Immediate laparoscopic cholecystectomy as definitive therapy for acute cholecystitis

The Efficacy of Percutaneous Transhepatic Gallbladder Drainage on Acute Cholecystitis in High-Risk Elderly Patients Based on the Tokyo Guidelines: A Retrospective Case-Control Study

To evaluate the efficacy of percutaneous transhepatic gallbladder drainage (PTGD) for high-risk elderly patients with acute cholecystitis.Retrospective analysis of 159 acute cholecystitis patients who were admitted to General Surgery Division III of the First Affiliated Hospital of Dalian Medical University between January 2005 and November 2012. A total of 123 patients underwent laparoscopic cholecystectomy (LC), and 36 received only PTGD treatment. The LC patients were divided into 3 groups based on their preoperative treatment: group A, emergency patients (33 patients); group B (26 patients), patients who were treated with PTGD prior to LC; and group C (64 patients), patients who received nonsurgical treatment prior to LC. General conditions, LC surgery duration, intraoperative blood loss, rate of conversion to open surgery, incidence of postoperative complications, total fasting time, and total hospitalization time were analyzed and compared among the 3 groups.The remission rates of patients in the PTGD treatment groups (including group B and PTGD treatment only group) were significantly higher within 24 and 48 hours than those of patients who received nonsurgical treatment prior to LC (P < 0.05). Among the patients in the 3 surgery groups, the operation conversion rate (19.2%) of group B was significantly higher than that of group A (3.0%) and group C (1.6%) (P < 0.05). The total hospitalization time of the patients in group B (18.5 ± 4.5 days) was longer than that of the patients in group A (8.2 ± 3.9 days) and group C (10.5 ± 6.4 days). The total fasting time of the patients in group A (2.4 ± 1.2 days) was significantly shorter than that of those in group B (4.1 ± 1.7 days) and group C (3.4 ± 2.7 days) (P < 0.05).For high-risk elderly patients, if there is any emergency surgery contraindication, PTGD therapy may be safe and effective and can relieve the symptoms within a short time. For acute cholecystitis patients without surgery contraindications, emergency surgery should be performed as soon as possible after diagnosis.

Comparison of clinical safety and outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis

Objective. To compare the clinical safety and outcomes of early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy for acute cholecystitis. Methods. Pertinent studies were selected from the Medline, EMBASE, and Cochrane library databases, references from published articles, and reviews. Seven randomized controlled trials (early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to Cochrane Collaboration was used for the pooling of the results. Results. Seven trials with 1106 patients were included. There was no significant difference between the two groups in terms of bile duct injury (Peto odds ratio 0.49 (95% confidence interval 0.05 to 4.72); P = 0.54) or conversion to open cholecystectomy (risk ratio 0.91 (95% confidence interval 0.69 to 1.20); P = 0.50). The total hospital stay was shorter by 4 days for early laparoscopic cholecystectomy (mean difference −4.12 (95% confidence interval −5.22 to −3.03) days; P < 0.00001). Conclusion. Early laparoscopic cholecystectomy during acute cholecystitis is safe and shortens the total hospital stay.

Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis

Many surgeons have found it difficult to decide whether to apply percutaneous transhepatic gallbladder drainage (PTGBD) in patients with acute cholecystitis that is not responsive to initial medical management (IMMx), because the indications of PTGBD are ambiguous. The aim of this study was to evaluate the appropriate treatment for acute cholecystitis that is not responsive to IMMx. Specifically, we focused on differences in surgical outcomes between elective and emergency laparoscopic surgeries. Between March 2006 and February 2009, 738 patients with acute cholecystitis who had undergone laparoscopic cholecystectomy (LC) at our institution were retrospectively studied. We divided them into 3 groups. Group I included 494 patients who underwent elective LC without pre-operative PTGBD, group II included 97 patients who intended to undergo elective LC after preoperative PTGBD, and group III included 147 patients who underwent emergency LC without preoperative PTGBD. We compared age, sex, symptom duration, body temperature, leukocyte counts, and American Society of Anesthesiologists (ASA) class on admission as clinical characteristics. We compared the time interval from symptom development and admission to surgery, operative time, the conversion rate to open surgery, postoperative complications, the total length of stay, and the postoperative length of stay as perioperative surgical outcomes. For patients with ASA 2 and 3, the conversion rate to open surgery in group II was significantly less than that in group III (P<.05, P<.01, respectively). We recommend PTGBD as the first choice for acute cholecystitis in patients who show no improvement after IMMx, to allow the patient to undergo an elective LC rather than emergency surgery for patients with ASA 2 and 3.

Management of acute gallbladder disease in England

BACKGROUND

Recent literature suggests that early laparoscopic cholecystectomy for acute gallbladder disease is safe and efficacious, but few data are available on the management of acute gallbladder disease in England.

METHODS

Hospital Episode Statistics data for the years 2003-2005 were obtained from the Department of Health. All patients admitted as an emergency with acute gallbladder disease during the period from April 2003 to March 2004 were included as a cohort. Repeat emergency admissions for acute gallbladder disease, and cholecystectomies performed during the first admission, an emergency readmission or an elective admission were followed up until March 2005.

