PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of bmjclinevidLink to Publisher's site
 
Clin Evid (Online). 2011; 2011: 0411.
Published online Dec 2, 2011.
PMCID: PMC3275134
Acute cholecystitis
Dr Valerie Halpin, Bariatric and General Surgeon# and Aditya Gupta, Fellow, Bariatric/Minimally Invasive Surgery#
Dr Valerie Halpin, Legacy Good Samaritan Hospital, Portland, OR, USA;
#Contributed equally.
VH and AG declare that they have no competing interests.
We would like to acknowledge the previous contributors of this review: Robb Whinney and Elizabeth Fialkowski.
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 April 2011 (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 17 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, open cholecystectomy, and percutaneous cholecystostomy.
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 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 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.
  • Minilaparoscopic surgery may be associated with slightly longer operative times than laparoscopic surgery, although it may reduce pain scores and the need for postoperative analgesia.
Routine abdominal drainage in both uncomplicated laparoscopic and open cholecystectomy is associated with an increase in wound infections compared with no drainage.
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).[1] 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.[1] The number of cholecystectomies carried out for acute cholecystitis increased from the mid 1980s to the early 1990s, especially in older people.[2] 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.[1]
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.[3] [4] The cause of acute acalculous cholecystitis is uncertain and may be multifactorial, including increased susceptibility to bacterial colonisation of static gallbladder bile.[1]
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%.[5]
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 April 2011. The following databases were used to identify studies for this systematic review: Medline 1966 to April 2011, Embase 1980 to April 2011, and The Cochrane Database of Systematic Reviews, Issue 1, 2011 (1966 to date of issue). An additional search within The Cochrane Library was carried out for the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews of RCTs and RCTs in any language, with any level of blinding (including "open" studies), and containing any number of individuals of whom at least 80% were followed up. There was no minimum length of follow-up required to include studies. We included systematic reviews of RCTs and RCTs where harms of an included intervention were studied 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
Table
GRADE Evaluation of interventions for Acute cholecystitis.
Glossary
Laparoscopic cholecystectomyLaparoscopic 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 evidenceFurther 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 cholecystectomyThis procedure involves removal of the gallbladder using a projection camera and 2–3-mm trocar ports.
Moderate-quality evidenceFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Open cholecystectomyOpen 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 evidenceAny estimate of effect is very uncertain.

