Early laparoscopy for the evaluation of nonspecific abdominal pain: a critical appraisal of the evidence

Abstract

Patients with nonspecific abdominal pain (NSAP) are frequently seen in emergency departments. Different studies have suggested that early laparoscopy (EL) could be an adequate tool to accelerate diagnosis and therapy. The aim of this study was to assess the effectiveness of EL in terms of diagnosis, persistence of NSAP, mortality, morbidity, cost, hospital stay, and quality of life relative to observation in NSAP. We performed a systematic review to identify randomized controlled trials (RTC) comparing EL versus active observation (AO) in NSAP. The primary outcomes were the number of patients with positive and negative findings, the utility for each group, and the cases with persistence of NSAP. Methodologic quality was assessed using the recommendations of the Cochrane Collaboration. Five studies that included a total of 921 patients were included: 460 in the EL group and 461 in the AO group. The use of an important methodologic heterogeneity between included studies avoided a pooled analysis. Data suggested that EL performed better in establishing a final diagnosis (79.2-96.9%) vs. AO (28.1-78.1%); however, the final therapeutic utility of laparoscopy was lower than the diagnostic rate (10.9-86.5%). The mortality rate of EL was similar to AO, and morbidity ranged from 1.15 to 23.72% in EL compared with the range from 1.9 to 31.14% in AO. The length of hospital stay ranged from 1.3 to 4.18 days in EL compared with the range from 2 to 7.3 days in AO. There is an important heterogeneity between the populations and in the degree of methodologic quality in the included studies. Data suggest that EL performs better in establishing a final diagnosis after admission, but the lack of uniform information does not allow for the recommendation of EL as a routine strategy in clinical practice. We recommend that a large trial be conducted with specific operative characteristics to solve problems identified in primary trials.