We read with great interest the paper by Venneman et al.1 regarding the effect of Ursodeoxycholic acid (UDCA) on symptoms in patients with symptomatic gallstone disease (GS) awaiting elective cholecystectomy. The authors, performing a randomized, double-blind, placebo-controlled trial on the effects of UDCA in 177 symptomatic GS patients scheduled for cholecystectomy, did not find any differences in symptom outcome after 3 months between the UDCA group and the placebo group. The authors concluded that early cholecystectomy is warranted in symptomatic GS. The study protocol included gallbladder motility measurement and the determination as to whether baseline gallbladder motility could affect clinical outcome; no protective effect of impaired gallbladder emptying on biliary symptoms was documented. In fact, the likelihood of remaining colic-free was comparable in strong and weak contractors (31% vs. 33%, respectively).
It is well known2, 3 that the choice of the most appropriate therapeutic strategy represents the crucial point in clinical decision-making for gallstone disease and in this sense, the paper by Venneman et al.1 represents an authoritative and important contribution.
However, we believe that the indications for cholecystectomy need to be clearly defined, in order to reduce the frequency of inappropriate surgical interventions, as has recently been the case after the introduction and widespread diffusion of laparoscopic cholecystectomy.4 We agree that cholecystectomy represents the gold standard for strongly symptomatic GS, but not in all cases. In fact, available epidemiological studies have clearly documented that at least 35% of symptomatic GS patients do not experience further biliary pain,3 even if, up to now, no definitive predictive factor for biliary pain persistence/recurrence in symptomatic GS has been clearly identified.5
Recently, we performed a prospective study6 evaluating the prognostic meaning of different characteristics of GS, including gallbladder motility, and we documented that gallbladder motility behavior during the follow-up represents an effective predictive factor for symptom persistence/disappearence; in fact, symptomatic patients which progressively reduced gallbladder emptying had no more symptoms while those who did not change their gallbladder motility remained symptomatic. Consequently, periodic evaluation of gallbladder motility could represent a safe and reliable predictive tool in the follow-up of GS, being able to identify patients suitable for early surgery (highly symptomatic GS with persistence of efficient gallbladder motility) from those where a “wait and see” policy may be adopted (symptomatic GS with progressively deficient gallbladder motility).