Protocol for a randomised controlled trial comparing laparoscopic cholecystectomy with observation/conservative management for preventing recurrent symptoms and complications in adults with uncomplicated symptomatic gallstones (C-Gall trial)

Undertaking Studies Within A Trial to evaluate recruitment and retention strategies for randomised controlled trials: lessons learnt from the PROMETHEUS research programme

Background

Randomised controlled trials ('trials') are susceptible to poor participant recruitment and retention. Studies Within A Trial are the strongest methods for testing the effectiveness of strategies to improve recruitment and retention. However, relatively few of these have been conducted.

Objectives

PROMoting THE Use of Studies Within A Trial aimed to facilitate at least 25 Studies Within A Trial evaluating recruitment or retention strategies. We share our experience of delivering the PROMoting THE Use of Studies Within A Trial programme, and the lessons learnt for undertaking randomised Studies Within A Trial.

Design

A network of 10 Clinical Trials Units and 1 primary care research centre committed to conducting randomised controlled Studies Within A Trial of recruitment and/or retention strategies was established. Promising recruitment and retention strategies were identified from various sources including Cochrane systematic reviews, the Study Within A Trial Repository, and existing prioritisation exercises, which were reviewed by patient and public members to create an initial priority list of seven recruitment and eight retention interventions. Host trial teams could apply for funding and receive support from the PROMoting THE Use of Studies Within A Trial team to undertake Studies Within A Trial. We also tested the feasibility of undertaking co-ordinated Studies Within A Trial, across multiple host trials simultaneously.

Setting

Clinical trials unit-based trials recruiting or following up participants in any setting in the United Kingdom were eligible.

Participants

Clinical trials unit-based teams undertaking trials in any clinical context in the United Kingdom.

Interventions

Funding of up to £5000 and support from the PROMoting THE Use of Studies Within A Trial team to design, implement and report Studies Within A Trial.

Main outcome measures

Number of host trials funded.

Results

Forty-two Studies Within A Trial were funded (31 host trials), across 12 Clinical Trials Units. The mean cost of a Study Within A Trial was £3535. Twelve Studies Within A Trial tested the same strategy across multiple host trials using a co-ordinated Study Within A Trial design, and four used a factorial design. Two recruitment and five retention strategies were evaluated in more than one host trial. PROMoting THE Use of Studies Within A Trial will add 18% more Studies Within A Trial to the Cochrane systematic review of recruitment strategies, and 79% more Studies Within A Trial to the Cochrane review of retention strategies. For retention, we found that pre-notifying participants by card, letter or e-mail before sending questionnaires was effective, as was the use of pens, and sending personalised text messages to improve questionnaire response. We highlight key lessons learnt to guide others planning Studies Within A Trial, including involving patient and public involvement partners; prioritising and selecting strategies to evaluate and elements to consider when designing a Study Within A Trial; obtaining governance approvals; implementing Studies Within A Trial, including individual and co-ordinated Studies Within A Trials; and reporting Study Within A Trials.

Limitations

The COVID-19 pandemic negatively impacted five Studies Within A Trial, being either delayed (n = 2) or prematurely terminated (n = 3).

Conclusions

PROMoting THE Use of Studies Within A Trial significantly increased the evidence base for recruitment and retention strategies. When provided with both funding and practical support, host trial teams successfully implemented Studies Within A Trial.

Future work

Future research should identify and target gaps in the evidence base, including widening Study Within A Trial uptake, undertaking more complex Studies Within A Trial and translating Study Within A Trial evidence into practice.

Study registration

All Studies Within A Trial in the PROMoting THE Use of Studies Within A Trial programme had to be registered with the Northern Ireland Network for Trials Methodology Research Study Within A Trial Repository.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/55/80) and is published in full in Health Technology Assessment; Vol. 28, No. 2. See the NIHR Funding and Awards website for further award information.

Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial

OBJECTIVE

To assess the clinical and cost effectiveness of conservative management compared with laparoscopic cholecystectomy for the prevention of symptoms and complications in adults with uncomplicated symptomatic gallstone disease.

DESIGN

Parallel group, pragmatic randomised, superiority trial.

SETTING

20 secondary care centres in the UK.

PARTICIPANTS

434 adults (>18 years) with uncomplicated symptomatic gallstone disease referred to secondary care, assessed for eligibility between August 2016 and November 2019, and randomly assigned (1:1) to receive conservative management or laparoscopic cholecystectomy.

INTERVENTIONS

Conservative management or surgical removal of the gallbladder.

MAIN OUTCOME MEASURES

The primary patient outcome was quality of life, measured by area under the curve, over 18 months using the short form 36 (SF-36) bodily pain domain, with higher scores (range 0-100) indicating better quality of life. Other outcomes included costs to the NHS, quality adjusted life years (QALYs), and incremental cost effectiveness ratio.

RESULTS

Of 2667 patients assessed for eligibility, 434 were randomised: 217 to the conservative management group and 217 to the laparoscopic cholecystectomy group. By 18 months, 54 (25%) participants in the conservative management arm and 146 (67%) in the cholecystectomy arm had received surgery. The mean SF-36 norm based bodily pain score was 49.4 (standard deviation 11.7) in the conservative management arm and 50.4 (11.6) in the cholecystectomy arm. The SF-36 bodily pain area under the curve up to 18 months did not differ (mean difference 0.0, 95% confidence interval -1.7 to 1.7; P=1.00). Conservative management was less costly (mean difference -£1033, (-$1334; -€1205), 95% credible interval -£1413 to -£632) and QALYs did not differ (mean difference -0.019, 95% credible interval -0.06 to 0.02).

CONCLUSIONS

In the short term (≤18 months), laparoscopic surgery is no more effective than conservative management for adults with uncomplicated symptomatic gallstone disease, and as such conservative management should be considered as an alternative to surgery. From an NHS perspective, conservative management may be cost effective for uncomplicated symptomatic gallstone disease. As costs, complications, and benefits will continue to be incurred in both groups beyond 18 months, future research should focus on longer term follow-up to establish effectiveness and lifetime cost effectiveness and to identify the cohort of patients who should be routinely offered surgery.

TRIAL REGISTRATION

ISRCTN registry ISRCTN55215960.

ASYMPTOMATIC CHOLELITHIASIS: EXPECTANT OR CHOLECYSTECTOMY. A SYSTEMATIC REVIEW

BACKGROUND

Asymptomatic cholelithiasis is a highly prevalent disease, and became more evident after the currently greater access to imaging tests. Therefore, it is increasingly necessary to analyse the risks and benefits of performing a prophylactic cholecystectomy.

AIMS

To seek the best evidence in order to indicate prophylactic cholecystectomy or conservative treatment (clinical follow-up) in patients with asymptomatic cholelithiasis.

METHODS

A systematic review was performed using the PubMed/Medline database, according to PRISMA protocol guidelines. The review was based on studies published between April 26, 2001 and January 07, 2022, related to individuals older than 18 years., The following terms/operators were used for search standardization: (asymptomatic OR silent) AND (gallstones OR cholelithiasis).

RESULTS

We selected 18 studies eligible for inference production after applying the inclusion and exclusion criteria. Also, the Tokyo Guideline (2018) was included for better clarification of some topics less or not addressed in these studies.

CONCLUSIONS

Most evidence point to the safety and feasibility of conservative treatment (clinical follow-up) of asymptomatic cholelithiasis. However, in post-cardiac transplant patients and those with biliary microlithiasis with low preoperative surgical risk, a prophylactic cholecystectomy is recommended. To establish these recommendations, more studies with better levels of evidence must be conducted.

The necessity and safety of simultaneous cholecystectomy during gastric surgery for patients with asymptomatic cholelithiasis

OBJECTIVES

The incidence of cholelithiasis is higher among individuals who have undergone gastric surgery. The benefits of concomitant gallbladder removal in asymptomatic gallstone patients remain uncertain. The aim was to investigate the necessity and safety of simultaneous cholecystectomy in this particular patient population.