Notes
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
Dr Valerie Halpin, Legacy Good Samaritan Hospital, Portland, OR, USA.
Aditya Gupta, Legacy Health System, Portland, USA.
1. Indar AA, Beckingham IJ. Acute cholecystitis. BMJ2002;325:639–643. [PMC free article] [PubMed]
2. Diettrich NA, Cacioppo JC, Davis RP. The vanishing elective cholecystectomy. Arch Surg1988;123:810–814. [PubMed]
3. Fukunaga FH. Gallbladder bacteriology, histology and gallstones: study of unselected cholecystectomy specimens in Honolulu. Arch Surg1973;106:169–171. [PubMed]
4. Lou MA, Mandal AK, Alexander JL, et al. Bacteriology of the human biliary tract and the duodenum. Arch Surg1977;112:965–967. [PubMed]
5. Isch JH, Finneran JC, Nahrwold DL. Perforation of the gallbladder. Am J Gastroenterol1971;55:451–458. [PubMed]
6. Papi C, Catarci M, D'Ambrosio L, et al. Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis. Am J Gastroenterol2004;99:147–155. [PubMed]
7. Shikata S, Noguchi Y, Fukui T. Early versus delayed cholecystectomy for acute cholecystitis: a meta-analysis of randomized controlled trials. Surg Today2005;35:553–560. [PubMed]
8. Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. In: The Cochrane Library, Issue 1, 2011. Chichester, UK: John Wiley & Sons, Ltd. Search date 2005. [PubMed]
9. Siddiqui T, MacDonald A, Chong PS, et al. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials. Am J Surg2008;195:40–47. [PubMed]
10. Lau H, Lo CY, Patil NG, et al. Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis. Surg Endosc2006;20:82–87. [PubMed]
11. Gurusamy K, Samraj K, Gluud C, et al. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg2010;97:141–150. [PubMed]
12. Johansson M, Thune A, Blomqvist A, et al. Impact of choice of therapeutic strategy for acute cholecystitis on patient's health-related quality of life. Results of a randomized, controlled clinical trial. Dig Surg2004;21:359–362. [PubMed]
13. Akyurek N, Salman B, Yuksel O, et al. Management of acute calculous cholecystitis in high-risk patients: percutaneous cholecystotomy followed by early laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech2005;15:315–320. [PubMed]
14. Johansson M, Thune A, Nelvin L, et al. Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis. Br J Surg2005;92:44–49. [PubMed]
15. Eldar S, Sabo E, Nash E, et al. Laparoscopic versus open cholecystectomy in acute cholecystitis. Surg Laparosc Endosc1997;7:407–414. [PubMed]
16. Kiviluoto T, Siren J, Luukkonen P, et al. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet1998;351:321–325. [PubMed]
17. Schiedeck THK, Schulte T, Gunarsson R, et al. Laparoscopic cholecystectomy in acute cholecystitis. Minim Invasive Chirurg 1997;6:48–51.
18. Gurusamy KS, Samraj K, Ramamoorthy R, et al. Miniport versus standard ports for laparoscopic cholecystectomy. In: The Cochrane Library, Issue 1, 2011. Chichester, UK: John Wiley & Sons, Ltd. Search date 2010.
19. Gurusamy KS, Samraj K, Mullerat P, et al. Routine abdominal drainage for uncomplicated laparoscopic cholecystectomy. In: The Cochrane Library, Issue 1, 2011. Chichester, UK: John Wiley & Sons, Ltd. Search date 2007.
20. Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications associated with laparoscopic cholecystectomy: a meta-analysis. Ann Surg1996;224:609–620. [PubMed]
21. Vetrhus M, Berhane T, Soreide O, et al. Pain persists in many patients five years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis. J Gastrointest Surg2005;9:826–831. [PubMed]
22. Vetrhus M, Soreide O, Nesvik I, et al. Acute cholecystitis: delayed surgery or observation: a randomized clinical trial. Scand J Gastroenterol2003;38:985–990. [PubMed]
23. Gurusamy KS, Samraj K. Routine abdominal drainage for uncomplicated open cholecystectomy. In: The Cochrane Library, Issue 1, 2011. Chichester, UK: John Wiley & Sons, Ltd. Search date 2006.

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 6 systematic reviews (search dates 2001,[6] 2003,[7] 2005,[8] 2006,[9] [10] and 2010[11]) 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: for example, the 5 RCTs reported in the sixth review[11] included all 4 RCTs reported in the fourth review[9] and 3 of the 4 RCTs reported by the fifth review.[10] To minimise duplication of reporting, therefore, we have not reported all outcomes for all reviews where the same RCTs were reported. Additionally, as the most recent review[11] is an update of a previously reported review,[8] we report only the update here. The two oldest reviews[6] [7] 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
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Mortality
[6]
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
[6]
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
[7]
Systematic review
1014 people with acute cholecystitis
10 RCTs in this analysis
6 RCTs included in review[6]
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
[11]
Systematic review
451 people with acute cholecystitis
5 RCTs in this analysis
Mortality
with early laparoscopic cholecystectomy
with delayed laparoscopic cholecystectomy

