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BMJ Clinical Evidence logoLink to BMJ Clinical Evidence
. 2008 Dec 4;2008:0411.

Acute cholecystitis

Elizabeth Fialkowski 1,#, Valerie Halpin 2,#, Robb R Whinney 3,#
PMCID: PMC2907986  PMID: 19445789

Abstract

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 1.5 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 December 2006 (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 12 systematic reviews, RCTs, or observational 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, minilaparoscopic cholecystectomy, observation alone, and open cholecystectomy.

Key Points

Acute cholecystitis causes unremitting right upper quadrant pain, anorexia, nausea, vomiting, and fever, and if untreated can lead to perforations, abscess formation, or fistulae.

  • About 95% of people with acute cholecystitis have gallstones.

  • It is thought that blockage of the bile duct by a gallstone or local inflammation can lead to acute cholecystitis, but we don't know whether bacterial infection is also necessary.

Early cholecystectomy within 7 days of onset of symptoms is the treatment of choice for acute cholecystitis.

  • Early surgery reduces the duration of hospital admission compared with delayed surgery, but does not reduce mortality or complications.

  • Up to a quarter of people scheduled for delayed surgery may require urgent operations because of recurrent or worsening symptoms.

Laparoscopic cholecystectomy reduces the duration of admission and may improve intraoperative and postoperative outcomes compared with open cholecystectomy, but increases the risk of bile duct injury.

  • Up to a quarter of people having laparoscopic cholecystectomy may need conversion to open surgery because of risks of complications or uncontrolled bleeding.

  • We don't know whether minilaparoscopic surgery leads to further reductions in duration of admission or improved outcomes compared with laparoscopic surgery.

About this condition

Definition

Acute cholecystitis results from obstruction of the cystic duct, usually by a gallstone, followed by distension and subsequent chemical or bacterial inflammation of the gallbladder. People with acute cholecystitis usually have unremitting right upper quadrant pain, anorexia, nausea, vomiting, and fever. About 95% of people with acute cholecystitis have gallstones (calculous cholecystitis) and 5% lack gallstones (acalculous cholecystitis). Severe acute cholecystitis may lead to necrosis of the gallbladder wall, known as gangrenous cholecystitis. This review does not include people with acute cholangitis, which is a severe complication of gallstone disease and generally a result of bacterial infection.

Incidence/ Prevalence

The incidence of acute cholecystitis among people with gallstones is unknown. Of people admitted to hospital for biliary tract disease, 20% have acute cholecystitis. The number of cholecystectomies carried out for acute cholecystitis increased from the mid 1980s to the early 1990s, especially in elderly people. Acute calculous cholecystitis is three times more common in women than in men up to the age of 50 years, and is about 1.5 times more common in women than in men thereafter.

Aetiology/ Risk factors

Acute calculous cholecystitis seems to be caused by obstruction of the cystic duct by a gallstone, or local mucosal erosion and inflammation caused by a stone, but cystic duct ligation alone does not produce acute cholecystitis in animal studies. The role of bacteria in the pathogenesis of acute cholecystitis is not clear; positive cultures of bile or gallbladder wall are found in 50-75% of cases. The cause of acute acalculous cholecystitis is uncertain and may be multifactorial, including increased susceptibility to bacterial colonisation of static gallbladder bile.

Prognosis

Complications of acute cholecystitis include perforation of the gallbladder, pericholecystic abscess, and fistula caused by gallbladder wall ischaemia and infection. In the USA, the overall mortality from untreated complications is about 20%.

Aims of intervention

To reduce mortality and morbidity associated with acute cholecystitis, with minimal adverse effects of treatment.

Outcomes

Mortality, persistent pain, intolerance to food, recurrent attacks of cholecystitis, quality of life, and adverse effects of treatment. Some outcomes relate to surgery: duration of surgery, need for nasogastric tube, analgesic use, antibiotic requirement, rate of surgical complications (bile duct injuries, pancreatitis, other), and duration of hospital stay. Postoperative fall in haemoglobin and conversion of a planned laparoscopic cholecystectomy to an open cholecystectomy are surrogate outcomes.

Methods

Clinical Evidence search and appraisal December 2006. Two of the RCTs explicitly stated that participants had calculous cholecystitis. The remaining RCTs did not report whether participants had calculous or acalculous cholecystitis. The RCTs excluded people unable to have surgery because of comorbid conditions (recent MI, severe chronic obstructive pulmonary disease or respiratory insufficiency, end-stage metastatic disease, and multisystem organ failure) and contraindications for cholecystectomy (e.g. use of antiplatelet treatment that could not safely be discontinued during the perioperative period). The following databases were used to identify studies for this systematic review: Medline 1966 to December 2006, Embase 1980 to December 2006, and The Cochrane Library (all databases) 2006, Issue 4. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) (all databases), Turning Research into Practice (TRIP), and NICE. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language with any level of blinding including ‘open’ studies. The maximum loss to follow-up allowed was 20%. There was no minimum number of participants or length of follow-up required to include studies. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ). To aid readability of the numerical data in our reviews, we round percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as RRs and ORs.

