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. 2014 Aug 20;2014:0411.

Acute cholecystitis

Valerie Halpin 1
PMCID: PMC4140413  PMID: 25144428

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 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.

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 cystic 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 one quarter of people scheduled for delayed surgery may require urgent operations because of recurrent or worsening symptoms.

Laparoscopic cholecystectomy may reduce the duration of hospital admission and improve some intra-operative and postoperative outcomes compared with open cholecystectomy, but it may increase the risk of bile duct injury.

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

We found limited evidence from one small RCT that percutaneous cholecystostomy plus early cholecystectomy may reduce time to symptomatic improvement and duration of hospital stay compared with medical treatment plus delayed cholecystectomy in people at high surgical risk.

  • However, evidence was weak. We found no studies in people at normal surgical risk.

Routine abdominal drainage in both uncomplicated laparoscopic and open cholecystectomy is associated with an increase in wound infections compared with no drainage.

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. The incidence of acute cholecystitis is about 20% among people with biliary colic. Biliary colic occurs in 1% to 4% of people with gallstones. 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 older people. The number of cholecystectomies for acute cholecystitis has been decreasing as the rate of elective cholecystectomy has increased. Acute calculous cholecystitis is three times more common in women than in men up to the age of 50 years, and is about one and a half 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% to 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 US, 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; morbidity (including gallstone-related complications, persistent pain, intolerance to food, gastrointestinal upset, recurrent attacks of cholecystitis); intra-operative outcomes (includes duration of surgery and need for nasogastric tube); postoperative outcomes (duration of hospital stay, complications, antibiotic use, and analgesia use); quality of life. Postoperative fall in haemoglobin and conversion of a planned laparoscopic cholecystectomy to an open cholecystectomy are surrogate outcomes and are reported in Further information on studies.

Methods

Clinical Evidence search and appraisal October 2013. The following databases were used to identify studies for this systematic review: Medline 1966 to October 2013, Embase 1980 to October 2013, and The Cochrane Database of Systematic Reviews, 2013, issue 9 (1966 to date of issue). Additional searches were carried out in the the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) Database. We also searched for retractions of studies included in the review. Titles and abstracts identified by the initial search, run by an information specialist, were first assessed against predefined criteria by an evidence scanner. Full texts for potentially relevant studies were then assessed against predefined criteria by an evidence analyst. Studies selected for inclusion were discussed with an expert contributor. All data relevant to the review were then extracted by an evidence analyst. Study design criteria for inclusion in this review were: published RCTs and systematic reviews of RCTs, blinded or open label trials, and containing >20 individuals of whom at least 80% were followed up. There was no minimum follow-up. We included RCTs and systematic reviews of RCTs where harms of an included intervention were assessed, applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table.

GRADE Evaluation of interventions for Acute cholecystitis.

Important outcomes Intra-operative outcomes, Morbidity, Mortality, Postoperative outcomes , Quality of life
Studies (Participants) Outcome Comparison Type of evidence Quality Consistency Directness Effect size GRADE Comment
What are the effects of treatments for acute cholecystitis?
at least 16 (at least 1255) Mortality Early versus delayed cholecystectomy 4 −1 0 −1 0 Low Quality point deducted for incomplete reporting of results; directness point deducted for differences in surgeon expertise
17 (at least 1289) Morbidity Early versus delayed cholecystectomy 4 −1 0 −2 0 Very low Quality point deducted for incomplete reporting of results; directness points deducted for differences in surgeon expertise and for unclear outcome assessment
at least 18 (at least 1337) Postoperative outcomes Early versus delayed cholecystectomy 4 −1 0 −1 0 Low Quality point deducted for incomplete reporting of results; directness point deducted for differences in surgeon expertise
7 (548) Intra-operative outcomes Early versus 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 (61) Morbidity Percutaneous cholecystostomy followed by early cholecystectomy versus medical treatment followed by delayed cholecystectomy 4 –3 0 –1 0 Very low Quality points deducted for sparse data, weak methods, and no intention-to-treat analysis; directness point deducted for restricted population (people at high surgical risk)
1 (61) Postoperative outcomes Percutaneous cholecystostomy followed by early cholecystectomy versus medical treatment followed by delayed cholecystectomy 4 –3 0 0 0 Very low Quality points deducted for sparse data, weak methods, and no intention-to-treat analysis
1 (70) Mortality Percutaneous cholecystostomy followed by early cholecystectomy versus medical treatment followed by delayed cholecystectomy 4 –2 0 –1 0 Very low Quality points deducted for sparse data and weak methods; directness point deducted for restricted population (people at high surgical risk)
1 (70) Morbidity Laparoscopic cholecystectomy versus open cholecystectomy 4 –1 0 0 0 Moderate Quality point deducted for sparse data
4 (606) Intra-operative outcomes Laparoscopic cholecystectomy versus open cholecystectomy 4 –1 –1 –2 0 Very low Quality point deducted for incomplete reporting of results; consistency point deducted for conflicting results for duration of surgery; directness points deducted for population differences and differences in techniques
4 (601) Postoperative outcomes Laparoscopic cholecystectomy versus open cholecystectomy 4 –1 0 –2 0 Very low Quality point deducted for incomplete reporting of results; directness points deducted for population differences and differences in techniques
3 (529) Postoperative outcomes Routine abdominal drainage versus no drainage in uncomplicated laparoscopic cholecystectomy 4 –3 0 0 +2 Moderate Quality points deducted for inclusion of poor-quality studies, low event rate, and sparse data in 1 outcome; effect-size points added for OR >5 or <0.2
1 (64) Morbidity Laparoscopic cholecystectomy versus no treatment/observation 4 –1 0 0 0 Moderate Quality point deducted for sparse data
1 (64) Mortality Laparoscopic cholecystectomy versus no treatment/observation 4 –2 0 0 0 Low Quality points deducted for sparse data and incomplete reporting of results
at least 17 (at least 3090) Postoperative outcomes Routine abdominal drainage versus no drainage in uncomplicated open cholecystectomy 4 –1 0 0 0 Moderate Quality point deducted for methodological weaknesses of included trials
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We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard 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.

