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Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews

  • Review
  • Overview

Authors


Abstract

Background

Patients with symptomatic cholecystolithiasis are treated by three different techniques of cholecystectomy: open, small-incision, or laparoscopic. There is no overview on Cochrane systematic reviews on these three interventions.

Objectives

To summarise Cochrane reviews that assess the effects of different techniques of cholecystectomy for patients with symptomatic cholecystolithiasis.

Methods

The Cochrane Database of Systematic Reviews (CDSR) was searched for all systematic reviews evaluating any interventions for the treatment of symptomatic cholecystolithiasis (Issue 4, 2009).

Main results

Three systematic reviews that included a total of 56 randomised trials with 5246 patients are included in this overview of reviews. All three reviews used identical inclusion criteria for trials and participants, and identical methodological assessments.

Laparoscopic versus small-incision cholecystectomy
Thirteen trials with 2337 patients randomised studied this comparison. Bias risk was relatively low. There was no significant difference regarding mortality or complications. Total complications of laparoscopic and small-incision cholecystectomy were high, ie, 17.0% and 17.5%. Total complications (risk difference, random-effects model -0.01 (95% confidence interval (CI) -0.07 to 0.05)), hospital stay (mean difference (MD), random-effects -0.72 days (95% CI -1.48 to 0.04)), and convalescence were not significantly different. Trials with low risk of bias showed a quicker operative time for small-incision cholecystectomy (MD, low risk of bias considering 'blinding', random-effects model 16.4 minutes (95% CI 8.9 to 23.8)) while trials with high risk of bias showed no statistically significant difference.

Laparoscopic versus open cholecystectomy
Thirty-eight trials with 2338 patients randomised studied this comparison. Bias risk was high. Laparoscopic cholecystectomy patients had a shorter hospital stay (MD, random-effects model -3 days (95% CI -3.9 to -2.3)) and convalescence (MD, random-effects model -22.5 days (95% CI -36.9 to -8.1)) compared with open cholecystectomy but did not differ significantly regarding mortality, complications, and operative time.

Small-incision versus open cholecystectomy
Seven trials with 571 patients randomised studied this comparison. Bias risk was high. Small-incision cholecystectomy had a shorter hospital stay (MD, random-effects model -2.8 days (95% CI -4.9 to -0.6)) compared with open cholecystectomy but did not differ significantly regarding complications and operative time.

Authors' conclusions

No statistically significant differences in the outcome measures of mortality and complications have been found among open, small-incision, and laparoscopic cholecystectomy. There were no data on symptom relief. Complications in elective cholecystectomy are high. The quicker recovery of both laparoscopic and small-incision cholecystectomy patients compared with patients on open cholecystectomy justifies the existing preferences for both minimal invasive techniques over open cholecystectomy. Laparoscopic and small-incision cholecystectomies seem to be comparable, but the latter has a significantly shorter operative time, and seems to be less costly.

摘要

背景

傳統式、小切口或腹腔鏡膽囊切除治療有症狀的膽囊結石患者。肝膽病Cochrane HepatoBiliary小組審查概述

有症狀的膽囊結石患者有三種不同膽囊切除術的治療方法:傳統式、小切口或腹腔鏡。在Cochrane systematic reviews 中尚沒有這三個治療方法的綜述。

目標

總括 Cochrane reviews是評估不同的膽囊切除術手術對有症狀的膽囊結石病人的影響。

搜尋策略

Cochrane Database of Systematic Reviews(CDSR)搜查所有systematic reviews 評估任何治療有症狀的膽囊結石的介入(2008年第4期)。

選擇標準

空白

資料收集與分析

空白s

主要結論

三個系統性回顧,包括一共有56篇隨機試驗的5246名病人在此概述的評論中。全部3評論審查都使用相同的試驗和參與者選擇標準和相同的評估方法。

作者結論

結果測量的死亡率和併發症中在傳統式、小切口或腹腔鏡膽囊切除術發現無顯著差異。沒有關於減輕症狀的報告。非緊急的膽囊切除術併發症較高。腹腔鏡和兩個小切口膽囊切除比傳統式腹膽囊切除術的恢復快,證明現有的微創技術比傳統式的膽囊切除術好。腹腔鏡和小切口膽囊切除術似乎是相媲美,但小切口膽囊切除術明顯縮短手術時間,而且比較不昂貴。

翻譯人

本摘要由高雄長庚醫院刁茂盟 翻譯。

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

總結

傳統式、小切口和腹腔鏡膽囊切除術相比,就死亡率和併發症似乎有差別,而且在西方社會,膽結石是一個主要發病的原因。無症狀和有症狀膽結石的病人約為5%和22%。而且大家有一共識,只有在出現症狀的膽結石患者才需要治療。因為目前存在有三種不同的膽囊切除操作技術包括:傳統式手術的技術和兩個微創手術技術,腹腔鏡和小切口技術。本概述評價了這三種手術方式,共包括56篇隨機試驗的5246名病人。併發症的比例在所有三種手術的技術上都很高,但三者之間在死亡率及併發症上並沒有顯著差異。這兩種微創技術在術後病人的恢復較優於傳統式的手術。本概述的三篇Cochrane HepatoBiliary Group systematic reviews 都表明,腹腔鏡和小切口在病人成果有關死亡率,併發症,住院天數,和恢復時間,被視為差不多的結果; 小切口技術在手術時間似乎更短和所須成本更低的成果。今天的問題是,為什麼腹腔鏡膽囊切除術在沒有很強的實驗證據下,已經成為大家治療這類症狀性膽囊結石病人的膽囊切除術標準手術方法。我們在此無法找到任何論據支持腹腔鏡膽囊切除術的標準地位。但在今後的試驗中,研究應更多集中在有關的病人的成果上,如:併發症和減輕病人的症狀。此外,執行的審判應符合CONSORT(www.consortstatement.org)的要求。

Plain language summary

Open, small-incision, and laparoscopic cholecystectomy seem comparable with regard to mortality and complications

Gallstones are one of the major causes of morbidity in western society. Prevalence of persons with asymptomatic and symptomatic gallstones varies between 5% and 22%. There is consensus that only patients with symptomatic gallstones need treatment. Three different operation techniques for removal of the gallbladder exist: the classical open operation technique and two minimally invasive procedures, the laparoscopic and the small-incision technique. This overview evaluates the three surgical procedures and comprises fifty-six trials with 5246 patients randomised.

Complication proportions in all three techniques are high, but there seem to be no significant differences in mortality and complications between the three operation techniques. Both minimally invasive techniques have advantages over the open operation considering postoperative recovery. This overview of three Cochrane Hepato-Biliary Group systematic reviews shows that the laparoscopic and the small-incision operation should be considered equal regarding patient-relevant outcomes (mortality, complications, hospital stay, and convalescence). Operative time seems to be quicker and costs seem to be lower using the small-incision technique.

The question today is why the laparoscopic cholecystectomy has become the standard treatment of cholecystectomy for patients with symptomatic cholecystolithiasis without the evidence being present. We were unable to find any arguments supporting the 'gold standard' status of laparoscopic cholecystectomy.

In future trials, research should concentrate more on outcomes that are relevant to patients (eg, complications and symptom relief). Furthermore, the execution of the trials should comply with CONSORT requirements (www.consort-statement.org).

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