Comment on: safety and economic analysis of selective histopathology following cholecystectomy: multicentre, prospective, cross-sectional FANCY study

Dear Editor

We read with great interest the results of the FANCY study by Bastiaenen et al¹., and commend the authors on work that can produce large cost and safety benefits for general surgical systems. Overwhelming evidence was obtained demonstrating that selective histopathological examination following cholecystectomy is not only safe for the patients involved but potentiates significant economic benefits for healthcare. At a local level, the significant reductions in the associated workload for pathology laboratories may theoretically allow for improved turnover of other critical investigations and the need for repeat surgical intervention. However, despite this robust data via strong study design, we believe that unfortunately evidence-based action may not be enacted by surgeons around the world due to the major medicolegal implications associated with missing cancer of the gallbladder or biliary tract.

The low rate of malignancy found in the FANCY study (0.22 per cent) implies that in a statistical sense, the chance of missing malignancy within a selective histopathological examination approach is extremely low¹. Despite a small rate of cancer being missed of 0.00089 per cent that was not statistically significant, a missed cancer diagnosis is still a significant and tangible risk for the patient with large potential medicolegal implications for clinicians. Furthermore, gallbladder cancer has a severely poor prognosis due to its indolent nature and late presentation. Compounded by a perceived significant medicolegal risk, further research into what surgeons would require to change their practice is required. It is currently unclear whether to move towards an approach to clinical practice that is based on this evidence surgeons require further scientific data or other formal defensive supports that would appropriately protect from litigation, such as a position statement from overseeing accreditation bodies.