Table.

GRADE evaluation of interventions for acute cholecystitis

Important outcomes Pain relief, recurrent attacks, mortality, duration of hospital stay, adverse effects
Number of studies (participants) Outcome Comparison Type of evidence Quality Consistency Directness Effect size GRADE Comment
What are the effects of treatments for acute cholecystitis?
16 (At least 1255) Mortality Early v delayed cholecystectomy 4 –1 0 –1 0 Low Quality point deducted for incomplete reporting of results. Directness point deducted for differences in surgeon expertise
16 (At least 1255) Morbidity Early v delayed cholecystectomy 4 –1 0 –1 0 Low Quality point deducted for incomplete reporting of results. Directness point deducted for differences in surgeon expertise
18 (At least 1255) Duration of hospital stay Early v delayed cholecystectomy 4 –1 0 –1 0 Low Quality point deducted for incomplete reporting of results. Directness point deducted for differences in surgeon expertise
1 (145) Quality of life Early v delayed cholecystectomy 4 –2 0 0 0 Low Quality points deducted for sparse data and incomplete reporting of results
1 (70) Duration of hospital stay Percutaneous cholecystostomy followed by early cholecystectomy v medical treatment followed by delayed cholecystectomy 4 –2 0 0 0 Low Quality points deducted for sparse data and no intention-to-treat analysis
1 (70) Symptom improvement Percutaneous cholecystostomy followed by early cholecystectomy v medical treatment followed by delayed cholecystectomy 4 –2 0 0 0 Low Quality points deducted for sparse data and no intention-to-treat analysis
4 (606) Duration of hospital stay Laparoscopic cholecystectomy v open cholecystectomy 4 –1 0 –1 0 Low Quality point deducted for incomplete reporting of results. Directness point deducted for population differences
4 (606) Duration of surgery Laparoscopic cholecystectomy v open cholecystectomy 4 –1 –1 –2 0 Very low Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. Directness points deducted for population differences and differences in techniques
4 (601) Postoperative complications Laparoscopic cholecystectomy v open cholecystectomy 4 –1 –1 –2 0 Very low Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. Directness points deducted for population differences and differences in techniques
1 (69) Duration of hospital stay Conventional laparoscopic cholecystectomy v minilaparoscopic cholecystectomy 4 –2 0 0 0 Low Quality points deducted for sparse data and incomplete reporting of results
1 (69) Conversion rates Minilaparoscopic cholecystectomy v conventional laparoscopic cholecystectomy 4 –1 0 0 0 Moderate Quality point deducted for sparse data
1 (69) Use of analgesia Minilaparoscopic cholecystectomy v conventional laparoscopic cholecystectomy 4 –2 0 0 0 Low Quality points deducted for sparse data and incomplete reporting of results
1 (69) Duration of surgery Minilaparoscopic cholecystectomy v conventional laparoscopic cholecystectomy 4 –2 0 0 0 Low Quality points deducted for sparse data and incomplete reporting of results
1 (64) Failure rates Observation alone v laparoscopic cholecystectomy 4 -1 0 0 0 Moderate Quality point deducted for sparse data
1 (64) Gallstone-related complications Observation alone v laparoscopic cholecystectomy 4 -1 0 0 0 Moderate Quality point deducted for sparse data
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Type of evidence: 4 = RCT; 2 = Observational; 1 = Non-analytical/expert opinion. Consistency: similarity of results across studies. Directness: generalisability of population or outcomes. Effect size: based on relative risk or odds ratio.

Glossary

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy involves removal of the gallbladder using a projection camera and 5–10 mm trocar ports. Conversion from laparoscopic to open cholecystectomy is needed if the laparoscopic procedure cannot be completed without risking injury to surrounding structures or when bleeding cannot be stopped. Open cholecystectomy is required in people who have a fistula from the gallbladder into the bile duct or intestine, and in some people who have perforation and abscess in the right upper quadrant.

Low-quality evidence

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Minilaparoscopic cholecystectomy

involves removal of the gallbladder using a projection camera and 2–3 mm trocar ports.

Moderate-quality evidence

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Open cholecystectomy

Open cholecystectomy involves removal of the gallbladder by laparotomy. Open cholecystectomy is required in people who have a fistula from the gallbladder into the bile duct or intestine, and in some people who have perforation and abscess in the right upper quadrant.

Very low-quality evidence

Any estimate of effect is very uncertain.

