS
Multiple stones without cholecystitis were found in fourteen patients whereas multiple stones with cholecystitis were found in ninetysix patients. Single stones and cholecystitis occurred in fourteen patients, only one patient having a single stone without cholecystitis. In three patients with subacute or chronic cholecystitis stones were not visualized on the preoperative roentgenogram, and the indication for surgery was a nonfunctioning gallbladder. Hydrops and cholelithiasis were found in one patient, and a polyp and cholecystitis in another. Cholesterolosis was found in four patients. The common duct was explored in 28.6 per cent of the symptomatic patients (503 of 1,756 patients) in our previous study which is in contrast to 11 per cent of ducts explored in asymptomatic patients (15 of 134 patients) reported on herein. No common duct stones were found in this group of asymptomatic patients. MORBIDITY
No postoperative complications were directly related to biliary tract surgery. Five minor wound infections were recorded, occurring in patients who had had concomitant surgical procedures; however, they did not prolong the
and Leach patient’s usual hospital stay. Complications related to associated disease accounted for twelve early postoperative problems. These included : confusion with cerebral arterioscerosis, one patient; symptoms of previous cerebrovascular accident, two; atelectasis in patient with chronic lung disease, three ; Hodgkin’s disease, two; prolapsed hemorrhoids, one; chronic cystitis, two; diabetic-insulin reaction, one. No late complications were related to disease of the biliary tract. Fourteen complications were related to disease that was either concomitant or subsequent to the asymptomatic gallstone. These included ; carcinoma of the lung, one patient; gastric ulcer, one ; carcinoma of the cecum, one; regional ileitis, one; metastatic carcinoma of the rectosigmoid to liver, one; irritable colon (new), one; coronary thrombosis, two; cerebrovascular accident, three; persistent pain, two; incisional hernia (not this operation), one. In two patients, vague abdominal pain developed several months after operation and was not localized to the upper part of the abdomen. Repeated gastrointestinal x-ray studies with barium failed to disclose an organic cause. MORTALITY
Only one postoperative death occurred. The patient was a seventy-eight year old woman with diffuse metastatic carcinoma not diagnosed preoperatively and who had a coronary thrombosis the day after operation. Three late deaths resulted from biliary tract disease which was unrelated to gallbladder surgery. Two patients died from cirrhosis. One aged fiftyseven years died two years after operation from severe viral hepatitis and cirrhosis. The second patient, aged fifty-two years, died five years after surgery from cirrhosis and ascites of unknown cause. The third late death occurred seven years after surgery; this fifty-six year old patient died from carcinoma of the common bile duct. FOLLOW-UP
STUDY
A follow-up study was conducted for eight years from 1958 to 1966. Results were obtained from clinic visits and letters of inquiry to the patient. Of the 134 patients, 115 are alive without symptoms of biliary tract disease including the oldest patient in the study whose diagnosis was made in 1932. Eighteen patients have died since surgery; fourteen without symptoms American
Journal of Surgery
Asymptomatic
Patient with Gallstones
of biliary tract disease died from other causes, one died from an unknown cause, and the three with disease related to the hepatobiliary tract who died are reported as late postoperative deaths. As indicated, these three deaths were not related to cholecystectomy. One patient was lost to follcw-up study. SUMMARY
.4ND CONCLUSIONS
True asymptomatic cholelithiasis is rare. Of 3.112 patients with cholecystitis and cholelithiasis operated upon in an eight year period, only 131 had no symptoms which could be attributed to the gallbladder. Only 11 per cent (15 of 134 patients) had common duct exploration, and no common duct stones were found. Of the 2,978 symptomatic patients operated upon for gallstones during this same period, the common duct was explored in 28.6 per cent, and common duct stones were found in approximately 9 per cent. This suggests that early surgery in patients with cholelithiasis, when these patients are still asymptomatic, may reduce the incidence of common duct disease. If so, it will also reduce the mortality and morbidity associated with disease of the biliary tract. Only one postoperative death occurred in these 134 patients (0.7 per cent). This patient was a seventy-eight year old woman with associated carcinoma who died of coronary thrombosis. No postoperative complications either early or late were related to the operative procedure. On late follow-up study, only three patients had died from biliary tract disease : one from carcinoma, one from cirrhosis, and one from hepatitis; all were unrelated to the operative procedure. Based on our experience, we believe that unless there is a strong contraindication to surgery, such as a recent coronary occlusion, the presence of cholelithiasis, even without symptoms, is an indication for cholecystectomy. REFERENCES 1. METHOD, H. L., MEHN, W. H., and FRABLE, W. J.
