Early versus delayed laparoscopic cholecystectomy for biliary colic
Abstract
Background
Biliary colic is one of the commonest indications for laparoscopic cholecystectomy. Laparoscopic cholecystectomy involves several months of waiting if performed electively. However, patients can develop life‐threatening complications during this waiting period.
Objectives
To assess the benefits and harms of early versus delayed laparoscopic cholecystectomy for patients with biliary colic due to gallstones.
Search methods
We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2008.
Selection criteria
We included only randomised clinical trials irrespective of language and publication status.
Data collection and analysis
Two authors independently extracted the data. We intended to calculate the risk ratio, risk difference with 95% confidence intervals (CI) for dichotomous outcomes, and weighted mean difference (WMD) with 95% CI for continuous outcomes using RevMan 4.2 based on intention‐to‐treat analysis.
Main results
Only one trial including 75 patients, randomised to early laparoscopic cholecystectomy (less than 24 hours of diagnosis) (n = 35) and delayed laparoscopic cholecystectomy (mean waiting period of 4.2 months) (n = 40), qualified for this review. This trial was of high risk of bias. During the waiting period in the delayed group (mean 4.2 months), the complications that the patients suffered included severe acute pancreatitis resulting in mortality (1), empyema of gallbladder (1), gallbladder perforation (1), acute cholecystitis (2), cholangitis (2), obstructive jaundice (2), and recurrent biliary colic requiring hospital visits (5). The rate of conversion to open cholecystectomy was lower in the early group (0%) than the delayed group (8/40 or 20%) (p = 0.0172). There was a statistically significant shorter operating time and hospital stay in the early group than the delayed group (WMD ‐14.80 minutes, 95% CI ‐18.02 to ‐11.58 and ‐1.25 days, 95% CI ‐2.05 to ‐0.45 respectively). Fourteen patients (35%) required 18 hospital admissions for symptoms related to gallstones during the mean waiting period of 4.2 months in the delayed group. This is equivalent to 11 admissions per 100 persons per month.
Authors' conclusions
Based on evidence from only one high‐bias risk trial, it appears that early laparoscopic cholecystectomy (< 24 hours of diagnosis of biliary colic) decreases the morbidity during the waiting period for elective laparoscopic cholecystectomy, decreases the rate of conversion to open cholecystectomy, decreases operating time, and decreases hospital stay. Further randomised clinical trials are necessary to confirm or refute this finding.
PICOs
Plain language summary
Early key hole removal of gallbladder for gallstone pain decreases morbidity during the waiting period; conversion to open removal of gallbladder; and decreases operating time and hospital stay but further low bias‐risk trials are necessary
Removal of gallbladder (cholecystectomy) for symptomatic gallstones is one of the commonest abdominal operations performed. Key‐hole removal of the gallbladder (laparoscopic cholecystectomy) is usually performed on a delayed (elective) basis for gallstone pain (without gallbladder inflammation), ie, biliary colic, but can be performed as an emergency surgery. Patients can develop life threatening complications while waiting for surgery. In this review, we identified one trial of high bias‐risk (meaning that there is a high risk of systematic error), which randomised 75 patients with biliary colic to immediate surgery (less than 24 hours of diagnosis) or to elective surgery (mean waiting time 4.2 months). Fourteen patients (35%) required at least one emergency hospital admission for complications related to gallstones during the waiting period in the elective surgery group. In total, there were 18 admissions in 40 patients in 4.2 months. This is equivalent to 11 admissions for 100 patients per month. Elective surgery resulted in more people requiring open operations (20% elective surgery group compared with none in emergency surgery group); and longer operating time (increased by about 15 minutes in the elective surgery group) and hospital stay (increased by one day in the elective surgery group). Further randomised clinical trials of low bias‐risk (meaning that they should have low risk of systematic error) are needed.
