Evidence
This page contains a snapshot of featured content which highlights evidence addressing key clinical questions including areas of uncertainty. Please see the main topic reference list for details of all sources underpinning this topic.
BMJ Best Practice evidence tables
Evidence tables provide easily navigated layers of evidence in the context of specific clinical questions, using GRADE and a BMJ Best Practice Effectiveness rating. Follow the links at the bottom of the table, which go to the related evidence score in the main topic text, providing additional context for the clinical question. Find out more about our evidence tables.
This table is a summary of the analysis reported in a Cochrane Clinical Answer that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and there may be no difference in effectiveness between the intervention and comparison for key outcomes.
Population: Adults with common bile duct stones
Intervention: Laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC plus LCBDE)
Comparison: Endoscopic retrograde cholangiopancreatography (ERCP) plus LC
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
LC plus LCBDE versus preoperative ERCP plus LC | ||
Mortality at 30 days | No statistically significant difference | Moderate |
Total morbidity (time point unclear) | No statistically significant difference | Moderate |
Retained stones (time point unclear) | No statistically significant difference | Moderate |
Failure of procedure (time point unclear) | No statistically significant difference | Moderate |
Conversion to open surgery (time point unclear) | No statistically significant difference | Moderate |
Quality of life (time point unclear) | No statistically significant difference ᵃ | GRADE assessment not performed for this outcome ᵇ |
Hospital stay | Unknown ᶜ | GRADE assessment not performed for this outcome |
LC plus LCBDE versus LC plus postoperative ERCP | ||
Mortality (time point unclear) | Unknown ᵃ | GRADE assessment not performed for this outcome |
Total morbidity (time point unclear) | No statistically significant difference | Moderate |
Retained stones after primary intervention (time point unclear) | Favors intervention | Moderate |
Failure of procedure (time point unclear) | No statistically significant difference | Moderate |
Conversion to open surgery (time point unclear) | No statistically significant difference | Moderate |
Hospital stay | Unknown ᵃ | GRADE assessment not performed for this outcome |
Quality of life | - | None of the studies identified by the review assessed this outcome |
Note ᵃ Results reported narratively (see the Cochrane Clinical Answer for more details). ᵇ The Cochrane reviewers did not perform a GRADE assessment but the single RCT providing evidence for this outcome was at low risk of bias for all domains. ᶜ No meta-analysis was done for this outcome and the results from five RCTs were reported narratively. Two showed a shorter stay with LC + LCBDE compared with preoperative ERCP + LC; the other three found no statistically significant difference between groups.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a Cochrane Clinical Answer that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and there may be no difference in effectiveness between the intervention and comparison for key outcomes.
Population: Adults with clinical signs/symptoms suggestive of acute gallstone pancreatitis or confirmed acute gallstone pancreatitis ᵃ
Intervention: ERCP combined with conservative management (within 72 hours of admission)
Comparison: Early conservative management (within 30 days of admission)
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
All-cause mortality during hospitalization up to 3 months | No statistically significant difference ᵃ | Low |
Local complications defined by the Atlanta Classification at 10 days to 3 months | No statistically significant difference ᵃ | Moderate |
Systemic complications defined by the Atlanta Classification at 10 days to 3 months | No statistically significant difference ᵃ | Moderate |
ERCP-related complication: post-ERCP bleeding (time period unclear) | No statistically significant difference | GRADE assessment not performed for this outcome |
ERCP-related complications other than bleeding (time period unclear) | See note ᵇ | GRADE assessment not performed for this outcome |
ERCP-related mortality | - | The reviewers did not assess this outcome |
Note The Cochrane review which underpins this Cochrane Clinical Answer (CCA) states that the timing of ERCP (urgent <24 hours versus early <72 hours) should depend on the level of suspicion, the condition of the patient, and response to initial conservative management The CCA also mentioned a possible benefit of early routine ERCP for patients with biliary obstruction (see the underlying Cochrane review for more details and subgroup analysis). ᵃ The CCA is for unselected patients with gallstone pancreatitis. However, it includes subgroup analyses selecting patients with concurrent cholangitis which found some benefit for early routine ERCP with reduced mortality, local complications, and systemic complications compared with conservative management. The reviewers did not perform a GRADE assessment (see CCA for more details and subgroup analysis). ᵇ Results reported narratively (see the CCA for more details).
This evidence table is related to the following section/s:
Cochrane Clinical Answers
Cochrane Clinical Answers (CCAs) provide a readable, digestible, clinically focused entry point to rigorous research from Cochrane systematic reviews. They are designed to be actionable and to inform decision making at the point of care and have been added to relevant sections of the main Best Practice text.
- How does early routine endoscopic retrograde cholangiopancreatography compare with early conservative management in people with acute gallstone pancreatitis?
- In adults with bile duct stones, how does surgical treatment compare with endoscopic treatment for improving outcomes?
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