Immediate laparoscopic cholecystectomy for acute cholecystitis: no need to wait

Comparison of the safety profile, conversion rate and hospitalization duration between early and delayed laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis

Background

Although the past decade has witnessed unprecedented medical progress, no consensus has been reached on the optimal approach for patients with acute cholecystitis. Herein, we conducted a systematic review and meta-analysis to assess the differences in patient outcomes between Early Laparoscopic Cholecystectomy (ELC) and Delayed Laparoscopic Cholecystectomy (DLC) in the treatment of acute cholecystitis. Our protocol was registered in the PROSPERO database (registration number: CRD42023389238).

Objectives

We sought to investigate the differences in efficacy, safety, and potential benefits between ELC and DLC in acute cholecystitis patients by conducting a systematic review and meta-analysis.

Methods

The online databases PubMed, Springer, and the Cochrane Library were searched for randomized controlled trials (RCTs) and retrospective studies published between Jan 1, 1999 and Jan 1, 2022.

Results

21 RCTs and 13 retrospective studies with a total of 7,601 cases were included in this research. After a fixed-effects model was applied, the pooled analysis showed that DLC was associated with a significantly high conversion rate (OR: 0.6247; 95%CI: 0.5115-0.7630; z = -4.61, p < 0.0001) and incidence of postoperative complications (OR: 0.7548; 95%CI: 0.6197-0.9192; z = -2.80, p = 0.0051). However, after applying a random-effects model, ELC was associated with significantly shorter total hospitalization duration than DLC (MD: -4.0657; 95%CI: -5.0747 to -3.0566; z = -7.90, p < 0.0001).

Conclusion

ELC represents a safe and feasible approach for acute cholecystitis patients since it shortens hospitalization duration and decreases the incidence of postoperative complications of laparoscopic cholecystectomy.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=389238, identifier (CRD42023389238).

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.

Early laparoscopic cholecystectomy for acute cholecystitis: should we operate beyond the first week?

BACKGROUND

The deadline for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is the subject of much debate. The aim of this study was to assess outcomes of ELC in patients with more than 7 days of symptoms.

METHODS

It is a retrospective analysis of 564 patients having undergone ELC for ACC between January 2003 and June 2021. Patients were divided into two groups according to the timing between the onset of symptoms and surgery: group 1 (G1), within the first 7 days of symptoms, and group 2 (G2) after day 7 of symptoms.

RESULTS

Apart from a longer operative time (G1 80 min vs. G2 90 min; p = 0.016), there were no significant differences regarding conversion rate (G1 14.5% vs. G2 13.2%; p = 0.748), both intra- and postoperative complications, mainly bile duct injuries (G1 0.2% vs. G2 0%; p = 1) and bile leakage (G1 1.2% vs. G2 0%; p = 1) and postoperative length of stay (G1 2 days [1-3] vs. G2 2 days [1-4]; p = 0.125).

CONCLUSION

Early laparoscopic cholecystectomy could be proposed for patients with acute calculous cholecystitis even beyond 7 days of symptoms.

Optimal Timing of Cholecystectomy for Acute Cholecystitis: A Retrospective Cohort Study

Background

Laparoscopic cholecystectomy performed less than 72 hours from hospital admission for acute cholecystitis has shown to decrease hospital cost without an increase in length of stay (LOS). Very few studies have examined clinical and cost outcomes of performing cholecystectomy less than 24 hours from hospital admission. The aim of this study was to examine the cost and LOS of laparoscopic cholecystectomy performed on an early (less than 24 hours from admission) and late (more than 24 hours from hospital admission) basis.

Methods

We performed a retrospective observational study of 569 patients at Baystate Medical Center, Springfield, USA, who underwent urgent laparoscopic cholecystectomy for acute cholecystitis between January 1, 2018 and February 28, 2020. We evaluated preoperative/postoperative LOS, operative duration, hospital cost, and patient complications.

Results

468 patients underwent urgent laparoscopic cholecystectomy for acute cholecystitis during our study period. Early cholecystectomy (less than 24 hours from admission) had an overall decreased LOS (43.6 hours versus 102.9 hours, p-value < 0.01) and decreased hospital cost ($23,736.70 versus $30,176.40, p-value < 0.01) compared to late cholecystectomy (more than 24 hours from admission). There was also a significantly higher rate of bile leak in patients who underwent surgery more than 24 hours from hospital admission compared to those who had surgery less than 24 hours from admission (5.9% versus 0.4%, p-value < 0.01). Additionally, those procedures performed greater than 24 hours from hospital admission were significantly more likely to be converted to an open procedure (6.9% versus 2.2%, p-value = 0.02). 

