Bastiaenen et al.1 reported that selective histopathological examination of the gallbladder after initial macroscopic assessment by the surgeon seems safe and could reduce costs of incidental gallbladder cancer (GBC). Their study is indeed an interesting series in the field and we congratulate the authors for their clinically relevant contribution; however, several issues need further consideration and discussion.

Bastiaenen et al. reported that 26·6% of incidentally detected cancers were suspected or diagnosed during surgery in countries with a low incidence of GBC. Additionally, the pooled intraoperative sensitivity was 49·5% in countries with a high incidence of GBC. After systematical examination of the gallbladder mucosa, only 66·7% and 76·9% of incidental GBC were recognized in countries with a low and high incidence of GBC, respectively. Even strong agreement between macroscopic gallbladder examination performed by surgeons and pathologists was found by Corten et al.2, we wonder that if these intraoperative sensitivities are really safe?

Additionally, Bastiaenen et al. reported that histopathological costs for a routine policy would have been €1 099 800 compared with €81 900 for a selective policy, indicating that the costs of routine histopathological examination for clinical benefit in one patient were at least €169 650. The researchers seem to think that these costs can only benefit the diagnosed GBC patients. Did the researchers consider the right of patients to know their true diagnosis, which would allow them to face their work and life with peace of mind? At least in China, a certain gold standard diagnosis is more convincing.

In summary, the intraoperative sensitivities of incidental GBC reported in this meta-analysis is not safe enough compared with routine histopathological examination. The cost of routine histopathological examination could not only benefit the diagnosed GBC patients, but also benefit the patients with benign gallbladder disease.

Acknowledgements

We acknowledge the Sichuan Science and Technology Program (No. 2018JY0019), the Fundamental Research Funds for the Central Universities (2019SCUH0021), Post-Doctor Research Project, West China Hospital, Sichuan University (2019HXBH025), and the Sichuan University Postdoctoral Interdisciplinary Innovation Start-up Fund (0040204153244).

Author contributions

Wen-jie Ma performed the majority of manuscript; Rong-Xing Zhou revised the manuscript critically and gave the final approval of the version to be published.

Foundation item

Science & Technology Support Project of Sichuan Province (2018JY0019), the Fundamental Research Funds for the Central Universities (2019SCUH0021), Post-Doctor Research Project, West China Hospital, Sichuan University (2019HXBH025), and the Sichuan University Postdoctoral Interdisciplinary Innovation Start-up Fund (0040204153244).