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.

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BMJ Clin Evid. 2014 Aug 20;2014:0411.

Early cholecystectomy

Summary

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 one quarter of people scheduled for delayed surgery may require urgent operations because of recurrent or worsening symptoms.

Benefits and harms

Early versus delayed cholecystectomy:

We found five systematic reviews (search dates 2001, 2003, 2006, and 2012) and two subsequent RCTs 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 reviews identified 19 RCTs between them. Crossover reporting was widespread (e.g., the five RCTs reported in the fifth review included all four RCTs reported in the third review and three of the four RCTs reported by the fourth review). To minimise duplication of reporting, therefore, we have not reported all outcomes for all reviews where the same RCTs were reported. The two oldest reviews reported RCTs dating back as far as 1970, while the more-recent reviews included RCTs dating from 1998. See Further information on studies for details of conversion rates.

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 (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Mortality

Systematic review		 916 people with acute cholecystitis
9 RCTs in this analysis		 Mortality
1/468 (0.2%) with early open cholecystectomy
7/448 (1.6%) with delayed open cholecystectomy
OR 0.53
95% CI 0.17 to 1.66 		Not significant

Systematic review		 228 people with acute cholecystitis
3 RCTs in this analysis		 Mortality
0/119 (0%) with early laparoscopic cholecystectomy
0/109 (0%) with delayed laparoscopic cholecystectomy
Reported as not significant
P value not reported 		Not significant

Systematic review		 1014 people with acute cholecystitis
10 RCTs in this analysis
6 RCTs included in review 		Mortality
with early cholecystectomy (open and laparoscopic)
with delayed cholecystectomy (open and laparoscopic)
Absolute results not reported
Risk difference −0.01
95% CI −0.03 to 0.00 		Not significant

Systematic review		 451 people with acute cholecystitis
5 RCTs in this analysis		 Mortality
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy
Significance not assessed
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No data from the following reference on this outcome.

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 (not further defined) in people with acute cholecystitis compared with delayed (at least 6 weeks after onset of symptoms) cholecystectomy. Early cholecystectomy may be more effective at reducing gastrointestinal symptoms (diarrhoea, indigestion, and abdominal pain) at 1 month in people with acute cholecystitis, but it may be no more effective at 3 to 6 months (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Morbidity

Systematic review		 916 people with acute cholecystitis
9 RCTs in this analysis		 Morbidity (not further defined)
83/468 (17.7%) with early open cholecystectomy
80/448 (17.9%) with delayed open cholecystectomy
OR 0.95
95% CI 0.66 to 1.38 		Not significant

Systematic review		 228 people with acute cholecystitis
3 RCTs in this analysis		 Morbidity (not further defined)
13/119 (11%) with early laparoscopic cholecystectomy
17/109 (16%) with delayed laparoscopic cholecystectomy
OR 0.69
95% CI 0.27 to 1.73 		Not significant

Systematic review		 1014 people with acute cholecystitis
10 RCTs in this analysis
6 RCTs included in review 		Morbidity (not further defined)
with early cholecystectomy (open and laparoscopic)
with delayed cholecystectomy (open and laparoscopic)
Absolute results not reported
Risk difference −0.06
95% CI −0.17 to +0.06 		Not significant
Gastrointestinal upset

