Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis of randomi

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Early versus delayed laparoscopic cholecystectomy
for acute cholecystitis a meta-analysis of
randomized clinical trials

• PGY???

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Background

• The appropriate timing for laparoscopic
  cholecystectomy in the treatment of acute
  cholecystitis remains controversial.

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Methods

• All randomized clinical studies published between
  1987 and 2006 comparing early versus delayed
  laparoscopic cholecystectomy for acute
  cholecystitis were analyzed, irrespective of
  language, blinding, or publication status

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Initial reports

• Early increased complication rates,
• prolonged operation times,
• increased conversion rates.
• Delayed increases the chances of further
• gallstone-related
  complications,
• further hospital admissions

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Recent

• early laparoscopic surgery
• safe option in acute cholecystitis
• conversion to open rates may be higher

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Methods

• Early within 7 days of the onset of symptoms
• Late defined as 6 weeks after admission

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Outcomes

• Primary outcomes morbidity (gallstone-related
  complications or surgery-related morbidity),
  conversion rate, and mortality.
• Secondary outcomes hospital stay, operation
  time, and any other adverse events that were not
  considered above (eg, blood loss and deep vein
  thrombosis).

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Results

• A total of 4 randomized clinical trials published
  between 1987 and 2006 matched the selection
  criteria.
• The 4 studies that fulfilled the inclusion
  criteria assessed a combined total of 375
  patients.
• Review of the data extraction showed 100
  agreement between the 2 reviewers.

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all complications
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conversion
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operating time
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total hospital stay
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Comments

• Early cholecystectomy
• reduced total hospital stay
• longer operation time
• Delayed cholecystectomy
• significantly reduced operation time
• Not associated with differences in complications,
  conversions or post operative morbidity.

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• Early within 72 hours from the onset of symptoms
  is suggested to be the optimal timing to perform.
• Delayed allows maturation of the inflammatory
  changes with the consequent fibrosis,
  contraction, and adhesions making surgery
  potentially more difficult.

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• The 4 randomized trials included in this
  meta-analysis were generally of good quality and
  did not show significant heterogeneity.
• All 4 prospective studies used similar inclusion
  criteria and stated methods of randomization.

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Conclusions

• Early laparoscopic cholecystectomy is superior to
  delayed laparoscopic cholecystectomy in terms of
  a reduction in total hospital stay.
• There was no significant increase in
  complications or conversion rate, although
  operating time was increased.

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Presently

• United States early. (Delayed surgery carries a
  risk of failure of conservative treatment,
  recurrent symptoms, or acute cholecystitis while
  waiting for operation and a longer overall
  hospital stay and greater overall costs.)
• United Kingdom delayed. (The risk of
  gallstone-related complications are higher after
  conservative treatment, and up to 36 of patients
  will have recurrent episodes or another
  gallstone-related event.)

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10 questions to help you make sense ofrandomised
controlled trials
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Screening Questions

• 1. Did the study ask a clearly focused question?
• Yes ?Cant tell ?No

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Screening Questions

• 2. Was this a randomised controlled trial (RCT)
  and was it appropriately so?
• Yes ?Cant tell ?No

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Is it worth continuing?
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Detailed questions

• 3. Were participants appropriately allocated to
  intervention and control groups?
• ?Yes Cant tell ?No

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Detailed questions

• 4. Were participants, staff and study personnel
  blind to participants study group?
• Yes ?Cant tell ?No

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Detailed questions

• 5. Were all of the participants who entered the
  trial accounted for at its conclusion?
• Yes ?Cant tell ?No

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Detailed questions

• 6. Were the participants in all groups followed
  up and data collected in the same way?
• ? Yes ?Cant tell No
• (please see Table 1)

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Detailed questions

• 7. Did the study have enough participants to
  minimise the play of chance?
• Yes ?Cant tell ?No

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Detailed questions

• 8. How are the results presented and what is the
  main result?

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Detailed questions

• 9. How precise are these results?

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• 10.Were all important outcomes considered so the
  results can be applied?
• Yes ?Cant tell ?No

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UpToDate
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