NOTES-Cholecystectomy may be a viable alternative to conventional laparoscopic cholecystectomy: A systematic review and meta-analysis of the published comparative studies

Objective: The objective of this article was to systematically analyse the published studies comparing the cholecystectomy by national orifice transluminal endoscopic surgery (NOTES-cholecystectomy) versus conventional four port laparoscopic cholecystectomy (CLC).

Methods: The meta-analysis was conducted according to the Quality of Reporting of Meta-analysis (QUORUM) standards. Pubmed, Medline and Cochrane library databases were searched to retrieve all types of published studies comparing the clinical and technical effectiveness of NOTES-cholecystectomy against CLC. The data from included studies was extracted and it was systematically analysed using RevMan^®. The summated outcomes were expressed as the odds ratios (OR) for dichotomous variables and standardised mean differences (SMD) for continuous variables.

Results: Eight published studies (one ran? domised trials, 3 non-randomised trials and 4 comparison cohorts) encompassing 527 patients were retrieved from the standard electronic databases. There were 234 patients in NOTES-cholecystectomy group and 293 in CLC group. There was significant hetero? geneity (Tau2 ((equals)) 1.37; chi ((equals)) 103.75, df ((equals)) 7, p < 0.00001; I ((equals)) 93%) among included studies. Therefore, in the random effects model, operative time (SMD, 1.62; 95% CI, 0.74, 2.51; z ((equals)) 3.60; p < 0.0003) for NOTES-cholecystectomy was shorter compared to CLC. In addition, the 24-hour postoperative pain score was lower (SMD, – 0.98; 95% CI, – 1.61, – 0.35; z ((equals)) 3.06; p < 0.002) and length of hospital stay was shorter (SMD, – 0.37; 95% CI, – 0.56, – 0.18; z ((equals)) 3.77; p < 0.0002) following NOTES-cholecystectomy. The risk of developing postoperative complications (OR, 0.55; 95% CI, 0.23, 1.29; z ((equals)) 1.37; p ((equals)) 0.17) and time to return to normal activities (SMD, – 2.94; 95% CI, – 6.96, – 1.09; z ((equals)) 1.43; p ((equals)) 0.15) were statistically comparable between two techniques.

Conclusion: NOTES-cholecystectomy is a safe and technically feasible approach to treat gallstones with proven advantages of shorter operative time, shorter length of hospital stay and lesser postoperative pain. However, stronger evidence in the form of a major, multicentre randomised trial is required before considering the wider application of this approach for cholecystectomy.