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Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis

  1. Kurinchi Selvan Gurusamy1,*,
  2. Christopher Davidson2,
  3. Christian Gluud3,
  4. Brian R Davidson1

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 30 JUN 2013

Assessed as up-to-date: 17 JUL 2012

DOI: 10.1002/14651858.CD005440.pub3


How to Cite

Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD005440. DOI: 10.1002/14651858.CD005440.pub3.

Author Information

  1. 1

    Royal Free Campus, UCL Medical School, Department of Surgery, London, UK

  2. 2

    Royal Free Campus, UCL Medical School, London, London, UK

  3. 3

    Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, The Cochrane Hepato-Biliary Group, Copenhagen, Denmark

*Kurinchi Selvan Gurusamy, Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital,, Rowland Hill Street, London, NW3 2PF, UK. kurinchi2k@hotmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 30 JUN 2013

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[Figure 1]
Figure 1. Study flow diagram.
[Figure 2]
Figure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
[Figure 3]
Figure 3. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
[Figure 4]
Figure 4. Trial sequential analysis of bile duct injuryThe diversity-adjusted required information size (DARIS) was calculated to 77,854 participants, based on the proportion of participants in the control group with the outcome of 0.9%, a relative risk reduction of 20%, an alpha of 5%, a beta of 20%, and a diversity of 0%. After accruing 438 participants in the five trials, we have only reached 0.56% of the DARIS. Accordingly, the trial sequential analysis does not show the required information size and the trial sequential monitoring boundaries. As shown, the conventional boundaries have also not been crossed. Less than 1% of the required sample size was reached in the trials included in the meta-analysis. This was too little to draw the trial sequential monitoring boundaries.
[Figure 5]
Figure 5. Trial sequential analysis of other serious complicationsThe diversity-adjusted required information size (DARIS) was calculated to 13,493 participants, based on the proportion of participants in the control group with the outcome of 5.0%, a relative risk reduction of 20%, an alpha of 5%, a beta of 20%, and a diversity of 0%. After accruing 438 participants in the five trials, we have only reached 3.25% of the DARIS. Accordingly, the trial sequential analysis does not show the required information size and the trial sequential monitoring boundaries. As shown, the conventional boundaries have also not been crossed.
[Figure 6]
Figure 6. Trial sequential analysis of conversion to open cholecystectomyThe diversity-adjusted required information size (DARIS) was calculated to 2225 participants, based on the proportion of participants in the control group with the outcome of 24.7%, a relative risk reduction of 20%, an alpha of 5%, a beta of 20%, and a diversity of 0%. After accruing 488 participants in the six trials, only 21.9% of the DARIS has been reached. Accordingly, the trial sequential analysis does not show the inner wedge futility area. As shown, none of the boundaries have been crossed, ie, neither the trial sequential monitoring boundaries nor the conventional boundaries.
[Figure 7]
Figure 7. Trial sequential analysis of hospital stay Trial sequential analysis of operating time showing that the accumulative Z-curve crosses the trial sequential monitoring boundary after the third trial. The diversity-adjusted required information size (DARIS) was 1649 participants based on a minimal relevant difference (MIRD) of one day, a variance (VAR) of 52.5, an alpha (a) of 5%, a beta (b) of 20%, and a diversity (D2) of 0%. The results are compatible with significant reduction of hospital stay favouring the early laparoscopic cholecystectomy group without risk of random errors.
[Figure 8]
Figure 8. Trial sequential analysis of operating timeThe diversity-adjusted required information size (DARIS) was 1107 participants based on a minimal relevant difference (MIRD) of 15 minutes, a variance (VAR) of 130.52, an alpha (a) of 5%, a beta (b) of 20%, and a diversity (D2) of 98.28%. After accruing 488 participants in the six trials, only 44.08% of the DARIS has been reached. Accordingly, the inner wedge futility area was not drawn. The trial sequential analysis shows that the trial sequential monitoring boundaries for benefits and harms were not crossed, but the conventional boundary for harm was initially crossed.
[Analysis 1.1]
Analysis 1.1. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 1 Bile duct injury.
[Analysis 1.2]
Analysis 1.2. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 2 Bile duct injury (sensitivity analysis).
[Analysis 1.3]
Analysis 1.3. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 3 Other serious complications.
[Analysis 1.4]
Analysis 1.4. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 4 Other serious complications (sensitivity analysis).
[Analysis 1.5]
Analysis 1.5. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 5 Conversion to open cholecystectomy.
[Analysis 1.6]
Analysis 1.6. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 6 Conversion to open cholecystectomy (sensitivity analysis).
[Analysis 1.7]
Analysis 1.7. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 7 Hospital stay.
[Analysis 1.8]
Analysis 1.8. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 8 Operating time.
[Analysis 1.9]
Analysis 1.9. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 9 Return to work [days].
[Analysis 1.10]
Analysis 1.10. Comparison 1 Early versus delayed laparoscopic cholecystectomy, Outcome 10 Morbidity in patients waiting for surgery in delayed laparoscopic cholecystectomy.
[Analysis 2.1]
Analysis 2.1. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 1 Bile duct injury (stratified by risk of bias).
[Analysis 2.2]
Analysis 2.2. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 2 Other serious complications (stratified by risk of bias).
[Analysis 2.3]
Analysis 2.3. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 3 Conversion to open cholecystectomy (stratified by risk of bias).
[Analysis 2.4]
Analysis 2.4. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 4 Hospital stay (stratified by risk of bias).
[Analysis 2.5]
Analysis 2.5. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 5 Operating time (stratified by risk of bias).
[Analysis 2.6]
Analysis 2.6. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 6 Bile duct injury (stratified by timing of early LC)).
[Analysis 2.7]
Analysis 2.7. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 7 Other serious complications (stratified by timing of early LC).
[Analysis 2.8]
Analysis 2.8. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 8 Conversion to open cholecystectomy (stratified by timing of early LC).
[Analysis 2.9]
Analysis 2.9. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 9 Hospital stay (stratified by timing of early LC).
[Analysis 2.10]
Analysis 2.10. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 10 Operating time (stratified by timing of early LC).
[Analysis 2.11]
Analysis 2.11. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 11 Bile duct injury (stratified by surgeon's experience).
[Analysis 2.12]
Analysis 2.12. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 12 Other serious complications (stratified by surgeon's experience).
[Analysis 2.13]
Analysis 2.13. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 13 Conversion to open cholecystectomy (stratified by surgeon's experience).
[Analysis 2.14]
Analysis 2.14. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 14 Hospital stay (stratified by surgeon's experience).
[Analysis 2.15]
Analysis 2.15. Comparison 2 Early versus delayed laparoscopic cholecystectomy (subgroup analysis), Outcome 15 Operating time (stratified by surgeon's experience).