RCT		 145 people with acute cholecystitis
In review 		Gastrointestinal upset (diarrhoea, indigestion, and abdominal pain) 1 month after surgery
with early cholecystectomy (open or laparoscopic)
with delayed cholecystectomy (open or laparoscopic)
Absolute results reported graphically
P <0.01 		Effect size not calculated early cholecystectomy

RCT		 145 people with acute cholecystitis
In review 		Gastrointestinal upset (diarrhoea, indigestion, and abdominal pain) 3 months after surgery
with early cholecystectomy (open or laparoscopic)
with delayed cholecystectomy (open or laparoscopic)
Absolute results reported graphically
Reported as not significant
P value not reported 		Not significant

RCT		 145 people with acute cholecystitis
In review 		Gastrointestinal upset (diarrhoea, indigestion, and abdominal pain) 6 months after surgery
with early cholecystectomy (open or laparoscopic)
with delayed cholecystectomy (open or laparoscopic)
Absolute results reported graphically
Reported as not significant
P value not reported 		Not significant
Open in a new tab

No data from the following reference on this outcome.

Postoperative outcomes

Early compared with delayed cholecystectomy Early (at the time of diagnosis or within 7 days of onset of symptoms) cholecystectomy 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. However, early cholecystectomy may be no more effective at reducing postoperative complications (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Duration of hospital stay

Systematic review		 1255 people with acute cholecystitis
12 RCTs in this analysis		 Duration of hospital stay
9.6 days with early cholecystectomy (open or laparoscopic)
17.8 days with delayed cholecystectomy (open or laparoscopic)
P <0.0001 		Effect size not calculated early cholecystectomy

Systematic review		 1014 people with acute cholecystitis
10 RCTs in this analysis
6 RCTs included in review 		Duration of hospital stay
with early cholecystectomy (open and laparoscopic)
with delayed cholecystectomy (open and laparoscopic)
Absolute results not reported
Mean difference –2.7 days
95% CI –4.9 days to –0.49 days with early v delayed laparoscopic cholecystectomy
Mean difference –10.2 days
95% CI –13.4 days to –7.0 days with early v delayed open cholecystectomy 		Effect size not calculated early cholecystectomy

Systematic review		 373 people with acute cholecystitis
4 RCTs in this analysis		 Duration of hospital stay
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy
Absolute numbers not reported
Mean difference –4.12 days
95% CI –5.22 days to –3.03 days
P <0.00001 		Effect size not calculated early cholecystectomy

Systematic review		 243 people with acute cholecystitis
3 RCTs in this analysis		 Duration of postoperative hospital stay
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy
Absolute numbers not reported
WMD 0.39
95% CI 0.13 to 0.66
P = 0.004 		Effect size not calculated delayed cholecystectomy

Systematic review		 346 people with acute cholecystitis
3 RCTs in this analysis		 Duration of hospital stay
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy
Absolute results not reported
WMD –1.14
95% CI –1.58 to –0.70
P <0.001 		Effect size not calculated early cholecystectomy

RCT		 60 people with acute cholecystitis Duration of hospital stay
4.77 days with early laparoscopic cholecystectomy
10.10 days with delayed laparoscopic cholecystectomy
Reported as significant 		early cholecystectomy
Postoperative complications

Systematic review		 916 people with acute cholecystitis
9 RCTs in this analysis		 Postoperative complications
with early open cholecystectomy
with delayed open cholecystectomy
Absolute results not reported
OR 0.95
95% CI 0.66 to 1.38 		Not significant

Systematic review		 228 people with acute cholecystitis
3 RCTs in this analysis		 Postoperative complications
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy
Absolute results not reported
OR 0.69
95% CI 0.27 to 1.73 		Not significant

Systematic review		 375 people with acute cholecystitis
4 RCTs in this analysis		 Proportion of people with bile leak
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy
Absolute numbers not reported
OR 2.42
95% CI 0.75 to 7.74
P = 0.14 		Not significant

Systematic review		 504 people with acute cholecystitis
4 RCTs in this analysis		 Proportion of people with bile leak
7/254 (0.3%) with early laparoscopic cholecystectomy
2/237 (0.1%) with delayed laparoscopic cholecystectomy
OR 2.22
95% CI 0.60 to 7.72
P = 0.21 		Not significant

