Asymptomatic cholelithiasis is the presence of gallstones that may be detected incidentally in patients that do not present any abdominal symptoms, or by palpation of the gallbladder during surgery for another reason.

There are no clinical trials that have evaluated the benefit of cholecystectomy in asymptomatic patients, nor have any prospective studies analyzing the clinical evolution of asymptomatic cholelithiasis demonstrated the efficacy of cholecystectomy. Approximately 0.7 and 2.5% of patients with asymptomatic cholelithiasis develop cholelithiasis-related symptoms each year, and the annual incidence of complications like cholecystitis, acute pancreatitis, obstructive jaundice or cholangitis is 0.1%–0.3%.7 Cholecystectomy in patients with asymptomatic cholelithiasis does not increase life expectancy because the risk of surgery in terms of mortality and morbidity is higher than the complications of cholelithiasis itself.8 In addition, the costs are lower if patients with gallstones are not treated until they present symptoms or some type of complication.9 Likewise, diabetic patients would also not benefit from prophylactic cholecystectomy.10

In Western countries, where the prevalence of gallbladder carcinoma is very low,11 cholecystectomy is not justified in general.12 It is estimated that, depending on additional risk factors, between 67 and 769 cholecystectomies would have to be done to avoid one case of gallbladder cancer.13 Some cases, however, deserve special consideration. In asymptomatic patients with porcelain gallbladder, cholecystectomy could be indicated due to the possibility of developing gallbladder cancer, although in the most recent studies the correlation between porcelain gallbladder and cancer has not been clearly established.14 As for gallbladder polyps, according to the recently published guidelines of the European Association for the Study of the Liver,15 cholecystectomy is recommended in patients with polyps ≥1cm with or without lithiasis, regardless of patient symptoms. Cholecystectomy should also be considered in patients with asymptomatic cholelithiasis and polyps between 6 and 10mm and in cases of polyp growth. Cholecystectomy is also recommended in asymptomatic patients with sclerosing cholangitis and gallbladder polyps, regardless of size. Nonetheless, cholecystectomy is not indicated in patients with asymptomatic cholelithiasis and polyps ≤5mm.

In the same manner, cholecystectomy is not recommended in patients with asymptomatic cholelithiasis treated with another surgical intervention, including bariatric surgery.15 Cholecystectomy should be considered in patients with spherocytosis or sickle-cell anemia if splenectomy is going to be performed.

In short, although there are no prospective studies comparing surgical intervention with conservative treatment for patients with asymptomatic cholelithiasis, routine cholecystectomy should not be recommended.

The increased number of surgical procedures and the need to monitor diuresis have made urinary catheterization a routine practice in a large number of patients. Occasionally, however, the duration of the catheterization is prolonged with no justification. Most urinary tract infections (UTI) occur in the presence of instrumentation, especially after catheterization.16 If urinary catheter use is prolonged for more than 4 days, the prevalence of bacteriuria is virtually 100%, with up to 20% UTI.17 Furthermore, prolonged catheterization also indirectly interferes in the recovery of surgical patients. The current tendency is to avoid catheterization or to minimize its use.18 The literature about the withdrawal of urinary catheters in the postoperative period is limited, but it has not been demonstrated that systematically maintaining catheterization provides any benefit. The existence of scheduled alerts and the implementation of protocols that program and justify the need for catheterization are associated with reduced UTI rates.19,20 Not many studies have focused on the early withdrawal of urinary catheters, but one prospective cohort study in the US analyzed the advantage of justifying and optimizing the use of urinary catheters in colorectal surgery, observing a very significant reduction in the incidence of UTI when these aspects were monitored.21 In conclusion, the lack of scientific evidence to recommend maintaining urinary catheterization for more than 48h in an ordinary postoperative situation make it an avoidable measure.

