The authors concluded that ambulatory laparoscopic cholecystectomy can be safely performed in selected patients with reduced costs and high levels of patient satisfaction. Evidence appeared to support the authors’ conclusions, but the lack of reporting of review methods and study quality and differences between studies made it difficult to comment on the reliability of review findings.

To compare ambulatory laparoscopic with in-patient laparoscopic cholecystectomy.

MEDLINE, EMBASE and The Cochrane Library were searched for studies in any language. Search terms were reported, but search dates were not. Reference lists were handsearched.

Prospective studies that compared the effects of ambulatory laparoscopic with in-patient laparoscopic cholecystectomy on complications, admissions, re-admissions and patient satisfaction were eligible for inclusion. Studies had to use well-defined criteria to select patients for ambulatory care and report quality of life data at 24 hours and one week. Studies that assessed other outcomes such as nausea and vomiting, analgesia and anaesthetic outcomes were excluded.

In the included studies, mean age was 42 years for ambulatory patients and 47 years for in-patients. All but one of the studies were in patients graded I or II using American Society of Anesthesiologists criteria; information was not provided in the remaining study. Studies used a standard protocol; patients who did not fulfill criteria were admitted overnight. Surgery was performed by consultants or trainees, where reported. In about half of the studies, cholangiograms were routinely or selectively performed; cholangiograms were not done in other studies. Most studies reported use of prophylactic analgaesia and about half of the studies used preoperative or postoperative local analgesia. Studies were conducted in Europe, USA and Australia.

Two reviewers independently screened reference lists, but no other details of the study selection process were reported.

The authors did not state that they assessed validity, but methods of randomisation were presented in a table.

For each study, numbers of patients with outcomes of interest were presented for each treatment group and odds ratios (OR) and 95% confidence intervals (CI) were calculated.

The authors did not state how many reviewers performed the data extraction.

Pooled odds ratios and 95% CIs were calculated using a random-effects model. Paired sample t-tests were used to compare patient satisfaction and return to work

Seven controlled studies were included (n=598). These included six RCTs (n=505) and one non-randomised study (n=93). Four RCTs used envelopes for randomisation.

There was no statistically significant difference between unexpected admissions in the ambulatory group and prolonged hospitalisation in the in-patient laparoscopic cholecystectomy (six studies).

There were no statistically significant differences between ambulatory and in-patient surgery for any of the following outcomes: immediate postoperative complication rate (six studies); conversion rate to open cholecystectomy; re-admission after hospital discharge (four studies), subsequent contact with clinicians (five studies); time to return to normal activities (five studies); patient satisfaction (five studies); and quality of life assessed at 24 hours and one week post-surgery (number of studies not clear).

Patient satisfaction levels ranged from 69% to 92% for ambulatory care and from 53% to 80% for inpatient care.

Three of the four studies that compared costs of ambulatory care with in-patient laparoscopic cholecystectomy reported reduced costs in the ambulatory care group; one study showed comparable costs. Studies used different parameters to assess costs. Average costs were 1,506.67 euros for ambulatory procedures and 1,898.72 euros for in-patient treatment (p=0.056).

Ambulatory laparoscopic cholecystectomy can be safely performed in selected patients with reduced costs and high levels of patient satisfaction.

The review question was clearly stated and inclusion criteria were appropriately defined. Several relevant sources were searched. Attempts were made to minimise language bias. No attempts were made to minimise publication bias. Methods used to select studies and extract data were not adequately described and so it was not known whether efforts were made to reduce reviewer errors and bias. Other than methods of randomisation, there was no assessment of study validity; this made it difficult to judge the reliability of the results. No information was provided about criteria used to select patients for study entry and so the generalisability of results could not be judged. Pooling data from RCTs and non-randomised studies without any subgroup analysis limited to RCTs may not have been appropriate since there was potential for bias in non-randomised studies. Although forest plots were presented, there was no formal assessment of statistical heterogeneity. In several analyses, numbers of events were small and this had potential to produce unreliable results. Evidence appeared to support the authors’ conclusions, but the lack of reporting of review methods and study quality and differences between studies made it difficult to comment on the reliability of review findings.

The authors did not state any implications for practice or research.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.