Gurusamy K S, Samraj K
Royal Free Hospital, Surgery, 291 Greenhaven Drive, Thamesmead, London, UK.
Cochrane Database Syst Rev. 2006 Oct 18(4):CD005440. doi: 10.1002/14651858.CD005440.pub2.
Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% become symptomatic in a year. Cholecystectomy for symptomatic gallstones is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
The aim was to compare the early laparoscopic cholecystectomy (less than seven days of onset of symptoms) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission) with regards to benefits and harms.
We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation IndexExpanded until November 2005.
We considered for inclusion all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis.
We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis.
We included five trials with 451 patients randomised: 223 to the early group and 228 to the delayed group. Surgery was performed on 222 patients in the early group and on 216 patients in the delayed group. There was no mortality in any of the trials. Four of the five trials were of high methodological quality. There was no statistically significant difference between the two groups for any of the outcomes including bile duct injury (OR 0.63, 95% CI 0.15 to 2.70) and conversion to open cholecystectomy (OR 0.84, 95% CI 0.53 to 1.34). Various other analyses including 'available case analysis', risk difference, statistical methods to overcome the 'zero-event trials' showed no statistically significant difference between the two groups in any of the outcomes measured. A total of 40 patients (17.5%) from the delayed group had to undergo emergency laparoscopic cholecystectomy due to non-resolving or recurrent cholecystitis; 18 (45%) of these had to undergo conversion to open procedure. The total hospital stay was about three days shorter in the early group compared with the delayed group.
AUTHORS' CONCLUSIONS: Early laparoscopic cholecystectomy during acute cholecystitis seems safe and shortens the total hospital stay. The majority of the outcomes occurred rarely; hence, the confidence intervals are wide. Therefore, further randomised trials on the issue are needed.
在西方成年人群中，约10%至15%的人患有胆结石。每年有1%至4%的患者出现症状。由于担心急性胆囊炎发作期间进行症状性胆结石胆囊切除术时发病率较高以及腹腔镜胆囊切除术转为开腹胆囊切除术的几率增加，所以主要在急性胆囊炎发作平息后进行该手术。
比较早期腹腔镜胆囊切除术（症状出现后不到7天）与延迟腹腔镜胆囊切除术（首次入院后超过6周）的利弊。
我们检索了Cochrane肝胆疾病组对照试验注册库、Cochrane图书馆中的Cochrane对照试验中央注册库（CENTRAL）、MEDLINE、EMBASE和科学引文索引扩展版，检索截至2005年11月。
我们纳入了所有比较急性胆囊炎早期与延迟腹腔镜胆囊切除术的随机临床试验。
我们从每个试验中收集了关于试验特征、试验方法学质量、死亡率、发病率、转化率、手术时间和住院时间的数据。我们使用RevMan分析软件，采用固定效应模型和随机效应模型对数据进行分析。对于每个结局，我们基于意向性分析计算了比值比（OR）及95%置信区间（CI）。
我们纳入了5项试验，共451例患者被随机分组：223例进入早期组，228例进入延迟组。早期组222例患者接受了手术，延迟组216例患者接受了手术。所有试验均无死亡病例。5项试验中有4项方法学质量较高。两组在包括胆管损伤（OR 0.63，95%CI 0.15至2.70）和转为开腹胆囊切除术（OR 0.84，95%CI 0.53至1.34）在内的任何结局方面均无统计学显著差异。包括“可用病例分析”、风险差异、克服“零事件试验”的统计方法在内的各种其他分析显示，两组在任何测量结局方面均无统计学显著差异。延迟组共有40例患者（17.5%）因胆囊炎未缓解或复发而不得不接受急诊腹腔镜胆囊切除术；其中18例（45%）不得不转为开腹手术。早期组的总住院时间比延迟组短约3天。
急性胆囊炎期间早期腹腔镜胆囊切除术似乎安全且可缩短总住院时间。大多数结局发生频率较低；因此，置信区间较宽。所以，需要针对该问题开展进一步的随机试验。
