Early versus delayed laparoscopic cholecystectomy for biliary colic

Kurinchi Selvan Gurusamy, Kumarakrishnan Samraj, Giuseppe Fusai, Brian R Davidson
Cochrane Database of Systematic Reviews 2008 October 8, (4): CD007196

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 STRATEGY: 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.

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