Significance not assessed
Morbidity
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Morbidity
[6]
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
[6]
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
[7]
Systematic review
1014 people with acute cholecystitis
10 RCTs in this analysis
6 RCTs included in review[6]
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
[12]
RCT
145 people with acute cholecystitis
In review [7]
Data from 1 RCT
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 calculatedearly cholecystectomy
[12]
RCT
145 people with acute cholecystitis
In review [7]
Data from 1 RCT
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
[12]
RCT
145 people with acute cholecystitis
In review [7]
Data from 1 RCT
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
Postoperative outcomes
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Duration of hospital stay
[6]
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 calculatedearly cholecystectomy
[7]
Systematic review
1014 people with acute cholecystitis
10 RCTs in this analysis
6 RCTs included in review[6]
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 calculatedearly cholecystectomy
[11]
Systematic review
388 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 <0.001
Effect size not calculatedearly cholecystectomy
[9]
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 calculateddelayed cholecystectomy
[10]
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 calculatedearly cholecystectomy
Postoperative complications
[6]
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
[6]
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
[11]
Systematic review
451 people with acute cholecystitis
5 RCTs in this analysis
Proportion of people with bile duct injury
1/222 (0.5%) with early laparoscopic cholecystectomy
3/216 (1.5%) with delayed laparoscopic cholecystectomy

RR 0.64
95% CI 0.15 to 2.65
P = 0.54
Not significant
[9]
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
[10]
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
[10]
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
[10]
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
Intra-operative outcomes
No data from the following reference on this outcome.[6] [7] [9] [10] [11]
Quality of life
No data from the following reference on this outcome.[6] [7] [9] [10] [11]
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: 45/222 [20%] people with early cholecystectomy v 51/216 [24%] with delayed cholecystectomy; RR 0.88, 95% CI 0.65 to 1.25.
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 evidence added.[9] [10] [11] Categorisation unchanged (Beneficial).

Percutaneous cholecystostomy followed by early cholecystectomy versus medical treatment followed by delayed cholecystectomy
Summary
Early percutaneous cholecystectomy followed by early cholecystectomy may lead to reduced duration of hospital stay and reduce the time to symptomatic improvement.
Benefits and harms
Percutaneous cholecystostomy followed by early cholecystectomy versus medical treatment followed by delayed cholecystectomy:
We found one RCT.[13]
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 (low-quality evidence).
Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Symptom improvement
[13]
RCT
70 people at high surgical risk (American Society of Anesthesiologists [ASA] grades II–IV) 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 calculatedpercutaneous cholecystostomy plus early cholecystectomy
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 (low-quality evidence).
Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Duration of hospital stay
[13]
RCT
70 people at high surgical risk (American Society of Anesthesiologists [ASA] grades II–IV) with acute cholecystitis 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)

P = 0.001
Effect size not calculatedpercutaneous cholecystostomy plus early cholecystectomy
Postoperative complications
[13]
RCT
70 people with acute cholecystitis Minor bile leak
1/31 (3%) with percutaneous cholecystostomy plus early cholecystectomy
0/30 (0%) with medical treatment plus delayed cholecystectomy

Significance not assessed
[13]
RCT
70 people with acute cholecystitis Dislodgement of the drainage catheter
1/31 (3%) with percutaneous cholecystostomy plus early cholecystectomy
0/30 (0%) with medical treatment plus delayed cholecystectomy

Significance not assessed
Mortality
No data from the following reference on this outcome.[13]
Intra-operative outcomes
No data from the following reference on this outcome.[13]
Quality of life
No data from the following reference on this outcome.[13]
Further information on studies
Criteria for percutaneous cholecystostomy People randomised to the percutaneous cholecystostomy (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 laparoscopic cholecystectomy (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. Conversion rate The RCT found no significant difference in 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).
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
No new evidence

Laparoscopic cholecystectomy
Summary
Laparoscopic cholecystectomy may reduce the duration of hospital admission and improve 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.
Conventional laparoscopic surgery may be more effective than minilaparoscopic surgery at reducing operative times.
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 4 RCTs.[14] [15] [16] [17]
Morbidity
Compared with open cholecystectomy Laparoscopic cholecystectomy seems no more effective at reducing postoperative pain (moderate-quality evidence).
Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Postoperative pain
[14]
RCT
70 people with acute cholecystitis Pain score at discharge
2 with laparoscopic cholecystectomy
1 with open cholecystectomy