Conclusion

Urgent laparoscopic cholecystectomy performed within 24 hours of hospital admission for acute cholecystitis decreased hospital cost, LOS, and operative complications in our institution's patient population. Our data suggests that performing laparoscopic cholecystectomy within 24 hours of hospital admission would be beneficial from a patient and hospital standpoint.

Laparoscopic cholecystectomy for acute cholecystitis: is the surgery still safe beyond the 7-day barrier? A multicentric observational study

Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.

Laparoscopic Cholecystectomy for Acute Cholecystitis: Is the Surgery Still Safe beyond the 7-Day Barrier?

BACKGROUND

The optimal timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study was to assess the outcomes of ELC in patients with delayed presentation.

METHODS

Retrospective analysis of 381 patients who underwent ELC for ACC between January 2010 and September 2018. Included patients were classified into two groups according to the timing of surgery from the onset of symptoms: group 1 (G1) within the first 7 days and group 2 (G2) beyond 7 days.

RESULTS

There were no significant differences regarding conversion rate (G1 8.6% vs. G2 11.8%; p = 0.527), operative time (G1 100 min [75-120] vs. G2 120 min [71-150]; p = 0.060), bile duct injuries (G1 0.3% vs. G2 0%; p = 1), major postoperative complications (G1 11% vs. G2 5.9%; p = 0.557), reoperation rates (G1 1.4% vs. G2 0%; p = 1), length of stay (G1 4 days [3-7] vs. G2 5 days [3-7]; p = 0.539), readmissions (G1 3.7% vs. G2 5.9%; p = 0.633) and costs (G1 6035 € [3693-8330] vs. G2 7243 € [4921-11,336]; p = 0.395).

CONCLUSION

ELC may be considered for patients with ACC who can tolerate surgery with more than 1 week of symptom duration.

The Treatment of Gallstone Disease

BACKGROUND

Gallstone disease affects up to 20% of the European population, and cholelithiasis is the most common reason for hospitalization in gastroenterology.

METHODS

This review is based on pertinent publications retrieved by a selective search of the literature, including the German clinical practice guidelines on the diagnosis and treatment of gallstones and corresponding guidelines from abroad.

RESULTS

Regular physical activity and an appropriate diet are the most important measures for the prevention of gallstone disease. Transcutaneous ultrasonography is the paramount method of diagnosing gallstones. Endoscopic retrograde cholangiography should only be carried out as part of a planned therapeutic intervention; endosonography beforehand lessens the number of endoscopic retrograde cholangiographies that need to be performed. Cholecystectomy is indicated for patients with symptomatic gallstones or sludge. This should be performed laparoscopically with a four-trocar technique, if possible. Routine perioperative antibiotic prophylaxis is not necessary. Cholecystectomy can be performed in any trimester of pregnancy, if urgently indicated. Acute cholecystitis is an indication for early laparoscopic cholecystectomy within 24 hours of admission to hospital. After successful endoscopic clearance of the biliary pathway, patients who also have cholelithiasis should undergo laparoscopic cholecystectomy within 72 hours.

CONCLUSION

The timing of treatment for gallstone disease is an essential determinant of therapeutic success.

Controversias en el manejo de la colecistitis aguda tardía

La colecistitis aguda es la inflamación de la vesícula biliar, en la mayoría de los casos, explicada por la presencia de cálculos mixtos o de colesterol que producen obstrucción y desencadenan factores inflamatorios diversos. La colecistectomía por vía laparoscópica se ha convertido en su tratamiento estándar y definitivo. El procedimiento quirúrgico debe realizarse idealmente en las primeras 72 horas después de iniciados los síntomas, lo que habitualmente se denomina como cuadro agudo. Existe controversia sobre cuál es el manejo más adecuado cuando han pasado más de 72 horas del inicio de los síntomas, condición denominada ‘colecistitis aguda tardía’, cuando se considera que el proceso inflamatorio es mayor y, el procedimiento, técnicamente más complejo y peligroso. Para esta condición, se han establecido dos estrategias iniciales de manejo: la cirugía temprana –durante la hospitalización inicial– o el tratamiento conservador con antibióticos para la supuesta resolución completa de la inflamación, es decir, ‘enfriar el proceso’; varias semanas después, se practica una colecistectomía laparoscópica tardía –diferida o electiva–. Existen muchas publicaciones sobre ambas estrategias, en las que se exponen los beneficios y probables complicaciones de cada una; en la actualidad, se sigue debatiendo sobre el momento óptimo para practicar la intervención quirúrgica. Los trabajos más recientes y con mayor peso epidemiológico, resaltan los beneficios de la cirugía temprana pues, aunque las complicaciones intraoperatorias ocurren en las mismas proporciones, la cirugía en la hospitalización inicial reduce los costos, los reingresos y los tiempos hospitalarios. Después de revisar la literatura disponible a favor y en contra, este artículo pretende recomendar el procedimiento temprano, inclusive cuando hayan pasado más de tres días de iniciados los síntomas y, solo en casos muy seleccionados, diferir la cirugía.

