Bottom line: Heavy alcohol users might benefit from a preoperative alcohol cessation program, but further studies are needed.
Citation: Oppedal K, Moller AM, Pedersen B, Tonnesen H. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev. 2012;7:CD008343.
Early Laparoscopic Cholecystectomy Is Safe and Effective for Gallstone Pancreatitis
Clinical question: Does early laparoscopic cholecystectomy (<48 hours of admission) in mild gallstone pancreatitis decrease LOS without increasing morbidity and mortality?
Background: Time to laparoscopic cholecystectomy (LC) for mild gallstone pancreatitis is greatly debated. Historically, surgeons have waited for normalization of laboratory values and decreased symptoms before performing laparoscopic or open cholecystectomy. Two previous studies demonstrated LC can be performed safely within 48 hours of admission, regardless of symptoms or laboratory values.
Study design: Retrospective cohort.
Setting: Two academic medical centers in California.
Synopsis: This retrospective review of 303 patients who underwent LC for mild gallstone pancreatitis from 2006 to 2011 found 117 (38.6%) underwent early LC and 186 (61.4%) underwent delayed LC (>48 hours after presentation). No significant differences in patient demographics, laboratory values, or admission Ranson scores were found between the groups. The mean LOS was significantly shorter in the early LC group (3.4 days) compared with the delayed LC group (6.3 days), and the delayed LC group had a higher rate of preoperative endoscopic retrograde cholangiopancreatography (ERCP). No differences were found with regard to mortality, complication rates, 30-day readmissions, or conversion to open cholecystectomy.
This study is limited by its retrospective design and potential for uncontrolled confounders. In addition, it did not evaluate preoperative management, postoperative recovery time, or timing of surgical consultation, which could have affected outcomes between the groups. It also is difficult to predict mild gallstone pancreatitis on admission, as some of the Ranson criteria should be calculated at 48 hours, and 5% to 10% of mild gallstone pancreatitis will progress to severe pancreatitis.
Bottom line: Early laparoscopic cholecystectomy (<48 hours of presentation) in mild gallstone pancreatitis is associated with shorter LOS and decreased ERCP use, with no difference in morbidity or mortality.
Citation: Faylor AE, de Virgilio C, Stabile BE, et al. Early laparoscopic cholecystectomy for mild gallstone pancreatitis. Time for a paradigm shift. Arch Surg. 2012;16:1-5.
Low-Dose Steroids in Shock Patients
Clinical question: Do low-dose corticosteroids improve mortality or shock reversal in adults with septic shock?
Background: Several trials have been published to evaluate the efficacy of low-dose corticosteroids in septic shock.
Study design: Systemic review and meta-analysis of randomized controlled trials.
Setting: Not identified.
Synopsis: Seven randomized controlled trials that utilized low-dose corticosteroids and reported either mortality or time-to-shock reversal in adults with septic shock were included in this review. Shock reversal was not consistently defined across trials but included time to withdrawal of vasopressors, proportion of patients on vasopressors on Day 3, or stable systolic blood pressure of >90 mm Hg for at least 24 hours without vasopressor support.
Pooled results found a significant improvement in shock reversal after low-dose corticosteroid administration (300 mg hydrocortisone in 24 hours [relative risk=1.17, 95% CI, 1.07-1.28]). Pooled results from six studies (n=965) did not find a significant difference in
mortality among those receiving low-dose corticosteroids.
Of note, two of the seven studies represented a disproportionate number of included patients, and the search only included the MEDLINE database, so some randomized controlled trials might have been missed.
Bottom line: Low-dose corticosteroids might reverse shock faster, but they do not improve mortality.
Citation: Sherwin RL, Garcia AJ, Bilkovski R. Do low-dose corticosteroids improve mortality or shock reversal in patients with septic shock? A systemic review and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2012;43:7-12.