Burden of gallstone disease

Gallstones are an ancient entity, having occurred more than 3500 years ago according to autopsies performed on Egyptian and Chinese mummies. Gallbladder disease today is a common problem: 20 to 25 million Americans harbor gallstones, representing 10% to 15% of the adult population. It constitutes a major health burden, with direct plus indirect costs of approximately $6.2 billion annually in the United States. This burden has increased more than 20% since the 1980s and accounts for an estimated 1.8 million ambulatory care visits. Gallstone disease is now a leading cause of hospital admissions for gastrointestinal problems, yielding 622,000 discharges (according to the most responsible diagnosis) each year in the United States. This hospital burden is actually an underestimate; most admissions occur for laparoscopic cholecystectomy, commonly done without an overnight stay and thus not included in hospitalization statistics. Gallstone disease has a low mortality rate of 0.6%, but considering the burden of the disease, there were still an estimated 1092 gallstone-related deaths in 2004. Case fatality rates have steadily diminished from more than 5000 deaths in 1950, falling more than 50% between 1979 and 2004. This decline represents the greatest decrease for any digestive disease.

Although most gallstones are clinically silent, 20% of people harboring stones experience true biliary symptoms at some time; 1% to 2% of patients each year experience complications and require surgical removal of the gallbladder. Yet the number of operations for cholelithiasis has increased since 1950 in developed countries. During the mid-twentieth century, the frequency of gallbladder surgeries was 6 times higher in the United States than in Western Europe. Gallstone disease in Europe, however, is similar to that in the United States, with a median prevalence in large population surveys ranging from 5.9% to 21.9%. The reason for this discrepancy does not lie in the prevalence of cholelithiasis but most likely represent differences in surgical practice. The introduction of laparoscopic cholecystectomy in 1989 further increased the cholecystectomy rate in the United States and the United Kingdom From 1990 to 1993, there was a 28% escalation in the numbers of cholecystectomies performed. A likely explanation for this increase is that laparoscopy is less invasive, providing a lower surgical risk and better patient acceptance compared with conventional (open) surgery, therefore leading to more surgeries in patients previously thought too high a risk or in those with minimal symptoms. Although there is undoubtedly an element of overuse, cholecystectomy is now the most common elective abdominal surgery performed in the United States, with more than 750,000 operations annually.