Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Laparoscopic cholecystectomy led to shorter hospital stays and shorter duration of convalescence in patients with symptomatic cholelithiasis

ACP J Club. 1993 May-June;118:68. doi:10.7326/ACPJC-1993-118-3-068


Source Citation

Barkun JS, Barkun AN, Sampalis JS, et al. Randomised controlled trial of laparoscopic versus mini cholecystectomy. Lancet. 1992 Nov 7;340:1116-9.


Abstract

Objective

To compare elective laparoscopic cholecystectomy (LC) and mini-cholecystectomy (MC) for length of hospitalization and duration of convalescence.

Design

Randomized controlled trial with 3-month follow-up.

Setting

5 university hospitals in Canada.

Patients

70 patients with at least 1 episode of right upper-quadrant or epigastric pain and ultrasound-proven cholelithiasis who presented for elective cholecystectomy were studied. Exclusion criteria were being unfit for general anesthesia, previous upper abdominal surgery, pregnancy, clinical suspicion of a common bile duct stone, or eligibility for lithotripsy treatment. 89% of patients had follow-up data.

Intervention

All 8 surgeons had done ≥ 30 LCs and could do both LC and MC. LC was done under general anesthesia with European or North American trocar positions. MC was done by a small transverse or mid-line incision. 38 patients were allocated to LC, but 1 withdrew after randomization. 32 patients were allocated to MC, but 3 withdrew and 4 chose nonstudy LC.

Main outcome measures

Analysis was by intention-to-treat. Primary end points were length of hospital stay and duration of convalescence. Secondary end points were postoperative pain and quality of life (3 indices).

Main results

Compared with patients who received MC, patients who received LC had a shorter hospital stay (median 3 vs 4 d, P = 0.001), a shorter mean duration of convalescence (12 vs 20 d, P = 0.04), and used fewer postoperative narcotics (mean 17 vs 79 mg morphine equivalents, P < 0.001). Using a Cox proportional hazards analysis, the rate of return to normal activities was 1.8 (95% CI 1.01 to 3.11, P = 0.03) times faster for the LC group than for the MC group. The groups did not differ for length of surgery (86 min for LC vs 73 min for MC), postoperative McGill Pain Index scores (16 for LC vs 22 for MC), or improvement in quality of life scores, although the latter scores improved faster in the LC group than in the MC group.

Conclusion

Patients with symptomatic cholelithiasis who had laparoscopic cholecystectomy had a shorter hospital stay and shorter duration of convalescence than patients who had mini-cholecystectomy.

Sources of funding: Medical Research Council of Canada University-Industrial Clinical trial grant in partnership with Ethicon Limited and the Fonds de la Recherche en Santé du Quebec.

For article reprint: Dr. J.L. Meakins, Department of Surgery, Room S10.34, Royal Victoria Hospital, 687 Pine Avenue W., Montreal, Quebec H3A 1A1, Canada. FAX 514-843-1503.


Commentary

Although few well-controlled clinical trials have been done, for many surgeons LC has already become the procedure of choice for treatment of patients with symptomatic gallstones. LC is associated with shorter hospital stays, faster postoperative recoveries, and less postoperative pain than traditional open cholecystectomy. MC is also associated with shorter hospital stays and faster recoveries than traditional open cholecystectomy but has not received as much attention as LC.

This randomized controlled trial by Barkun and colleagues shows that for patients with symptomatic gallbladder stones, LC yields shorter hospital stays, faster return to full activity, and less postoperative pain than MC. The shorter hospitalizations and faster returns to full activity should yield major cost savings to patients, the health care system, and society.

This study was not large enough to assess potential differences in operative mortality or complications such as bile duct injury or retained bile duct stones, and some concerns exist that LC may be associated with a slightly increased risk for bile duct injury (1). Although the panel at a recent National Institutes of Health Consensus Conference concluded that LC is a safe and effective treatment for most patients with symptomatic gallstones, the panel emphasized that adequate training in doing this new procedure is needed to minimize the risk for complications (2).

Eric B. Bass, MD, MPH
Johns Hopkins UniversityBaltimore, Maryland, USA


References

1. Moosa AR, Easter DW, Van Sonnenberg E, Casola G, D'Agostino H. Laparoscopic injuries to the bile duct. A cause for concern. Ann Surg. 1992;215:203-8.

2. NIH Consensus Development Conference. Gallstones and laparoscopic cholecystectomy. JAMA. 1993;269:1018-24.