Systematic review		 504 people with acute cholecystitis
4 RCTs in this analysis		 Overall complications
36/254 (14%) with early laparoscopic cholecystectomy
35/237 (15%) with delayed laparoscopic cholecystectomy
OR 0.97
95% CI 0.59 to 1.61
P = 0.91 		Not significant

Systematic review		 504 people with acute cholecystitis
4 RCTs in this analysis		 Intra-abdominal collection
11/254 (4%) with early laparoscopic cholecystectomy
8/237 (3%) with delayed laparoscopic cholecystectomy
OR 1.28
95% CI 0.51 to 3.25
P = 0.60 		Not significant

Systematic review		 438 people with acute cholecystitis
5 RCTs in this analysis		 Bile duct injury
1/219 (0.5%) with early laparoscopic cholecystectomy
2/219 (1.0%) with delayed laparoscopic cholecystectomy
RR 0.49
95% CI 0.05 to 4.72
P = 0.54 		Not significant

Systematic review		 438 people with acute cholecystitis
5 RCTs in this analysis		 Serious complications other than bile duct injury
14/219 (6.4%) with early laparoscopic cholecystectomy
11/219 (5.0%) with delayed laparoscopic cholecystectomy
RR 1.29
95% CI 0.61 to 2.72
P = 0.50 		Not significant

RCT		 60 people with acute cholecystitis Bile leak
1/30 with early laparoscopic cholecystectomy
0/30 with delayed laparoscopic cholecystectomy
P = 1.0 		Not significant

RCT		 60 people with acute cholecystitis Wound site infection
1/30 with early laparoscopic cholecystectomy
1/30 with delayed laparoscopic cholecystectomy
P = 1.0 		Not significant

RCT		 50 people with acute cholecystitis Injury to the biliary tree (not further defined)
6/25 (24%) with early laparoscopic cholecystectomy
17/25 (68%) with delayed laparoscopic cholecystectomy
P = 0.01 		early laparoscopic cholecystectomy

RCT		 50 people with acute cholecystitis Postoperative wound infection
8/25 (32%) with early laparoscopic cholecystectomy
19/25 (76%) with delayed laparoscopic cholecystectomy
P <0.01 		early laparoscopic cholecystectomy

RCT		 50 people with acute cholecystitis Postoperative haematoma
4/25 (16%) with early laparoscopic cholecystectomy
10/25 (40%) with delayed laparoscopic cholecystectomy
P <0.01 		early laparoscopic cholecystectomy
Open in a new tab

Intra-operative outcomes

Early compared with delayed cholecystectomy We don’t know how effective early cholecystectomy and delayed cholecystectomy are, compared with each other, in reducing operating time (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Intra-operative outcomes

Systematic review		 488 people with acute cholecystitis
6 RCTs in this analysis		 Operating time
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy
Absolute results not reported
Mean difference –1.22
95% CI –3.07 to +0.64 minutes
P = 0.20 		Not significant

RCT		 60 people with acute cholescystitis Operating time
98.83 minutes with early laparoscopic cholecystectomy
80.67 minutes with delayed laparoscopic cholecystectomy
P <0.05 		delayed cholecystectomy
Open in a new tab

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Further information on studies

The review found no significant difference between groups in conversion to open cholecystectomy (conversion: 21/119 [18%] with early cholecystectomy v 28/109 [26%] with delayed cholecystectomy; OR 0.62, 95% CI 0.32 to 1.19). Unplanned urgent operation was needed in 23% of people allocated to delayed surgery.

The review found no significant difference between early cholecystectomy and delayed cholecystectomy in risk of conversion to open surgery (absolute numbers not reported; risk difference –0.40, 95% CI –0.13 to +0.49).

The review found no significant difference between groups in rates of conversion to open cholecystectomy (conversion: 49/244 [20%] people with early cholecystectomy v 54/244 [22%] with delayed cholecystectomy; RR 0.89, 95% CI 0.63 to 1.25, P = 0.5).

This RCT found no difference in the rate of conversion to open procedure (3/30 [10%] with early cholecystectomy v 4/30 [10%] with delayed cholecystectomy; P = 1.00)

This RCT found a higher conversion rate to open operation after delayed than early cholecystectomy (12/25 [48%] v 4/25 [16%], P <0.01). High rates of postoperative complications were reported for both groups. The high complication rate is likely dependent on other unreported systematic factors, but is clearly higher in the delayed group in this type of setting.

Comment

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. The meta-analyses included here suggest that early laparoscopic cholecystectomy allows significantly shorter total hospital stay with no significant differences in conversion rates or complications.

Substantive changes

Early cholecystectomy New systematic review added and two subsequent RCTs. Categorisation unchanged (beneficial).

BMJ Clin Evid. 2014 Aug 20;2014:0411.

