title: Systematic review of the clinical and cost effectiveness of cholecystectomy versus observation/conservative management for uncomplicated symptomatic gallstones or cholecystitis.
abstract: BACKGROUND
  Gallstone disease is a common gastrointestinal disorder in industrialised countries. Although symptoms can be severe, some people can be symptom free for many years after the original attack. Surgery is the current treatment of choice, but evidence suggests that observation is also feasible and safe. We reviewed the evidence on cholecystectomy versus observation for uncomplicated symptomatic gallstones and conducted a cost-effectiveness analysis.
  
  
  METHODS
  We searched six electronic databases (last search April 2014). We included randomised controlled trials (RCTs) or non-randomised comparative studies where adults received either cholecystectomy or observation/conservative management for the first episode of symptomatic gallstone disease (biliary pain or cholecystitis) being considered for surgery in secondary care. Meta-analysis was used to combine results. A de novo Markov model was developed to assess the cost effectiveness of the interventions.
  
  
  RESULTS
  Two RCTs (201 participants) were included. Eighty-eight percent of people randomised to surgery and 45 % of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications (RR = 6.69, 95 % CI = 1.57-28.51, p = 0.01), in particular acute cholecystitis (RR = 9.55, 95 % CI = 1.25-73.27, p = 0.03), and less likely to undergo surgery (RR = 0.50, 95 % CI = 0.34-0.73, p = 0.0004) or experience surgery-related complications (RR = 0.36, 95 % CI = 0.16-0.81, p = 0.01) than those randomised to surgery. Fifty-five percent of people randomised to observation did not require surgery, and 12 % of people randomised to cholecystectomy did not undergo surgery. On average, surgery costs £1,236 more per patient than conservative management, but was more effective.
  
  
  CONCLUSIONS
  Cholecystectomy is the preferred treatment for symptomatic gallstones. However, approximately half the observation group did not require surgery or suffer complications indicating that it may be a valid alternative to surgery. A multicentre trial is needed to establish the effects, safety and cost effectiveness of observation/conservative management relative to cholecystectomy.
authors.affiliation: Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK, m.brazzelli@abdn.ac.uk.
authors.forename: Miriam
authors.initials: M
authors.lastname: Brazzelli
authors.forename: Moira
authors.initials: M
authors.lastname: Cruickshank
authors.forename: Mary
authors.initials: M
authors.lastname: Kilonzo
authors.forename: Irfan
authors.initials: I
authors.lastname: Ahmed
authors.forename: Fiona
authors.initials: F
authors.lastname: Stewart
authors.forename: Paul
authors.initials: P
authors.lastname: McNamee
authors.forename: Andy
authors.initials: A
authors.lastname: Elders
authors.forename: Cynthia
authors.initials: C
authors.lastname: Fraser
authors.forename: Alison
authors.initials: A
authors.lastname: Avenell
authors.forename: Craig
authors.initials: C
authors.lastname: Ramsay
mesh_terms: D002763:Cholecystectomy / Q000191:economics*; D002764:Cholecystitis / Q000191:economics / Q000628:therapy*; D003362:Cost-Benefit Analysis; D042882:Gallstones / Q000191:economics / Q000628:therapy*; D006801:Humans; D019370:Observation / Q000379:methods*