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

Contributor Information

Elizabeth Fialkowski, Washington University School of Medicine, Washington, USA.

Dr Valerie Halpin, Washington University School of Medicine, St Louis, MO, USA.

Dr Robb R Whinney, Washington University School of Medicine, St Louis, MO, USA.

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BMJ Clin Evid. 2008 Dec 4;2008:0411.

Early versus delayed cholecystectomy

Summary

MORTALITY Early compared with delayed cholecystectomy: Early (at the time of diagnosis or within 7 days of onset of symptoms) cholecystectomy may be no more effective at reducing mortality in people with acute cholecystitis compared with delayed (at least 6 weeks after onset of symptoms) cholecystectomy ( very low-quality evidence ). MORBIDITY Early compared with delayed cholecystectomy: Early (at the time of diagnosis or within 7 days of onset of symptoms) cholecystectomy may be no more effective at reducing morbidity in people with acute cholecystitis compared with delayed (at least 6 weeks after onset of symptoms) cholecystectomy ( very low-quality evidence ). DURATION OF HOSPITAL STAY Early compared with delayed cholecystectomy: Early cholecystectomy (at the time of diagnosis or within 7 days of onset of symptoms) may be more effective at reducing the duration of hospital stay in people with acute cholecystitis compared with delayed (at least 6 weeks after onset of symptoms) cholecystectomy (very low-quality evidence). QUALITY OF LIFE Early compared with delayed cholecystectomy: Early cholecystectomy (at the time of diagnosis or within 7 days of onset of symptoms) may be more effective at reducing gastrointestinal symptoms (diarrhoea, indigestion, and abdominal pain) at 1 month in people with acute cholecystitis compared with delayed (at least 6 weeks after onset of symptoms) cholecystectomy, but may be no more effective at 3–6 months (very low-quality evidence).

Benefits

We found three systematic reviews comparing early (at the time of diagnosis or within 7 days of onset of symptoms) versus delayed (at least 6 weeks after onset of symptoms) cholecystectomy (open or laparoscopic).

The first systematic review analysed laparoscopic and open surgery separately and found no significant difference between groups in risk of postoperative mortality or morbidity, but found that early surgery (laparoscopic or open) significantly reduced total hospital stay (search date 2001, 1255 people with acute cholecystitis; 9 RCTs of open surgery, 3 RCTs of laparoscopic surgery; mortality with open surgery: 1/468 [0.2%] with early v 7/448 [1.6%] with delayed; OR 0.53, 95% CI 0.17 to 1.66; morbidity with open surgery: 83/468 [17.7%] with early v 80/448 [17.9%] with delayed; OR 0.95, 95% CI 0.66 to 1.38; mortality with laparoscopic surgery: 0/119 with early v 0/109 with delayed; morbidity with laparoscopic surgery: 13/119 [11%] with early v 17/109 [16%] with delayed; OR 0.69, 95% CI 0.27 to 1.73; hospital stay: 9.6 days with early v 17.8 days with delayed; P less than 0.0001; see comment below). The review found no significant difference between groups in conversion to open cholecystectomy (conversion: 21/119 [18%] with early v 28/109 [26%] with delayed; OR 0.62, 95% CI 0.32 to 1.19). Unplanned urgent operation was needed in 23% of people allocated to delayed surgery.

The second systematic review found no significant differences between early versus delayed cholecystectomy (open or laparoscopic) in mortality or morbidity (search date 2003, 10 RCTs, 6 of which were included in the first review, 1014 people with acute cholecystitis; mortality: absolute figures not reported; risk difference [RD] –0.01, 95% CI –0.03 to 0.00; morbidity: absolute figures not reported; RD –0.06, 95% CI –0.17 to +0.06). The review found no significant difference between early and delayed cholecystectomy in risk of conversion to open surgery, but found that early surgery reduced duration of hospital stay compared with delayed surgery, (conversion rate: absolute figures not reported, RD –0.40, 95% CI –0.13 to +0.49; hospital stay: absolute figures not reported, mean difference –10.2 days, 95% CI –13.4 days to –7.0 days with open surgery v mean difference –2.7 days, 95% CI –4.9 days to –0.49 days with laparoscopic surgery). One RCT included in the second systematic review compared the effects on health-related quality of life of early versus delayed cholecystectomy. It found that gastrointestinal symptoms (diarrhoea, indigestion, and abdominal pain) were significantly improved in early versus delayed cholecystectomy groups at 1 month after surgery, although not at 3 or 6 months (145 people with acute cholecystitis; quality of life at 1 month: results presented graphically; P less than 0.01).