RESULTS

Some 25,743 patients were admitted as an emergency with acute gallbladder disease, of whom 3791 had an emergency cholecystectomy during the first admission (open cholecystectomy (OC) 29.8 per cent, laparoscopic conversion rate (LCR) 10.7 per cent) and 9806 patients had an elective cholecystectomy (OC 11.3 per cent, LCR 8.3 per cent) during the study period.

CONCLUSION

Early cholecystectomy for acute gallbladder disease is not widely practised by surgeons in England. Open cholecystectomy is more commonly used in the emergency than in the elective setting. Early laparoscopic cholecystectomy following an emergency admission carries a higher conversion rate than elective cholecystectomy.

A survey of the timing and approach to the surgical management of patients with acute cholecystitis in Japanese hospitals

BACKGROUND/PURPOSE

Despite the fact that there is evidence advocating early laparoscopic cholecystectomy for acute cholecystitis (AC), the practice of this treatment has not been investigated sufficiently. This study was designed to assess the current practice of laparoscopic cholecystectomy for AC among Japanese general surgeons.

METHODS

A postal questionnaire was sent to the 291 councillors of the Japanese Society of Abdominal Emergency Medicine in order to ascertain their current management of patients with AC.

RESULTS

The response rate was 72.5%. A policy of early cholecystectomy for AC was adopted by 41.7% of the responding surgeons. However, almost the same percentage of surgeons routinely managed their patients conservatively, and opted for delayed cholecystectomy at a later date. The adoption of laparoscopic cholecystectomy was made by 79.1% of surgeons. Laparoscopic cholecystectomy for patients with AC who had percutaneous transhepatic gallbladder drainage (PTGBD) was adopted by 73.9% of the surgeons. Of the surgeons opting for laparoscopic cholecystectomy, 37.3% performed intraoperative cholangiography laparoscopically for all patients with AC.

CONCLUSIONS

Although early cholecystectomy for patients with AC was not adopted by the majority of the surgeons who responded, laparoscopic cholecystectomy was a common procedure for early and delayed cholecystectomy. Despite evidence that strongly supports the use of early cholecystectomy, the use of this treatment remains suboptimal in Japan.

Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines

Cholecystectomy has been widely performed in the treatment of acute cholecystitis, and laparoscopic cholecystectomy has been increasingly adopted as the method of surgery over the past 15 years. Despite the success of laparoscopic cholecystectomy as an elective treatment for symptomatic gallstones, acute cholecystitis was initially considered a contraindication for laparoscopic cholecystectomy. The reasons for it being considered a contraindication were the technical difficulty of performing it in acute cholecystitis and the development of complications, including bile duct injury, bowel injury, and hepatic injury. However, laparoscopic cholecystectomy is now accepted as being safe for acute cholecystitis, when surgeons who are expert at the laparoscopic technique perform it. Laparoscopic cholecystectomy has been found to be superior to open cholecystectomy as a treatment for acute cholecystitis because of a lower incidence of complications, shorter length of postoperative hospital stay, quicker recuperation, and earlier return to work. However, laparoscopic cholecystectomy for acute cholecystitis has not become routine, because the timing and approach to the surgical management in patients with acute cholecystitis is still a matter of controversy. These Guidelines describe the timing of and the optimal surgical treatment of acute cholecystitis in a question-and-answer format.

Laparoscopic cholecystectomy for acute cholecystitis: the evolving trend in an institution

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis (AC). We review the evolving role of LC for AC in our institution.

METHODS

A retrospective study was conducted of patients who received LC for AC between January 1994 and June 2001. Patients' demographics, clinical findings and perioperative outcomes were evaluated.

RESULTS

There were 140 men and 141 women with a mean age of 56.9 years (range, 23-89 years). Two hundred and eighteen of these patients underwent successful LC. There were 63 conversions (22.4%) for uncertain anatomy and difficult dissection (41), gangrenous or perforated gallbladder (16) and bleeding (6). The conversion rates as stratified to surgeon's seniority were 25.1%, 22.8% and 9.7% for registrar, senior registrar and consultant, respectively. The mean operative time was 84.3 minutes (range, 30-255 minutes) and the mean postoperative stay was 5.8 days (range, 1-35 days). The overall complication rate was 11.6%, including two bile duct injuries and two perioperative deaths.

CONCLUSION

LC for AC is safe and effective and associated with a low incidence of complications when routinely applied by surgical residents. The conversion rate is related to operators' surgical experience.

Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy

This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease.

Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis

BACKGROUND

Early laparoscopic cholecystectomy has been advocated for the management of acute cholecystitis, but little evidence exists to support the superiority of this approach over delayed-interval operation. The current systematic review was undertaken to compare the outcomes and efficacy between early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis in an evidence-based approach using metaanalytical techniques.