METHODS

We performed a systematic review and meta-analysis to assess the incidence of asymptomatic cholelithiasis converting to symptomatic after gastric surgery and the complication rate associated with simultaneous cholecystectomy. PubMed, Embase, and the Cochrane Library were searched for relevant articles published until 10 March 202210 March 2022.

RESULTS

Patients with asymptomatic cholelithiasis after gastric surgery were at a higher risk of developing symptomatic cholelithiasis compared to those without cholelithiasis (relative risk [RR] 2.28, 95% confidence interval [CI] 1.23-4.25) and those with unknown gallbladder conditions (RR 2.70, 95% CI 1.54-4.73). Additionally, patients who underwent simultaneous cholecystectomy did not face a higher risk of complications compared to those who only underwent gastric surgery (RR 0.86, 95% CI 0.48-1.53).

CONCLUSIONS

Simultaneous cholecystectomy is both necessary and safe for patients with asymptomatic cholelithiasis undergoing gastric surgery. It is crucial to assess the gallbladder's condition before gastric surgery, and if the gallbladder status is unknown, simultaneous cholecystectomy should be avoided.

Variation in the practice of cholecystectomy for benign biliary disease in Aotearoa New Zealand: a population-based cohort study

INTRODUCTION

Cholecystectomy for benign biliary disease is common and its delivery should be standardised. However, the current practice of cholecystectomy in Aotearoa New Zealand is unknown.

METHODS

A prospective, national cohort study of consecutive patients having cholecystectomy for benign biliary disease was performed between August and October 2021 with 30-day follow-up, through STRATA, a student- and trainee-led collaborative.

RESULTS

Data were collected for 1171 patients from 16 centres. 651 (55.6%) had an acute operation at index admission, 304 (26.0%) had delayed cholecystectomy following a previous admission, and 216 (18.4%) had an elective operation with no preceding acute admissions. The median adjusted rate of index cholecystectomy (as a proportion of index and delayed cholecystectomy) was 71.9% (range 27.2%-87.3%). The median adjusted rate of elective cholecystectomy (as proportion of all cholecystectomies) was 20.8% (range 6.7%-35.4%). Variations across centres were significant (p < 0.001) and inadequately explained by patient, operative, or hospital-factors (index cholecystectomy model R² = 25.8, elective cholecystectomy model R² = 50.6).

CONCLUSIONS

Notable variation in the rates of index and elective cholecystectomy exists in Aotearoa New Zealand not attributable to patient, operative or hospital factors alone. National quality improvement efforts to standardise availability of cholecystectomy are needed.

Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study

BACKGROUND

Incidence of gallstones in those aged ≥ 80 years is as high as 38%-53%. The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging.

AIM

To assess the risk of morbidity of the “oldest-old” patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population.

METHODS

A retrospective study was conducted between 2010 and 2019. Perioperative variables were collected and compared between patients who had postoperative complications. A model was created and tested to predict severe postoperative morbidity.

RESULTS

The 269 patients were included in the study (193 complicated). The 9.7% of complications were grade 3 or 4 according to the Clavien-Dindo classification. Bilirubin levels were lower in patients who did not have any postoperative complications. American Society of Anesthesiologists scale 4 patients, performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo > 2 complications (P < 0.001). The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11% and 32% of developing a severe complication.

CONCLUSION

Patients with American Society of Anesthesiologists scale 4, higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course. Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.

Tailoring diagnosis and treatment in symptomatic gallstone disease

BACKGROUND

There is a lack of consensus in selecting patients who do or do not benefit from surgery when patients present with abdominal pain and gallbladder stones are present. This review aimed to give an overview of results from recent trials and available literature to improve treatment decisions in patients with uncomplicated cholecystolithiasis.

