Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis

Abstract

The collective review by Lau et al. [3] is a clear exposition of early laparoscopic cholecystectomy for acute cholecystitis, but it contains some shortcomings in literature selection. On the one hand, the metaanalysis included one pseudorandomized trial, which was not randomized at all, whereas, on the other hand, it omitted one randomized trial. Although the authors reference the article published by Chandler et al. [1], the reported randomized trial is not included in the metaanalysis. Furthermore, another trial was published in the meantime [2], but was not yet included by Lau et al. because their literature search was updated last in June 2004. The study by Serralta et al. [5] cannot be considered as pseudorandomized because the study authors explicitly describe that ‘‘patients assignments depended on the surgeons experience in laparoscopic surgery’’. It is no surprise, therefore, that the operation time was much shorter for the patients treated by early laparoscopy. In fact, the study by Serralta et al. is only one of many nonrandomized controlled investigations on this topic. In a pseudo(or quasi-) randomized trial, patients assignment to treatment arms is based on an unconcealed random criterion such as date of birth (odd vs even), date of admission, or insurance number [4]. Any ‘‘randomization by on-call schedule’’ is certainly no valid method of randomization. When only data from properly randomized trials is used (and unreported standard deviations are estimated from mean values), the main advantage of early laparoscopic surgery turns out to be shortening of the hospital stay by more than 3 days (Fig. 1). Conversion rates are similar. I therefore concur with the overall conclusion of Lau et al. [3] on the better cost effectiveness of early cholecystectomy for acute cholecystitis.