Cholecystectomy versus conservative management for patients with uncomplicated symptomatic gallstones and cholecystitis: an updated systematic review and meta-analysis

BACKGROUND: Gallstone disease affects 10-25% of the population, with higher prevalence in women over 40 years of age. Laparoscopic cholecystectomy is the standard treatment for symptomatic or complicated cases. However, it is costly, can cause adverse effects, and can result in post-cholecystectomy syndrome. Conservative management remains an option, especially for high surgical risk patients. The optimal management of uncomplicated gallstones remains controversial. This updated systematic review and meta-analysis incorporates recently published randomized controlled trials (RCTs) comparing the safety and efficacy of cholecystectomy with conservative treatment in symptomatic uncomplicated gallstones and mild acute cholecystitis. METHODS: This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Scopus, Web of Science, and Cochrane Central for RCTs comparing cholecystectomy versus conservative management in adults with uncomplicated gallstones or mild acute cholecystitis. Primary outcomes were biliary colic and overall gallstone-related complications, while secondary outcomes included mortality and surgery-related complications. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using fixed or random effect models based on heterogeneity. Risk of bias was assessed using the Cochrane risk of bias 2.0 (RoB-2) tool, and the certainty of evidence was evaluated using the GRADE approach. RESULTS: Four RCTs, involving a total of 677 patients, were included. Their quality ranged from moderate to high when assessed by the ROB-2 tool. Cholecystectomy was found to decrease both biliary colic (RR = 0.43, 95% CI [0.24 to 0.78], P = 0.006) and overall gallstone complications (RR = 0.40, 95% CI [0.23 to 0.69], P = 0.0009). However, conservative management was associated with fewer overall surgical complications (RR = 0.40, 95% CI [0.23 to 0.69], P = 0.0009) and the proportion of patients who underwent surgery. Largely because many patients avoided or deferred operative intervention during follow-up. There was no significant difference in mortality, acute cholecystitis, acute pancreatitis, or common bile duct stones between the two groups. CONCLUSION: Our findings suggest that cholecystectomy provides better biliary pain control. However, conservative management may be considered in selected patients due to its lower surgical complication rate and comparable major clinical outcomes. Additional large RCTs are needed to confirm these findings. TRIAL REGISTRATION: The PROSPERO database has the study protocol recorded with ID CRD420250651103.