METHODS

First, an overview of different symptom criteria for laparoscopic cholecystectomy in patients with uncomplicated cholecystolithiasis is given, based on national and international guidelines. Second, treatment outcomes (absence of biliary colic, pain-free state, biliary and surgical complications) are summarized, with data from three clinical trials. Finally, personal advice for treatment decisions in patients with uncomplicated cholecystolithiasis is provided, based on recent trials, the available literature, and expert opinion.

RESULTS

This review describes different guidelines and criteria sets for uncomplicated cholecystolithiasis, provides an overview of outcomes after cholecystectomy, and advises on treatment decisions in patients with abdominal pain and gallbladder stones. After cholecystectomy, biliary colic is resolved in 95 per cent of patients. However, non-specific abdominal pain persists in 40 per cent. Irritable bowel syndrome and functional dyspepsia significantly increase the risk of persistent pain. Age, previous abdominal surgery, baseline pain score on a visual analogue scale, pain characteristics, nausea, and heartburn are part of the SUCCESS criteria, and are associated with clinically relevant pain reduction after gallbladder removal.

CONCLUSION

The surgical community can now give more personalized advice on surgery to improve care for patients with abdominal pain and uncomplicated cholecystolithiasis.

The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease

Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.

Health-related quality of life among patients with gallstone disease: a systematic review and meta-analysis of EQ-5D utility scores

PURPOSE

Gallstone disease or cholelithiasis is a chronic illness that usually presents with pain in the abdomen, vomiting and indigestion leading to impaired quality of life. EQ-5D utility score is a validated measure of health-related quality of life (HRQoL). We systematically reviewed the literature and synthesised EQ-5D utility scores among patients with gallstone disease and its improvement on treatment.

METHODS

We have systematically searched observational studies reporting EQ-5D utility scores of gallstone disease in PubMed, Scopus, and Embase databases, from inception until February 2021. We selected the studies adhering to the PRISMA guidelines. The selected studies were reviewed, and the EQ-5D utility values of pre and post cholecystectomy were pooled using the random-effects model.

RESULT

From identified 4,817 records of database search, eleven studies predominantly from western countries with 2,189 participants were included for systematic review and meta-analysis. The pooled EQ-5D and visual analogue scores were 0.87 (0.82 to 0.91, I² = 93.73%) and 83.30 (60.59 to 106.12, I² = 99.30%) respectively with high heterogeneity. The pooled EQ-5D and EQ-5D visual analogue scores post cholecystectomy treatment were 0.93 (0.91 to 0.95, I² = 90.17%) and 91.7 (85.99 to 96.35, I² = 97.93%) respectively. The mean difference between the baseline and post intervention were 0.05 (0.01 to 0.10, I² = 93.50%) and 10.58 (-8.63 to 29.79, I² = 98.32%) for EQ-5D and visual analogue scores respectively with high heterogeneity between the studies.

CONCLUSION

The pooled mean difference indicates improvement in HRQoL after cholecystectomy but with high heterogeneity. Further high-quality studies from Asian countries are required for globally representative quantification and precise estimates of HRQoL among gallstone diseases.

PROSPERO REGISTRATION ID

CRD42021234467.

Bah humbug! Association between sending Christmas cards to trial participants and trial retention: randomised study within a trial conducted simultaneously across eight host trials

OBJECTIVES

To determine the effectiveness of sending Christmas cards to participants in randomised controlled trials to increase retention rate at follow-ups, and to explore the feasibility of doing a study within a trial (SWAT) across multiple host trials simultaneously.

DESIGN

Randomised SWAT conducted simultaneously across eight host trials.

SETTING

Eight randomised controlled trials researching various areas including surgery and smoking cessation.

PARTICIPANTS

3223 trial participants who were still due at least one follow-up from their host randomised controlled trial.

INTERVENTION

Participants were randomised (1:1, separately by each host trial) to either received a Christmas card in mid-December 2019 or to not receive a card.