The third systematic review (search date 2005, 5 RCTs, 3 of which were included in the previous 2 reviews, 451 people with acute cholecystitis) compared early (223 people) versus delayed laparoscopic cholecystectomy (228 people).The review reported that four of the five trials were of high methodological quality. Of the people randomised to the delayed group, 40 (18%) required emergency laparoscopic cholecystectomy due to non-resolution of symptoms or symptom recurrence prior to the planned elective procedure. Of these 40 people, conversion to an open cholecystectomy procedure was required in 18 (45%). The review found no significant difference between groups in the rates of conversion from laparoscopic cholecystectomy to open cholecystectomy (5 RCTs; 45/223 [20%] with early cholecystectomy v 51/228 [22%] with late cholecystectomy, OR 0.48, 95% CI 0.53 to 1.34. P = 0.5). The duration of hospital stay was longer for the delayed group in all trials by 1.1 to 5 days (CI and P value not reported).

Harms

The first systematic review found no significant differences in operative or perioperative complications and postoperative mortality between treatment groups for open cholecystectomy (operative and perioperative complications: OR 0.95, 95% CI 0.66 to 1.38: postoperative mortality: OR 0.53, 95% CI 0.17 to 1.66). The complications in the RCTs included pneumonia, wound infection, wound dehiscence, incisional hernia, intra-abdominal abscess, mesenteric thrombosis, pancreatitis, MI, and transient psychosis. There were no significant differences in operative or perioperative complications between treatment groups (operative and perioperative complications: OR 0.69, 95% CI 0.27 to 1.73), and the review reported no postoperative deaths in either treatment group. Postoperative complications included subphrenic collection, bile leak from the cystic duct stump, superficial wound infection, postoperative respiratory failure requiring mechanical ventilation, postoperative ileus, and atrial fibrillation. The second systematic review did not compare operative complications between groups due to lack of data in included studies. The third review reported no significant difference in the rates of bile duct injury (5 RCTs; 1/22 [0.5%] with early cholecystectomy v 3/228 [1%] with late cholecystectomy, OR 0.63, 95% CI 0.15 to 2.70, P = 0.5) or intraabdominal abscess requiring drainage (5 RCTs, 6/223 [3%] with early cholecystectomy v 3/228 [1%] with late cholecystectomy, OR 1.86, 95% CI 0.56 to 6.18, P = 0.3). However, the review found that delayed cholecystecomy significantly reduced the risk of bile leakage compared with early cholecystectomy (7/223 [3%] with early cholecystectomy v 0/228 [0%] with delayed cholecystectomy, OR 5.78, 95% CI 1.00 to 33.29, P = 0.05) with a fixed-effect model of analysis. This result became non-significant when a sensitivity analysis was performed which included only trials of high methodological quality. Two patients in the delayed group developed cholangitis while awaiting their procedures.

Comment

Surgeons performing open cholecystectomies in the first systematic review had a variety of experience, while all laparoscopic cholecystectomies were carried out by “experienced surgeons”. Only one of the RCTs gave information on the number of people who did not have surgery because of successful conservative treatment.

Clinical guide:

Early cholecystectomy affords certain advantages and is the treatment of choice in people with acute cholecystitis. People with acute cholecystitis who have multiple comorbid conditions and relative contraindications for cholecystectomy may be treated with antibiotics, a low-fat diet, and, in some instances, a cholecystostomy tube.

Substantive changes

Early v delayed cholecystectomy One systematic review added comparing early versus late cholecystectomy. The review found no difference between groups in the rates of conversion from laparoscopic cholecystectomy to open cholecystectomy. Categorisation unchanged (Beneficial).

BMJ Clin Evid. 2008 Dec 4;2008:0411.

Percutaneous cholecystostomy followed by early cholecystectomy versus medical treatment followed by delayed cholecystectomy

Summary

DURATION OF HOSPITAL STAY Percutaneous cholecystostomy within 8 hours plus early cholecystectomy compared with medical treatment followed by delayed cholecystectomy: Early percutaneous cholecystectomy followed by early cholecystectomy may lead to reduced duration of hospital stay ( low-quality evidence ). SYMPTOM IMPROVEMENT Percutaneous cholecystostomy within 8 hours plus early cholecystectomy compared with medical treatment followed by delayed cholecystectomy: Early percutaneous cholecystectomy followed by early cholecystectomy may be more effective at reducing the time to symptomatic improvement (low-quality evidence).