Is Nighttime Really Not the Right Time for a Laparoscopic Cholecystectomy?

PURPOSE

The impact of an out-of-hours laparoscopic cholecystectomy on outcome is controversial. We sought to determine the association between an out-of-hours procedure and postoperative complications within 90 days.

METHODS

Between 2014 and 2016, 1553 laparoscopic cholecystectomies were performed. Therapeutic, operative, and outcome data were prospectively collected and analyzed. We defined out of hours as during weekends, national holidays, and daily between 5PM and 8AM.

RESULTS

Most patients operated on were female (n=988; 63.6%) and the majority of procedures were electives (n=1341; 86.3%). Although all procedures were performed with a laparoscopic intent, 42 (2.7%) were converted to open procedure. In total, 145 (9.3%) procedures were out of hours, all nonelective, and in most cases for acute cholecystitis (n=111; 7.1%). Overall, there were 212 complications in 191 patients (12.3%), most (n=153; 9.9%) classified as minor. The conversion rate in the out-of-hours group was significantly higher (9.7% vs 2.0%; p<0.001). While univariate analyses revealed out-of-hours procedure (OR=1.83; p=0.008) to be associated with an increased risk of complications, when controlling for confounding factors by multivariate analysis, this association was not found. However, operation by surgical staff (OR=1.71) and conversion to laparotomy (OR=3.74) were found to be independently associated with an increased risk of complications (both p<0.05), while an emergency procedure tended to be associated with postoperative morbidity (OR=1.82; p=0.069).

CONCLUSION

An out-of-hours laparoscopic cholecystectomy was not found to be an independent risk factor for developing postoperative morbidity and time of day should therefore only be a relative contraindication.

Delayed Presentation of Acute Cholecystitis: Comparative Outcomes of Same-Admission Versus Delayed Laparoscopic Cholecystectomy

INTRODUCTION

Studies have shown that same-admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis (AC). However, no studies have compared both modalities in patients with delayed presentation. The aim of the study was to compare outcomes between SALC and DLC in AC patients with more than 7-day symptom duration.

METHODS

A retrospective analysis of 83 AC patients who underwent LC after presenting with >7 days of symptoms from June 2010 to June 2015 was performed. Patients were divided into L-SALC and L-DLC, defined as LC performed within the same admission and between 4 and 24 weeks after discharge, respectively. Peri-operative outcomes were evaluated.

RESULTS

In L-SALC patients, the intra-operative severity was higher (p < 0.001) and median operative time was longer (L-SALC, 107 min (46-220) vs L-DLC, 95 mins (25-186)) (p = 0.048). Conversion rates were also higher in L-SALC than that in L-DLC (L-SALC, 21.4% vs L-DLC, 4.9%) (p = 0.048). While post-operative morbidity was similar, L-SALC was associated with a longer post-operative length of stay as compared to L-DLC (L-SALC, 2 (1-17) vs L-DLC, 1 (1-6)) (p < 0.001).

CONCLUSION

DLC provides lower conversion rates and shorter length of stay in AC patients presenting beyond 7 days of symptoms. This group of patients should be offered DLC.

Laparoscopic cholecystectomy in the treatment of acute cholecystitis: comparison of results between early and late cholecystectomy

Introduction

Laparoscopic cholecystectomy has become the gold standard in the treatment of symptomatic gallstones. The common opinion about treatment of acute cholecystitis is initially conservative treatment due to preventing complications of inflamation and following laparoscopic cholecystectomy after 6- 8 weeks. However with the increase of laparoscopic experience in recent years, early laparoscopic cholecystectomy has become more common.

Methods

We aimed to compare the outcomes of the patients to whom we applied early or late cholecystectomy after hospitalization from the emergency department with the diagnosis of AC between March 2012-2015.

Results

We retrospectively reviewed the files of totally 66 patients in whom we performed early cholecystectomy (within the first 24 hours) (n: 33) and to whom we firstly administered conservative therapy and performed late cholecystectomy (after 6 to 8 weeks) (n: 33) after hospitalization from the emergency department with the diagnosis of acute cholecystitis. The groups were made up of patients who had similar clinical and demographic characteristics. While there were no statistically significant differences between the durations of operation, the durations of hospitalization were longer in those who underwent early cholecystectomy. Moreover, more complications were seen in the patients who underwent early cholecystectomy although the difference was not statistically significant.

Conclusion

Early cholecystectomy is known to significantly reduce the costs in patients with acute cholecystitis. However, switching to open surgery as well as increase of complications in patients who admitted with severe inflammation attack and who have high comorbidity, caution should be exercised when selecting patients for early operation.

