When Patients Decline Cholecystectomy: Characteristics, Motivations, and 12-Month Outcomes After Organ-Preserving Gallstone Extraction

Technical Summary: When Patients Decline Cholecystectomy

Problem Statement
Laparoscopic cholecystectomy remains the standard of care for symptomatic cholelithiasis in the United States. However, a subset of patients who are deemed appropriate surgical candidates actively declines the procedure, often citing a preference for organ preservation, fear of surgical/anesthetic complications, or concerns regarding post-cholecystectomy symptoms. While conservative management options such as medical dissolution (ursodiol) or watchful waiting exist, they do not provide definitive stone clearance. Consequently, gastroenterologists and surgeons face a clinical gap: there is limited data characterizing the demographics and motivations of patients seeking organ-preserving alternatives, nor is there robust evidence regarding the 12-month clinical outcomes of such alternatives in surgically eligible populations.

Methodology
This study is a single-center, retrospective analysis conducted at MedStar Washington Hospital Center and MedStar Georgetown University Hospital. The cohort consisted of 216 self-referred patients who completed an initial consultation for elective Gallstone Organ-Sparing Cholangioscopy and Percutaneous Extraction (GO-SCOPE) between January 2024 and May 2026.

• Patient Selection: All patients were independently self-referred via internet searches or educational materials and were subsequently evaluated by a board-certified surgeon. Inclusion required that patients be deemed appropriate candidates for cholecystectomy. Patients with acute cholecystitis, indwelling cholecystostomy tubes, or non-elective indications were excluded.
• Intervention: The GO-SCOPE technique involves percutaneous gallbladder access, tract dilation, cholangioscopy-assisted lithotripsy, and drain management. Pre-procedural counseling explicitly outlined the standard role of cholecystectomy, the relative risks/benefits of GO-SCOPE, the possibility of stone recurrence, and the physiologic role of the gallbladder.
• Data Analysis: The study analyzed patient demographics, stated motivations for declining surgery, geographic referral patterns, and treatment uptake (GO-SCOPE, conservative management, or eventual cholecystectomy). Clinical outcomes for treated patients included single-session technical success, need for additional sessions, 30-day adverse events (classified by Society of Interventional Radiology criteria), and 12-month symptom status and imaging findings.

Key Contributions
This paper provides the first detailed characterization of the "demand side" of organ-preserving gallstone treatment. It specifically addresses:

1. Patient Profile: Who are the surgically eligible patients seeking alternatives to cholecystectomy?
2. Motivations: What drives these patients to decline standard care?
3. Geographic Reach: How widespread is the interest in these alternatives?
4. Outcomes: What are the 12-month clinical outcomes and safety profiles for patients undergoing GO-SCOPE?

Results

• Cohort Characteristics: Among 216 consults, 120 (55.6%) underwent GO-SCOPE, 89 (41.2%) elected conservative management, and 7 (3.2%) elected cholecystectomy. The mean age was 45.6 ± 11.8 years, with 65% female. The median symptom duration prior to consultation was 24 months (IQR 12–48).
• Motivations: 97.7% of patients cited organ preservation as their primary reason for declining cholecystectomy.
• Geographic Distribution: Patients originated from 39 U.S. states and 8 countries. Notably, 75% of consultations came from outside the authors' local catchment area.
• Temporal Trends: Consultation volume increased by 46% during the study period (from 6.8 to 9.9 patients per month, p=0.002).
• Clinical Outcomes (GO-SCOPE Cohort):
  • Technical Success: Single-session removal of all visualized stones was achieved in 91.7% of patients.
  • Re-intervention: 30.0% of patients required an additional cholangioscopy session to complete stone removal.
  • Safety: 30-day adverse events occurred in 13.3% of treated patients (16/120). This included 7 severe events (4 abscesses, 2 pancreatitis, 1 bacteremia) and 9 moderate events. Crucially, no patient required intensive care admission or surgical intervention for these events, and all resolved without permanent sequelae.
  • 12-Month Follow-up: Among the subset of treated patients with available 12-month follow-up (n=39), 92.3% reported resolution or sustained improvement of biliary colic. Asymptomatic recurrent gallstones were identified in 10.3% of this follow-up cohort (all ≤8 mm), and no patient developed cholecystitis or cholangitis.

Significance and Claims
The paper claims that a substantial, geographically diverse, and growing population of surgically eligible patients actively seeks alternatives to cholecystectomy. The authors argue that the prolonged median symptom duration (24 months) suggests these patients occupy a "therapeutic gap" where existing non-operative options are perceived as unacceptable.

The study concludes that GO-SCOPE offers a viable, evidence-based alternative for select patients who decline surgery. The 12-month data demonstrates durable symptom relief (comparable to cholecystectomy outcomes reported in literature) with an acceptable safety profile. The authors assert that awareness of gallbladder-preserving techniques like GO-SCOPE can facilitate shared decision-making, allowing clinicians to address patient preferences for organ preservation without compromising safety, while acknowledging that stone recurrence remains a possibility and cholecystectomy remains the standard of care. The paper explicitly states it does not challenge the role of cholecystectomy but rather provides an answer to a specific patient population seeking alternatives.