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

Summary

Early percutaneous cholecystostomy followed by early cholecystectomy may lead to reduced duration of hospital stay and reduce the time to symptomatic improvement compared with medical treatment followed by delayed cholecystectomy in people at high surgical risk (admitted with ASA grades II–IV; APACHE II score 12 or higher).

However, evidence was weak. We found no RCTs in people at normal surgical risk.

Benefits and harms

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

We found one systematic review (search date 2012), which included one RCT. The systematic review included additional data and analysis not reported in the original RCT, and so both are reported here. The RCT compared percutaneous cholecystostomy within 8 hours plus early laparoscopic cholecystectomy versus medical treatment plus delayed laparoscopic cholecystectomy 8 weeks after symptoms settled. It included 70 people at high surgical risk (admitted with American Society of Anesthesiologists [ASA] grades II–IV and Acute Physiology and Chronic Health Evaluation [APACHE] II score of 12 or higher). The review reported that an APACHE II score of 12 or higher indicated a greater than 10% risk of in-hospital mortality. People were only operated on if their condition improved (APACHE II score of <12 within 96 hours of percutaneous cholecystostomy). Hence, the RCT reported results based on 61 people for most outcomes (see Further information about studies).

Morbidity

Percutaneous cholecystostomy within 8 hours plus early cholecystectomy compared with medical treatment followed by delayed cholecystectomy Early percutaneous cholecystostomy followed by early cholecystectomy may be more effective at reducing the time to symptomatic improvement in people at high surgical risk. We found no evidence in people not at high surgical risk (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Symptom improvement

RCT		 70 people at high surgical risk (admitted with ASA grades II–IV; APACHE II score of 12 or higher) with acute cholecystitis Mean time to symptomatic improvement
15 hours with percutaneous cholecystostomy within 8 hours of admission plus early cholecystectomy
55 hours with medical treatment plus delayed cholecystectomy (8 weeks after full recovery)
P = 0.001 		Effect size not calculated percutaneous cholecystostomy plus early cholecystectomy
Open in a new tab

No data from the following reference on this outcome.

Postoperative outcomes

Percutaneous cholecystostomy within 8 hours plus early cholecystectomy compared with medical treatment followed by delayed cholecystectomy Early percutaneous cholecystostomy followed by early cholecystectomy may lead to reduced duration of hospital stay and may be associated with a similar rate of postoperative complications in people at high surgical risk. We found no evidence in people not at high surgical risk (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Duration of hospital stay

RCT		 70 people at high surgical risk (admitted with ASA grades II–IV; APACHE II score of 12 or higher) with acute cholecystitis
In review 		Duration of hospital stay
5.3 days with percutaneous cholecystostomy within 8 hours of admission plus early cholecystectomy
15.2 days with medical treatment plus delayed cholecystectomy (8 weeks after full recovery)
MD –9.90 days
95% CI –12.31 to –7.49 days
P = 0.001 		Effect size not calculated percutaneous cholecystostomy plus early cholecystectomy
Postoperative complications

Systematic review		 70 people at high surgical risk (admitted with ASA grades II–IV; APACHE II score of 12 or higher) with acute cholecystitis
Data from 1 RCT		 Minor bile leak
1/31 (3%) with percutaneous cholecystostomy plus early cholecystectomy
0/30 (0%) with medical treatment plus delayed cholecystectomy
P = 1.00 		Not significant

RCT		 70 people at high surgical risk (admitted with ASA grades II–IV; APACHE II score of 12 or higher) with acute cholecystitis
In review 		Dislodgement of the drainage catheter
1/31 (3%) with percutaneous cholecystostomy plus early cholecystectomy
Not applicable with medical treatment plus delayed cholecystectomy
Significance not assessed
Gallstone-related complications

Systematic review		 70 people at high surgical risk (admitted with ASA grades II–IV; APACHE II score of 12 or higher) with acute cholecystitis
Data from 1 RCT		 Pancreatitis
0/31 (0%) with percutaneous cholecystostomy plus early cholecystectomy
2/30 (6.7%) with medical treatment plus delayed cholecystectomy
P = 0.24 		Not significant
Open in a new tab

Mortality

Percutaneous cholecystostomy within 8 hours plus early cholecystectomy compared with medical treatment followed by delayed cholecystectomy We don't know whether percutaneous cholecystostomy followed by early cholecystectomy and medical treatment followed by delayed cholecystectomy differ in effectiveness at improving mortality in people at high surgical risk (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Mortality

Systematic review		 70 people at high surgical risk (admitted with ASA grades II–IV; APACHE II score of 12 or higher) with acute cholecystitis
Data from 1 RCT		 Death
0/37 with percutaneous cholecystostomy plus early cholecystectomy
1/33 with medical treatment plus delayed cholecystectomy
P = 0.47 		Not significant
Open in a new tab

Intra-operative outcomes

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Further information on studies

Conversion rate The RCT found no significant difference in rates of conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy between groups (2/31 [6%] with percutaneous cholecystostomy (PC) plus early cholecystectomy v 4/30 [13%] with medical treatment plus delayed cholecystectomy; P = 0.42).