Same admission laparoscopic cholecystectomy for acute cholecystitis: is the "golden 72 hours" rule still relevant?

BACKGROUND

Studies have shown that same admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy for acute cholecystitis (AC). While some proposed a"golden 72-hour" for SALC, the optimal timing remains controversial. The aim of the study was to compare the outcomes of SALC in AC patients with different time intervals from symptom onset.

METHODS

A retrospective analysis of 311 patients who underwent SALC for AC from June 2010-June 2015 was performed. Patients were divided into three groups based on the time interval between symptom onset and surgery: <4 days (E-SALC), 4-7 days (M-SALC), >7 (L-SALC).

RESULTS

The mean duration of symptoms was 2(1-3), 5(4-7) and 9 (8-13) days for E-SALC, M-SALC and L-SALC, respectively (p < 0.001). Conversion rates were higher in the L-SALC group [E-SALC, 8.2% vs M-SALC, 9.6% vs L-SALC, 21.4%] (p = 0.048). The total length of stay was longer in patients with longer symptom duration [E-SALC, 4 (2-33) vs M-SALC, 2 (2-23) vs L-SALC, 7 (2-49)] (p < 0.001).

CONCLUSION

Patients with AC presenting beyond 7 days of symptoms have higher conversion rates and longer length of stay associated with SALC. However, patients with less than a week of symptoms should be offered SALC.

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.

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.

Determination of optimal operation time for the management of acute cholecystitis: a clinical trial

INTRODUCTION

Although all studies have reported that laparoscopic cholecystectomy (LC) is a safe and effective treatment for acute cholecystitis, the optimal timing for the procedure is still the subject of some debate.

AIM

This retrospective analysis of a prospective database was aimed at comparing early with delayed LC for acute cholecystitis.

MATERIAL AND METHODS

The LC was performed in 165 patients, of whom 83 were operated within 72 h of admission (group 1) and 82 patients after 72 h (group 2) with acute cholecystitis between January 2012 and August 2013. All data were collected prospectively and both groups compared in terms of age, sex, fever, white blood count count, ultrasound findings, operation time, conversion to open surgery, complications and mean hospital stay.

RESULTS

The study included 165 patients, 53 men and 112 women, who had median age 54 (20-85) years. The overall conversion rate was 27.9%. There was no significant difference in conversion rates (21% vs. 34%) between groups (p = 0.08). The operation time (116 min vs. 102 min, p = 0.02) was significantly increased in group 1. The complication rates (9% vs. 18%, p = 0.03) and total hospital stay (3.8 days vs. 7.9 days, p = 0.001) were significantly reduced in group 1.

CONCLUSIONS

Early LC within 72 h of admission reduces complications and hospital stay and is the preferred approach for acute cholecystitis.

Determination of optimal operation time for the management of acute cholecystitis: a clinical trial

Introduction

Although all studies have reported that laparoscopic cholecystectomy (LC) is a safe and effective treatment for acute cholecystitis, the optimal timing for the procedure is still the subject of some debate.

Aim

This retrospective analysis of a prospective database was aimed at comparing early with delayed LC for acute cholecystitis.

Material and methods

The LC was performed in 165 patients, of whom 83 were operated within 72 h of admission (group 1) and 82 patients after 72 h (group 2) with acute cholecystitis between January 2012 and August 2013. All data were collected prospectively and both groups compared in terms of age, sex, fever, white blood count count, ultrasound findings, operation time, conversion to open surgery, complications and mean hospital stay.

Results

The study included 165 patients, 53 men and 112 women, who had median age 54 (20–85) years. The overall conversion rate was 27.9%. There was no significant difference in conversion rates (21% vs. 34%) between groups (p = 0.08). The operation time (116 min vs. 102 min, p = 0.02) was significantly increased in group 1. The complication rates (9% vs. 18%, p = 0.03) and total hospital stay (3.8 days vs. 7.9 days, p = 0.001) were significantly reduced in group 1.

Conclusions

Early LC within 72 h of admission reduces complications and hospital stay and is the preferred approach for acute cholecystitis.

[Acute cholecystitis: primarily conservative or operative approach?]

Acute cholecystitis is one of the most common acute surgical diseases. There is a consensus that laparoscopic cholecystectomy is recommended as the treatment of choice; however, there is a controversy about the best time for surgery. In contrast to delayed cholecystectomy after initial antibiotic treatment, early or immediate cholecystectomy seems to have some advantages. Recent studies and meta-analyses have several limitations due to small patient numbers and inhomogeneity in treatment design. Nevertheless, international guidelines tend to recommend early cholecystectomy but the most recent concept of immediate cholecystectomy within 24 h after diagnosis independent of the onset of symptoms is not considered. A current prospective multicenter, randomized controlled trial will shortly bring more clarity to this topic (ACDC trial).

