H. G. Gooszen

Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis

BACKGROUNDnCholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Laparoscopic cholecystectomy was introduced in the 1980s.nnnOBJECTIVESnTo compare the beneficial and harmful effects of laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis.nnnSEARCH STRATEGYnWe searched TheCochrane Hepato-Biliary Group Controlled Trials Register (April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials.nnnSELECTION CRITERIAnAll published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied.nnnDATA COLLECTION AND ANALYSISnTwo authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed when appropriate.nnnMAIN RESULTSnThirty-eight trials randomised 2338 patients. Most of the trials had high bias risk. There was no significant difference regarding mortality (risk difference 0,00, 95% confidence interval (CI) -0.01 to 0.01). Meta-analysis of all trials suggests less overall complications in the laparoscopic group, but the high-quality trials show no significant difference (allocation concealment high-quality trials risk difference, random effects -0.01, 95% CI -0.05 to 0.02). Laparoscopic cholecystectomy patients have a shorter hospital stay (weighted mean difference (WMD), random effects -3 days, 95% CI -3.9 to -2.3) and convalescence (WMD, random effects -22.5 days, 95% CI -36.9 to -8.1) compared to open cholecystectomy.nnnAUTHORS CONCLUSIONSnNo significant differences were observed in mortality, complications and operative time between laparoscopic and open cholecystectomy. Laparoscopic cholecystectomy is associated with a significantly shorter hospital stay and a quicker convalescence compared with the classical open cholecystectomy. These results confirm the existing preference for the laparoscopic cholecystectomy over open cholecystectomy.

The Atlanta Classification of acute pancreatitis revisited.

In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed.

Timing and impact of infections in acute pancreatitis

Although infected necrosis is an established cause of death in acute pancreatitis, the impact of bacteraemia and pneumonia is less certain.

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis

BACKGROUNDnRestorative proctocolectomy with ileo pouch anal anastomosis (IPAA) is the main surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). With the advancements of minimal-invasive surgery this demanding operation is increasingly being performed laparoscopically. Therefore, the presumed benefits of the laparoscopic approach need to be systematically evaluated.nnnOBJECTIVESnTo compare the beneficial and harmful effects of laparoscopic versus open IPAA for patients with UC and FAP.nnnSEARCH STRATEGYnWe searched The Cochrane IBD/FBD Group Specialized Trial Register (April 2007), The Cochrane Library (Issue 1, 2007), MEDLINE (1990 to April 2007), EMBASE (1990 to April 2007), ISI Web of Knowledge (1990 to April 2007) and the web casts of the American Society of Colon and Rectal Surgeons (ASCRS) (up to 2006) for all trials comparing open versus laparoscopic IPAA.nnnSELECTION CRITERIAnAll trials in patients with UC or FAP comparing any kind of laparoscopic IPAA versus open IPAA. No language limitations were applied.nnnDATA COLLECTION AND ANALYSISnTwo authors independently performed selection of trials and data extraction. The methodological quality of all included trials was evaluated to assess bias risk. Analysis of RCTs and non-RCTs was performed separately. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate.nnnMAIN RESULTSnEleven trials included 607 patients of whom 253 (41%) in the laparoscopic IPAA group. Only one of the included trials was a randomised controlled trial. There were no significant differences in mortality or complications between the two groups. Reoperation and readmission rates were not significantly different. Operative time was significantly longer in the laparoscopic group both in the RCT and meta-analysis of non-RCTs (weighted mean difference (WMD) 91 minutes; 95% Confidence Interval (CI) 53 to 130). There were no significant differences between the two groups regarding postoperative recovery parameters. Total incision length was significantly shorter in the laparoscopic group, while two trials evaluating cosmesis found significantly higher cosmesis scores in the laparoscopic group. Other long-term outcomes were poorly reported.nnnAUTHORS CONCLUSIONSnThe laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable. Large high-quality trials focusing on differences regarding specific postoperative complications, cosmesis, quality of life and costs are needed.

Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis?

Objective In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking. Methods A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis. Results 315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p<0.001), persistent multiple organ failure (15% vs 36%, p<0.001), infected necrosis (16% vs 47%, p<0.001), intervention (18% vs 57%, p<0.001) and mortality (9% vs 20%, p<0.001). When infection of extrapancreatic necrosis developed, outcomes between groups were equal (mortality with infected necrosis: EXPN 28% vs pancreatic necrosis 18%, p=0.16). Conclusion EXPN causes fewer complications than pancreatic parenchymal necrosis. It should therefore be considered a separate entity in acute pancreatitis. Outcome in cases of infected necrosis is similar.

Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]

BackgroundInfected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes.Methods/DesignThe TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4xa0year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6xa0months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs.DiscussionThe TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.

Towards an update of the Atlanta classification on acute pancreatitis: Review of new and abandoned terms

Objectives: The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium. Methods: We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: phlegmon, infected pseudocyst, hemorrhagic pancreatitis, and persistent pancreatitis. Results: A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms hemorrhagic pancreatitis and persistent pancreatitis are hardly encountered, in contrast, both infected pseudocyst and phlegmon are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of organized pancreatic necrosis, necroma, extrapancreatic necrosis, and central gland necrosis. Conclusions: This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.

Robustness assessments are needed to reduce bias in meta-analyses that include zero-event randomized trials.

OBJECTIVES:Meta-analysis of randomized trials with binary data can use a variety of statistical methods. Zero-event trials may create analytic problems. We explored how different methods may impact inferences from meta-analyses containing zero-event trials.METHODS:Five levels of statistical methods are identified for meta-analysis with zero-event trials, leading to numerous data analyses. We used the binary outcomes from our Cochrane review of randomized trials of laparoscopic vs. small-incision cholecystectomy for patients with symptomatic cholecystolithiasis to illustrate the influence of statistical method on inference.RESULTS:In seven meta-analyses of seven outcomes from 15 trials, there were zero-event trials in 0 to 71.4% of the trials. We found inconsistency in significance in one of seven outcomes (14%; 95% confidence limit 0.4%–57.9%). There was also considerable variability in the confidence limits, the intervention-effect estimates, and heterogeneity for all outcomes.CONCLUSIONS:The statistical method may influence the inference drawn from a meta-analysis that includes zero-event trials. Robustness assessments are needed to reduce bias in meta-analyses that include zero-event trials.

Timing of cholecystectomy after mild biliary pancreatitis

The aim of the study was to evaluate recurrent biliary events as a consequence of delay in cholecystectomy following mild biliary pancreatitis.