Evidence based medicine in complicated and uncomplicated gallstone disease

Gallstone disease is one of the most frequent gastroenterological disorders in the western world, associated with significant morbidity and increasing health care costs. Most of the evidence in the management of gallstones seems to be based on expert opinion and not on evidence.
This thesis aims to increase the evidence-based management of both uncomplicated and complicated gallstone disease. International guidelines were reviewed and no consensus was found on major subjects, such as the definition of symptomatic gallstone disease and the use of laboratory tests in the prediction of common bile duct stones. Also, there is no consensus on the use of antibiotics after spill of bile and/or gallstones during cholecystectomy and in the conservative treatment of acute cholecystitis. This thesis shows that both are not necessary and this clinical practice should be evaluated.
This thesis concludes with the SECURE-trial, a multicenter non-inferiority randomized controlled trial comparing a restrictive strategy to usual care for the effectiveness of cholecystectomy in patients with uncomplicated gallstone disease. Usual care, which represents current standard of care, is not optimal in gallstone patients, resulting in a high percentage of patients that are not painfree after cholecystectomy. A more restrictive strategy, using the Rome criteria of a biliary colic and two additional criteria, also does not improve results regarding pain after cholecystectomy. As the Rome criteria are advocated worldwide in the selection of patients for cholecystectomy, this will have a major effect on clinical management.