My conclusion was drawn after comparing Dr. Greenlee’s article with that of UpToDate—the most popular, authoritative, unbiased opinions among current medical professionals.
To operate or not to operate for the asymptomatic (“silent”) gallstone was the question Dr. Greenlee pondered in 1941 and is still the dilemma that we (physicians and patients alike) are facing today.
The dilemma arises from the fact that the incidence of gallstone turning to gallbladder cancer is very low, but the outcome is so dire. Dr. Greenlee wrote, “The prognosis in most cases of carcinoma of the gall bladder is poor; few patients live more than one year after the diagnosis has been made.” Sadly this remains true with the accelerated advance of high tech medicine that gave us so many tools of image studies, such as ultrasound, CT scan and MRI etc.
“Despite the increased risk of gallbladder cancer (GBC) in patients with gallstones, the overall incidence of GBC in patients with cholelithiasis [gallstone] is only 0.5 to 3 percent.” This is from UpTodate. Dr. Greenlee cited various reports of average incidence ranging from 0.5 to 6.5 percent; he wrote, “It seems safe to say that the average incidence is about 2 to 3 percent.”
Dr. Greenlee’s approach and recommendation was very reasonable to this day; few can argue against it. The following paragraph is an excerpt from the COMMENT section of his article.
“While, perhaps, one could not argue too strongly for operation on the gallbladder in any case of gallstones on account of the possibility of malignant tumor developing later, there are some other justifiable bases for early operation: (1) to prevent the distress of recurrent colic and dyspepsia; (2) to avoid stone in the common duct with infection and hepatic damage, and (3) to prevent remote visceral degenerative changes. It seems that the possibility of carcinoma could be given as a fourth reason for early operation in such cases.”
I wonder Dr. Greenlee’s inclination of advocating early surgical intervention for the ‘silent’ (or just one uncomplicated episode) was influenced by Dr. William Mayo (the founding father of Mayo Clinic, where Dr. Greenlee was trained in 1920s) who expressed in 1911 that nearly all gallstones produced symptoms and regarded “innocent” gallstones as a myth, whereas Dr. William Osler (1890s-1910s) believed that most gallstones caused no symptoms.
I came across an article at N.E.J.M. (9/23/1982) of “The natural history of silent gallstones—the innocent gallstone is not a myth”; an obvious dispute to Dr. William Mayo’s claim and that of Dr. Greenlee’s (Mayo brothers were still active practicing surgery when Dr. Greenlee was there.) The study group consists of 110 men and 13 women with gallstones, all faculty members of the University of Michigan, none died of gallstone disease in 15 years of follow up and only 18% developed biliary pain or complications (thus, not entirely “innocent” as the author claims.)
The incidence of gallbladder cancer, rare though it may be, Dr. Greenlee pointed out, “When it is considered that between 8 percent to 10 percent of adults have gallstones, the importance of the proper concepts regarding the many problems of disease of the gallbladder cannot be overestimated.”
There was a school of thought suggesting that “stones are the result rather than the cause of primary carcinoma of the gallbladder” in Dr. Greenlee’s day. He explained in a very convincing way in the article that the other way around was the case. He was again correct as we read in UpToDate, “gallstones are present in 70 to 90 percent of patients with GBC, and a history of gallstones appears to be one of the strongest risk factors for the development of GBC.”
Dr. Greenlee also stated that “cancer of the gallbladder is much more common in females than in males, the ratio being about 4 or 5 to 1”, we read “women are affected two to six times more often than men” in UpToDate.
“Gallbladder cancer is an uncommon but highly fatal malignancy with fewer than 5000 new cases diagnosed each year in the United States” (from UpToDate), I am surprised to read that Dr. Greenlee encountered “Five cases of primary carcinoma of the gallbladder have been observed in a year and a half, and 4 of these were observed within six months.”
Dr. Greenlee wrote, “The diagnosis is made for the most part either at operation or during routine laboratory examination [pathology report] of the removed gallbladder.” With so much high tech medical advance seventy some years later we’re still no better than Dr. Greenlee was. We read in UpToDate, “Malignancy diagnosed incidentally on pathologic examination after a simple cholecystectomy is the most common mode of presentation of early stage disease.”
(There are 13 pages of his original article; here are the scanned copies)
thanks for this post.
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