Reviewed for medical accuracy by Dr Evelyne Jonniaux, Medical Advisor
Last updated 17 September 2026
Gallstones: 37% of those operated on still have pain five years later
That is the result of the Dutch SECURE trial, 1,067 patients randomised and followed for five years (JAMA Surg, 2024). Among those actually operated on, 63.6% are pain-free at five years. The authors write that whichever strategy was used, only two thirds of patients were pain-free. Upstream, the question is different: about 75% of people whose gallstones are found incidentally will never have a symptom at fifteen years, and the risk of becoming symptomatic is about 2% a year. These figures describe populations, not one gallbladder. Noria Health arranges a full digestive work-up near Brussels within 24 to 48 hours.
How many people have gallstones, and how many will suffer from them
Worldwide prevalence is 6.1%, with an interval from 5.6 to 6.5, across 115 studies and 32.6 million participants (Wang, Clin Gastroenterol Hepatol, 2024). A second independent meta-analysis finds 5.86%. The often quoted 10% to 15% applies only to particular populations: older women, Latin America, Indigenous American populations.
The question that matters more is what becomes of those stones.
| People with asymptomatic stones who become symptomatic | Cumulative proportion |
|---|---|
| At 5 years | 10% (10 to 11) |
| At 10 years | 19% (14 to 25) |
| At 15 years | 26% (12 to 40) |
About three in four remain asymptomatic at fifteen years. The pooled annual risk is 2%, with an interval from 1% to 5%, and it is not constant: higher in the first years, then flattening.
The Italian MICOL cohort, 11,229 people followed for 8.7 years on average, produces a counter-intuitive result worth knowing. Among those with severe symptoms at baseline, 52.1% had none by the end of follow-up. Among those with mild symptoms, 58.5% had none. And 41.3% of the cholecystectomies performed in that cohort were done in asymptomatic patients.
When symptoms do appear, the first manifestation is biliary pain in 60% of cases, acute cholecystitis in 19%, a bile duct stone in 19%, pancreatitis in 7%.
What the operation settles, and what it does not
The SECURE trial compared two strategies in 1,067 patients with abdominal pain and stones on ultrasound: a restrictive strategy based on strict criteria, and usual care.
| What is measured | Restrictive strategy | Usual care |
|---|---|---|
| Pain-free at 12 months | 56% | 60% |
| Pain-free at 5 years | 61.2% | 62.8% |
| Pain-free at 5 years, among those operated on | 63.0% | 63.6% |
| Cholecystectomies performed by 5 years | 73.2% | 81.5% |
The figure to hold on to is the third row. About 37% of patients who had their gallbladder removed still have pain five years later. An external validation across 1,240 operated patients followed for five years finds 70.2% with a clinically meaningful reduction in pain, so about 30% with no significant benefit.
That same validation produced a useful prediction model, with a discrimination of 0.75. The patients who benefit most are those with severe pain radiating to the back, with nausea, and above all without constipation, without diarrhoea and without bloating after meals. Those last three symptoms predict failure.
The risk of the operation, by national registry
| Registry | Number | Bile duct injury |
|---|---|---|
| Czechia, 2018 to 2021 | 76,345 cholecystectomies | 0.24% major injuries, of which 0.06% laparoscopic |
| Estonia, 2008 to 2018 | 29,739 laparoscopic | 0.81% all injuries, 0.13% major |
| German specialist centre | 1,313 cholecystectomies | 0.07% major injuries |
The often quoted 0.5% corresponds to series from the 1990s, the early days of laparoscopy. Today the risk of major injury is of the order of 0.1% to 0.3%. Mortality from these injuries, in the Estonian series, is 4.6%, and 11.2% of patients are left with a long-term biliary stricture. It is rare, but it is serious.
What the studies do not allow us to claim
That post-cholecystectomy syndrome affects 10% to 15% of patients rests on no consensus definition since 1947. Published figures range from 3.21% with a strict definition to 34% with a broad one, and up to 47% in some reviews. We give a range and explain why, never a single figure.
That 10% to 15% of the population has gallstones needs correcting to about 6%.
In practice, if this concerns you
Three questions structure the discussion. Does your pain really look like biliary pain, since that is what predicts benefit from the operation. Do you also have bloating, constipation or diarrhoea, since those are failure signals. And were the stones found for some reason other than your symptoms, since a silent stone is not an indication.
Noria Health arranges a full digestive work-up near Brussels within 24 to 48 hours: precise characterisation of the pain, abdominal ultrasound, liver tests, and bile duct imaging where the examination justifies it. The report is issued within 24 hours, follow-up is structured at D14, D30 and D90, and surgery is considered only around day 10 if it is needed.
What Noria Health does not do: propose a cholecystectomy on the presence of stones on ultrasound alone. Severe abdominal pain with fever, jaundice, or unrelenting vomiting are matters for the emergency services in your country, immediately, not for an appointment.
Further reading
- Hernia, gallbladder, reflux: when to operate and when to wait
- Colonoscopy: 19% fewer cancers
- Metabolic surgery, what the trials measure
Sources
- Wang X, Yu W, Jiang G, et al. Global epidemiology of gallstones in the 21st century. Clin Gastroenterol Hepatol, 2024;22:1586-1595. https://pubmed.ncbi.nlm.nih.gov/38382725/
- Ning Q, et al. Global prevalence of gallstone disease. Ann Med, 2025;57:2570795. https://pubmed.ncbi.nlm.nih.gov/41069192/
- Alzoubi M, et al. Natural history of asymptomatic gallstones, a systematic review and meta-analysis. PLOS ONE, 2026. https://doi.org/10.1371/journal.pone.0345462
- Festi D, Dormi A, Capodicasa S, et al. Natural history of gallstone disease, the MICOL cohort. J Gastroenterol Hepatol, 2010;25:719-724. https://pubmed.ncbi.nlm.nih.gov/20492328/
- van Dijk AH, Wennmacker SZ, de Reuver PR, et al. Restrictive strategy versus usual care for cholecystectomy, SECURE. The Lancet, 2019;393:2322-2330. https://pubmed.ncbi.nlm.nih.gov/31036336/
- Comes DJ, Wennmacker SZ, Latenstein CSS, et al. Long-term follow-up of a restrictive strategy for cholecystectomy. JAMA Surg, 2024;159:1235-1243. https://pubmed.ncbi.nlm.nih.gov/39167382/
- Comes DJ, et al. External validation of a prediction model for pain relief after cholecystectomy. Int J Surg, 2025;111:5205-5214. https://pubmed.ncbi.nlm.nih.gov/40440684/
- Vetrhus M, Berhane T, Soreide O, Sondenaa K. Pain persists in many patients five years after removal of the gallbladder. J Gastrointest Surg, 2005;9:826-831. https://pubmed.ncbi.nlm.nih.gov/15985239/
- Klos D, et al. Major bile duct injuries after cholecystectomy, a national registry study. Langenbecks Arch Surg, 2023;408:154. https://pubmed.ncbi.nlm.nih.gov/37079112/
- Reinsoo A, et al. Bile duct injuries during laparoscopic cholecystectomy, an Estonian nationwide study. Eur J Trauma Emerg Surg, 2023;49:2269-2276. https://pubmed.ncbi.nlm.nih.gov/36462050/
- Burns R, et al. Risk factors for bile duct injury during cholecystectomy. BJS Open, 2025;9:zraf076. https://pubmed.ncbi.nlm.nih.gov/40751483/
See also: all our articles on digestive surgery.
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