P = 0.165
Not significant
No data from the following reference on this outcome.[15] [16] [17]
Intra-operative outcomes
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Duration of surgery
[15]
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 calculatedlaparoscopic cholecystectomy
[16]
RCT
63 people with acute cholecystitis Duration of surgery
108 minutes with laparoscopic cholecystectomy
99 minutes with open cholecystectomy

P = 0.49
Not significant
[17]
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
[14]
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 calculatedopen cholecystectomy
Need for nasogastric tube
[15]
RCT
271 people with acute cholecystitis Use of nasogastric tube
51% with laparoscopic cholecystectomy
94% with open cholecystectomy

P <0.0001
Effect size not calculatedlaparoscopic cholecystectomy
Postoperative outcomes
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Duration of hospital stay
[15]
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 calculatedlaparoscopic cholecystectomy
[16]
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 calculatedlaparoscopic cholecystectomy
[17]
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
[14]
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 calculatedlaparoscopic cholecystectomy
Analgesic use
[15]
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 calculatedlaparoscopic cholecystectomy
Postoperative complications
[15]
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
[16]
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 calculatedlaparoscopic cholecystectomy
[16]
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 calculatedlaparoscopic cholecystectomy
[17]
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
[14]
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
Mortality
No data from the following reference on this outcome.[14] [15] [16] [17]
Quality of life
No data from the following reference on this outcome.[14] [15] [16] [17]
Laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy:
We found one systematic review (search date 2010) comparing minilaparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy.[18]
Intra-operative outcomes
Compared with minilaparoscopic cholecystectomy Conventional laparoscopic cholecystectomy seems more effective at reducing the duration of surgery (moderate-quality evidence).
Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Duration of surgery
[18]
Systematic review
777 people with acute cholecystitis
13 RCTs in this analysis
Mean duration of surgery
with laparoscopic cholecystectomy
with minilaparoscopic cholecystectomy
Absolute numbers not reported

Mean difference 4.82 minutes
95% CI 3.02 minutes to 6.61 minutes
P <0.00001
Effect size not calculatedlaparoscopic cholecystectomy
Postoperative outcomes
Compared with minilaparoscopic cholecystectomy Conventional laparoscopic cholecystectomy may be less effective at reducing postoperative pain scores at up to 24 hours, and at reducing the need of analgesia, but we don't know how conventional laparoscopic and minilaparoscopic cholecystectomy compare at reducing other postoperative outcomes including length of hospital stay (low-quality evidence).
Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Postoperative pain and analgesic use
[18]
Systematic review
175 people with acute cholecystitis
2 RCTs in this analysis
Postoperative pain scores 4 to 8 hours
with laparoscopic cholecystectomy
with minilaparoscopic cholecystectomy
Absolute numbers not reported

SMD –0.46
95% CI –0.76 to –0.16
P = 0.003
Effect size not calculatedminilaparoscopic cholecystectomy
[18]
Systematic review
215 people with acute cholecystitis
3 RCTs in this analysis
Postoperative pain scores 9 to 24 hours
with laparoscopic cholecystectomy
with minilaparoscopic cholecystectomy
Absolute numbers not reported

SMD –0.29
95% CI –0.56 to –0.02
P = 0.02
Effect size not calculatedminilaparoscopic cholecystectomy
[18]
Systematic review
215 people with acute cholecystitis
4 RCTs in this analysis
Mean opiate use 9 to 24 hours
with laparoscopic cholecystectomy
with minilaparoscopic cholecystectomy
Absolute numbers not reported

SMD –0.40
95% CI –0.68 to –0.13
P = 0.004
Effect size not calculatedminilaparoscopic cholecystectomy
Duration of hospital stay
[18]
Systematic review
315 people with acute cholecystitis
5 RCTs in this analysis
Mean duration of hospital stay
with laparoscopic cholecystectomy
with minilaparoscopic cholecystectomy
Absolute numbers not reported

