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Digestive Surgery 2016Preoperative risk factors for the conversion of laparoscopic cholecystectomy to open surgery have been identified, but never been explored systematically. Our objective... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Preoperative risk factors for the conversion of laparoscopic cholecystectomy to open surgery have been identified, but never been explored systematically. Our objective was to systematically present the evidence of preoperative risk factors for conversion of laparoscopic cholecystectomy to open surgery.
METHODS
PubMed and Embase were searched systematically in March 2014. Observational studies evaluating preoperative risk factors for conversion of laparoscopic cholecystectomy to open surgery in patients with gallstone disease were included. The outcome variables extracted were patient demographics, medical history, severity of gallstone disease, and preoperative laboratory values.
RESULTS
A total of 1,393 studies were screened for eligibility. We found 32 studies, including 460,995 patients operated with laparoscopic cholecystectomy, eligible for the systematic review. Of these, 10 studies were suitable for 7 meta-analyses on age, gender, body mass index, previous abdominal surgery, severity of disease, white blood cell count, and gallbladder wall thickness.
CONCLUSIONS
A gallbladder wall thicker than 4-5 mm, a contracted gallbladder, age above 60 or 65, male gender, and acute cholecystitis were risk factors for the conversion of laparoscopic cholecystectomy to open surgery. Furthermore, there was no association between diabetes mellitus or white blood cell count and conversion to open surgery.
Topics: Age Factors; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Conversion to Open Surgery; Gallbladder; Humans; Preoperative Period; Risk Factors; Sex Factors
PubMed: 27160289
DOI: 10.1159/000445505 -
World Journal of Gastrointestinal... Aug 2015To investigate the role of laparoscopy in diagnosis and treatment of intra abdominal infections.
AIM
To investigate the role of laparoscopy in diagnosis and treatment of intra abdominal infections.
METHODS
A systematic review of the literature was performed including studies where intra abdominal infections were treated laparoscopically.
RESULTS
Early laparoscopic approaches have become the standard surgical technique for treating acute cholecystitis. The laparoscopic appendectomy has been demonstrated to be superior to open surgery in acute appendicitis. In the event of diverticulitis, laparoscopic resections have proven to be safe and effective procedures for experienced laparoscopic surgeons and may be performed without adversely affecting morbidity and mortality rates. However laparoscopic resection has not been accepted by the medical community as the primary treatment of choice. In high-risk patients, laparoscopic approach may be used for exploration or peritoneal lavage and drainage. The successful laparoscopic repair of perforated peptic ulcers for experienced surgeons, is demonstrated to be safe and effective. Regarding small bowel perforations, comparative studies contrasting open and laparoscopic surgeries have not yet been conducted. Successful laparoscopic resections addressing iatrogenic colonic perforation have been reported despite a lack of literature-based evidence supporting such procedures. In post-operative infections, laparoscopic approaches may be useful in preventing diagnostic delay and controlling the source.
CONCLUSION
Laparoscopy has a good diagnostic accuracy and enables to better identify the causative pathology; laparoscopy may be recommended for the treatment of many intra-abdominal infections.
PubMed: 26328036
DOI: 10.4240/wjgs.v7.i8.160 -
International Journal of Surgery... Jun 2015Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC) in the treatment of acute cholecystitis (AC). Laparoscopic... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC) in the treatment of acute cholecystitis (AC). Laparoscopic cholecystectomy (LC) is now considered the gold standard of therapy for symptomatic cholelithiasis and chronic cholecystitis. However no definitive data on its use in AC has been published. CIAO and CIAOW studies demonstrated 48.7% of AC were still operated with the open technique. The aim of the present meta-analysis is to compare OC and LC in AC.
MATERIAL AND METHODS
A systematic-review with meta-analysis and meta-regression of trials comparing open vs. laparoscopic cholecystectomy in patients with AC was performed. Electronic searches were performed using Medline, Embase, PubMed, Cochrane Central Register of Controlled Trials (CCTR), Cochrane Database of Systematic Reviews (CDSR) and CINAHL.
RESULTS
Ten trials have been included with a total of 1248 patients: 677 in the LC and 697 into the OC groups. The post-operative morbidity rate was half with LC (OR = 0.46). The post-operative wound infection and pneumonia rates were reduced by LC (OR 0.54 and 0.51 respectively). The post-operative mortality rate was reduced by LC (OR = 0.2). The mean postoperative hospital stay was significantly shortened in the LC group (MD = -4.74 days). There were no significant differences in the bile leakage rate, intraoperative blood loss and operative times.
CONCLUSIONS
In acute cholecystitis, post-operative morbidity, mortality and hospital stay were reduced by laparoscopic cholecystectomy. Moreover pneumonia and wound infection rate were reduced by LC. Severe hemorrhage and bile leakage rates were not influenced by the technique. Cholecystectomy in acute cholecystitis should be attempted laparoscopically first.
Topics: Blood Loss, Surgical; Cholecystectomy; Cholecystitis, Acute; Humans; Laparoscopy; Length of Stay; Operative Time; Postoperative Complications
PubMed: 25958296
DOI: 10.1016/j.ijsu.2015.04.083 -
Health Technology Assessment... Aug 2014Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of... (Comparative Study)
Comparative Study Review
Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation.
BACKGROUND
Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management.
OBJECTIVES
To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis.
DATA SOURCES
We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field.
REVIEW METHODS
Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions.
RESULTS
Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model.
CONCLUSIONS
The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed.
STUDY REGISTRATION
The study was registered as PROSPERO CRD42012002817.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Adult; Cholecystectomy; Cholecystitis; Cost-Benefit Analysis; Female; Gallstones; Humans; Male; Recurrence; Treatment Outcome; Watchful Waiting
PubMed: 25164349
DOI: 10.3310/hta18550 -
BMJ Clinical Evidence Aug 2014Of people admitted to hospital for biliary tract disease, 20% have acute cholecystitis. Up to the age of 50 years, acute calculous cholecystitis is three times more... (Review)
Review
INTRODUCTION
Of people admitted to hospital for biliary tract disease, 20% have acute cholecystitis. Up to the age of 50 years, acute calculous cholecystitis is three times more common in women than in men, and about one and a half times more common in women than in men thereafter. About 95% of people with acute cholecystitis have gallstones. Optimal therapy for acute cholecystitis, based on timing and severity of presentation, remains controversial.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute cholecystitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 18 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: early cholecystectomy, laparoscopic cholecystectomy, observation alone, open cholecystectomy, and percutaneous cholecystostomy.
Topics: Cholecystectomy; Cholecystitis, Acute; Gallstones; Humans
PubMed: 25144428
DOI: No ID Found