Early versus delayed laparoscopic cholecystectomy for acute cholecystitis
Abstract
Background
Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% become symptomatic in a year. Cholecystectomy for symptomatic gallstones is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
Objectives
The aim was to compare the early laparoscopic cholecystectomy (less than seven days of onset of symptoms) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission) with regards to benefits and harms.
Search methods
We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until November 2005.
Selection criteria
We considered for inclusion all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis.
Data collection and analysis
We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay from each trial. We analysed the data with both the fixed‐effect and the random‐effects models using RevMan Analysis. For each outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention‐to‐treat analysis.
Main results
We included five trials with 451 patients randomised: 223 to the early group and 228 to the delayed group. Surgery was performed on 222 patients in the early group and on 216 patients in the delayed group. There was no mortality in any of the trials. Four of the five trials were of high methodological quality. There was no statistically significant difference between the two groups for any of the outcomes including bile duct injury (OR 0.63, 95% CI 0.15 to 2.70) and conversion to open cholecystectomy (OR 0.84, 95% CI 0.53 to 1.34). Various other analyses including 'available case analysis', risk difference, statistical methods to overcome the 'zero‐event trials' showed no statistically significant difference between the two groups in any of the outcomes measured. A total of 40 patients (17.5%) from the delayed group had to undergo emergency laparoscopic cholecystectomy due to non‐resolving or recurrent cholecystitis; 18 (45%) of these had to undergo conversion to open procedure. The total hospital stay was about four days shorter in the early group compared with the delayed group.
Authors' conclusions
Early laparoscopic cholecystectomy during acute cholecystitis seems safe and shortens the total hospital stay. The majority of the outcomes occurred rarely; hence, the confidence intervals are wide. Therefore, further randomised trials on the issue are needed.
PICOs
Plain language summary
Early laparoscopic cholecystectomy during acute cholecystitis is safe and shortens the total hospital stay
Cholecystectomy for symptomatic gallstones is mainly performed after an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis. This systematic review of five randomised trials shows that there is no significant difference in the complication rate or the conversion rate in regard to the time when the laparoscopic cholecystectomy is performed during acute cholecystitis versus performed 6 to 12 weeks after the symptoms settle. No mortality was reported in any of the trials. Early laparoscopic cholecystectomy during acute cholecystitis appears to be safe and shortens the total hospital stay.
