Uncomplicated Gallstone Research Articles

Symptomatic uncomplicated gallstone disease is associated with a high short-term risk of gallstone-related complications: a contemporary cohort study

Background The natural history of symptomatic uncomplicated gallstone disease is largely unknown. We examined the risk of progressing from symptomatic uncomplicated to complicated gallstone disease in a large regional cohort of patients, where disruptions in elective surgical capacities have led to the indefinite postponement of surgery for benign conditions, including cholecystectomies. Methods Patients with radiologically diagnosed incident symptomatic and uncomplicated gallstone disease were identified from outpatient clinics and emergency departments on the Island of Funen, Denmark. The absolute risk of complications (cholecystitis, cholangitis, pancreatitis, acute cholecystectomy for unremitting pain) was calculated using death and elective cholecystectomies as competing risks using the Aalen-Johansen method. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) of gallstone complications associated with patient and gallstone characteristics. Results Two hundred eighty-six patients diagnosed with incident symptomatic, uncomplicated gallstone disease from 1 January 2020 to 1 July 2023 were identified. During 79,170 person-years of observation, 176 (61.5%) patients developed a gallstone-related complication. The 6-, 12- and 24-month risk of developing gallstone-related complications were 36%, 55% and 81%. The risk of developing complications related to common bile duct stones was lowest with larger stones (aHR per millimeter increase = 0.89 (0.82–0.97), p < 0.01), while no covariates were statistically significantly associated with the risk of cholecystitis. Eighty-five (30%) patients underwent elective laparoscopic cholecystectomy, with one patient (1.2%) developing a gallstone-related complication afterward. Conclusions The risk of developing complications to symptomatic gallstones in a general Scandinavian population is high, and prophylactic cholecystectomy should be considered.

Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones: the C-GALL RCT.

Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease. To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care. Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease. Secondary care elective settings. Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion. Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management. The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation. Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p-value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -£1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals. The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery. This trial is registered as ISRCTN55215960. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.

An Audit of Laparoscopic Cholecystectomy.

Objective: Gallstones is a common problem, particularly among women .In modern medicine, uncomplicatedgall stones are usually treated with Laparoscopic Cholecystectomy “Key-hole Surgery” .It carries significantlylower morbidity and mortality as compared to open surgery . At Muhammad Medical College Hospital (MMCH)we have started the procedure in recent years. .Aims: To look into various demographic and clinic aspects of Laparoscopic Cholecystectomy done at MMCH.Methods: Retrospective audit of record of last consecutive 99 patients undergoing Laparoscopic Cholecystectomy at MMCH. Research Ethics Committee approval was obtained (No.250811/REC/003).Results: 33 Men and 66 women underwent this procedure. Average age was 45 year (range 16 to 75). Commonest presenting symptoms were Nausea/vomiting (n=36) and abdominal discomfort /pain (n=36). All patientshad pre-procedure ultrasound scan showing gall stones .At surgery, 99/99 were confirmed to have gallstones .Although 9 also had adhesions, 6 were acutely inflamed and 3 had empyema gall bladder. There were 2conversions Average duration of stay in hospital after procedure was 9 days (range 3 to 20). 2 patients hadwound infection and 3 atelectasis. No mortality was seen.Conclusions: Laparoscopic Cholecystectomy is a safe procedure for gall stones disease.Keywords: Laparoscopic cholecystectomy, conversion rate morbidity.

Efficacy of single-dose versus triple-doses perioperative antimicrobial prophylaxis in patients undergoing laparoscopic cholecystectomy

Introduction: Although debatable, prophylactic antibiotics may be required for patients undergoing cholecystectomy for symptomatic gallstone disease with certain associated risk factors. Our study aimed to perform a non-randomised prospective comparative trial evaluating a single-dose pre-operative antibiotic versus a triple-dose prophylactic post-operative antibiotic in patients with symptomatic uncomplicated cholelithiasis undergoing laparoscopic cholecystectomy. Methodology: This study was a non-randomised prospective comparative study in a single institution. Two hundred patients were enrolled and allocated to two groups. Group A patients were given a single dose of pre-operative prophylactic antibiotic, and Group B patients received a triple dose of prophylactic antibiotic therapy. We also studied the bacteriological profile of bile in all the patients using bile culture and antibiotic sensitivity, and we analysed their association with post-operative surgical site infection (SSI). Results: All the patients were followed up on post-operative days 7 and 30. On post-operative day 7, 2% of patients in Group A and 1% of patients in Group B were found to have SSI, and no statistically significant difference in SSI between the two groups was noted (P = 0.558). On post-operative day 30, no patient was found to have a SSI in either of the two groups. Moreover, post-operative bile culture was obtained in all the cases, and 6% of patients had a positive bile culture. However, none of them developed SSIs on post-operative day 7. Conclusion: A single-dose pre-operative antibiotic is as effective as three perioperative doses in preventing SSI in laparoscopic cholecystectomy for symptomatic, uncomplicated gallstone disease. Our study did not associate port-site SSI with a positive bile culture.

