Meta-analysis Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis B. de Goede 1,4 , P. J. Klitsie 1 , S. M. Hagen 1 , B. J. H. van Kempen 2 , S. Spronk 2 , H. J. Metselaar 3 , J. F. Lange 1 and G. Kazemier 4 Departments of 1 Surgery, 2 Epidemiology and Radiology and 3 Gastroenterology and Hepatology, Erasmus MC, University Medical Centre Rotterdam, and 4 Department of Surgery, VUmc, University Medical Centre Amsterdam, Amsterdam, The Netherlands Correspondence to: Dr G. Kazemier, Department of Surgery, VUmc, University Medical Centre Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands (e-mail: g.kazemier@vumc.nl) Background: Open cholecystectomy (OC) is often preferred over laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and portal hypertension, but evidence is lacking to support this practice. This meta-analysis aimed to clarify which surgical technique is preferable for symptomatic cholecystolithiasis in patients with liver cirrhosis. Methods: A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and October 2011 were identified from MEDLINE, Embase and the Cochrane Library. Randomized clinical trials (RCTs) comparing outcomes of OC versus LC for cholecystolithiasis in patients with liver cirrhosis were included. The quality of the RCTs was assessed using the Jadad criteria. Results: Following review of 1422 papers by title and abstract, a meta-analysis was conducted of four RCTs comprising 234 surgical patients. They provided evidence of at least level 2b on the Oxford Level of Evidence Scale, but scored poorly according to the Jadad criteria. Some 97·0 per cent of the patients had Child–Turcotte–Pugh (CTP) grade A or B liver cirrhosis. In all, 96·6 per cent underwent elective surgery. No postoperative deaths were reported. LC was associated with fewer postoperative complications (risk ratio 0·52, 95 per cent confidence interval (c.i.) 0·29 to 0·92; P = 0·03), a shorter hospital stay (mean difference −3·05 (95 per cent c.i. −4·09 to −2·01) days; P < 0·001) and quicker resumption of a normal diet (mean difference −27·48 (−30·96 to −23·99) h; P < 0·001). Conclusion: Patients with CTP grade A or B liver cirrhosis who undergo LC for symptomatic cholecystolithiasis have fewer overall postoperative complications, a shorter hospital stay and resume a normal diet more quickly than those who undergo OC. Paper accepted 5 July 2012 Published online 3 October 2012 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.8911 Introduction Gallbladder stones are common in patients with liver cirrhosis. Up to 30 per cent of such patients suffer from cholecystolithiasis compared with 13 per cent of patients with a non-cirrhotic liver 1–4 . Factors associated with a higher prevalence of gallbladder stones in patients with liver cirrhosis include hypersplenism, increased blood levels of oestrogen, increased haemolysis, and reduced gallbladder motility and emptying 2–3,5 . If gallbladder stones become symptomatic in patients with liver cirrhosis, they are associated with higher morbidity and mortality rates than those in patients with a non-cirrhotic liver 6,7 . Cholecystectomy in patients with liver cirrhosis is also associated with a higher mortality rate compared with that in patients with a non-cirrhotic liver 7,8 . Mortality rates after cholecystectomy have been shown to be largely dependent on the severity of underlying liver disease, and may be as high as 83 per cent for those with end-stage liver disease 9,10 . Cholecystectomy in patients with liver cirrhosis is often regarded as a technically demanding procedure, particu- larly in the presence of portal hypertension. Significant intraoperative blood loss and bacterial contamination of ascites owing to inadvertent intraoperative rupture of  2012 British Journal of Surgery Society Ltd British Journal of Surgery 2013; 100: 209–216 Published by John Wiley & Sons Ltd