This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
A study compared 2 treatments for gallstones: surgery to remove the gallbladder or a watch and wait approach. After 18 months:
- both approaches were associated with similar levels of pain
- the watch and wait approach was less costly than surgery.
The findings could support shared decision-making between clinicians and people with uncomplicated gallstones.
More information on gallstones can be found on the NHS website.
The issue: is surgery for gallstones necessary?
Gallstones are stones that form in the gallbladder; they become more common with age. They do not usually cause symptoms or complications, but if they become trapped, they can cause severe abdominal pain. Painful attacks can occur and need medical attention.
International guidelines recommend surgery to remove the gallbladder (cholecystectomy) as first-line treatment for people with gallstones who experience pain or other symptoms. However, surgery carries its own risks and some people continue to experience symptoms afterwards, for reasons that remain unclear.
An alternative option is to adopt a ‘watch and wait’ strategy before operating to see if symptoms resolve.
This study compared the outcomes of a watch and wait approach with those of surgery. It included people whose gallstones caused pain but had not yet led to more serious problems such as infection, jaundice or sepsis.
What’s new?
The study included 434 adults with confirmed gallstones from 20 UK hospitals. Most (79%) were women and their average age was 50 years. Participants had symptoms (pain, for instance) but no gallstone-related complications (such as jaundice).
Half the participants were in the surgery group; half in the watch and wait group (these people took painkillers when needed and received self-management advice). If symptoms became too severe, those in the watch and wait group could opt for surgery.
By 18 months, most (67%) people in the surgery group had received surgery; most of the others had refused surgery, or were on a waiting list. Some (25%) in the watch and wait group had surgery; but most neither had surgery nor were waiting for it.
The researchers found that:
- pain was the same in both groups after 18 months
- surgery cost the NHS more per participant (£2,510) than watch and wait (£1,477) after 24 months
- there was no difference in quality of life over 24 months from when people started the study, meaning watch and wait was highly likely to be cost-effective.
There were no meaningful differences in quality of life, or the need for further treatment up to 24 months from the beginning of the study.
Why is this important?
The researchers say that, at 18 months, a watch and wait approach is as effective as surgery for people with uncomplicated gallstones. The findings could improve shared decision making for people with gallstones. Some (15% people) in the surgery group refused surgery. The researchers suggest this could indicate a willingness among people with gallstones not to undergo surgery.
Performing fewer surgeries for gallstones could avoid the associated risks for many people. Also, in England in 2019, gallbladder removals cost the NHS more than £200 million. More people following a watch and wait approach could, therefore, save NHS resources.
The researchers caution that their findings apply only to people who have uncomplicated gallstones. More research is needed for those with gallstone-related complications (such as infections).
What’s next?
Longer-term follow up is needed in this group (people with gallstones causing pain alone). It could show how the effectiveness and value for money of the 2 approaches change over time. Further research could also explore whether some groups would benefit from earlier surgery.
Can I act on this knowledge?
What else do I need to know?
The results of this study are beginning to influence practice, and to allow patients to opt for watch and wait rather than being listed for surgery immediately.
You may be interested to read
This is a summary of: Ahmed I, and others. Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial. British Medical Journal 2023; 383: 1 – 12.
An NHS decision guide for people considering treatment options for gallstones.
Information on gallstones from the British Liver Trust.
National Institute for Health and Care Excellence (NICE) guidelines on gallstone disease.
Information on taking part in NIHR research on gallstone disease.
Funding: This study was funded by the NIHR Health and Technology Assessment programme.
Conflicts of Interest: None relevant.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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