Criteria for percutaneous cholecystostomy People randomised to the PC group (37 people) would receive early cholecystectomy if they achieved resolution of sepsis and an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of <12 within 96 hours after PC. Six patients in this first group had an APACHE II score of >12 after 96 hours, and were excluded from the study. Early LC was performed in the remaining 31 patients. In the delayed group (33 people), two people refused surgical treatment, and one person died owing to ongoing sepsis. These three people were excluded; the remaining 30 were included in the analysis.

The review reported that allocation concealment was unclear in the RCT, as was blinding of participants and outcome assessment. There were post-randomisation dropouts.

Comment

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

Percutaneous cholecystostomy followed by early cholecystectomy versus medical treatment followed by delayed cholecystectomy New systematic review added. Categorisation unchanged (likely to be beneficial).

BMJ Clin Evid. 2014 Aug 20;2014:0411.

Laparoscopic cholecystectomy

Summary

Laparoscopic cholecystectomy may reduce the duration of hospital admission and improve some intra-operative and postoperative outcomes compared with open cholecystectomy, but it may increase the risk of bile duct injury.

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

Routine abdominal drainage after uncomplicated laparoscopic cholecystectomy seems to increase wound infections compared with no drainage.

Benefits and harms

Laparoscopic cholecystectomy versus open cholecystectomy:

We found no systematic review but found four RCTs.

Morbidity

Laparoscopic cholecystectomy compared with open cholecystectomy Laparoscopic cholecystectomy seems no more effective at reducing postoperative pain (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Postoperative pain

RCT		 70 people with acute cholecystitis Pain score at discharge
2 with laparoscopic cholecystectomy
1 with open cholecystectomy
P = 0.165 		Not significant
Open in a new tab

No data from the following reference on this outcome.

Intra-operative outcomes

Laparoscopic cholecystectomy compared with open cholecystectomy We don’t know how laparoscopic cholecystectomy and open cholecystectomy compare at reducing the duration of surgery in people with acute cholecystitis. Laparoscopic cholecystectomy may be more effective at reducing the need for nasogastric tube (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Duration of surgery

RCT		 271 people with acute cholecystitis Mean duration of surgery
60 minutes with laparoscopic cholecystectomy
90 minutes with open cholecystectomy
P <0.00001 		Effect size not calculated laparoscopic cholecystectomy

RCT		 63 people with acute cholecystitis Duration of surgery
108 minutes with laparoscopic cholecystectomy
99 minutes with open cholecystectomy
P = 0.49 		Not significant

RCT		 230 people with acute cholecystitis Duration of surgery
95 minutes with laparoscopic cholecystectomy
102 minutes with open cholecystectomy
Reported as not significant
P value not reported 		Not significant

RCT		 70 people with acute cholecystitis Median duration of surgery
90 minutes with laparoscopic cholecystectomy
80 minutes with open cholecystectomy
P = 0.04 		Effect size not calculated open cholecystectomy
Need for nasogastric tube

RCT		 271 people with acute cholecystitis Use of nasogastric tube
51% with laparoscopic cholecystectomy
94% with open cholecystectomy
P <0.0001 		Effect size not calculated laparoscopic cholecystectomy
Open in a new tab

Postoperative outcomes

Laparoscopic cholecystectomy compared with open cholecystectomy Laparoscopic cholecystectomy may be more effective at reducing the duration of hospital stay and postoperative use of analgesia in people with acute cholecystitis, but we don’t know how laparoscopic and open cholecystectomy compare at reducing postoperative complications (including haemorrhage, pneumonia, thrombosis, bile duct stones, bile leakage, and wound infections) in people with acute cholecystitis (very low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Duration of hospital stay

RCT		 271 people with acute cholecystitis Duration of hospital stay
3 days with laparoscopic cholecystectomy
7 days with open cholecystectomy
P <0.0001 		Effect size not calculated laparoscopic cholecystectomy

RCT		 63 people with acute cholecystitis Duration of hospital stay
4 days with laparoscopic cholecystectomy
14 days with open cholecystectomy
P = 0.0063 		Effect size not calculated laparoscopic cholecystectomy

