Randomized clinical trial of conventional cholecystectomyversus minicholecystectomy

Systematic review: open, small-incision or laparoscopic cholecystectomy for symptomatic cholecystolithiasis

BACKGROUND

Laparoscopic cholecystectomy has become the method of choice for gallbladder removal, although evidence of superiority over open and small-incision cholecystectomy is lacking.

AIM

To compare the effects of open, small-incision and laparoscopic cholecystectomy techniques for patients with symptomatic cholecystolithiasis.

METHODS

We conducted updated searches until January 2007 in multiple databases. We assessed bias risk.

RESULTS

Fifty-nine trials randomized 5556 patients. No significant differences in primary outcomes (mortality and complications) were found among all three techniques. Both minimal invasive techniques show advantages over open cholecystectomy in terms of convalescence. Small-incision cholecystectomy showed shorter operative time compared with laparoscopic cholecystectomy (random effects, weighted mean difference, 16.4 min; 95% confidence interval, 8.9-23.8), but the two techniques did not differ regarding hospital stay and conversions.

CONCLUSIONS

No significant differences in mortality and complications were found among all three techniques. Laparoscopic cholecystectomy and small-incision cholecystectomy are preferred over open cholecystectomy for quicker convalescence. Laparoscopic cholecystectomy and small-incision cholecystectomy show no clear differences on patient outcomes.

Mini-cholecystectomy under local anaesthesia

OBJECTIVE

Reports of mini-cholecystectomy (MC) under general anaesthesia in the surgical treatment of gallbladder disease are common, but those of MC under local anaesthesia are much more limited. We report our experience of MC under local anaesthesia.

METHODS

Forty-two patients with gallstone disease scheduled for MC under local anaesthesia were included in this study. Twenty-seven were female, with a median age of 54.5 years (range, 29-71) and median body mass index (BMI) of 20.5 (range, 17.6-23.4). None of the patients had evidence of acute cholecystitis on admission or previous upper abdominal surgery. MC was performed by a standardized technique and under the combination of local anaesthesia (1% xylocaine with adrenaline) and intravenous administrations of fentanyl (0.001-0.002 mg/kg) and midazolam (0.05-0.1 mg/kg).

RESULTS

The median operative time was 40 minutes (range, 35-64). Local anaesthesia was converted to general anaesthesia in two patients owing to the discomfort caused by lysis of dense adhesions around the gallbladder, giving a success rate of 95%. MC was done successfully in all patients without any postoperative complications. The median hospital stay was 5 days (range, 2-7).

CONCLUSION

MC under local anaesthesia is an effective surgical procedure for patients with BMI of less than 24, who have no evidence of acute inflammation of the gallbladder and no previous upper abdominal surgery.

Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis

BACKGROUND

Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Laparoscopic cholecystectomy was introduced in the 1980s.

OBJECTIVES

To compare the beneficial and harmful effects of laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis.

SEARCH STRATEGY

We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials.

SELECTION CRITERIA

All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed when appropriate.

MAIN RESULTS

Thirty-eight trials randomised 2338 patients. Most of the trials had high bias risk. There was no significant difference regarding mortality (risk difference 0,00, 95% confidence interval (CI) -0.01 to 0.01). Meta-analysis of all trials suggests less overall complications in the laparoscopic group, but the high-quality trials show no significant difference ('allocation concealment' high-quality trials risk difference, random effects -0.01, 95% CI -0.05 to 0.02). Laparoscopic cholecystectomy patients have a shorter hospital stay (weighted mean difference (WMD), random effects -3 days, 95% CI -3.9 to -2.3) and convalescence (WMD, random effects -22.5 days, 95% CI -36.9 to -8.1) compared to open cholecystectomy.

AUTHORS' CONCLUSIONS

No significant differences were observed in mortality, complications and operative time between laparoscopic and open cholecystectomy. Laparoscopic cholecystectomy is associated with a significantly shorter hospital stay and a quicker convalescence compared with the classical open cholecystectomy. These results confirm the existing preference for the laparoscopic cholecystectomy over open cholecystectomy.

Laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis

BACKGROUND

Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. Laparoscopic cholecystectomy was introduced in the 1980s.

OBJECTIVES

To compare the beneficial and harmful effects of laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis.

SEARCH STRATEGY

We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials.

SELECTION CRITERIA

All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus small-incision or other kind of minimal incision open cholecystectomy. No language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate.

MAIN RESULTS

Thirteen trials randomised 2337 patients. Methodological quality was relatively high considering the four quality criteria. Total complications of laparoscopic and small-incision cholecystectomy are high: 26.6% versus 22.9%. Total complications (risk difference, random-effects -0.01, 95% confidence interval (CI) -0.07 to 0.05), hospital stay (weighted mean difference (WMD), random-effects -0.72 days, 95% CI -1.48 to 0.04), and convalescence were not significantly different. High-quality trials show a quicker operative time for small-incision cholecystectomy (WMD, high-quality trials 'blinding', random-effects 16.4 minutes, 95% CI 8.9 to 23.8) while low-quality trials show no significant difference.

AUTHORS' CONCLUSIONS

Laparoscopic and small-incision cholecystectomy seem to be equivalent. No differences could be observed in mortality, complications, and postoperative recovery. Small-incision cholecystectomy has a significantly shorter operative time. Complications in elective cholecystectomy are prevalent.

[Laparoscopic versus mini-laparotomy cholecystectomy]

OBJECTIVES

To describe differences in operating time, pain scores, analgesic consumption, complications, length of hospital stay, and quality of life in laparoscopic cholecystectomy (LC) vs mini-laparotomy cholecystectomy (MLC).

