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Invited Critique |

The Spectrum and Cost of Complicated Gallstone Disease in California—Invited Critique

Jack Pickleman, MD
Arch Surg. 2000;135(9):1027. doi:10.1001/archsurg.135.9.1027.
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When first asked by the editor to submit a critique of this study, I was supplied only with the title, and armed with this, I was confident I could trash and burn the work sufficiently to justify the editor's confidence in me. Alas, my generally feisty mood rapidly dissipated on the review of the data that unarguably show the increased cost, in human and financial terms, of the delayed treatment of symptomatic gallstones. This is not the first study that has shown that physician delay, either rooted in medical ignorance or mandated by bureaucratic indifference, can lead to a higher incidence of complications in a group of patients who should sustain very little morbidity and negligible mortality if treated expeditiously at the onset of symptoms. These California data demonstrate that the cases of 44% of the patients treated for gallstones were complicated by the presence of acute cholecystitis or other sequelae of untreated gallbladder disease and that half of this number had premonitory biliary colic; therefore, almost one quarter of all patients could have been treated electively by laparoscopic cholecystectomy if early operation had been undertaken. If the California figures can be assumed to be representative, hundreds of millions of dollars and countless lives could be saved nationally by earlier intervention. One disturbing piece of data noted by the authors was that 25% of all elective cholecystectomies in California are still being performed as open procedures. In my opinion, this is an unacceptably high number which I suspect reflects a lack of expertise in performing laparoscopic cholecystectomy by a substantial number of surgeons practicing in that state. These data presented here throw down the gauntlet to physicians and surgeons, virtually demanding earlier laproscopic intervention in all symptomatic patients. The medical and medicolegal implications of these data should be fully understood by practicing family physicians, internists, and gastroenterologists. Also, it should give pause to those politicians advocating a single governmental payer system in the United States as this will inevitably give rise, as noted by our friends north of the border, to rationing of care and long waiting lists for medical services. The accompanying article clearly shows that this represents inappropriate medical care for patients with symptomatic gallstones.

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