Experiencing abdominal pain from gallstones doesn’t always improve after gallbladder removal (cholecystectomy). Even five years post-surgery, around one-third of patients continue to have ongoing pain. Furthermore, some individuals who haven’t had surgery persist with their discomfort. The cause of these symptoms may stem not only from gallstones but could also relate to digestive issues or irritable bowel syndrome.
Every year, approximately 100,000 individuals seek medical help for abdominal pain, with about 30,000 of those diagnosed with gallstones. The typical treatment is laparoscopic cholecystectomy. Since the 1990s, the frequency of these surgeries has surged, despite the absence of clear international guidelines. Consequently, gallbladder removal has become one of the most prevalent surgeries in the Netherlands, but it doesn’t always alleviate pain: around one-third of patients still report abdominal pain following the procedure. Historically, this surgery has been criticized for being unnecessary, yet this perception is now evolving.
In a 2019 study by Radboud university medical center, researchers split patients suffering from gallstone-related abdominal pain into two groups. One group received the standard cholecystectomy treatment, while the other moved forward with surgery only after assessing various pain symptoms. Although the restrictive selection group had fewer surgeries, a year later, one-third of patients in both groups still experienced abdominal pain. This research suggests caution in performing cholecystectomy for those with gallstones and associated abdominal pain.
Five-year follow-up
Five years later, researchers re-assessed the patients, and the findings from this study conducted in 24 Dutch hospitals were recently published in JAMA Surgery. Daan Comes, the physician-researcher and lead author, noted: ‘Our aim was to evaluate the long-term implications of a restrictive surgical approach for this patient category. We reached out to over a thousand patients by phone, who then filled out questionnaires, and we also reviewed their medical histories.’
What were the results? The incidence of pain among patients had not significantly changed over the years, with only two-thirds still pain-free. However, the restrictive approach resulted in fewer needless cholecystectomies. ‘In the restrictive group, we did not identify any more complications from gallstones or the surgery compared to the other group. It appears that a cautious selection strategy is viable, but only for the appropriate patients.’
Improved selection criteria
To better determine the right patient demographics, Radboudumc created a decision framework in 2021, drawing from scientific evidence and patient information. Surgeon and principal investigator Philip de Reuver remarked, ‘Our findings indicate that intense, sporadic pain is a solid sign for requiring surgery. Furthermore, a history of abdominal surgeries or additional symptoms like bloating, heartburn, and persistent pain mean one should proceed carefully with surgery.’
This knowledge empowers both doctors and patients to make more informed choices. ‘Patients suffering from recurring biliary colic definitely benefit from this surgery. However, a significant portion of patients with gallstones also experience dyspepsia symptoms and irritable bowel syndrome. In such instances, surgery may not provide any relief. We should thoroughly exclude these conditions before suggesting a cholecystectomy.’
Consequently, De Reuver is embarking on a follow-up study focusing on the impact of lifestyle changes for individuals with abdominal pain and gallstones, where the decision framework indicates that surgery would likely be of limited value. He anticipates that this lifestyle intervention will enhance patients’ overall health, quality of life, and alleviate pain. ‘In the Netherlands, about 65 individuals undergo gallbladder surgery daily. That’s an entire bus of people. If we can lower this number, we can save costs and resources while still improving quality of life, which is incredible,’ De Reuver stated.
Are you experiencing abdominal pain and have gallstones?
If you have abdominal pain along with gallstones, it’s crucial to have a comprehensive conversation with your doctor regarding your symptoms and collaboratively determine if gallbladder surgery is the best option. An initial step could involve adjusting your diet, reducing fat intake, and monitoring if your symptoms ease. Numerous decision aids are accessible, providing thorough information about the surgery, potential complications, and long-term repercussions. Make sure to review a decision aid before speaking with your doctor.