THERAPEUTIC EFFECT OF ABHAYA LAVANA WITH SHARAPUNKHA KWATHA IN THE MANAGEMENT OF CHOLELITHIASIS – CASE STUDY

Cholelithiasis is a worldwide medical condition, resulting from a combination of several factors like supersaturation of bile with cholesterol, accelerated nucleation of cholesterol monohydrate in bile, and bile stasis or delayed gallbladder emptying. Gallbladder stones present in one of three clinical stages: asymptomatic, symptomatic and with complications. The treatment options for asymptomatic range from no treatment to selective cholecystectomy. Laparoscopic cholecystectomy remains the default option for symptomatic cases. A definite non-invasive management is be a boon in asymptomatic and symptomatic uncomplicated gallstones. Abhaya Lavana is a strategic combination of Kshara &amp; Lavana kalpana described in classical texts. Its indications point towards that this combination has a definite result in cholelithiasis and associated symptoms. Kwatha of Sharapunkha as anupana would definitely help to carry the drug to its site of action. To evaluate the effect of the treatment, A pre-post-test clinical study was conducted among the 13 participants. Clinical Intervention was done with 2g of Abhaya Lavana with 96ml of Sharapunkha Kwatha in the Middle of every Breakfast for 45 Days. Assessment of Subjective Parameters and Associated symptoms were done prior to the intervention and on 15th, 30th and 45th day. Pre and Post Assessment of Primary Objective - USG and Secondary objective - Lipid Profile were Conducted after Study. Safety of the Drug has been assessed by Pre and Post RFT and LFT. This study reveals that combined effect of Abhaya Lavana and Sharapunkha Kwatha is effective in Cholelithiasis and reducing associated symptoms.

Top 5 Research Studies of the month for Italian Primary Care Physicians: March 2024.

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) A simple, well-validated risk score can help clinicians counsel patients with atrial fibrillation regarding the use of DOACs to prevent stroke. The score shares its name with the drug class (the "DOAC" score). 2) Presumably by perturbing the intestinal microbiome, antibiotic treatment is associated with an increase in the likelihood of the development of irritable bowel disease; this is especially true with multiple courses of antibiotics. 3) Patients with uncomplicated gallstones can be managed over time with analgesia and monitoring, though approximately 25% will eventually undergo cholecystectomy over the next 18 months. Still, there appears to be no need to rush to surgery without evidence of common bile duct blockage or acute pancreatitis. 4) Delivering bad news (e.g. a cancer diagnosis) by telephone does not affect levels of anxiety, depression, or satisfaction with care as compared with delivering the news in person. 5) An updated high quality systematic review found that, in conjunction with psychosocial interventions, oral naltrexone (50 mg/day) and oral acamprosate have the strongest evidence for being effective in the treatment of alcohol use disorder.

Cholelithiasis management during hepatitis C treatment: a case report including pathophysiology and literature review

This case reports a 56-year-old male attending a nurse-led hepatitis C (HCV) clinic complaining of abdominal pain. Right upper quadrant abdominal tenderness on palpation with a positive Murphy's sign (pain on inspiration during palpation to the right subcostal area) encouraged timely investigation and diagnosis of non-obstructive cholelithiasis (gallstones). This was managed with interval review and regular clinical assessment pending successful HCV treatment and surgical referral. The main lessons from this case study emphasise the importance of considering concurrent diagnoses for patients complaining of abdominal pain when presenting with a primary diagnosis of HCV. This case also supports a pragmatic approach in considering the treatment of HCV before the surgical intervention of uncomplicated gallstones. Furthermore, it also highlights the value of advanced nurse practice within the multi-disciplinary team.

Early Cholecystectomy in Patients with Sickle Cell Disease with Uncomplicated Cholelithiasis Is Associated with Better Outcomes.