What is the optimal time for laparoscopic cholecystectomy in gallbladder empyema?

PURPOSE

With the accumulating experience in laparoscopic surgery, early laparoscopic cholecystectomy (LC) is increasingly offered for acute cholecystitis. However, early LC without percutaneous transhepatic gallbladder drainage (PTGBD) for gallbladder empyema is still believed to be unsafe. The purpose of this study was to determine the optimal time for LC in gallbladder empyema.

METHODS

A retrospective analysis was carried out of patients who underwent LC without PTGBD for gallbladder empyema between August 2007 and December 2010. All cases were confirmed by biopsy. The patients were divided into two groups on the basis of a cutoff of 72 h.

RESULTS

LC for gallbladder empyema was performed without PTGBD in 61 patients during the study period. The overall conversion rate was 6.6 %. Based on the 72 h cutoff, there were 33 patients in the early group and 28 in the delayed group. There were no significant differences between early and late patients with respect to operation duration (75.5 vs. 71.4 min, p = 0.537), postoperative hospital stay (4.2 vs. 3.3 days, p = 0.109), conversion rate (12.1 vs. 0 %, p = 0.118), and complication rate (12.1 vs. 3.6 %, p = 0.363). However, the early group had a significantly shorter total hospital stay (5.3 vs. 8.7 days, p = 0.001).

CONCLUSIONS

Early LC without PTGBD is safe and feasible for gallbladder empyema and is associated with a low conversion rate. Delayed LC for gallbladder empyema has no advantages and results in longer total hospital stays. LC should be performed as soon as possible within 72 h after admission to decrease length of hospital stay.

No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

The objective of our analysis was to determine the optimal timing of cholecystectomy during admission for acute cholecystitis.

METHODS

All patients from the American College of Surgeons National Surgical Quality Improvement Program Participant User Files from 2005 through 2010 who underwent emergency cholecystectomy within 7 days of hospital admission for acute cholecystitis were included for analysis. The association between timing of cholecystectomy and postoperative outcomes was determined using multivariate logistic regression analyses after adjustment for patient demographics, acute and chronic comorbid medical conditions, preoperative sepsis classification, American Society of Anesthesiologists physical status classification, and preoperative liver function tests.

RESULTS

A total of 5,268 patients were included for analysis. The timing of operation was day of admission for 49.7% of these patients, 1 day after admission for 33.4%, 2 days after admission for 9.5%, 3 days after admission for 3.9%, and 4 days to 7 days after admission for 3.6%. Multivariate logistic regression analyses revealed no significant association between timing of operation and 30-day postoperative mortality or overall morbidity. Patients who underwent operation later in the course of admission were more likely to require an open procedure and sustained significantly longer postoperative and overall lengths of hospitalization. Similar findings were demonstrated for a subgroup of patients who exhibited characteristics that placed them at higher risk for surgical intervention.

CONCLUSION

Immediate cholecystectomy is preferred for patients who require hospitalization for acute cholecystitis.

LEVEL OF EVIDENCE

Economic/decision analysis, level III.

Clinical review of laparoscopic cholecystectomy in acute cholecystitis

BACKGROUNDS/AIMS

Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, its higher conversion rate and postoperative morbidities remain controversial. The purpose of this retrospective study is to evaluate the clinical significance of laparoscopic cholecystectomy that is performed at our institution in patients with acute cholecystitis.

METHODS

Between January 2003 and December 2009, a retrospective study was carried out for 190 cases of acute cholecystitis undergoing laparoscopic cholecystectomy at our institution. They were divided into 2 groups, based on the time of operation from the onset of the symptom and other previous abdominal operation history. These groups were compared in the conversion rate and perioperative clinical outcomes, such as sex, age, accompanied disease, operation time, complications, postoperative hospital stay, total hospital stay and total costs.

RESULTS

We compared the two groups based on the timing of laparoscopic cholecystectomy and history of previous abdominal operation. There were no significant differences in the open conversion rate, postoperative complications and postoperative hospital stay, total hospital stay and total costs. The sex ratio, female in the previous abdominal operation group, was larger than the non-previous abdominal operation group (70.2% vs. 43.2%, p=0.003, OR=0.32 [95% CI, 0.15-0.70]). Early operation group was larger than delayed operation group, at previous abdominal operation history (26.1% vs. 13.3%, p=0.026, OR=0.43 [95% CI, 0.20-0.91]) and closed suction drain use (79.3% vs. 66.3%, p=0.044, OR=0.51 [95% CI, 0.27-0.99]).

