Acute cholecystitis: the golden 72-h period is not a strict limit to perform early cholecystectomy. Results from 316 consecutive patients

Symptom Duration and Surgeon Volume: Impact on Early Laparoscopic Cholecystectomy for Acute Cholecystitis

BACKGROUND

The 'golden 72 hours' rule from the onset of symptoms still applies in laparoscopic cholecystectomy for acute cholecystitis. This rule has been discussed with increasing experience in laparoscopic surgery in recent years.

OBJECTIVE

This study aims to determine the optimal symptom duration based on the surgeon's volume when deciding on early laparoscopic cholecystectomy for acute cholecystitis.

MATERIALS AND METHODS

 The patients were categorized into two groups: Group 1 (≤3 days) and Group 2 (>3 days) based on the symptom duration, and high-volume surgeons (performing >100 laparoscopic cholecystectomies in a year) and low-volume surgeons (performing <100 laparoscopic cholecystectomies in a year) based on the surgeon volume. All surgeons had received advanced training in laparoscopic surgery.

RESULTS

There was no statistical difference in postoperative outcomes between groups, except for a few data (p>0.05). The operative time was longer in Group 2, the postoperative hospital stay was longer for low-volume surgeons than for high-volume surgeons after three days, and operative time was longer after three days than the first three days in low-volume surgeons (p<0.05).

CONCLUSIONS

Early laparoscopic cholecystectomy may be recommended for acute cholecystitis with symptom duration of more than three days, regardless of the surgeon volume, as long as they are competent in laparoscopic surgeries.

The Optimal Timing of Laparoscopic Cholecystectomy in Acute Cholecystitis: A Single-Center Study

Introduction Early laparoscopic cholecystectomy (ELC) is a treatment option for acute cholecystitis (AC). However, the timing of ELC is controversial. Delayed laparoscopic cholecystectomy (DLC) continues to be a common practice. This study aims to determine the optimal timing of ELC in AC. Materials and methods Patients who underwent surgery for AC between 2014 and 2020 were divided into three groups: immediate laparoscopic cholecystectomy (ILC), prolonged ELC (pELC), and DLC. The demographic, laboratory, radiological findings, and postoperative results of all patients were retrospectively reviewed. Results The study included 178 patients, with 63 in the ILC group, 27 in the pELC group, and 88 in the DLC group. Postoperative outcomes, excluding hospital stay, were similar between the groups. The total hospital stay was significantly longer in the pELC and DLC groups (p<0.05). In addition, postoperative hospital stay was longer in the pELC group (p<0.05), and 17.7% of the patients who waited for delayed surgery experienced recurrent attacks during the interval period. Conclusion ILC is recommended in AC to minimize hospital stays.

The Bad Gallbladder

Laparoscopic cholecystectomy is a common operation; approximately 20 million Americans have gallstones, the most common indication. Surgeons who operate on the biliary tree must be familiar with the presentations and treatment options for acute and chronic biliary pathology. We focus on the difficult "bad" gallbladder. We explore the available evidence as to what to do when a gallbladder is too inflamed, too technically challenging, or a patient is too sick to undergo standard laparoscopic cholecystectomy. We discuss whether or not open cholecystectomy is a relevant tool and what can be done to manage common bile duct stones found unexpectedly intraoperatively.

Early laparoscopic cholecystectomy for acute cholecystitis is safe regardless of timing

PURPOSE

The optimal timing for laparoscopic cholecystectomy for acute cholecystitis (AC) has not been resolved. In the revised Tokyo Guidelines from 2018 (TG18), early laparoscopic cholecystectomy (ELC) is recommended regardless of the duration of symptoms. The aim of this study was to evaluate the safety of ELC compared with delayed laparoscopic cholecystectomy (DLC) for AC. In addition, we assessed the perioperative outcomes after ELC based on duration of symptoms.

METHODS

A retrospective cohort study of patients operated for acute calculous cholecystitis from January 1, 2017, to June 30, 2018, at Copenhagen University Hospital, Herlev. ELC was divided into three subgroups based on the duration of symptoms from onset to operation, ≤ 72 h, > 72-120 h, > 120 h.