Up to 85% of patients with sickle cell disease (SCD) will develop gallstones by their third decade. Cholecystectomy is the most commonly performed procedure in these patients. Cholecystectomy is recommended for patients with SCD with symptomatic cholelithiasis and leads to lower morbidity. No contemporary large studies have evaluated this recommendation or associated clinical outcomes. This study evaluates clinical outcomes after cholecystectomy in patients with SCD and cholelithiasis with specific advanced clinical presentations. The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were divided into groups based on their disease presentation, including uncomplicated cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. Clinical outcomes associated with disease presentation were analyzed. Statistical analysis was performed using the Student's t -test, chi-square test, ANOVA, and logistic regression. There were 6,662 patients with SCD who presented with cholelithiasis. Median age was 20 (interquartile range 16 to 34) years and 54% were female patients. Cholecystectomy was performed in 1,779 patients with SCD with the most common indication being chronic cholecystitis (44%), followed by uncomplicated cholelithiasis (27%), acute cholecystitis (21%), and choledocholithiasis or gallstone pancreatitis (8%). On multivariable regression, advanced clinical presentation was the strongest predictor of perioperative vaso-occlusive crisis, which was the most common complication. Patients undergoing cholecystectomy for uncomplicated cholelithiasis were at lower risk than those with acute cholecystitis (odds ratio [OR] 2.37; 95% CI 1.64 to 3.41), chronic cholecystitis (OR 1.74; 95% CI 1.26 to 2.4), and choledocholithiasis or gallstone pancreatitis (OR 2.24; 95% CI 1.41 to 3.57). Seventy-three percent of patients with SCD have advanced clinical presentation at the time of their cholecystectomy. After cholecystectomy, perioperative vaso-occlusive events were significantly increased in patients with advanced clinical presentation. These data support screening abdominal ultrasounds and early cholecystectomy for cholelithiasis in patients with SCD.

Prevalence of anxiety and depression in patients eligible for cholecystectomy for uncomplicated gallstone disease: a post-hoc analysis of Dutch trial data

Prevalence of anxiety and depression in patients eligible for cholecystectomy for uncomplicated gallstone disease: a post-hoc analysis of Dutch trial data

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

ObjectiveTo assess the clinical and cost effectiveness of conservative management compared with laparoscopic cholecystectomy for the prevention of symptoms and complications in adults with uncomplicated symptomatic gallstone disease.DesignParallel group, pragmatic...

Endogenous hepatic toxicity and oxidative stress in the complications of gallstones associated with cholestatic jaundice

Introduction. Cholestatic jaundice installed in gallstones is considered a multifactorial pathogenetic process. The correlation of endogenous hepatic intoxication with the reaction of the pro- and antioxidant system, characteristic of various complications of gallstones associated with cholestatic jaundice, remains an undefined subject. Material and methods. The study included the investigation of 105 patients with complicated gallstones and associated cholestatic jaundice, and the control group – 35 patients with uncomplicated gallstones. The age of the patients varied between 51 and 72 years, with an F/M ratio of 3/1. Results. The degree of endotoxemia, assessed at hospitalization by peptides with average mass values, was consistent with the inflammation present in groups 2 and 3, reporting a statistically significant difference compared to the control group [p c/2 &lt; 0.001 (t = 11.1); p c/3 &lt; 0.001 (t = 11.07)]. DAM, as the final product of lipid peroxidation, evaluated at hospitalization, shows double marked values in all groups compared to the control group [p &lt; 0.001 (t = 10.7); (t = 10.9); (t = 16.5)]. The antioxidant activity, assessed at hospitalization, shows a statistically significant decrease in superoxide dismutase values [p &lt; 0.001 (t = 6.4); (t = 4.1); (t = 5.7)], as well as catalase [p &lt; 0.001 (t = 6.7); (t = 5.6); (t = 7.2)] in all groups, by 30-40% compared to the control group. Conclusions. In established cholestatic jaundice, there is an obvious activation of lipoperoxidation processes, contributing to the increase of endogenous intoxication and early suppression of antioxidant activity. There is a direct relationship between the increase in prooxidant activity and the level of endogenous intoxication in all complications of gallstones associated with cholestatic jaundice, but it is more elevated in infectious complications, indicating a need for an early approach.

