Therapy: Clinical Scenario
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.
Read the article and decide:
- 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?