RESULTS

Two hundred twenty-two patients underwent ELC and 26 (10.5%) patients underwent DLC. We found no difference in mortality, morbidity, conversion rate, or bile duct injuries between DLC and ELC or in the subgroups based on duration of symptoms. We found significantly longer total hospital length of stay for patients with symptoms > 72 h (4.1-5.6 days) compared to ≤ 72 h (3.1 days) and the longest in DLC (9.9 days). Twenty-three percent of DLC needed an emergency operation in the waiting period with a high conversion rate (1/3).

CONCLUSION

ELC for AC even beyond 5 days of symptoms is safe and not associated with increased complications. The duration of symptoms in AC is not an independent predictor and should not influence the surgeonsmsdecision to perform an ELC. Delaying cholecystectomy has a high failure rate.

Timing of cholecystectomy for acute cholecystitis impacts surgical morbidity and mortality: an NSQIP database analysis

The aim of this study is to identify the optimal timing for cholecystectomy for acute cholecystitis. Patients undergoing cholecystectomy for acute cholecystitis from the National Surgery Quality Improvement Program database between 2014 and 2016 were included. The patients were divided into 4 groups, those who underwent surgery at days 0, 1, 2, or 3+ days. The primary outcome was short-term surgical morbidity and mortality. A total of 21,392 patients were included. After adjusting for confounders, compared to day 0 patients, those who underwent surgery at day 1 and day 2 had lower composite morbidity rate, while day 3+ patients had significantly higher bleeding and mortality rate. Subgroup analysis shows this trend to be more significant in the elderly and in diabetic patients who were delayed. Delay in cholecystectomy for over 72 h from admission is associated with statistically significant increase in bleeding and mortality.

Safety and feasibility of prolonged versus early laparoscopic cholecystectomy for acute cholecystitis: a single-center retrospective study

Background

Laparoscopic cholecystectomy (LC) is the standard treatment for acute cholecystitis (AC), and it should be performed within 72 h of symptoms onset if possible. In many undesired situations, LC was performed beyond the golden 72 h. However, the safety and feasibility of prolonged LC (i.e., performed more than 72 h after symptoms onset) are largely unknown, and therefore were investigated in this study.

Methods

We retrospectively enrolled the adult patients who were diagnosed as AC and were treated with LC at the same admission between January 2015 and October 2018 in an emergency department of a tertiary academic medical center in China. The primary outcome was the rate and severity of adverse events, while the secondary outcomes were length of hospital stay and costs.

Results

Among the 104 qualified patients, 70 (67.3%) underwent prolonged LC and 34 (32.7%) underwent early LC (< 72 h of symptom onset). There were no differences between the two groups in mortality rate (none for both), conversion rates (prolonged LC 5.4%, and early LC 8.8%, P = 0.68), intraoperative and postoperative complications (prolonged LC 5.7% and early LC 2.9%, P ≥ 0.99), operation time (prolonged LC 193.5 min and early LC 198.0 min, P = 0.81), and operation costs (prolonged LC 8,700 Yuan, and early LC 8,500 Yuan, P = 0.86). However, the prolonged LC was associated with longer postoperative hospitalization (7.0 days versus 6.0 days, P = 0.03), longer total hospital stay (11.0 days versus 8.0 days, P < 0.01), and subsequently higher total costs (40,400 Yuan versus 31,100 Yuan, P < 0.01).

Conclusions

Prolonged LC is safe and feasible for patients with AC for having similar rates and severity of adverse events as early LC, but it is also associated with longer hospital stay and subsequently higher total cost.

Early laparoscopic cholecystectomy by a dedicated emergency surgical unit confers excellent outcomes in acute cholecystitis presenting beyond 72 hours

BACKGROUND

Early laparoscopic cholecystectomy (ELC) within 72 h of symptom onset is preferred for management of acute cholecystitis (AC). Beyond 72 h, acute-on-chronic fibrosis sets in rendering surgery challenging. This study aims to compare the outcomes of ELC for AC within and beyond 72 h of symptom onset by a dedicated acute surgical unit.

METHODS

This is a single-centre retrospective study of 217 patients with AC who underwent ELC by an acute surgical unit from January 2017 to August 2018. Outcomes collected include post-operative morbidity, length of hospitalization and operation duration. A subgroup analysis for the same outcomes was performed for elderly patients.