CONCLUSIONS

Although this study was limited, early laparoscopic cholecystectomy for acute cholecystitis with previous abdominal operation history seems to be safe and feasible for patients, having a benefit of decrease in total hospital stay.

Predictive factors for successful early laparoscopic cholecystectomy in acute cholecystitis: a prospective study

BACKGROUND

Early laparoscopic cholecystectomy has become the treatment of choice for acute cholecystitis. However, the rate of intraoperative conversion to open surgery remains high and has provoked an interest in studying the predictive factors for better patient selection to minimize the conversion rates.

MATERIALS AND METHODS

50 patients of acute cholecystitis were operated within 5 days of onset of symptoms. Comparative evaluation of the patient groups undergoing successful versus failed early laparoscopic cholecystectomy was done to identify preoperative factors predicting conversion/failure of the laparoscopic procedure. Predictive factors for intraoperative and histopathological severity of acute cholecystitis were also identified.

RESULTS

40 patients underwent successful completion of early laparoscopic cholecystectomy, 8 required conversions to open, while in 2 patients the procedure had to be abandoned due to phlegmon formation. Male sex, preoperative duration of symptoms WBC counts, serum alkaline phosphatase, serum amylase, and serum C-reactive protein were significant predictors of histopathological severity of acute cholecystitis. Intraoperative and histopathological severity of acute cholecystitis had good association with conversion rate of early laparoscopic cholecystectomy. Male sex and serum C-reactive protein levels >3.6 mg/dl at admission were very strong predictors of conversion/failure of early laparoscopic cholecystectomy in acute cholecystitis.

CONCLUSION

Male patients of acute cholecystitis or patient with serum C-reactive protein levels of >3.6 mg/dl at admission have high risk of conversion in early laparoscopic cholecystectomy and warrant a conservative early management followed by delayed laparoscopic cholecystectomy.

Index laparoscopic cholecystectomy for acute admissions with cholelithiasis provides excellent training opportunities in emergency general surgery

BACKGROUND

There is minimal data on the outcome of early laparoscopic cholecystectomy (LC) for acute gallbladder disease when performed by trainees. This study assesses the outcomes of a policy of same admission LC incorporated into a surgical training programme in a major teaching hospital.

METHODS

447 index LCs performed over a 3-year period were reviewed retrospectively. The indications, operating surgeon, operating time, use of IOC, conversion rates, reasons for conversion and post-operative stay were analysed. Multivariate analysis of reasons for conversion was performed.

RESULTS

150 LCs were performed by consultants and 297 by registrars; 67 were performed by year 1-3 specialist registrars (SpR) and 230 by year 4-6 SpRs. The indications were biliary colic (n=7), acute cholecystitis (n=180), chronic cholecystitis (n=260), carcinoma (n=1). No difference was found in demographics, operating time (105 min Vs 115 min), use of IOC (34% Vs 29%; P=0.2) and post-operative stay (2 days Vs 1 day) between consultants and registrars. The conversion rates were higher for consultants compared to registrars (29 (19%) Vs 28 (9%), P=0.004). The overall conversion rate was 11%. There were no bile duct injuries. Predictors for conversion were CRP>50 at admission and acute cholecystitis.

CONCLUSION

In a teaching hospital setting most acute admission LCs (66%) were performed by trainees. A step wise training programme with active consultant supervision of all index LCs results in low morbidity, low conversion rates, and a short post-operative stay for acute gallbladder disease. This model of same admission cholecystectomy provides a good training opportunity in emergency general surgery.

Is early laparoscopic cholecystectomy safe after the "safe period"?

BACKGROUND

Early laparoscopic cholecystectomy (ELC) in acute cholecystitis improves hospital stay and outcome. Operative difficulty is said to increase with delay, and surgery is usually advised within 3 days of presentation. It can be difficult to accommodate all these patients within 3 days; this study evaluates results within and after this "safe period."

MATERIALS AND METHODS

In total, 137 patients (male:female 45:92) presenting as an emergency due to acute cholecystitis over 45 months from August 1, 2003, who then underwent ELC with an on-table cholangiogram (OTC) or laparoscopic ultrasound were prospectively studied. Outcome was compared between those who underwent surgery within 72 hours (group 1) or after 72 hours (group 2).

RESULTS

There were 87 patients in group 1 versus 50 in group 2. There was no significant difference with reference to ASA grading, length of operation (median 90 vs. 90 minutes; P = 1.000), conversion rates (7 vs. 10%; P = 0.523), median postoperative stay (2 vs. 3 days; P = 0.203), or 30-day readmission rates [5/87 [6%] vs. 3/50 [6%]; P = 1.000] between groups, respectively. There was no mortality. One patient had a biliary leak from a duct of Lushka in group 2, which settled after endoscopic stenting.

CONCLUSION

In experienced hands, ELC is safe even after 72 hours.

