The Significance of Calculus Size in Determining the Indication for Elective Cholecystectomy

Abstract

Recent advances in the total management of the older patient have reduced the morbidity and mortality of all major operations.Primary biliary tract procedures have become standardized from the technical standpoint, and present efforts are now directed at making the patient safe for operation.Prophylactic procedures in the asymptomatic patient are being evaluated in many clinics in reference to the treatment of colonic polyps, adenomas of the thyroid, discrete pulmonary masses, and biliary calculi.The present study for the 5-year period ending July 1, 1954, has been directed at formulating a rational approach to the problem of the patient with asymptomatic calculus disease of the gall bladder.The biliary findings have been reviewed in 1,334 consecutive autopsies in patients over the age of 50 whose deaths were unrelated to the extrahepatic biliary tract.Seventeen per cent of these patients had calculi in their gall bladders.While no history of biliary colic or acute cholecystitis was recorded on any of these charts, much of the documentation was inadequate to warrant the statement that there had been no symptoms related to these stones.Common duct stones were found in 7.5 per cent of the total of 226 cases.The calculi encountered were considered in two categories.The first group, comprising 22.5 per cent of the total, consisted of those with one or two large stones, 2 em. or more in diameter.These stones, usually cholesterol in type, often formed a partial cast of the gall bladder, and were occasionally accompanied by several smaller chipped-off fragments.The second group, 77.5 per cent, contained gravel or numerous small stones less than 2 em. in size.In the group containing the larger calculi, 67.2 per cent showed gross and microscopic evidence of chronic cholecystitis.In the group containing the multiple small stones, only 23.8 per cent showed pathologic changes in the gall-bladder wall.The surgical material comprised 85 consecutive primary gall-bladder operaations performed by several staff and resident surgeons for calculus disease in patients 50 years of age.There were 80 cholecystectomies and five cholecystostomies.Forty-six (54.1 per cent) of these were elective operations performed for recurrent symptoms.Thirty-nine (45.9 per cent) were urgent procedures carried out for acute obstructive cholecystitis.There was no mortality in the group operated upon electively.There were two deaths in the urgent