Benefits

We found one RCT (70 people at high surgical risk [ASA grades II through IV] with acute cholecystitis) comparing percutaneous cholecystostomy (PC) within 8 hours of admission followed by early cholecystectomy (37 people) versus medical treatment followed by delayed cholecystectomy (8 weeks after full recovery, 33 people). People randomised to the first group would receive early cholecystectomy if they achieved resolution of sepsis and an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of less than 12 within 96 hours after PC. Six patients in this first group had an APACHE II score of greater than 12 after 96 hours, and were excluded from the study. Early laparoscopic cholecystectomy (LC) was performed in the remaining 31 patients. In the delayed group, two people refused surgical treatment, and one person died owing to ongoing sepsis. These three people were excluded, the remaining 30 included in the analysis. The RCT found no difference for rates of conversion from laparoscopic cholecystectomy to open cholecystectomy between groups (2/31 [6%] with PC plus early cholecystectomy v 4/30 [13%] with medical treatment plus delayed cholecystectomy, P = 0.42.) The RCT found that PC plus early cholecystectomy significantly reduced duration of hospital stay compared with medical treatment plus delayed cholecystectomy (mean number of days; 5.3 days with PC plus early cholecystectomy v 15.2 days with medical treatment plus delayed cholecystectomy, P = 0.001). The RCT also found that PC plus early cholecystectomy significantly reduced the mean time to symptomatic improvement (mean time to symptomatic improvement; 15 hours with PC plus early cholecystectomy v 55 hours with medical treatment plus delayed cholecystectomy, P = 0.001).

Harms

The RCT reported that adverse effects related to percutaneous cholecystostomy included minor bile leak (1/ 31 [3%]) and one dislodgement of the drainage catheter (1/31 [3%]) which is comparable to other studies. There were no mortalities related to PC, and no postoperative mortalities after cholecystectomy. The RCT reported no other adverse effects.

Comment

Clinical guide

Early cholecystectomy affords certain advantages and is the treatment of choice in people with acute cholecystitis. People with acute cholecystitis who have multiple comorbid conditions and relative contraindications for cholecystectomy may be treated with antibiotics, a low-fat diet, and, in some instances, a cholecystostomy tube.

Substantive changes

BMJ Clin Evid. 2008 Dec 4;2008:0411.

Laparoscopic cholecystectomy

Summary

FAILURE RATES Compared with observation alone/no treatment: Laparoscopic cholecystectomy may be more effective and reducing failure rates ( moderate-quality evidence ). GALLSTONE-RELATED COMPLICATIONS Compared with laparoscopic cholecystectomy: Laparoscopic cholecystectomy is no more effective than observation alone at reducing the rate of gallstone-related complications (recurrent cholecystitis, pancreatitis, intractable pain) in people with acute cholecystitis (moderate-quality evidence). DURATION OF HOSPITAL STAY Compared with open cholecystectomy: Laparoscopic cholecystectomy may be more effective at reducing the duration of hospital stay in people with acute cholecystitis ( low-quality evidence ). Compared with minilaparoscopic cholecystectomy: Conventional laparascopic cholecystectomy may be no more effective at reducing the duration of hospital stay (low-quality evidence). POSTOPERATIVE COMPLICATIONS Compared with open cholecystectomy: We don’t know how laparoscopic and open cholecystectomy compare in their effect on postoperative complications in people with acute cholecystitis (very low-quality evidence). CONVERSION RATES Compared with minilaparoscopic cholecystectomy: Conventional laparoscopic cholecystectomy is as effective as minilaparoscopic cholecystectomy at reducing the rate of conversion to open cholescystectomy (moderate-quality evidence). ANALGESIC USE Compared with minilaparoscopic cholecystectomy: Conventional cholecystectomy may be no more effective at reducing the need of analgesia ( low-quality evidence ).

Benefits

Laparoscopic surgery versus open cholecystectomy:

