Syllabi - General Surgery - Therapy Scenario
Read the article and decide:An obese 47 year old barrister is admitted under your care as an emergency with acute abdominal pain, and a diagnosis of acute gallstone-associated cholecystitis is made on ultrasound examination. You explain the likelihood of recurrent attacks and recommend surgery. Your patient is determined to return to work as soon as possible. Because of this, she indicates her preference for an immediate rather than a delayed cholecystectomy. You point out that the recovery time is likely to be longer if she has a conventional (non-mini) open cholecystectomy than if she has a laparoscopic procedure. She asks you whether the option of immediate laparoscopic operation is possible, as this seems to be the option which would allow her to return to work in the shortest time. You tell her that acute cholecystitis has, until recently, been regarded as a contraindication to laparoscopic cholecystectomy (LC), but that it is now being tried. She asks what the evidence is about its safety and efficacy. You decide, after talking with her further, that what she is seeking is evidence about the percentage of cases in which early laparoscopic cholecystectomy is feasible, and about whether it is as safe as early open cholecystectomy (has an equivalent incidence of serious and non-serious complications). You formulate the question: In people with acute cholecystitis can LC be carried out, and is the complication rate greater or less than that for open cholecystectomy?
A Medline search (using the terms 'laparascopic cholecystectomy' and 'open cholecystectomy') yields a recent Lancet paper, reporting a randomised controlled trial of Laparoscopic versus open (conventional incision) cholecystectomy in acute cholecystitis Lancet 1998; 351: 321-5.
- Is the evidence from this randomised trial valid?
- If valid, is it important?
- If valid and important, can you apply the evidence in caring for your patient?
Completed Therapy Worksheet for Evidence-Based General Surgery
Citation
Kiviluoto T, Siren J, Luukkonen P & Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998; 351: 321-5.Are the results of this therapy study valid?
- Was the assignment of patients to treatments randomised?
- Yes
- Were all patients who entered the trial accounted for at the conclusion? Were they analysed in the groups to which they were randomised?
- Yes
- Were patients and clinicians kept blind as to which treatment was being received?
- No
- Aside from the experimental treatment, were the groups treated equally?
- The management of suspected common bile duct stones was different in the two groups: This may have prolonged the mean operating time of the patients undergoing open cholecystectomy, because 60% of them had an operative cholangiogram added to the procedure.
- Were the groups similar at the start of the trial?
- Yes
Are the valid results of this randomised study important?
End points considered: hospital morbidity, length of hospital stay, length of time off work, percentage of LC converted to OC.
It is worth pointing out that, whilst physicians are usually interested in the percentage benefit from their treatments, and the percentage of their patients in which this occurs, there are many situations in which surgeons can reasonably expect a 100% response rate in all of their patients (as here, where it is impossible to get cholecystitis after the operation). In these situations, comparisons of different techniques must necessarily concentrate on minimising the adverse effects of the surgery. Many surgical publications deal mainly with these effects: The commonly used, generally applicable measures of adverse effects are:
- Mortality
- Morbidity (defined as any adverse event related to the treatment, but usually applied only to COMPLICATIONS, defined as adverse effects of treatment which are NOT INEVITABLE)
- Hospital Stay
- Pain (from the operation)
- Time off Work
Calculations
Hospital morbidity
| OC Complication Rate (CER) |
LC Complication Rate (EER) |
RRR | ARR | NNT |
|---|---|---|---|---|
| 42% | 3% (19%)* | 93% (55%)* | 38% (23%)* | 2.6 (4.3)* |
| 95% CI on NNT = +/- 0.25 (0.21) *(IF CONVERSION TO OC IS COUNTED AS A COMPLICATION) | ||||
Length of morbidity
| OC median stay (CER) |
LC median stay (EER) |
HSR |
|---|---|---|
| 6 days | 4 days | 1.5 |
Length of time off work
| OC sick leave > 2/52* (CER) |
LC sick leave > 2/52* (EER) |
RRR | ARR | NNT |
|---|---|---|---|---|
| 100% | 40% | 60% | 60% | 1.67 |
|
95% CI on NNT = +/- 0.06 *arbitrary cut-off point chosen by reviewer |
||||
Percentage of LC converted to OC
Calculations inapplicable: rate was 16%Can you apply this valid, important evidence in caring for your patient?
These results apply to my patient?
- Is your patient so different from those in the trial that its results can't help you?
- No: similar
- How great would the potential benefit of therapy actually be for my patient?
- Method I: Risk of (complications or conversion to OC) in my patient relative to risk in the trial, expressed as a decimal : presumed to be 1.
NNT/f = 4.3
-
Method II: Your patient's expected event rate if they received the control treatment:
1 / (PEERxRRR)
= 1 / (42%x55%)
= 4.32 - Are my patient's values and preference satisfied by the regimen and its consequences?
Needs to be assessed in each patient, but YES for the patient described.
Clinical Bottom Line
This was a small study, and the difference in the rate of complications between the groups was really quite surprising, since most uncontrolled reports have shown the biggest risk of complications is amongst LC patients who undergo conversion to OC. The LC were all carried out by experts, whilst the OC were mostly carried out by trainees. As with many surgical trials, adequate blinding could not be carried out. This may have influenced length of hospital stay (see Squirrel et al, Surgery 1998; 123: 485-95). Overall, the conclusion that LC is better has to be regarded with some caution.Additional Notes
-Acute Cholecystitis - Lap chole may be as safe as open chole
Clinical Bottom Line
Acute Cholecystitis - Lap chole may be as safe as open chole.Citation
Kiviluoto T, Siren J, Luukkonen P & Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998; 351: 321-5.Clinical Question
In patients with acute cholecystectomy, what is the complication rate of laparascopic cholecystectomy versus open cholecystectomy?Search Terms
laparascopic cholecystectomy and open cholecystectomy and cholecystitis in Medline.The Study
- Non-blinded randomised controlled trial without intention-to-treat.
- The Study Patients: patients with acute cholecystitis
- Control group (N = 31; analysed): open cholecystectomy
- Experimental group (N = 32; analysed): lap chole
The Evidence
| Outcome | CER | EER | RRR | ARR | NNT |
|---|---|---|---|---|---|
| Complication from surgery | 42% | 3% | 93% | .39 | (2 to 5) |
| Complication including conversion to open chole | 42% | 19% | 55% | .23 | 4 (2 to 106) |
Comments
- small study
- lap chole carried out by experts while open chole mostly carried out by trainees