Impact of delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis

Laparoscopic cholecystectomy (LC) for complicated acute cholecystitis is associated with high rates of complications and conversion to open cholecystectomy. Percutaneous transhepatic gallbladder drainage (PTGBD) is a safe and effective treatment for acute inflammation of the gallbladder. This study was a retrospective analysis of patients who underwent an LC with or without PTGBD for complicated acute cholecystitis at our hospital between January 2002 and January 2007. Patients were classified into 3 groups: group 1, patients who underwent an LC without preoperative PTGBD (n=60); group 2, patients who underwent an early scheduled LC within 7 days of PTGBD (n=35); and group 3, patients in whom the LC was delayed for a mean of 19.9 days (range, 14 to 39 d) after PTGBD (n=38). The conversion rate to open cholecystectomy and the postoperative complication rate were lower in group 3 than in group 1 (P<0.05). Elective delayed LC after PTGBD may lower the conversion and complication rates of patients with complicated acute cholecystitis.

A survey of surgical management of acute cholecystitis in eastern Saudi Arabia

BACKGROUND/AIM

It is now 60 years since early cholecystectomy was advocated for acute cholecystitis (AC). Yet, surgical opinion remains divided regarding its optimal timing. Furthermore, recent surveys have shown low utilization of early laparoscopic cholecystectomy (LC) for AC.

AIM

This survey aimed to assess the current management of AC in Eastern Saudi Arabia.

MATERIALS AND METHODS

A postal survey was conducted by means of a questionnaire sent to 95 surgeons practicing LC. The questionnaire addressed the surgical management of AC in relation to the subspecialty of interest, duration of consultant status, number of cholecystectomies performed per year, and the percentage performed laparoscopically.

RESULTS

There were 87 responders (92%); two were excluded from the analysis for different reasons. Early LC was preferred by 71% of the responders. With regard to the timing of LC, there was no significant difference in relation to the surgeon's subspecialty of interest or duration of consultant status. However, increased number of cholecystectomies and percentage of cholecystectomies performed with a laparoscopic approach were significantly associated with early LC.

CONCLUSION

Early LC for AC is practiced by th e majority of surgeons in Eastern Saudi Arabia. This practice is significantly associated with increased number of cholecystectomies performed as well as with the percentage performed with a laparoscopic approach. According to the current literature, early LC for AC results in a shorter total hospital stay and reduced cost of treatment.

Laparoscopic cholecystectomy for acute cholecystitis: safe implementation of successful strategies to reduce conversion rates

INTRODUCTION

A higher rate of conversion to open surgery is a well-known problem in patients with acute cholecystitis undergoing laparoscopic cholecystectomy. The aim of this study is to analyze factors which may impact on conversion rates, and to analyze our outcomes following implementation of a departmental strategy in reducing conversion rates.

MATERIALS AND METHODS

122 patients with acute cholecystitis were considered for laparoscopic cholecystectomy from July 2003 to July 2007. An audit of the results of laparoscopic cholecystectomy was done in July 2005 and a departmental strategy aimed at reducing the conversion rates was introduced. The strategies included early laparoscopic cholecystectomy (within 72 hours of admission), performed or supervised by specialist hepatobiliary surgeons, and modifications of operative techniques. This study compares the conversion rates before and after that audit. Forty-eight patients (group A) were from the preaudit period and the remaining 74 (group B) were from the postaudit period. A multivariate analysis was performed to identify risk factors for conversion to open surgery and whether the strategies implemented resulted in decrease in conversion rates.

RESULTS

In the group A patients, there was a conversion rate of 29.2%. Gallbladder wall thickness of greater than 5 mm was found to be a statistically significant (p = 0.028) risk factor for conversion to open surgery. In group B patients, the conversion rates were significantly lower at 6.75% (p = 0.001). Analyzing both groups of patients, using multivariate analysis, gallbladder wall thickness, increasing age, and preaudit operative period were found to be independently associated with conversion to open surgery.

CONCLUSIONS

This study demonstrated that, with specific strategies to decrease conversion and with technical improvements, the conversion rates can be decreased with no demonstrable difference in postoperative complications. Gallbladder wall thickness and increasing age are risk factors for conversion to open surgery.

Outcome of laparoscopic cholecystectomy is not influenced by chronological age in the elderly

AIM: To evaluate the outcome of laparoscopic cholecystectomy (LC) in patients aged 80 years and older.

METHODS: A total of 353 patients aged 65 to 79 years (group 1) and 35 patients aged 80 years and older (group 2) underwent LC. Patients were further classified into two other groups: those with uncomplicated gallbladder disease (group A) or those with complicated gallbladder disease (group B).

