Early versus delayed laparoscopic cholecystectomy for acute cholecystitis

  • Review
  • Intervention

Authors

  • Kurinchi Selvan Gurusamy,

    Corresponding author
    1. Royal Free Hospital and University College School of Medicine, University Department of Surgery, London, UK
    • Kurinchi Selvan Gurusamy, University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, NW3 2QG, UK. kurinchi2k@hotmail.com.

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  • Kumarakrishnan Samraj

    1. John Radcliffe Hospital, Department of General Surgery, Oxford, UK
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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.

摘要

背景

針對急性膽囊炎,早期和延遲腹腔鏡膽囊切除術的比較

西方國家中大約10% – 15%的成年人有膽結石。 每一年會有1% −4% 的人出現相關症狀。 由於擔心併發症較高,使得急性膽囊炎發病過程中,腹腔鏡膽囊切除術轉變成傳統膽囊切除手術, 所以急性膽囊炎發作之後,主要會對症狀性膽囊結石實施膽囊切除術。

目標

本次文獻回顧的目的在於比較早期腹腔鏡膽囊切除術 (症狀出現後7天內)和延期腹腔鏡膽囊切除術 (因病住院後6周以上) 的利弊。

搜尋策略

我們搜尋2005年11月之前的The Cochrane Library The Cochrane HepatoBiliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE 和cience Citation Index Expanded。

選擇標準

我們考慮了所有比較急性膽囊炎使用早期和延期腹腔鏡膽囊切除術的隨機臨床試驗。

資料收集與分析

我們收集了試驗特徵,試驗方法學品質,每次試驗的死亡率、併發症、治癒率、手術時間和住院天數等資料。我們使用固定效果模型和隨機效果模型,以RevMan 分析資料。我們根據治療意向分析,計算了每個結果的比數比 (OR) ,95% 信賴區間 (CI) 。

主要結論

我們共包括5次試驗,共隨機挑選451位病人: 223 人分配到早期組,228人分配到延期組。 早期組有222位病人實施手術,延期組有216 位病人實施手術。任何試驗無死亡率。5次試驗有4次試驗具有較高的方法學品質。 2個小組在結果方面沒有顯著差異,這些結果包括膽管受損(OR 0.63, 95% CI 0.15 – 2.70) ,轉換至傳統膽囊切除術(OR 0.84, 95% CI 0.53 0 – 1.34)。 其他分析還包括‘可獲得案例的分析’, 風險差異, 統計學方法,以便避免發生‘零事件試驗’, 2個小組在測量的結果方面沒有體現顯著差異。由於膽囊炎沒有治癒或反覆發作,延期組共有 40 位病人(17.5%) 必須接受緊急腹腔鏡膽囊切除術 18 (45%) 個人必須轉移至傳統手術。比較延期組,早期組的總體住院日約縮短4天。

作者結論

在急性膽囊炎發病期間實施早期腹腔鏡膽囊切除術似乎是安全的,且能縮短總體住院日。大多數不良結果(指膽道受損及轉換手術)比較罕見; 因此設定較寬的信賴信賴區間。 因此,需要對此問題實施進一步的隨機試驗。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

在急性膽囊炎發病期間實施早期腹腔鏡膽囊切除術是安全的,且縮短了總體住院日。針對症狀性膽結石引發急性膽囊炎,通常會早期實施膽囊切除術。主要原因是擔心高發病率,及病程中既定腹腔鏡膽囊切除術可能轉變成傳統膽囊切除手術。 本次對5次隨機試驗的系統性文獻回顧指出, 比較症狀出現6周−12周後再實施腹腔鏡膽囊切除術,若於發病期間實施腹腔鏡膽囊切除術其併發症率或治癒率沒有表現明顯差異。 所有的試驗皆沒有死亡個案。急性膽囊炎發病期間實施早期腹腔鏡膽囊切除術比較安全,能夠縮短總體住院日。

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.

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