MAIN OUTCOME MEASURE

Proportion of participants completing their next follow-up (retention rate) within their host randomised controlled trial.

RESULTS

1469 participants (age 16-94 years; 70% (n=1033) female; 96% (813/847) white ethnicity) across the eight host randomised controlled trials were involved in the analysis (cut short owing to covid-19). No evidence was found of a difference in retention rate between the two arms for any of the host trials when analysed separately or when the results were combined (85.3% (639/749) for cards versus 85.4% (615/720) for no card; odds ratio 0.96, 95% confidence interval 0.71 to 1.29; P=0.77). No difference was observed when comparing just participants who were due a follow-up in the 30 days after receiving the card (odds ratio 0.96, 0.42 to 2.21). No evidence of a difference in time to complete the questionnaire was found (hazard ratio 1.01, 95% confidence interval 0.91 to 1.13; P=0.80). These results were robust to post hoc sensitivity analyses. The cost of this intervention was £0.76 (€0.91; $1.02) per participant, and it will have a carbon footprint of approximately 140 g CO2 equivalent per card. One benefit of this approach was the need to only submit one ethics application.

CONCLUSIONS

Sending Christmas cards to participants in randomised controlled trials does not increase retention. Undertaking a SWAT within multiple randomised controlled trials at the same time is, however, possible. This approach should be used more often to build an evidence base to support selection of recruitment and retention strategies. Although no evidence of a boost to retention was found, embedding a SWAT in multiple host trials simultaneously has been shown to be possible.

STUDY REGISTRATION

SWAT repository https://www.qub.ac.uk/sites/TheNorthernIrelandNetworkforTrialsMethodologyResearch/FileStore/Filetoupload,846275,en.pdf#search=SWAT%2082.

Healthcare utilisation of patients with cholecystolithiasis in primary care: a multipractice comparative analysis

OBJECTIVES

To examine general practitioners' (GP) management of cholecystolithiasis and to evaluate persisting abdominal complaints in the years after the diagnosis.

DESIGN

Retrospective analysis of registry data and a subset of individual medical records.

SETTING

Seventeen primary care practices affiliated with the Radboudumc Practice Based Research Network in the Netherlands.

PARTICIPANTS

633 patients with cholecystolithiasis diagnosed between 2012 and 2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome of this study was the healthcare utilisation of patients with cholecystolithiasis diagnosed by the GP in terms of referrals to secondary care, laboratory diagnostics, prescribed medication and the prevalence of concomitant abdominal-related diagnoses in a time interval of 3 years before and 3 years after diagnosis of cholecystolithiasis. For secondary outcomes, electronic medical records were studied from seven practices to assess emergency department visits, operation rates and repeat visits for persistent abdominal symptoms. We compared the non-referred group with the referred group.

RESULTS

In 57% of patients, concomitant abdominal-related diagnoses were recorded besides the diagnosis cholecystolithiasis. In-depth analyses of 294 patients showed a referral rate of 79.3% (n=233); 62.9% (n=185) underwent cholecystectomy. After referral, 55.4% (129/233) returned to the GP for persistent abdominal symptoms. Patients returning after referral were more often treated for another abdominal-related diagnosis before cholecystolithiasis was recorded (51.9% vs 28.8%, p<0.001).

CONCLUSIONS

The majority of patients in general practice with gallstones are referred and undergo cholecystectomy. Patients with concomitant abdominal-related diagnoses are likely to return to their physician. GPs should inform patients about these outcomes to improve the shared decision-making process before gallbladder surgery.

A Clinical Decision Tool for Selection of Patients With Symptomatic Cholelithiasis for Cholecystectomy Based on Reduction of Pain and a Pain-Free State Following Surgery

Importance

There is currently no consensus on the indication for cholecystectomy in patients with uncomplicated gallstone disease.

Objective

To report on the development and validation of a multivariable prediction model to better select patients for surgery.