“Silent” gallstones. Arch. Surg., 85: 338, 1962. FOSBURG, R. G. Gallstones in young adults. An analysis of 178 patients under thirty years of age. .Im. J. Surg., 106: 82, 1963. 3 CAHOW, C. E., JR. and GLENN, F. Sequelae attributed to delayed surgical treatment of gallstones. .1nn. &rg., 161: 21, 1965. 4. COMFORT, M. W., GRAY, H. K., and WILSON, J. M. Silent gallstone: 10 to 20 year follow-up study of 112 cases. Ann. Surg., 128: 931, 1948. 2
Vol. II.?, January
1967
47
Lucn, J. Surgical indications in cholclithiasi~: prcjphylactic cholelithiasis: prophylactic cholccystcctomy elucidated on the basis of lorlK-trrm follow up on 5’16 nonoperated cases. .lnn. .Yu~x.. 1.51 : IT,:<, 1960. 6. MAYO. W. J. “Innocent” rnllstonc.~ :i myth. J.;I.M..I., 56: 1021. 1911. 7. Downy, (;. S., JR. and WALDRON, G. W. Importance of coexistent factors in biliary tract surgery. An analysis of 2,285 operations. .-1vrh. SUV,~.. XX: 314, 1964. COIXOCK, B. P. and MCMANUS. J. E. Esperienccs with 1,356 cases of cholecystitis and cholclithiasis. surg. Gynec. 6 Ohst., 101: 161. 1955. COLCOCK, B. P. and PEREY. B. The treatment of cholelithiasis. Surg. Gyner. a Obst., 117: X9. 1963. 1i
DISCUSSION
WARREN H. COLE (Chicago, Ill.) : You recall that Dr. Colcock said verv few of these so-called silent stones are actually silent. These patients usually have some minor symptoms which, of course, may develop into more severe symptoms in the \-et-y near future. In our clinic we utilize the principle that if the stones are silent and the patient has a life expectancy of eight or nine years, we advise removing the gallbladder. We have adopted this philosophy because we believe the chance of having one of the several complications mentioned by Dr. Colcock is so great that we believe chances of survival are helter if the stones are removed. The fact that no stones were found in the common duct in Dr. Colcock’s series might, of course, make one think the situation is not so serious and operation is not necessary. The point is that an elective operation will hopefully prevent serious complications from developing later. HARWELL WILSON (Memphis, Term.): I believe that Dr. Colcock has expressed a point of view shared by most surgeons and that more studies of this type should help convince internists and general practitioners of the importance of this point of view. CLAUDE E. WELCH (Boston, Mass.): There was a good deal of speculation a number of years ago on whether the cause of gallbladder disease might be traced to a tight sphincter of Oddi, and a suggestion was made that all cholecystectomies should he accompanied by dilatation of the sphincter. Dr. Colcock’s follow-up study, however, demonstrates that it is unnecessary and that almost surely the cause of gallbladder disease resides in the gallbladder itself. We might say that we have reduced the incidence of cancer of the gallbladder by removing these stones, but here again we may be on rather tenuous grounds. Perhaps the liver secretes some sort of carcinogen that is merely concentrated in the gallbladder, and it may be that after removal of the gall-
Colcock,
Killen,
bladder we will encounter more cases of carcinoma of the common duct or perineum. WILLIAM HERVEY REZXINE(Rochester, Minn.) : Generally, we at the Mayo Clinic are in accord with Dr. Colcock. Whenever we have an asymptomatic patient with gallstones, we usually advise removal of the stones. I am particularly interested in the patient who has other complicating problems. For instance, our internists frequently see patients who have diabetes or a myocardial problem as well as gallstones, and I think it is extremely important to remove the gallbladder in the asymptomatic patient with gallbladder before the other complicating problems can become worse.
and Leach These other problems will become worse, and if the patient has an acute gallbladder attack when the cardiac problem is more severe or when the diabetes is in a difficult state, the gallbladder disease can be a lethal one. BENTLEYP. COLCOCK(closing) : As Dr. Wilson has stated, there are many physicians who are not convinced of what we are so thoroughly convinced of from our experience in the operating room. I do not think for one moment that this paper will change many minds, however, I hope we have added some facts to those which others will add. Someday it will be apparent that serious trouble will be prevented in some patients if gallstones discovered accidentally are removed.
American
Journal
of Surgery