Medical Management of Uncomplicated Symptomatic Small Gallstones in Elderly

Medical Management of Uncomplicated Symptomatic Small Gallstones in Elderly

FTP5.8 Gall bladder service developments to improve outcomes based on national guidelines

Abstract Introduction Nationally, acute gallstone disease accounts for over 1/3rd of emergency general surgery admissions and referrals. Guidelines recommend laparoscopic cholecystectomy within 1 week for acute cholecystitis, on index admission for acute gallstone pancreatitis and within 18 weeks for uncomplicated gallstone disease. Presently, NHS Trusts struggle to meet these targets due to unrelenting demand for limited resources. We present interventions to improve a laparoscopic cholecystectomy service which nearly halved the elective surgery waiting time. Method Retrospective data was collected on patients who underwent elective laparoscopic cholecystectomy at a DGH pre- and post-intervention (March-July 2021 &amp; January-April 2022). Data collected from electronic medical records included patient demographics, waiting list times, operation details and post-operative outcomes. Interventions included introduction of a boarding card which included Cholecystectomy As A Day-case (CAAD) scoring and laparoscopic cholecystectomy standard operating procedure (SOP). The SOP specified criteria for preoperative investigations, theatre list organisation, post-operative admission and high-risk patients requiring specialist surgeon input. Results Pre-intervention cycle included 82 patients, with 78 patients booked as day-case operations and 40.2% unplanned postoperative admissions rate. The post-intervention period assessed 72 patients, with 46 patients booked as day-cases and 30.6% unplanned postoperative admissions. The median day-case LOS remained at 0 days pre- and post-intervention. Median elective laparoscopic cholecystectomy waiting time significantly decreased from 140 to 75 days (p&amp;lt; 0.0001). Conclusion Our study demonstrates interventions to restructure a laparoscopic cholecystectomy service significantly shortened waiting times, with national targets of 18-week wait for uncomplicated gallstone disease surgery met. Additionally, fewer unplanned postoperative admissions allows better bed management therefore reducing disruption to elective and emergency service delivery.

Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients

ObjectiveTo characterise the extent of unnecessary care in general surgery inpatients using a triple bottom line approach.DesignPatients with uncomplicated acute surgical conditions were retrospectively evaluated for unnecessary bloodwork according to...

A mixed-methods study to define Textbook Outcome for the treatment of patients with uncomplicated symptomatic gallstone disease with hospital variation analyses in Dutch trial data

BackgroundInternational consensus on the ideal outcome for treatment of uncomplicated symptomatic gallstone disease is absent. This mixed-method study defined a Textbook Outcome (TO) for this large group of patients. MethodsFirst, expert meetings were organised with stakeholders to design the survey and identify possible outcomes. To reach consensus, results from expert meetings were converted in a survey for clinicians and for patients. During the final expert meeting, clinicians and patients discussed survey outcomes and a definitive TO was formulated. Subsequently, TO-rate and hospital variation were analysed in Dutch hospital data from patients with uncomplicated gallstone disease. ResultsFirst expert meetings returned 32 outcomes. Outcomes were distributed in a survey among 830 clinicians from 81 countries and 645 Dutch patients. Consensus-based TO was defined as no more biliary colic, no biliary and surgical complications, and the absence or reduction of abdominal pain. Analysis of individual patient data showed that TO was achieved in 64.2% (1002/1561). Adjusted-TO rates showed modest variation between hospitals (56.6-74.9%). ConclusionTO for treatment of uncomplicated gallstone disease was defined as no more biliary colic, no biliary and surgical complications, and absence or reduction of abdominal pain.TO may optimise consistent outcome reporting in care and guidelines for treating uncomplicated gallstone disease.

A comparative study of laparoscopic cholecystectomy with and without abdominal drain

Background: Laparoscopic cholecystectomy (LC) has been considered the Gold-standard for the management of benign gallbladder disease. With increasing surgeon experience and advancement of instrumentations and equipment, LC is approaching continuously toward a more safe and less invasive technique. There is a consensus that drainage should not be considered mandatory or standard after elective LC. Aims and Objectives: The aims of this study were to assess the effectiveness of the LC without abdominal drain over sub hepatic drainage and to compare the post-operative outcome between two groups. Materials and Methods: A descriptive observational comparison study has been carried out in the department of General Surgery BSMCH, from September 1, to December 1, in 130 patients undergoing elective LC. Patients have been divided into two groups: Comparison group and study group after proper matching. Data have been collected via interview, clinical examination, and scrutinizing relevant medical records. Each patient has been followed up after operation. Data have been summarized for estimating various parameters such as mean duration of surgery and hospital stay between the groups and proportion of patient complaining of pain 24 h after surgery. Results: The mean duration of surgery in drainage group is 108 min which is significantly more than the non-drainage group 88 min. In this present study, the patients with abdominal drain are showing more incidence of post-operative nausea and vomiting (PONV) 21.53% compared to no-drain group 6.15%. In this study, 35.38% of patients with subhepatic drain developed pain after surgery, whereas only 12.3% of the patients with no drain experienced the same. Overall six patients from the drain group still had significant subhepatic collection and eight patients with no drain have the same. The mean duration of stay in hospital of the drain group is 4.06 days, whereas, in no-drain group, it is 2.26. Conclusion: An uncomplicated gallstone disease can be treated by LC without need for drain with reasonable safety by an experienced surgeon. Hence, no use of drain scores over use of drain in terms of PONV, post-operative pain, and therefore, there is less use of analgesics and also short duration of hospital stay. When a dry operative field is achieved during LC the drain insertion may be avoided.

