Are laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery gallbladder preserving cholecystolithotomy truly comparable? A propensity matched study

BACKGROUND: Cholecystectomy is the preferred treatment option for symptomatic gallstones. However, another option is gallbladder-preserving cholecystolithotomy which preserves the normal physiological functions of the gallbladder in patients desiring to avoid surgical resection. AIM: To compare the feasibility, safety and effectiveness of pure natural orifice transluminal endoscopic surgery (NOTES) gallbladder-preserving cholecystolithotomy vs laparoscopic cholecystectomy (LC) for symptomatic gallstones. METHODS: We adopted propensity score matching (1:1) to compare trans-rectal NOTES cholecystolithotomy and LC patients with symptomatic gallstones. We reviewed 2511 patients with symptomatic gallstones from December 2017 to December 2020; 517 patients met the matching criteria (NOTES, 110; LC, 407), yielding 86 pairs. RESULTS: The technical success rate for the NOTES group was 98.9% vs 100% for the LC group. The median procedure time was 119 min [interquartile ranges (IQRs), 95-175] with NOTES vs 60 min (IQRs, 48-90) with LC (P < 0.001). The frequency of post-operative pain was similar between NOTES and LC: 4.7% (4/85) vs 5.8% (5/95) (P = 0.740). The median duration of post-procedure fasting with NOTES was 1 d (IQRs, 1-2) vs 2 d with LC (IQRs, 1-3) (P < 0.001). The median post-operative hospital stay for NOTES was 4 d (IQRs, 3-6) vs 4 d for LC (IQRs, 3-5), (P = 0.092). During follow-up, diarrhea was significantly less with NOTES (5.8%) compared to LC (18.6%) (P = 0.011). Gallstones and cholecystitis recurrence within a median of 12 mo (range: 6-40 mo) following NOTES was 10.5% and 3.5%, respectively. Concerns regarding the presence of abdominal wall scars were present in 17.4% (n = 15/86) of patients following LC (mainly women). CONCLUSION: NOTES provides a feasible new alternative scar-free treatment for patients who are unwilling or unable to undergo cholecystectomy. This minimally invasive organ-sparing procedure both removes the gallstones and preserves the physiological function of the gallbladder. Reducing gallstone recurrence is essential to achieving widespread clinical adoption of NOTES.