One of the principles of antibiotic prophylaxis (AP) in surgery is not extending the infusion of antibiotics beyond the first 24h.22 In spite of this, audits about the compliance with prophylaxis protocols have shown that the most frequent error made is precisely excessive duration.23 Clinical studies have been unable to demonstrate any benefits of the prolonged administration of antibiotics beyond the preoperative dose. In a meta-analysis of 25 general surgery studies,24 surgical site infection (SSI) rates did not decrease with the prolongation of AP after surgery.24 The same results were observed in several meta-analyses focused on bowel surgery.25 Systematic reviews that focus on other types of surgery have confirmed identical results. In a cohort study, the administration of AP>48h was not associated with a lower SSI (OR 1.2; CI: 0.8–1.6), but there was an associated higher risk for bacterial resistance (OR 1.6; CI: 1.1–2.6).26 The epidemic increase of infections by Clostridium difficile has been related with the increased use of antibiotic therapies and, specifically, prolonged AP.27 In conclusion, the prolongation of prophylaxis beyond 24h cannot be justified. Current clinical guidelines insist on limiting AP to a single preoperative dose or, at the very most, treatment within the first 24h post-op.28,29 Extending AP increases pharmacological toxicity, costs, risk for bacterial resistance and postoperative infection by C. difficile.

In general, AP is indicated when the probabilities of infection are high or when the consequences of a postoperative infection are potentially serious. The indication of AP in this surgery depends on the type of operation, patient comorbidities and the existence of prosthesis. In clean, non-prosthetic surgery lasting less than 2h without a lot of tissue attrition, the use of prophylaxis is not necessary. Table 2 summarizes the situations in which AP is not necessary in surgery.30 Contrarily, AP would be indicated when the effects of infection are very severe or irreversible (infection of a mesh or vascular access device) or when there are relevant risk factors, such as obesity or immunosuppression. In hernia surgery, meta-analyses found a protective effect of AP in hernioplasty (OR 0.61; 95% CI: 0.40–0.92),31 so it is therefore recommended in inguinal hernia repair and, by inference, abdominal hernioplasties or abdominoplasties.32 In breast surgery, AP is indicated when implants are inserted for esthetic reasons, in reconstruction due to neoplasm and breast reduction.33 AP is also effective in oncologic surgery without reconstruction, with an evident reduction of the incidence of SSI (RR 0.67; 95% CI: 0.53–0.85).34 AP does not significantly reduce SSI in clean surgery of the head and neck (2.4 with AP versus 3.7% in control groups; OR 0.49; 95% CI: 0.19–1.23; P=.13), so it is not routinely recommended.35 In conclusion, AP should not be administered in short (<2h) clean surgeries with no implantation of prosthesis, in patients with good immune response or in those in whom the consequences of SSI would not be catastrophic.

The definition and use of the concept “uncomplicated” refers to the initial appearance in clean-contaminated surgery in which the focus is eliminated and, therefore, only requires a single dose of antibiotic prophylaxis.36 Uncomplicated appendicitis has no abscess, no perforation and the patient presents no peritonitis.37 Currently, there is no evidence demonstrating that prolonged antibiotic treatment after acute uncomplicated appendicitis provides any sort of benefit, not even for the prevention of surgical site infections.38,39 Thus, the recommendation to not use antibiotics in the postoperative period of an uncomplicated appendicitis is mainly based on the absence of evidence recommending its use. Rational use that respects this recommendation would generate savings in medication costs, and probably also for hospitalization, by avoiding prolonged hospital stay for the administration of the antibiotic itself, the generation of resistances and the prevention of complications.40,41 There are few reports in the literature, although they provide very interesting data in favor of no antibiotic use and no data in favor of their systematic use. In this context, there are very extensive observational cohort studies comparing the incidence of any type of infection depending on the use or not of postoperative antibiotics, with no observed differences.42 There are 2 randomized clinical trials that have studied the subject. One found no differences in the appearance of infectious complications after comparing 7 days of antibiotic treatment versus placebo in the postoperative period of 756 patients with appendicitis of all types.43 Another compared one dose versus 3 and versus 5 doses in 269 cases of uncomplicated appendicitis, and, once again, there were no differences in the appearance of infectious complications or in hospital stay; however, the number of diarrheas was significantly greater when 5 doses were administered.44 Therefore, there is currently no scientific evidence to recommend the use of postoperative antibiotics for uncomplicated appendicitis.

We can conclude that the “what not to do” program, developed by the Ministry of Health, informs healthcare professionals which medical actions do not add value to the healthcare process. This program is based on the selection of the best evidence available to avoid exposing patients to potential risks and to improve the adaptation of healthcare resources. The participation of AEC in this campaign has provided reflection on which interventions contribute no added value in our specialty, and it is expected that the communication of this identification and selection process will lead to improved patient care.