The Symptomatic Outcomes of Cholecystectomy for Gallstones

Cholecystectomy is the definite treatment for symptomatic gallstones, and rates are rapidly rising. Symptomatic complicated gallstones are generally treated with cholecystectomy, but there is no consensus on the clinical selection of patients with symptomatic uncomplicated gallstones for cholecystectomy. The aim of this review is to describe symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones as reported in prospective clinical studies and to discuss patient selection for cholecystectomy. Following cholecystectomy, resolution of biliary pain is high and reported for 66-100%. Dyspepsia has an intermediate resolution of 41-91% and may co-exist with biliary pain but may also develop following cholecystectomy with an increase of 150%. Diarrhea has a high increase and debuts in 14-17%. Persisting symptoms are mainly determined by preoperative dyspepsia, functional disorders, atypical pain locations, longer duration of symptoms, and poor psychological or physical health. Patient satisfaction following cholecystectomy is high and may reflect symptom alleviation or a change in symptoms. Comparison of symptomatic outcomes in available prospective clinical studies is limited by variations in preoperative symptoms, clinical presentations, and clinical management of post-cholecystectomy symptoms. When selecting patients with biliary pain only in a randomized controlled trial, 30-40% still have persisting pain. Strategies for the selection of patients with symptomatic uncomplicated gallstones based on symptoms alone are exhausted. For the development of a selection strategy, future studies should explore the impact of objective determinants for symptomatic gallstones on pain relief following cholecystectomy.

Cost-effectiveness of cholecystectomy compared to conservative management in people presenting with uncomplicated symptomatic gallstones or cholecystitis in India

Objectives Gallstone diseases impose a significant economic burden on the health care system; thus, determining cost-effective management for gallstones is essential. We aim to estimate the cost-effectiveness of cholecystectomy compared with conservative management in individuals with uncomplicated symptomatic gallstones or cholecystitis in India. Methods A decision-analytic Markov model was used to compare the costs and QALY of Early laparoscopic cholecystectomy (ELC), Delayed laparoscopic cholecystectomy (DLC) and Conservative Management (CM) in patients with symptomatic uncomplicated gallstone/cholecystitis from a Indian health system perspective. Incremental cost-effectiveness ratio (ICER) was calculated. One-way and probabilistic sensitivity analyses were performed to test parameter uncertainties. Results ELC and DLC, compared to CM, incurred an incremental cost of -₹10,948 ($146) and ₹1,054 ($14) for the 0.032 QALYs gained. The ICER was -₹3,42,758 ($4577) for ELC vs. CM, and ₹33,183 ($443) for DLC vs. CM, suggesting ELC and DLC is cost-effective. ELC saved ₹12,001 ($160) for 0.0002 QALYs gained compared to DLC, resulting in an ICER of -₹6,43,89,441 ($8,59,733). Results were robust to changes in the input parameters in sensitivity analyses. Conclusion ELC is dominant compared to both DLC and CM, and DLC is more cost-effective than CM. Thus, ELC may be preferable to other gallstone disease managements.

Cholecystectomy vs Conservative Management to Prevent Recurrent Symptoms/Complications in Adults with Uncomplicated Symptomatic Gallstones (C-GALL): A Multicentre RCT

Cholecystectomy vs Conservative Management to Prevent Recurrent Symptoms/Complications in Adults with Uncomplicated Symptomatic Gallstones (C-GALL): A Multicentre RCT

A Mixed-methods Study to Define Textbook Outcome for the Treatment of Patients with Uncomplicated Symptomatic Gallstone Disease with Dutch Hospital Variation Analyses

A Mixed-methods Study to Define Textbook Outcome for the Treatment of Patients with Uncomplicated Symptomatic Gallstone Disease with Dutch Hospital Variation Analyses