Design, Setting, and Participants

This study evaluates data from 2 multicenter prospective trials (the previously published Scrutinizing (In)efficient Use of Cholecystectomy: A Randomized Trial Concerning Variation in Practice [SECURE] and the Standardized Work-up for Symptomatic Cholecystolithiasis [Success] trial) collected from the outpatient clinics of 25 Dutch hospitals between April 2014 and June 2019 and including 1561 patients with symptomatic uncomplicated cholelithiasis, defined as gallstone disease without signs of complicated cholelithiasis (ie, biliary pancreatitis, cholangitis, common bile duct stones or cholecystitis). Data were analyzed from January 2020 to June 2020.

Exposures

Patient characteristics, comorbidity, surgical outcomes, pain, and symptoms measured at baseline and at 6 months' follow-up.

Main Outcomes and Measures

A multivariable regression model to predict a pain-free state or a clinically relevant reduction in pain after surgery. Model performance was evaluated using calibration and discrimination.

Results

A total of 1561 patients were included (494 patients in 7 hospitals in the development cohort and 1067 patients in 24 hospitals in the validation cohort; 6 hospitals included patients in both cohorts). In the development cohort, 395 patients (80.0%) underwent cholecystectomy. After surgery, 225 patients (57.0%) reported that they were pain free and 295 (74.7%) reported a clinically relevant reduction in pain. A multivariable prediction model showed that increased age, no history of abdominal surgery, increased visual analog scale pain score at baseline, pain radiation to the back, pain reduction with simple analgesics, nausea, and no heartburn were independent predictors of clinically relevant pain reduction after cholecystectomy. After internal validation, good discrimination was found (C statistic, 0.80; 95% CI, 0.74-0.84) between patients with and without clinically relevant pain reduction. The model had very good overall calibration and minimal underestimation of the probability. External validation indicated a good discrimination between patients with and without clinically relevant pain reduction (C statistic, 0.74; 95% CI, 0.70-0.78) and fair calibration with some overestimation of probability by the model.

Conclusions and Relevance

The model validated in this study may help predict the probability of pain reduction after cholecystectomy and thus aid surgeons in deciding whether patients with uncomplicated cholelithiasis will benefit from cholecystectomy.

Identification and categorisation of relevant outcomes for symptomatic uncomplicated gallstone disease: in-depth analysis to inform the development of a core outcome set

BACKGROUND

Many completed trials of interventions for uncomplicated gallstone disease are not as helpful as they could be due to lack of standardisation across studies, outcome definition, collection and reporting. This heterogeneity of outcomes across studies hampers useful synthesis of primary studies and ultimately negatively impacts on decision making by all stakeholders. Core outcome sets offer a potential solution to this problem of heterogeneity and concerns over whether the 'right' outcomes are being measured. One of the first steps in core outcome set generation is to identify the range of outcomes reported (in the literature or by patients directly) that are considered important.

OBJECTIVES

To develop a systematic map that examines the variation in outcome reporting of interventions for uncomplicated symptomatic gallstone disease, and to identify other outcomes of importance to patients with gallstones not previously measured or reported in interventional studies.

RESULTS

The literature search identified 794 potentially relevant titles and abstracts of which 137 were deemed eligible for inclusion. A total of 129 randomised controlled trials, 4 gallstone disease specific patient-reported outcome measures (PROMs) and 8 qualitative studies were included. This was supplemented with data from 6 individual interviews, 1 focus group (n=5 participants) and analysis of 20 consultations. A total of 386 individual recorded outcomes were identified across the combined evidence: 330 outcomes (which were reported 1147 times) from trials evaluating interventions, 22 outcomes from PROMs, 17 outcomes from existing qualitative studies and 17 outcomes from primary qualitative research. Areas of overlap between the evidence sources existed but also the primary research contributed new, unreported in this context, outcomes.

CONCLUSIONS

This study took a rigorous approach to catalogue and map the outcomes of importance in gallstone disease to enhance the development of the COS 'long' list. A COS for uncomplicated gallstone disease that considers the views of all relevant stakeholders is needed.