RESULTS

Of the 217 patients, 88 were operated within 72 h of symptom onset while 129 were operated beyond 72 h. Twenty-six patients received ELC after 7 days. There was no occurrence of bile duct injury. There was no statistical difference in conversion rates, wound infections and post-operative collections. Patients receiving ELC beyond 72 h had longer duration of operation (125.4 versus 116 min, P = 0.035) and length of hospitalization (4.59 versus 3.09 days, P = 0.001) without increase in morbidity. Patients older than 75 years had a higher incidence of post-operative collection (P < 0.001).

CONCLUSION

Patients with AC undergoing ELC by a dedicated acute surgical unit can have good outcomes even beyond 72 h of symptom onset. Meticulous haemostasis should be performed for the elderly subgroup of patients.

Outcomes of Consistent Conservative Management for Acute Cholecystitis Followed by Delayed Cholecystectomy

OBJECTIVE

This study's objective was to assess outcomes of a totally conservative strategy for acute cholecystitis (AC) followed by delayed elective cholecystectomy.

PATIENTS AND METHODS

Consecutive patients who underwent cholecystectomy for AC were divided into the Emergent and Elective cholecystectomy groups. Patients in the elective cholecystectomy group were divided into early, medium, and late groups according to time from symptoms onset.

RESULTS

The success rate for conservative management reached 97.2%. Increased blood loss and a higher conversion rate were significantly associated with the emergent group. Patients in the late group had significantly lower operative time and tended to have lower blood loss and less frequent conversion to open surgery than those in the early and medium groups.

CONCLUSIONS

Most AC cases could be managed conservatively, and elective cholecystectomy was performed safely regardless of the time. Elective cholecystectomy carried out in late phase was likely to be associated with decreased surgical difficulty.

Early Versus Delayed Cholecystectomy for Acute Cholecystitis, Are the 72 hours Still the Rule?: A Randomized Trial

OBJECTIVE

The aim of this study was to compare clinical outcomes of early versus delayed laparoscopic cholecystectomy (LC) in acute cholecystitis with more than 72 hours of symptoms.

BACKGROUND

LC is the treatment of acute cholecystitis, with consensus recommendation that patients should be operated within 72 hours of evolution. Data however remain weak with no prospective study focusing on patients beyond 72 hours of symptoms.

METHODS

Patients with acute cholecystitis and more than 72 hours of symptoms were randomly assigned to early LC (ELC) or delayed LC (DLC). ELC was performed following hospital admission. DLC was planned at least 6 weeks after initial antibiotic treatment. Primary outcome was overall morbidity following initial diagnosis. Secondary outcomes were total length of stay, duration of antibiotic therapy, hospital costs, and surgical outcome.

RESULTS

Eighty-six patients were randomized (42 in ELC and 44 in DLC group). Overall morbidity was lower in ELC [6 (14%) vs 17 (39%) patients, P = 0.015]. Median total length of stay (4 vs 7 days, P < 0.001) and duration of antibiotic therapy (2 vs 10 days, P < 0.001) were shorter in the ELC group. Total hospital costs were lower in ELC (9349&OV0556; vs 12,361 &OV0556;, P = 0.018). Operative time and postoperative complications were similar (91 vs 88 min; P = 0.910) and (15% vs 17%; P = 1.000), respectively.

CONCLUSIONS

ELC for acute cholecystitis even beyond 72 hours of symptoms is safe and associated with less overall morbidity, shorter total hospital stay, and duration of antibiotic therapy, as well as reduced cost compared with delayed cholecystectomy (NCT01548339).

Propensity score-matching analysis of the efficacy of late cholecystectomy for acute cholecystitis

BACKGROUND

Urgent cholecystectomy within 72 h from symptom onset is recommended. We assessed the feasibility of performing late cholecystectomy (4-7 days from symptom onset) for acute cholecystitis.

METHODS

One hundred sixty-four patients with grades 1 and 2 cholecystitis, who underwent urgent cholecystectomy within 7 days from symptom onset between June 2011 and June 2015 were enrolled. One hundred thirteen patients underwent operation within 72 h from symptom onset (early operation group), and 51 underwent operation between 4 and 7 days (late operation group). Surgical outcomes and postoperative complications were analyzed using propensity score-matching analysis.

