Letter to the editor “Development and validation of a clinical decision tool for predicting long-term pain reduction following laparoscopic cholecystectomy in patients with symptomatic cholecystolithiasisa prospective cohort study”

We read with great interest the study by Comes et al, which aimed to develop a clinical decision tool for predicting long-term (5-year) clinically significant pain relief after laparoscopic cholecystectomy (LC) in symptomatic gallstone patients without severe complications[1]. The study included 2 multicenter trials from 25 hospitals and ultimately analyzed 1240 patients who underwent LC after 5 years, among whom 70.2% achieved clinically relevant pain relief, defined as a reduction of ≥4 points on the Visual Analog Scale (VAS) pain score. Independent predictors identified through multivariate logistic regression included male gender, elevated baseline VAS pain score, pain radiating to the back, nausea, and the absence of constipation, diarrhea, and postprandial bloating. A user-friendly online calculator (https://gallbladderresearch.shinyapps.io/SUCCESS5year/) has also been developed, offering a personalized, patient-centered perspective for informed decision making. The model can help patients and surgeons better evaluate the potential benefits of LC and facilitate shared decision making between doctors and patients. However, the study’s enrolled population lacks further subgroup analysis. Caution should be exercised when using this model to support medical decisions in a clinical setting. A completed TITAN 2025 checklist has been provided as a supplementary file[2]. This study describes the patient population as individuals aged 18–95 years presenting with abdominal pain, confirmed to have gallbladder stones via ultrasound[1,3]. In actual clinical practice, deciding whether and when to perform elective LC surgery for patients with symptomatic gallbladder stones requires additional assessment of how frequently biliary colic attacks occur since symptoms started, how long each attack lasts, and the time interval between surgery and the first signs of symptoms[4]. Early assessment of whether a patient has mild gallstone symptoms directly impacts the likelihood of developing severe complications during follow-up after surgery, thereby influencing surgeons’ risk-benefit evaluations[5]. In this model, the complication risk indicated by these population characteristics has not been fully considered, which will also influence whether to perform LC. In other words, the likelihood of a patient experiencing baseline acute complications will impact the accuracy of the pain relief prediction model. Suppose delayed surgery is chosen based on the VAS relief obtained from the first calculation. In that case, they still need follow-up tests to monitor the need for emergency treatment, which makes the decision system contradictory. A recent study in the International Journal of Surgery by Liu, Qiaofei et al discuss a related clinical scenario, the research methods of which may serve as a valuable reference for the study conducted by Comes et al[6]. This study, conducted by Peking Union Medical College Hospital, is a prospective cohort study involving 721 patients with complex acute cholecystitis (AC). The study evaluated the safety and feasibility of early laparoscopic cholecystectomy (ELC) and found that having a longer course of disease before surgery increases the risk of complications, extends postoperative hospital stays, and raises medical costs[6]. Although a symptom duration of ≥7 days is linked to more partial cholecystectomy and complications, there is no significant difference in these rates between patients with symptoms over 7 days and those with 4–6 days. Symptom duration also does not affect the rate of converting ELC to open surgery. This finding clarifies the vague statements in current guidelines regarding the use of ELC in patients with longer symptom durations. It supports the use of ELC as a viable treatment option for patients with complex AC and delayed symptom onset. Similarly, in the study by Comes et al, adding more subgroup analyses based on different operation timing to forecast the overall complication rates will complement the pain relief prediction model. This enhancement will enable the model to provide a more comprehensive evaluation and elaborate on when to operate elective LC. In conclusion, the pain relief prediction model developed in this study is a valuable tool for optimizing decision making regarding whether to apply elective LC in patients with symptomatic gallbladder stones. Future iterations of this model should incorporate additional factors, such as symptom frequency, disease duration, and the interval between surgery and the onset of initial symptoms, to more accurately assess the risk of postoperative complications. This will better align with the clinical complexity and further enhance its utility in personalized patient care.