We found no systematic review but found four RCTs. All four RCTs found that laparoscopic cholecystectomy improved intraoperative and postoperative outcomes compared with open cholecystectomy. The first RCT (271 people with acute cholecystitis) compared laparoscopic (146 people) versus open (97 people) cholecystectomy. The rate of conversion from laparoscopic to open cholecystectomy was 27%. The people randomised to receive open cholecystectomy were, on average, 10 years older than people receiving laparoscopic cholecystectomy (P less than 0.001), and had a significantly higher incidence of comorbid conditions (P = 0.002) and gangrenous cholecystitis (P = 0.03). The RCT found that, compared with open cholecystectomy, laparoscopic cholecystectomy significantly reduced duration of surgery (mean: 60 minutes with laparoscopic v 90 minutes with open cholecystectomy; P less than 0.00001), use of nasogastric tube (51% with laparoscopic v 94% with open cholecystectomy; P less than 0.0001), mean use of analgesia (75 mg pethidine with laparoscopic v 175 mg pethidine with open cholecystectomy; P less than 0.0001; 1 g oral metamizole with laparoscopic v 3 g oral metamizole with open cholecystectomy; P less than 0.0001), and hospital stay (3 days with laparoscopic v 7 days with open cholecystectomy; P less than 0.0001). The second RCT (63 people with acute cholecystitis) reported that the rate of conversion from laparoscopic to open cholecystectomy was 16%. The RCT found that laparoscopic cholecystectomy significantly reduced hospital stay compared with open cholecystectomy (4 days with laparoscopic v 14 days with open cholecystectomy; P = 0.0063). It found no significant difference in duration of surgery between laparoscopic and open cholecystectomy (mean: 108 minutes with laparoscopic v 99 minutes with open cholecystectomy; P = 0.49). The third RCT (230 people with acute cholecystitis) reported a conversion rate from laparoscopic to open cholecystectomy of 5/109 (4%). It found no significant difference in duration of surgery between laparoscopic and open cholecystectomy, although laparoscopic cholecystectomy tended to be slightly shorter (95 ± 43.7 minutes with laparoscopic cholecystectomy v 102.3 ± 46.3 minutes with open cholecystectomy; P value reported as not significant). Similarly, the RCT found no significant difference in mean fall in haemoglobin postoperatively between laparoscopic and open cholecystectomy, although the mean fall was smaller in the laparoscopic cholecystectomy group (mean fall in haemoglobin: 1.9 g/L with open cholecystectomy v 1.1 g/L with laparoscopic cholecystectomy; P = 0.6). Postoperative hospital stay was shorter in the laparoscopic cholecystectomy group (8.5 ± 3.9 days with open cholecystectomy v 5.8 ± 4.2 days with laparoscopic cholecystectomy; P value not reported). The fourth RCT found that conversion from laparoscopic to open cholecystectomy was about 23%. It found that laparoscopic surgery significantly reduced the duration of hospital stay (70 people with acute calculous cholecystitis; hospital stay: range of 1–10 days [median 2 days] with laparoscopic surgery v range of 1–8 days [median 2 days] with open surgery; P = 0.01,mean stay presented graphically, mean significantly longer with open surgery although median stay the same in both groups) compared with open surgery. It found no significant difference between groups in blood loss (3/35 [9%] in each group had perioperative bleeding in excess of 500 mL; P = 1.0), postoperative pain (pain score at discharge: 2 with laparoscopic surgery v 1 with open surgery; P = 0.165), or number of days sick leave (11 days with laparoscopic surgery v 14 days with open surgery; P = 0.771; see comment below). Operative time was significantly shorter with open surgery compared with laparoscopic surgery (median: 90 minutes with laparoscopic surgery v 80 minutes with open surgery; P = 0.04).

Conventional laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy:

We found one RCT (69 people with acute cholecystitis) comparing minilaparoscopic cholecystectomy (2–3 mm diameter instruments) versus conventional laparoscopic cholecystectomy (5 mm diameter instruments). It found no significant difference between minilaparoscopic and conventional laparoscopic cholecystectomy in the rate of conversion to open cholecystectomy (8% with minilaparoscopic v 6% with conventional laparoscopic; P = 0.597). It found that a similar proportion of people needed postoperative antiemetics plus analgesics (30/35 [86%] with minilaparoscopic v 22/29 [76%] with conventional laparoscopic; P value not reported), and found no significant difference in duration of hospital stay between minilaparoscopic and conventional laparoscopic cholecystectomy (mean: 4.3 days with minilaparoscopic v 4.2 days with conventional laparoscopic; P value reported as not significant, CI not reported). Similarly, the RCT found no significant difference in duration of surgery between minilaparoscopic and conventional laparoscopic cholecystectomy, but the operation tended to be marginally longer with minilaparoscopic cholecystectomy (mean: 113.8 minutes with minilaparoscopic v 98.2 minutes with conventional laparoscopic; P = 0.056).

Harms

Laparoscopic cholecystectomy versus open cholecystectomy:

The first RCT found no significant difference between laparoscopic cholecystectomy and open cholecystectomy in the proportion of people with postoperative complications (24/146 [16%] with laparoscopic v 25/97 [26%] with open; reported as not significant, CI not reported). Complications were classified as surgical infections (wound infection, subphrenic or subhepatic abscess), non-infectious surgical (bile duct injury or haemorrhage), remote infections (urinary or respiratory), and miscellaneous (atelectasis or deep vein thrombosis). The second RCT found that laparoscopic cholecystectomy significantly reduced postoperative complications compared with open cholecystectomy (major complications: 0% with laparoscopic v 23% with open cholecystectomy; minor complications: 3% with laparoscopic v 19% with open cholecystectomy; P = 0.0048 for overall complication rate comparing laparoscopic v open cholecystectomy). Major complications included MI, pneumonia and sepsis, femoral artery embolism, serious wound infection, late incisional hernia requiring surgical repair, adhesive intestinal obstruction within 1 month of cholecystectomy, and retained common bile duct stone. Minor complications included diarrhoea, urinary infection, and confusion. The RCT found no deaths or bile duct injuries in either treatment group. The third RCT found higher intraoperative and postoperative complication rates with open cholecystectomy compared with laparoscopic cholecystectomy (overall complication rate: 26/116 [22%] with open cholecystectomy v 14/109 [13%] with laparoscopic cholecystectomy; intraoperative complication rate: 12/116 [10%] with open cholecystectomy v 8/109 [7%] with laparoscopic cholecystectomy; postoperative complication rate: 14/116 [12%] with open cholecystectomy v 6/109 [6%] with laparoscopic cholecystectomy; P values not reported). Intraoperative complications included haemorrhage, bile duct injury, and passing of stones. Postoperative complications were defined as haemorrhage, pneumonia, thrombosis, bile duct stones, bile leakage, or wound infections. The fourth RCT found no significant difference between groups in postoperative complication rate (2/35 [6%] with laparoscopic cholecystectomy v 3/35 [9%] with open cholecystectomy; P = 0.65). Postoperative complications included minor stroke, wound infection, and pneumonia.

