Clinical manifestations and impact of gallstone disease.

The main symptom of gallstone disease is biliary pain. Biliary pain is not necessarily colicky or postprandial, and it most frequently occurs at night during the same clock-time. The relief of biliary pain by cholecystectomy would support the idea that the gallbladder or the stones caused pain. Long-term follow-up studies after cholecystectomy are infrequent, however. Our studies show that biliary pain is relieved in 99% of patients after 4 years of follow-up. The nonspecific symptoms associated with gallstones (i.e., dyspepsia, bloating, belching, etc.) remained in 12% of these patients. We have also shown that the gallbladder itself, without stones, can cause pain and that this biliary pain is relieved in 77% of patients by cholecystectomy. The impact of gallstones on the patient depends on the quality of cholecystectomy as classically measured by morbidity and mortality. However, quality must also be monitored by comparing the long-term relief of biliary pain and the cost. Quality cannot be monitored through inaccurate national databases or multicenter trials. Rather, the continuous quality improvement (CQI) technique of larger centralized health care systems may be the most accurate monitoring system. This technique coordinates the entire health care system by assuming that any process can improve its quality, no matter how good it may already be. Our CQI laparoscopic cholecystectomy database has yielded preliminary perspectives on accurate data collection and improving costs. After a thorough examination, 5% of the database contained cases not done laparoscopically (coding errors), whereas it missed 21% of true laparoscopic cholecystectomy cases (staff errors). Only with the accuratized database were we able to provide insight into cost-savings procedures.