Assessment of available evidence in the management of gallbladder and bile duct stones:a systematic review of international guidelines

BACKGROUND: Gallstone disease is a frequent disorder in the Western world with a prevalence of 10-20%. Recommendations for the assessment and management of gallstones vary internationally. The aim of this systematic review was to assess quality of guideline recommendations for treatment of gallstones. METHODS: PubMed, EMBASE and websites of relevant associations were systematically searched. Guidelines without a critical appraisal of literature were excluded. Quality of guidelines was determined using the AGREE II instrument. Recommendations without consensus or with low level of evidence were considered to define problem areas and clinical research gaps. RESULTS: Fourteen guidelines were included. Overall quality of guidelines was low, with a mean score of 57/100 (standard deviation 19). Five of 14 guidelines were considered suitable for use in clinical practice without modifications. Ten recommendations from all included guidelines were based on low level of evidence and subject to controversy. These included major topics, such as definition of symptomatic gallstones, indications for cholecystectomy and intraoperative cholangiography. CONCLUSION: Only five guidelines on gallstones are evidence-based and of a high quality, but even in these controversy exists on important topics. High quality evidence is needed in specific areas before an international guideline can be developed and endorsed worldwide

A comparison of technique modifications in laparoscopic donor nephrectomy: a systematic review and meta-analysis.

ObjectiveTo compare the effectiveness of different technique modifications in laparoscopic donor nephrectomy.DesignSystematic review and meta-analyses.Data sourcesSearches of PubMed, EMBASE, Web of Science and Central from January 1st 1997 until April 1st 2014.Study designAll cohort studies and randomized clinical trials comparing fully laparoscopic donor nephrectomy with modifications of the standard technique including hand-assisted, retroperitoneoscopic and single port techniques, were included.Data-extraction and analysisThe primary outcome measure was the number of complications. Secondary outcome measures included: conversion to open surgery, first warm ischemia time, estimated blood loss, graft function, operation time and length of hospital stay. Each technique modification was compared with standard laparoscopic donor nephrectomy. Data was pooled with a random effects meta-analysis using odds ratios, weighted mean differences and their corresponding 95% confidence intervals. To assess heterogeneity, the I2 statistic was used. First, randomized clinical trials and cohort studies were analyzed separately, when data was comparable, pooled analysis were performed.Results31 studies comparing laparoscopic donor nephrectomy with other technique modifications were identified, including 5 randomized clinical trials and 26 cohort studies. Since data of randomized clinical trials and cohort studies were comparable, these data were pooled. There were significantly less complications in the retroperitoneoscopic group as compared to transperitoneal group (OR 0.52, 95%CI 0.33-0.83, I2 = 0%). Hand-assisted techniques showed shorter first warm ischemia and operation times.ConclusionsHand-assistance reduces the operation and first warm ischemia times and may improve safety for surgeons with less experience in laparoscopic donor nephrectomy. The retroperitoneoscopic approach was significantly associated with less complications. However, given the, in general, poor to intermediate quality and considerable heterogeneity in the included studies, further high-quality studies are required.Trial registrationThe review protocol was registered in the PROSPERO database before the start of the review process (CRD number 42013006565)

Search strategy.

<p>[tiab]: word in title or abstract</p><p>[mesh]: medical subheading, controlled vocabulary as used by National Library or Medicine for indexing articles</p><p>*: truncation; retrieves all possible suffix variations of root word indicated</p><p>Search strategy.</p

8a: Forest plot comparing initial series of HALDN versus LDN (RCT and cohort studies combined).

<p>Six studies were included. The initial series of HALDN were associated with less complications (OR 0.45, 95% CI 0.23–0.88, p = 0.02). 8b: Forest plot comparing recent series of HALDN versus LDN (RCT and cohort studies combined). Six studies were included, no association between number of complications and hand-assistance could be observed (OR 0.99, 95% CI 0.49–1.99, p = 0.98).</p

Quality assessment of cohort studies.

<p><i>0–3 low quality</i></p><p><i>4–5 intermediate quality</i></p><p><i>6–7 high quality</i></p><p>Quality assessment of cohort studies.</p

9a: Funnel plot comparing complications in HALDN versus LDN.

<p>9b. Funnel plot comparing complications in RDN versus LDN. 9c: Funnel plot comparing complications in HARDN versus LDN. 9d: Funnel plot comparing complications in LESS versus LDN. 9e: Funnel plot comparing complications in retroperitoneal versus transperitoneal approach. Studies at the bottom tend to cluster towards the right. 9f: Funnel plot comparing complications in hand-assisted versus fully laparoscopic approach.</p

Characteristics of cohort studies.

<p>* <i>with LDN as reference</i></p><p>Characteristics of cohort studies.</p

Forrest plots comparing HARDN versus LDN (RCT and cohort studies combined).

<p>a. Complications of HARDN versus LDN. Four studies compared complications in HARDN versus LDN (ORT 0.59, 95% CI 0.31–1.10, I² = 0%), there was a tendency towards less complications for HARDN. b. Conversion to ODN in HARDN versus LDN. Two studies compared the number of conversions to ODN in HARDN versus LDN (OR 0.37, 95%CI 0.04–3.70, I² = 0%). c. WIT1 (seconds) in HARDN versus LDN. Three studies described WIT1 in HARDN versus LDN (MD -109.40, 95% CI-152.74- -66.06, I² = 74%). HARDN was associated with shorter WIT1. d. ORT (minutes) in HARDN versus LDN. Three studies described ORT in HARDN versus LDN (MD -38.64, 95% CI -60.76- -16.53, I² = 79%). HARDN was associated with shorter ORT.</p