Review question

There is considerable controversy regarding how long one should wait after a sudden attack of acute gallstone pancreatitis before removing the gallbladder.

We set out to answer this question by performing a thorough search of the literature for studies which compared the different times at which laparoscopic cholecystectomy was performed. We included only randomised controlled trials (studies which can help avoid arriving at wrong conclusions if designed and conducted appropriately). We searched the literature for all studies reported until January 2013. Two authors independently assessed trials for inclusion and independently extracted data to minimise errors. We considered 'early' laparoscopic cholecystectomy as laparoscopic cholecystectomy performed within three days of onset of symptoms. We considered all laparoscopic cholecystectomies performed beyond three days of onset of symptoms as 'delayed'. For severe acute pancreatitis, we considered 'early' laparoscopic cholecystectomy as laparoscopic cholecystectomy performed within the same admission as the sudden attack of pancreatitis. We considered all laparoscopic cholecystectomies performed in a subsequent admission as 'delayed'.

Background

The pancreas is an abdominal organ that secretes several digestive juices which help in the digestion of food. It also lodges the insulin-secreting cells which maintain the blood sugar levels. Acute pancreatitis is a sudden inflammatory process in the pancreas which might involve nearby organs or may have an effect on other organ systems including blood circulation. Depending upon the presence of organ failure (such as kidneys, lungs or blood circulation) and the presence of local complications such as fluid collection around the pancreas, pancreatitis can be classified as severe acute pancreatitis or mild acute pancreatitis. People with severe pancreatitis have organ failure or local complications, or both, while those with mild pancreatitis do not have such features. The two main causes of acute pancreatitis are gallstones and alcohol, accounting for more than 80% of acute pancreatitis. Removal of the gallbladder (cholecystectomy) is the definitive treatment for prevention of further attacks of acute gallstone pancreatitis if the person is suitable for surgery. Laparoscopic removal (key-hole surgery) of the gallbladder is the currently preferred method of cholecystectomy with more than 99% of patients recovering completely without any major ill health.

Study characteristics

We identified one trial comparing early versus delayed laparoscopic cholecystectomy for people with mild acute pancreatitis. Out of the 50 participants included in this trial, 25 underwent early laparoscopic cholecystectomy while the remaining 25 underwent delayed laparoscopic cholecystectomy. All 50 participants were alive at the end of the trial. There was no significant difference between the two groups in the proportion of participants who developed complications. Health-related quality of life was not reported in this trial. There were no conversions to open cholecystectomy in either group. The total hospital stay was shorter by approximately two days in the early laparoscopic cholecystectomy group than in the delayed laparoscopic cholecystectomy group. The trial did not report the number of work-days lost or the costs. We did not identify any trials comparing early versus delayed laparoscopic cholecystectomy after severe acute pancreatitis.

Key results

Based on the observations in the one trial included in this review, there appears to be no evidence of increased risk of complications after early laparoscopic cholecystectomy. Early laparoscopic cholecystectomy may shorten the total hospital stay in people with mild acute pancreatitis. If appropriate facilities and expertise are available, early laparoscopic cholecystectomy appears preferable to delayed laparoscopic cholecystectomy in people with mild acute pancreatitis. There is currently no evidence to support or refute early laparoscopic cholecystectomy for people with severe acute pancreatitis. Further well-designed randomised controlled trials are necessary in people with mild acute pancreatitis and severe acute pancreatitis.

Quality of the evidence

The one trial identified is at high risk of bias, i.e. there was potential to arrive at wrong conclusions because of the way that the study was designed and conducted.