To the Editors:

The incidence of gallstones and associated cholecystitis is known to be higher in patients after gastrectomy than in the general population. The hypothesis for this high incidence of cholelithiasis is the surgical dissection of the vagal nerve branches. Acute cholecystitis can lead immunocompromised cancer patients to severe complications, including sepsis, and even to death. Therefore, some surgeons advocated concomitant cholecystectomy during the gastric cancer operation because it might carry the minimal range of risk [1]. The Japanese surgeons proposed vagus nerve preservation during radical gastrectomy to preserve normal intestinal and biliary function after gastrectomy [2].

The Italian surgeons had questions about prophylactic cholecystectomy at the time of gastrectomy and started a prospective randomized trial to investigate the incidence of cholelithiasis after gastric cancer surgery and the outcomes of concomitant cholecystectomy [3]. Recently, we read the article “The Cholegas Study: safety of prophylactic cholecystectomy during gastrectomy for cancer: preliminary results of a multicentric randomized clinical trial” by Bernini et al. [4] in the E-pub issue of Gastric Cancer with interest. In their study, cholecystectomy did not increase the postoperative morbidity, mortality, or costs.

This is a very interesting study. However, we are concerned about several issues, including the ethical problems.

Although we admit that vagal denervation could increase the risk of gallstone formation and subsequent acute cholecystitis with stones, and this can cause serious complications including sepsis in a gastrectomized patient, the actual number of patients who might need surgery for it is quite small. Also, the presumed serious postoperative complication after cholecystectomy in patients with gastrectomy is also rare. The operative risk of metachronous cholecystectomy is not well defined. Rather, a minimally invasive approach can safely be applied to patients with cholecystitis and even to those with choledocholithiasis [5].

Although gastrectomy could increase the risk of gallstones and concomitant cholecystectomy does not increase postoperative morbidity, this reasoning does not fully support the ethics and rationale of proposing prophylactic cholecystectomy for a patient with a normal gallbladder. Most of the patients, at least 75 %, will not have gallstone disease, and possibly can experience functional digestive problems as a result of unnecessary cholecystectomy. We believe that the operative risk for patients with cholecystitis after gastrectomy and the digestive problems after cholecystectomy should also be discussed if the authors claim the necessity of prophylactic cholecystectomy during gastrectomy.