RCT		 230 people with acute cholecystitis Duration of hospital stay
5.8 days with laparoscopic cholecystectomy
8.5 days with open cholecystectomy
Significance not assessed

RCT		 70 people with acute calculous cholecystitis Duration of hospital stay
1–10 days (median 2 days) with laparoscopic cholecystectomy
1–8 days (median 2 days) with open cholecystectomy
Absolute results reported graphically
Mean duration of stay was significantly longer with open surgery, although median duration of stay was the same in each group
P = 0.01 		Effect size not calculated laparoscopic cholecystectomy
Analgesic use

RCT		 271 people with acute cholecystitis Mean use of analgesia
75 mg pethidine with laparoscopic cholecystectomy
175 mg pethidine with open cholecystectomy
P <0.0001 		Effect size not calculated laparoscopic cholecystectomy
Postoperative complications

RCT		 271 people with acute cholecystitis Postoperative complications
24/146 (16%) with laparoscopic cholecystectomy
25/97 (26%) with open cholecystectomy
Reported as not significant
P value not reported 		Not significant

RCT		 63 people with acute cholecystitis Incidence of major postoperative complications
0% with laparoscopic cholecystectomy
23% with open cholecystectomy
Absolute results not reported
See Further information on studies for details of types of complication reported
P = 0.0048 for overall complication rate (includes major and minor complication rates) 		Effect size not calculated laparoscopic cholecystectomy

RCT		 63 people with acute cholecystitis Incidence of minor postoperative complications
3% with laparoscopic cholecystectomy
19% with open cholecystectomy
Absolute results not reported
See Further information on studies for details of types of complication reported
P = 0.0048 for overall complication rate (includes major and minor complication rates) 		Effect size not calculated laparoscopic cholecystectomy

RCT		 230 people with acute cholecystitis Postoperative complications
6/109 (6%) with laparoscopic cholecystectomy
14/116 (12%) with open cholecystectomy
postoperative complications were defined as haemorrhage, pneumonia, thrombosis, bile duct stones, bile leakage, or wound infections
Significance not assessed

RCT		 70 people with acute cholecystitis Postoperative complications
2/35 (6%) with laparoscopic cholecystectomy
3/35 (9%) with open cholecystectomy
postoperative complications included minor stroke, wound infection, and pneumonia
P = 0.65 		Not significant
Open in a new tab

Mortality

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Routine abdominal drainage versus no drainage in uncomplicated laparoscopic cholecystectomy:

We found one systematic review (search date 2007).

Postoperative outcomes

Routine abdominal drainage compared with no drain after uncomplicated laparoscopic cholecystectomy Drainage after uncomplicated laparoscopic cholecystectomy seems less effective at reducing wound infections and the proportion of people discharged on the same day (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Postoperative outcomes

Systematic review		 529 patients who had uncomplicated laparoscopic cholecystectomy
3 RCTs in this analysis		 Proportion of people with wound infection
8/261 (3.1%) with drain
1/268 (0.4%) with no drain
OR 5.86
95% CI 1.05 to 32.70
P = 0.04 		Large effect size no drain

Systematic review		 68 patients who had uncomplicated laparoscopic cholecystectomy
Data from 1 RCT		 Proportion of people discharged on same day as treatment
0/33 (0%) with drain
11/35 (31%) with no drain
OR 0.03
95% CI 0 to 0.57
P = 0.02 		Large effect size no drain
Open in a new tab

Mortality

No data from the following reference on this outcome.

Morbidity

No data from the following reference on this outcome.

Intra-operative outcomes

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Further information on studies

Conversion rate The RCT found that conversion from laparoscopic to open cholecystectomy was about 23%. Blood loss The RCT found no significant difference between groups in blood loss (3/35 [9%] in both the laparoscopic and open cholecystectomy groups had perioperative bleeding in excess of 500 mL; P = 1.0).

Population differences at baseline The people randomised to receive open cholecystectomy were, on average, 10 years older than people receiving laparoscopic cholecystectomy (P <0.001) and had a significantly higher incidence of comorbid conditions (P = 0.002) and gangrenous cholecystitis (P = 0.03). Conversion rate The RCT found that the rate of conversion from laparoscopic to open cholecystectomy was 27%. Complications Complications were classed 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).

Conversion rate The RCT reported that the rate of conversion from laparoscopic to open cholecystectomy was 16%. Complications 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.

Conversion rate The RCT reported a conversion rate from laparoscopic to open cholecystectomy of 5/109 (4%). Postoperative fall in haemoglobin 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).

One RCT included in the review (41 people randomised to suction drain v closed passive drain) suggested that suction drains carried less pain than passive drains.