SMD –0.28 days
95% CI –0.61 days to +0.04 days
P = 0.09
Not significant
Patient satisfaction
[18]
Systematic review
40 people with acute cholecystitis
Data from 1 RCT
Patient satisfaction scores
2.49 with laparoscopic cholecystectomy
2.37 with minilaparoscopic cholecystectomy

SMD –0.03
95% CI –0.65 to +0.59
P = 0.93
Not significant
Postoperative complications
[18]
Systematic review
317 people with acute cholecystitis
6 RCTs in this analysis
Proportion of people with wound infection
2/172 (1%) with laparoscopic cholecystectomy
6/145 (4%) with minilaparoscopic cholecystectomy

RR 0.39
95% CI 0.11 to 1.48
P = 0.17
Not significant
[18]
Systematic review
212 people with acute cholecystitis
3 RCTs in this analysis
Proportion of people with bile duct injury
0/117 (0%) with laparoscopic cholecystectomy
2/95 (2%) with minilaparoscopic cholecystectomy

RR 0.26
95% CI 0.01 to 5.11
P = 0.17
Not significant
Mortality
No data from the following reference on this outcome.[18]
Morbidity
No data from the following reference on this outcome.[18]
Quality of life
No data from the following reference on this outcome.[18]
Routine abdominal drainage versus no drainage in uncomplicated laparoscopic cholecystectomy:
We found one systematic review (search date 2007).[19]
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Postoperative outcomes
[19]
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 sizeno drain
[19]
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 sizeno drain
Mortality
No data from the following reference on this outcome.[19]
Morbidity
No data from the following reference on this outcome.[19]
Intra-operative outcomes
No data from the following reference on this outcome.[19]
Quality of life
No data from the following reference on this outcome.[19]
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).
Conversion rate The review found no significant difference between minilaparoscopic and conventional laparoscopic cholecystectomy in the rate of conversion to open cholecystectomy (12 RCTs, 752 people; conversion: 12/391 [3.1%] people with minilaparoscopic cholecystectomy v 13/361 [3.6%] people with conventional laparoscopic cholecystectomy; RR 0.97, 95% CI 0.45 to 2.08).
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.[15] We found one systematic review in people with symptomatic gallstones, which did not differentiate between people with and without acute cholecystitis.[20] 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.[21] 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 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.[21]
Laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy:
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 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
Laparoscopic cholecystectomy Two Cochrane systematic reviews added.[18] [19] Categorisation unchanged (Beneficial).

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.[22] For complications of cholecystectomy, see option on laparoscopic cholecystectomy.
Morbidity
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Gallstone-related complications
[22]
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
Mortality
No data from the following reference on this outcome.[22]
Intra-operative outcomes
No data from the following reference on this outcome.[22]
Postoperative outcomes
No data from the following reference on this outcome.[22]
Quality of life
No data from the following reference on this outcome.[22]
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
No new evidence

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).[23]
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)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Postoperative outcomes
[23]
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 sizeno drain
[23]
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
Mortality
No data from the following reference on this outcome.[23]
Morbidity
No data from the following reference on this outcome.[23]
Intra-operative outcomes
No data from the following reference on this outcome.[23]
Quality of life
No data from the following reference on this outcome.[23]
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
Open cholecystectomy New evidence added.[23] Categorisation unchanged (Trade-off between benefits and harms).

Minilaparoscopic cholecystectomy
Summary
Minilaparoscopic surgery may be associated with slightly longer operative times compared with laparoscopic surgery, although it may reduce pain scores and the need for analgesia.
Benefits and harms
Minilaparoscopic cholecystectomy versus no treatment/observation:
We found no systematic review or RCTs comparing only minilaparoscopic cholecystectomy versus no treatment.
Minilaparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy:
See option on laparoscopic cholecystectomy.
Further information on studies
None.
Comment
None.
Substantive changes
Minilaparoscopic cholecystectomy New evidence added.[18] Categorisation unchanged (Unknown effectiveness).
Articles from Clinical Evidence are provided here courtesy of
BMJ Publishing Group