2012/08/28 Presented by PGY: 沈世閔 EBM report 2012/08/28 Presented by PGY: 沈世閔 1 1 1

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將問題寫成PICOT P I C O Cholelithiasis Laparoscopic cholecystectomy Without laparoscopic cholecystectomy O Prognosis 3

Key words Cholelithiasis (gallstone) Cholecystectomy Gallbladder cancer Postcholecystectomy syndrome 4

Literature search UpToDate Pubmed The cochrance collaboration 5

Asymptomatic cholelithiasis: is cholecystectomy really needed Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy Dig Dis Sci. 2007 May;52(5):1313-25. Epub 2007 Mar 28 Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis 6

Recurrence of acute gallstone pancreatitis and relationship with cholecystectomy or endoscopic sphincterotomy. J Gastroenterol. 2004;99(12):2417 Patients who did not undergo surgery after the first attack had 31-fold risk of recurrence 7

Failure to perform cholecystectomy for acute cholecystitis in elderly patients is associated with increased morbidity, mortality, and cost. J Am Coll Surg. 2010;210(5):668 Compared to patients who underwent cholecystectomy in the initial hospitalization, patients who were discharged without surgery were more likely to require readmission (38 versus 4 percent) and had higher mortality (hazard ratio 1.56, 95% CI 1.47-1.65) over the following two years. 8

Review Postcholecystectomy syndrome (PCS) International Journal of Surgery 8 (2010) 15–17 The incidence of postcholecystectomy syndrome has been reported to be as high as 40% in one study, and the onset of symptoms may range from 2 days to 25 years Textbook of gastroenterology. 2nd ed. Philadelphia: Lippincott; 1995 [chapter 104] In one study, the incidence of recurrent symptoms among female patients was 43%, compared to 28% among male patients Cystic duct remnant after cholecystectomy: incidence studied by cholegraphy in 500 cases, and significance in 103 reoperations. Ann Surg 1966;163:382–90 9

Gallstones, cholecystectomy and risk of cancers of the liver, biliary tract and pancreas British Journal of Cancer (1999) 79(3/4), 640–644 Non-cholecystectomy group: risks for cancers of liver and gallbladder remained significantly elevated at 5 or more years of follow-up risks for cancers of extrahepatic bile duct, ampulla of Vater and pancreas declined to near unity at 5 or more years of follow-up Cholecystectomy group: risks for cancers of liver and extrahepatic bile duct cancers dropped at 5 or more years of follow-up risks for cancers of ampulla of Vater and pancreas remained elevated, with the excess of pancreas cancer being statistically significant throughout follow-up 10

Reviewers' conclusions Asymptomatic cholelithiasis: not indicated for most subjects with asymptomatic cholelithiasis Symptomatic cholelithiasis: high recurrent rate and readmission rate PCS: The incidence of postcholecystectomy syndrome has been reported to be as high as 40% Non-cholecystectomy versus Cholecystectomy: Elevate risk of cancers of liver and gallbladder versus elevate risk of cancers of ampullar of vater and pancrease 11

Clinical practice Asymptomatic cholelithiasis: not indicated for most subjects with asymptomatic cholelithiasis Symptomatic cholelithiasis: favor cholecystectomy for symptoms relieving but should discussed with patient about the associated factors and takes option which patient 12

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