Comment

Laparoscopic cholecystectomy versus open cholecystectomy:

One 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 cholecystectomy 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 cholecystectomy v 19–29/10,000 with open cholecystectomy; CI not reported) compared with open cholecystectomy.

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 <60 years (P = 0.004; no other data reported). The study reported that neither the duration of symptom history before 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.

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 may carry 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

No new evidence

BMJ Clin Evid. 2014 Aug 20;2014:0411.

Observation alone

Summary

Observation alone leads to a higher rate of gallstone-related complications.

Benefits and harms

Laparoscopic cholecystectomy versus no treatment/observation:

We found no systematic review or RCTs comparing only laparoscopic cholecystectomy versus no treatment. We found one RCT comparing cholecystectomy (laparoscopic or open) versus observation alone and one study reporting long-term follow-up of this RCT. For complications of cholecystectomy, see option on Laparoscopic cholecystectomy.

Morbidity

Observation alone compared with laparoscopic cholecystectomy Observation or no treatment seems no more effective than cholecystectomy at reducing the rate of gallstone-related complications (recurrent cholecystitis, pancreatitis, intractable pain) in people with acute cholecystitis (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Gallstone-related complications

RCT		 64 people with acute cholecystitis Gallstone-related events (admissions for pain, recurrent cholecystitis, and pancreatitis)
6/31 (19%) with cholecystectomy
12/33 (36%) with observation
P = 0.16 		Not significant
Open in a new tab

No data from the following reference on this outcome.

Mortality

Observation alone compared with cholecystectomy We don’t know if observation alone is more effective than cholecystectomy at reducing mortality at 14 months in people with acute cholecystitis (low-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Mortality

RCT		 64 people with acute cholecystitis Death at 14 months' follow-up
10/31 (32.3%) with cholecystectomy
8/33 (24.2%) with observation
Significance not assessed
Open in a new tab

No data from the following reference on this outcome.

Intra-operative outcomes

No data from the following reference on this outcome.

Postoperative outcomes

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Further information on studies

Operation rate 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 <0.0001). Complications The RCT found no significant difference in the rates of major or minor operative complications between those initially randomised to cholecystectomy and those who converted to cholecystectomy (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).

Comment

None.

Substantive changes

Observation alone New RCT added. Categorisation unchanged (trade-off between benefits and harms).

BMJ Clin Evid. 2014 Aug 20;2014:0411.

Open cholecystectomy

Summary

Open cholecystectomy is associated with longer hospital stay and more intra-operative and postoperative complications compared with laparoscopic cholecystectomy, but it may carry a lower risk of bile duct injury.

Routine abdominal drainage after uncomplicated open cholecystectomy may increase wound infections compared with using no drainage.

We don't know whether open cholecystectomy is more effective than no treatment or observation.

Benefits and harms

Open cholecystectomy versus no treatment/observation:

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

Open cholecystectomy versus laparoscopic cholecystectomy:

See option on Laparoscopic cholecystectomy.

Routine abdominal drainage versus no drainage in uncomplicated open cholecystectomy:

We found one systematic review (search date 2006).

Postoperative outcomes

Routine abdominal drainage compared with no drainage Routine abdominal drainage in uncomplicated open cholecystectomy seems less effective at reducing wound infections, or they may be equally effective at preventing other complications (moderate-quality evidence).

Ref (type) Population Outcome, Interventions Results and statistical analysis Effect size Favours
Postoperative outcomes

Systematic review		 3090 people with acute cholecystitis
17 RCTs in this analysis		 Proportion of people with wound infection
85/1594 (5%) with drain
51/1496 (3%) with no drain
OR 0.61
95% CI 0.43 to 0.87
P = 0.006 		Small effect size no drain

Systematic review		 2128 people with acute cholecystitis
12 RCTs in this analysis		 Proportion of people with chest infection
91/1138 (8%) with drain
53/990 (5%) with no drain
OR 0.84
95% CI 0.49 to 1.44
P = 0.52 		Not significant
Open in a new tab

Mortality

No data from the following reference on this outcome.

Morbidity

No data from the following reference on this outcome.

Intra-operative outcomes

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Further information on studies

The review reported that none of the included trials reported whether they used an intention-to-treat analysis, but that 17 (65%) of the 26 trials were considered high quality, with adequate allocation concealment and follow-up. None of the trials reported blinding of participants or outcome assessors. The review reported no statistically significant differences between drainage and no drainage in mortality, bile peritonitis, total abdominal collections, abdominal collections requiring different treatments, or infected abdominal collections.

Comment

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

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

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