RESULTS

The rate of conversion, intraoperative bleeding, and complications were comparable between the groups. After a one-to-two propensity score-matched analysis was performed, outcomes of the late operation group were not inferior to those of the early operation group.

CONCLUSION

Late cholecystectomy was acceptable for treating grades 1 and 2 acute cholecystitis.

Systematic review of antibiotic treatment for acute calculous cholecystitis

BACKGROUND

Intravenous antibiotics are frequently used in the initial management of acute calculous cholecystitis (ACC), although supportive care alone preceding delayed elective cholecystectomy may be sufficient. This systematic review assessed the success rate of antibiotics in the treatment of ACC.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Primary outcomes were the need for emergency intervention and recurrence of ACC after initial non-operative management of ACC. Risk of bias was assessed. Pooled event rates were calculated using a random-effects model.

RESULTS

Twelve randomized trials, four prospective and ten retrospective studies were included. Only one trial including 84 patients compared treatment with antibiotics to that with no antibiotics; there was no significant difference between the two groups in terms of length of hospital stay and morbidity. Some 5830 patients with ACC were included, of whom 2997 had early cholecystectomy, 2791 received initial antibiotic treatment, and 42 were treated conservatively. Risk of bias was high in most studies, and all but three studies had a low level of evidence. For randomized studies, pooled event rates were 15 (95 per cent c.i. 10 to 22) per cent for the need for emergency intervention and 10 (5 to 20) per cent for recurrence of ACC. The pooled event rate for both outcomes combined was 20 (13 to 30) per cent.

CONCLUSION

Antibiotics are not indicated for the conservative management of ACC or in patients scheduled for cholecystectomy.

Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation

Background

Acute cholecystitis is a common diagnosis and surgery is the standard of care for young and fit patients. However, due to high risk of postoperative morbidity and mortality, surgical management of critically ill patients remains a controversy. It is not clear, whether the increased risk of perioperative complications associated with the management of critically ill patients with acute cholecystitis is secondary to reduced physiologic reserve per se or to the severity of gallbladder inflammation.

Methods

A retrospective analysis of prospectively collected data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital over a three-year-period was performed. The ASA scores at the time of presentation were used to categorize patients into two groups. The study group consisted of critically ill patients with ASA 3 and 4, while the control group was made up of fit patients with ASA 1 and 2. Both groups were compared with regard to perioperative data, postoperative outcome and extent of gallbladder inflammation on histopathology.

Results

Two hundred and seventeen cases of acute cholecystitis with complete charts were available for analysis. The study group included 67 critically ill patients with ASA 3 and 4, while the control group included 150 fit patients with ASA 1 and 2. Both groups were comparable with regard to perioperative data. Histopathology confirmed severe cholecystitis in a significant number of cases in the study group compared to the control group (37 % vs. 18 %, p = 0.03). Significantly higher rates of morbidity and mortality were recorded in the study group (p < 0.05). Equally, significantly more patients from the study group were managed in the ICU (40 % vs. 8 %, p = 0.001).

Conclusion

Critically ill patients presenting with acute cholecystitis are at increased risk for extensive gallbladder inflammation. The increased risk of morbidity and mortality seen in such patients might partly be secondary to severe acute cholecystitis.

Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies

BACKGROUND

Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures.

METHODS

A search of electronic databases was performed for case-control studies published between 1985-February 2015.

RESULTS

Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely.

CONCLUSIONS

Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.