PATIENTS AND METHOD

Between 1991 and July 1999, we performed a study of 1041 patients with gallstones who underwent LC (group A, n = 421 patients) or MLC (group B, n = 620 patients). Age, sex, ASA score, pain scores (visual analog scale), analgesic and antiemetic consumption, operating time, complications and length of hospital stay were recorded. Nottingham Health Profile questionnaires were completed by a subgroup of 200 patients, and respiratory response was evaluated using a Fokuda spirometer before surgery and at 24 and 48 hours after surgery. Patient satisfaction and quality of life were evaluated. The results were interpreted using the SPSS program and descriptive statistics were performed with p = 0.05.

RESULTS

The mean age was 48.9 +/- 14.2 years; 80.5% of the patients were women; 87.88% of the patients were ASA I. Elective surgery was performed in 89.78%. The mean operating time was 94 +/- 45 minutes in LC and was 108 +/- 48 minutes in MLC (p < 0.001). LC was associated with lower postoperative pain (0 = 68.88%), lower analgesic-antiemetic requirements (0 = 9.03%) and shorter length of hospital stay. Complications were significantly more frequent in group B (p = 0.05); two patients in group B died within 30 days of surgery (0.32%).

CONCLUSIONS

LC appears to be associated with lower pain scores and analgesic-antiemetic requirements and shorter recovery times than MLC. The results in terms of quality of life in LC were excellent.

Minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a randomized study with special reference to obesity

BACKGROUND

Minilaparotomy cholecystectomy (MC) has recently challenged the role of the laparoscopic approach (LC) for cholecystectomies. However, the situation is far from clear when operating times and recovery are evaluated.

METHODS

Altogether 157 patients with uncomplicated symptomatic gallstones were randomized into MC (n = 85) and LC (n = 72) groups. Both groups were similar in terms of age, body mass index, American Society of Anesthesiology (ASA) physical fitness classification, and operating surgeon.

RESULTS

The mean operating time was 55 +/- 19.5 min in the MC group and 79 +/- 27.0 min in the LC group (p < 0.0001). The postoperative hospital stay and length of sick leave did not differ between the two groups. There were no significant differences in postoperative pain, analgesic consumption, or postoperative pulmonary function between the groups. The body mass index did not influence operating time or patient recovery in either group. No major complications occurred in either groups.

CONCLUSION

The MC procedure seems to be a faster technique than the LC approach for noncomplicated gallstone disease, with no difference in recovery times. The MC procedure also seems to be suitable for the obese patient.

Mini-cholecystectomy: a personal series in acute and chronic cholecystitis

BACKGROUND

Minimally invasive techniques in the surgical treatment of gallbladder disease include laparoscopic cholecystectomy (LC) and mini-cholecystectomy (MC). Reports of LC in acute or chronic inflammation of the gallbladder are common, but those of MC are much more limited, particularly in complicated cases.

METHODS

Thirty-six consecutive patients with gallstone disease who underwent mini-cholecystectomy (MC) were included in this study. Twenty-four were female, median age 62 years (range 23-82) and median body mass index (BMI) was 23.4 (range 17.0-28.4). Seventeen of 36 patients had an acutely inflamed gallbladder, one with septicaemia, and six had gangrenous cholecystitis. Three patients presented with acute pancreatitis. MC was performed by a standardised technique. Operative time, frequency of postoperative analgesic injections, time to start oral diet after operation and length of postoperative hospital stay were compared between patients with chronic and acute cholecystitis.

RESULTS

The median operative time was 92.5 minutes (range 35-130). There was no difference in operative time between patients with chronic and acute cholecystitis: 80 minutes (range 35-120) vs 95 minutes (range 60-130). The frequency of postoperative analgesic injections was also similar in the two groups. Oral diet could be started within 24 h of operation in all except one patient with chronic cholecystitis but in only 8 of 17 with acute cholecystitis. Postoperative hospital stay was shorter in patients with chronic cholecystitis: 2 days (range 2-5) vs 4 days (range 2-14), p =0.0009.

CONCLUSIONS

MC is an effective surgical procedure for an inflamed gallbladder regardless of the degree and type of inflammation. Patients with chronic cholecystitis recover more quickly and have a shorter hospital stay.

Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomized, single-blind study

OBJECTIVE

To analyze outcomes after open small-incision surgery (minilaparotomy) and laparoscopic surgery for gallstone disease in general surgical practice.

METHODS

This study was a randomized, single-blind, multicenter trial comparing laparoscopic cholecystectomy (LC) to minilaparotomy cholecystectomy (MC). Both elective and acute patients were eligible for inclusion. All surgeons normally performing cholecystectomy, both trainees under supervision and consultants, operated on randomized patients. LC was a routine procedure at participating hospitals, whereas MC was introduced after a short training period. All nonrandomized cholecystectomies at participating units during the study period were also recorded to analyze the external validity of trial results. The randomization period was from March 1, 1997, to April 30, 1999.

RESULTS

Of 1,705 cholecystectomies performed at participating units during the randomization period, 724 entered the trial and 362 patients were randomized to each of the procedures. The groups were well matched for age and sex, but there were fewer acute operations in the LC group than the MC group. In the LC group 264 and in the MC group 150 operations were performed by surgeons who had done more than 25 operations of that type. Median operating times were 100 and 85 minutes for LC and MC, respectively. Median hospital stay was 2 days in each group, but in a nonparametric test it was significantly shorter after LC. Median sick leave and time for return to normal recreational activities were shorter after LC than MC. Intraoperative complications were less frequent in the MC group, but there was no difference in the postoperative complication rate between the groups. There was one serious bile duct injury in each group, but no deaths.

CONCLUSIONS

Operating time was longer and convalescence was smoother for LC compared with MC. Further analyses of LC versus MC are necessary regarding surgical training, surgical outcome, and health economy.