Conventional laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy:

The RCT found no major complications (common bile duct injury, bile leakage, intra-abdominal bleeding, abscess formation) associated with minilaparoscopic or conventional laparoscopic cholecystectomy (see comment below). It found similar rates of minor complications (wound infection, short-term postoperative ileus, bleeding from the subumbilical port site) between the two treatment groups (4/35 [11%] with minilaparoscopic cholecystectomy v 2/29 [7%] with conventional laparoscopic cholecystectomy; P value not reported).

Comment

Laparoscopic cholecystectomy versus open cholecystectomy:

The first RCT found that laparoscopic surgery was associated with fewer complications if performed by more experienced surgeons. We found one systematic review in people with symptomatic gallstones, which did not differentiate between people with and without acute cholecystitis. The review (search date 1995) indirectly compared outcomes in people who had laparoscopic cholecystectomy (98 case series or RCTs, 78,747 people with symptomatic gallstones) versus outcomes in people who had open cholecystectomy (28 case series or RCTs, 12,973 people treated with open cholecystectomy). It found that laparoscopic cholecystectomy was associated with lower mortality (86–91/100,000 with laparoscopic v 660–740/100,000 with open cholecystectomy; CI not reported) but a higher rate of bile duct injury (36–47/10,000 with laparoscopic v 19–29/10,000 with open cholecystectomy; CI not reported).

One prospective observational study (278 people who had undergone cholecystectomy) investigated the prevalence of persistent abdominal pain 5 years after cholecystectomy. The study analysed follow-up data on populations from two RCTs. The people received either laparoscopic or open cholecystectomy (rates not reported). Of the 124 people included in the two RCTs with acute cholecystitis, 34 people (27%) reported pain at 5-year follow-up. Of the 101 women included in the RCTS, 29 reported pain (29%) compared with 5/23 men (22%). In women, diffuse pain was more prevalent than pain attacks (21% diffuse pain v 8% pain attack, P = 0.024, absolute figures not reported), especially in women aged below 60 years (P = 0.004, no other data reported). The study reported that, neither the duration of symptom history prior to cholecystectomy (more or less than 2 years), indication for cholecystectomy (27% of people with biliary colic v 29% of patients with acute cholecystitis), nor the surgical method (open v laparoscopic) made a significant difference in the prevalence of abdominal pain 5 years after cholecystectomy. Furthermore, those people who received a cholecystectomy after failing a trial of observation had a similar prevalence of pain to people who had been randomised to a planned procedure.

Conventional laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy:

The RCT may have been underpowered to detect clinically important differences between techniques. To date, there is no formal training in minilaparoscopy outside of traditional laparoscopic training. Most published studies using minilaparoscopy come from either non-US centres or large academic centres in the USA, which allows no estimate of the extent of its use outside this setting.

Clinical guide:

Laparoscopic cholecystectomy is the procedure of choice in people with acute cholecystitis, with the caveat that although it is associated with favourable postoperative outcomes, it carries a higher incidence of bile duct injury. Open cholecystectomy is primarily required in people who have a fistula from the gallbladder into the bile duct or intestine, and in some people who have perforation and abscess in the right upper quadrant. Conversion from laparoscopic to open cholecystectomy is needed if the laparoscopic procedure cannot be completed without risking injury to surrounding structures, or when haemostasis cannot be secured.

Substantive changes

Laparoscopic cholecystectomy One observational study added to the comments section investigating the prevalence of persistent abdominal pain 5 years after cholecystectomy. The study found that neither the duration of symptom history prior to cholecystectomy, indication for cholecystectomy, nor the surgical method made a difference in the prevalence of abdominal pain 5 years after cholecystectomy. Categorisation unchanged (Beneficial).

