Treatment and Textbook Outcome in Patients with Cholelithiasis: Results of Three Multicenter Prospective Trials

Introduction: Current guidelines advise cholecystectomy as treatment for symptomatic cholelithiasis. However, not all patients present with characteristic biliary symptoms, as some have atypical abdominal symptoms. This study defined a textbook outcome (TO) and evaluated outcomes of patients with gallstone disease. Methods: Data were used from three prospective multicentre studies. Patients with gallstones and abdominal pain, without a history of complicated cholelithiasis were included. The proportion of patients was assessed who reached a TO after six months of follow-up. TO was defined as absence of pain and major biliary- or surgical complications. Moreover, between-hospital variation in reaching TO was assessed. Results: In total, 1956 patients were included from 29 hospitals. Within 6 months, 3.3% had a major biliary complication, 72.4% had undergone cholecystectomy, of whom 2.0% had a major surgical complication. TO was reached in 71.7% of patients, more often after cholecystectomy than after conservative treatment (79.9% vs. 53.5%, p<0.001). A between-hospital variation in achieving TO was found (Range: 59.3%-100%, p=0.018). Factors associated with TO were: cholecystectomy (OR 3.4, 95%CI 2.64-4.50, p<0.001) and higher age (OR 1.01, 95%CI 1.00-1.02, p=0.028). However, presence of heartburn (OR 0.76, 95%CI, p=0.036) and obstipation (OR 0.74, 95%CI 0.56-1.00, p=0.046) were associated with not reaching TO. Discussion: TO was achieved in 71.7% of patients. Cholecystectomy more often leads to TO. Major biliary- and surgical complications occurred in 3.3% and 2.0% of patients, respectively. Cholecystectomy and higher age were associated with achieving TO, while non-typical symptoms like heartburn and obstipation were associated with worse outcomes.