Early Percutaneous Cholecystostomy in Severe Acute Cholecystitis Reduces the Complication Rate and Duration of Hospital Stay

The optimal timing of percutaneous cholecystostomy for severe acute cholecystitis is unclear. The aim of this study was to investigate the timing of percutaneous cholecystostomy and its relationship to clinical outcomes in patients with inoperable acute severe cholecystitis.From 2008 to 2010, 209 consecutive patients who were admitted to our hospital due to acute cholecystitis and were treated by percutaneous cholecystostomy were retrospectively reviewed. The time periods from symptom onset to when percutaneous cholecystostomy was performed and when patients were discharged were recorded.In the 209 patients, the median time period between symptom onset and percutaneous cholecystostomy was 23 hours (range, 3-95 hours). The early intervention group (≤24 hours, n = 109) had a significantly lower procedure-related bleeding rate (0.0% vs 5.0%, P = 0.018) and shorter hospital stay (15.8 ± 12.9 vs 21.0 ± 17.5 days) as compared with the late intervention group (>24 hours, n = 100). Delayed percutaneous cholecystostomy was a significant independent factor for a longer hospital stay (odds ratio 3.03, P = 0.001).In inoperable patients with acute severe cholecystitis, early percutaneous cholecystostomy reduced hospital stay and procedure-related bleeding without increasing the mortality rate.

Surgical management of acute cholecystitis

BACKGROUND

Acute cholecystitis occurs in approximately 1% of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis.

METHODS

A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings 'cholecystitis', 'acute', 'gallbladder', 'inflammation', 'surgery', 'cholecystectomy', 'laparoscopic', 'robotic', 'telerobotic' and 'computer-assisted' were used.

RESULTS

Data from eight randomised controlled trails and three population-based analyses show that early cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective cholecystectomy. Delaying cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis.

CONCLUSIONS

Trial evidence would favour a policy of early laparoscopic cholecystectomy following admission with acute cholecystitis. The optimal approach to support early cholecystectomy is suggested but requires evidence from further randomised trials.

Cholecystectomy for acute cholecystitis. How time-critical are the so called "golden 72 hours"? Or better "golden 24 hours" and "silver 25-72 hour"? A case control study

Introduction

Early cholecystectomy within 72 hours has been shown to be superior to late or delayed cholecystectomy with regard to outcome and cost of treatment. Recently, immediate cholecystectomy within 24 hours of onset of symptom was proposed as standard procedure for the management of fit patients presenting with acute cholecystitis. We sort to find out if there are any differences in surgical outcomes between patients managed within 24 h and those managed 25-72 h following symptom begin for acute cholecystitis.

Patients and methods

A retrospective analysis was performed. The outcomes of patients undergoing laparoscopic cholecystectomy within 24 h were compared to those of patients managed 25-72 h following symptom onset for acute cholecystitis.

Results

35 patients managed 25-72 h following begin of symptoms were matched with 35 patients with similar baseline features, medical comorbidities and disease severity managed within 24 hours of symptom onset. There were no significant differences in the duration of surgery, postoperative complications, rate of conversion and length of hospital stay.

Conclusion

Immediate laparoscopic cholecystectomy for acute cholecystitis within 24 hour of symptom onset is not superior to surgery 25–72 hour after symptoms begin. Laparoscopic cholecystectomy for acute cholecystitis therefore can be safely performed anytime within the golden 72 h.

Cholecystectomy for acute cholecystitis. How time-critical are the so called "golden 72 hours"? Or better "golden 24 hours" and "silver 25-72 hour"? A case control study

INTRODUCTION

Early cholecystectomy within 72 hours has been shown to be superior to late or delayed cholecystectomy with regard to outcome and cost of treatment. Recently, immediate cholecystectomy within 24 hours of onset of symptom was proposed as standard procedure for the management of fit patients presenting with acute cholecystitis. We sort to find out if there are any differences in surgical outcomes between patients managed within 24 h and those managed 25-72 h following symptom begin for acute cholecystitis.

PATIENTS AND METHODS

A retrospective analysis was performed. The outcomes of patients undergoing laparoscopic cholecystectomy within 24 h were compared to those of patients managed 25-72 h following symptom onset for acute cholecystitis.

RESULTS

35 patients managed 25-72 h following begin of symptoms were matched with 35 patients with similar baseline features, medical comorbidities and disease severity managed within 24 hours of symptom onset. There were no significant differences in the duration of surgery, postoperative complications, rate of conversion and length of hospital stay.

CONCLUSION

Immediate laparoscopic cholecystectomy for acute cholecystitis within 24 hour of symptom onset is not superior to surgery 25-72 hour after symptoms begin. Laparoscopic cholecystectomy for acute cholecystitis therefore can be safely performed anytime within the golden 72 h.