BMJ Clin Evid. 2008 Dec 4;2008:0411.

Observation alone

Summary

FAILURE RATES Compared with laparoscopic cholecystectomy: Observation or no treatment is less effective at reducing the rate of treatment failure in people with acute cholecystitis ( moderate-quality evidence ). GALLSTONE-RELATED COMPLICATIONS Compared with laparoscopic cholecystectomy: Observation or no treatment is as effective as cholecystectomy at reducing the rate of gallstone-related complications (recurrent cholecystitis, pancreatitis, intractable pain) in people with acute cholecystitis (moderate-quality evidence).

Benefits

Laparoscopic cholecystectomy versus no treatment/observation:

We found no systematic reviews or RCTs comparing only laparascopic cholecystectomy versus no treatment. We found one RCT (64 people with acute cholecystitis) comparing cholecystectomy (laparoscopic or open) versus observation alone. In the cholecystectomy group, 27/31 (87%) people had the operation at a median of 3.6 months after randomisation. After 8 years, 10/33 (30%) people originally randomised to observation had undergone cholecystectomy (failure rate). In the cholecystectomy group, 4/31 (13%) refused operation on the grounds of freedom from symptoms. A greater proportion of people in the cholecystectomy group than in the observation group underwent cholecystectomy (P less than 0.0001). The RCT found no significant difference in the overall rate of gallstone-related events (complications or emergency admissions for pain: 6/31 [19%] with cholecystectomy v 12/33 [36%] with observation; P = 0.16).

See benefits of laparoscopic cholecystectomy.

Harms

Laparoscopic cholecystectomy versus no treatment/observation:

We found no RCTs comparing laparoscopic cholecystectomy versus no treatment/observation. The RCT comparing cholecystectomy versus observation found no significant difference in the rates of major or minor operative complications between cholecystectomy and observation groups (major complication rate: 3/27 [11%] in the group randomised to cholecystectomy v 1/10 [10%] in the group randomised to observation; minor complication rate: 7/27 [26%] in the group randomised to cholecystectomy v 1/10 [10%] in the group randomised to observation; P = 0.66 for difference in overall postoperative complications between the groups). Major complications included bile duct injuries or haemorrhage, whereas minor complications included wound infection, subphrenic collections, or miscellaneous infections (urinary and respiratory). The RCT found no gallstone-related deaths in either group.

See harms of laparoscopic cholecystectomy.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2008 Dec 4;2008:0411.

Open cholecystectomy

Summary

DURATION OF HOSPITAL STAY Compared with laparoscopic cholecystectomy: Open cholecystectomy may lead to longer duration of hospital stay in people with acute cholecystitis ( low-quality evidence ). POSTOPERATIVE COMPLICATIONS Compared with laparoscopic cholecystectom: y We don’t know whether open cholecystectomy is more effective at reducing postoperative complications in people with acute cholecystitis (very low-quality evidence).

Benefits

Open cholecystectomy versus no treatment/observation:

We found no systematic review or RCTs only comparing open cholecystectomy versus no treatment.

Open cholecystectomy versus laparoscopic cholecystectomy:

See benefits of laparoscopic cholecystectomy.

Harms

Open cholecystectomy versus no treatment/observation:

We found no systematic review or RCTs only comparing open cholecystectomy versus no treatment.

Open cholecystectomy versus laparoscopic cholecystectomy:

See harms of laparoscopic cholecystectomy.

Comment

Open cholecystectomy versus laparoscopic cholecystectomy:

See comment on laparoscopic cholecystectomy.

Clinical guide:

Open cholecystectomy is primarily required in people who have a fistula from the gallbladder into the bile duct or intestine, and in some people who have perforation and abscess in the right upper quadrant.

Substantive changes

No new evidence

BMJ Clin Evid. 2008 Dec 4;2008:0411.

Minilaparoscopic cholecystectomy

Summary

DURATION OF HOSPITAL STAY Compared with conventional laparoscopic cholecystectomy: Minilaparoscopic cholecystectomy may lead to similar duration of hospital stay ( low-quality evidence ). ANALGESIC USE Compared with conventional laparoscopic cholecystectomy: Minilaparoscopic cholecystectomy may lead to similar need for analgesia ( low-quality evidence ).

Benefits

Minilaparoscopic cholecystectomy versus no treatment:

We found no systematic review and no RCTs comparing minilaparoscopic cholecystectomy versus no treatment.

Minilaparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy:

See benefits of laparoscopic cholecystectomy.

Harms

Minilaparoscopic cholecystectomy versus no treatment:

We found no RCTs.

Minilaparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy:

See harms of laparoscopic cholecystectomy.

Comment

None.

Substantive changes

No new evidence

Articles from BMJ Clinical Evidence are provided here courtesy of BMJ Publishing Group

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