RESULTS: There were no significant differences between the age groups (groups 1 and 2) with respect to clinical characteristics such as age, gender, comorbid disease, or disease presentation. Mean operative time, conversion rate, and the incidence of major postoperative complications were similar in groups 1 and 2. However, the percentage of high-risk patients was significantly higher in group 2 than in group 1 (20.0% vs 5.7%, P < 0.01). Group A comprised 322 patients with a mean age of 71.0 ± 5.3 years, and group B comprised 51 patients with a mean age of 69.9 ± 4.8 years. In group B, mean operative time (78.4 ± 49.3 min vs 58.3 ± 35.8 min, P < 0.01), mean postoperative hospital stay (7.9 ± 6.5 d vs 5.0 ± 3.7 d, P < 0.01), and the incidence of major postoperative complications (9.8% vs 3.1%, P < 0.05) were significantly greater than in group A. The conversion rate tended to be higher in group B, but this difference was not significant.

CONCLUSION: Perioperative outcomes in elderly patients who underwent LC seem to be influenced by the severity of gallbladder disease, and not by chronologic age. In octogenarians, LC should be performed at an earlier, uncomplicated stage of the disease whenever possible to improve perioperative outcomes.

Early versus delayed cholecystectomy in patients with biliary acute pancreatitis

BACKGROUND

In patients with biliary acute pancreatitis (AP), cholecystectomy is mandatory to prevent further biliary events, but timing of cholecystectomy remains a subject of ongoing debate. The objective of the present, retrospective study was to compare the outcomes of early (within 2 weeks after onset of disease) versus delayed cholecystectomy in patients with biliary AP.

METHODS

Between January 2000 and December 2005, 112 patients underwent cholecystectomy because of biliary AP. Thirteen patients were excluded from analysis because of necrotizing pancreatitis on the initial computed tomography. Thirty-two were operated within 14 days (group A) and 67 after a longer time period (group B). The primary end point of the study was the rate of biliary complications before cholecystectomy.

RESULTS

There were no differences regarding conversion rates to open surgery (6% vs 3%; P = .59), local (3% vs 4%; P = 1.00), or systemic complications (0% vs 3%; P = 1.00), and mean postoperative stay (4.7 vs 5.7 days; P = .40). Nevertheless, a greater rate of recurrent biliary pancreatitis was found in the group undergoing cholecystectomy later (0% vs 13%; P < .03).

CONCLUSION

The timing of cholecystectomy seems to have no clinically relevant effect on local or systemic complications, but delaying cholecystectomy is associated with an increase of biliary complications in patients with non-necrotizing biliary AP.

Cross-sectional imaging of acute and chronic gallbladder inflammatory disease

OBJECTIVE

The purpose of this article is to provide a comprehensive review of the clinical and cross-sectional imaging features of a variety of acute and chronic gallbladder inflammatory diseases.

CONCLUSION

Inflammatory gallbladder diseases are a common source of abdominal pain and cause considerable morbidity and mortality. Although acute uncomplicated cholecystitis and chronic cholecystitis are frequently encountered, numerous other gallbladder inflammatory conditions may also occur that can be readily diagnosed by cross-sectional imaging.

Considerations concerning laparoscopic cholecystectomy in the extremely elderly

BACKGROUND

Since octogenarians become a growing part of the population and surgical care is possible in them, this study was conducted to evaluate the outcome of laparoscopic cholecystectomy in patients 80 years of age and over.

METHODS

From June 1993 to May 2006, a total of 1263 patients underwent a laparoscopic cholecystectomy, applying the four-trocar American technique; 21 among them were >/=80 years. We retrospectively reviewed patients' age, gender, indication for surgery, comorbid conditions, American Society of Anesthesiologists (ASA) score, conversion to open procedure, postoperative complications, and length of hospital stay.

RESULTS

The mean age in the >/=80 group was 82.5+/-3 and 57% were women, while in the <80 group 72% of patients were women. Recurrent biliary colic was the most frequent (62%) indication for surgery among the elderly patients. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed preoperatively in 6 elderly patients (29%); there were 4 cases of acute calculus pancreatitis and 2 cases of acute cholangitis. A high surgical risk (ASA score of III and IV) was estimated in 11 patients (52%) from the >/=80 group versus 32% in the <80 group (P =0.047). Conversion rate was higher (19%) and hospital stay was longer (4.9 days) in the >/=80 group, compared to younger patients (P =0.01). Mortality was zero and morbidity was 14% versus 3% in the <80 group (P =0.03), including 1 case of postoperative bleeding, 1 case of wound infection, and 1 case of pulmonary atelectasis, respectively.

CONCLUSIONS

Laparoscopic cholecystectomy in the extremely elderly is safe and well tolerated; however, it is associated with a higher conversion rate, increased morbidity, and a longer hospital stay.