METHODS

A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1988 and June 2004. Only randomized or quasi-randomized prospective clinical trials in the English language comparing the outcomes of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were recruited. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where feasible and appropriate.

RESULTS

A total of four clinical trials comprising 504 patients met the inclusion criteria. Failure of conservative treatment requiring emergency cholecystectomy occurred for 43 patients (23%) in the delayed group. Metaanalyses demonstrated a significantly shortened total length of hospital stay in the early group (weighted mean difference, -1.12; 95% confidence interval [CI], -1.42 to -0.99; p < 0.001). Pooled estimates did not show any significant differences between the two approaches in terms of operation time, conversion rate, overall complication rate, incidence of bile leakage, and intraabdominal collection.

CONCLUSIONS

The safety and efficacy of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were comparable. Because evidence suggested that early laparoscopic cholecystectomy reduced the total length of hospital stay and the risk of readmissions attributable to recurrent acute cholecystitis, it is therefore a more cost-effective approach for the management of acute cholecystitis.

Management of acute cholecystitis in UK hospitals: time for a change

Early cholecystectomy for patients with acute cholecystitis is safe, cost effective, and leads to less time off work compared with delayed surgery. This study was designed to assess current practice in the management of acute cholecystitis in the UK. A postal questionnaire was sent to 440 consultant general surgeons to ascertain their current management of patients with acute cholecystitis. Replies were received from 308 consultants who were involved in treating patients with acute cholecystitis of whom 18 transferred these patients on to another team for further management the day after admission. Thirty two consultants (11%) routinely treated patients by early cholecystectomy, with limiting factors stated to be the availability of surgical staff, theatre space, and radiological investigations. The remaining consultants (n = 258) routinely manage their patients conservatively with intravenous antibiotics and allow the inflammation to resolve before undertaking cholecystectomy at a later date. Indications for undertaking early cholecystectomy during the first admission by this latter group included the presence of spreading peritonitis due to bile leak, empyema, and unexpected space on theatre list. The commonest method for both elective and early cholecystectomy is laparoscopic, but the percentage of consultants using an open method rises from 8% in the elective situation to 47% for urgent early cholecystectomy. Despite evidence which strongly advocates early cholecystectomy, this practice is routinely carried out by only 11% of consultants in the UK at present.

Elective laparoscopic cholecystectomy: implications of prolonged waiting times for surgery

BACKGROUND

The aim of the present study was to assess the impact of surgical waiting times on patients scheduled for elective laparoscopic cholecystectomy (LC), with emphasis on morbidity and costs incurred.

METHODS

A retrospective review of all patients who underwent cholecystectomy at the Launceston General Hospital between 1 January 1999 and 31 December 2001 was performed.

RESULTS

A total of 322 LCs was performed during the study period. Median time on the waiting list was 130 (1-1481) days. While awaiting surgery, 44/322 patients (14%) re-presented to the emergency department with biliary symptoms (89 separate presentations); 21 patients (6%) were admitted (28 admissions), of whom 18 (86%) were on the waiting list for biliary colic symptoms only. Reasons for emergency admission included pancreatitis (1), cholangitis (3), choledocholithiasis (7), cholecystitis (7), and exacerbation of symptoms (10). Median hospital stay was 4 days (1-14 days) (total cost of 124 hospital days, excluding subsequent admission for cholecystectomy, $A128 712 according to average bed day costs), and 11 patients required endoscopic retrograde cholangiopancreatography (13 procedures). Mean (median) time on the surgical waiting list for patients who developed complications was 238 (203) days versus 185 (126) days for patients who had LC without interval complications. A total of 198 cancellations occurred in 124/322 patients (39%) before surgery.

CONCLUSIONS

Prolonged waiting times for elective LC are associated with morbidity in 14% of patients at the Launceston General Hospital. This, combined with frequent cancellation of elective surgery, may result in significant costs to the health-care sector.

Empyema of the gall bladder: reappraisal in the laparoscopy era

BACKGROUND

In evaluations of laparoscopic cholecystectomy for acute cholecystitis, the role of this technique specifically for empyema of the gall bladder has not been separately addressed. Therefore, we describe the demographic characteristics, clinical and laboratory findings, management and outcome of patients presenting with empyema of the gall bladder who were treated with open cholecystectomy or laparoscopic cholecystectomy.

PATIENTS AND METHODS

Our retrospective evaluation included 1449 patients who underwent cholecystectomy over 88 months, including a 30-month period when open cholecystectomy was the standard operation and a 58-month period when laparoscopic cholecystectomy became the standard operation for acute and chronic cholecystitis.

RESULTS

Of the 1449 cholecystectomies, 29 cases proved to have empyema, an incidence of 2%. Males constituted 48.3% of the patients (vs. 22% for the whole cholecystectomy group, P < or = 0.005) and the average age was 54.6 years (vs. 43 years for the whole cholecystectomy group, P < or = 0.005). The clinical picture was indistinguishable from other forms of acute cholecystitis. Laparoscopic cholecystectomy was attempted for all the patients in the laparoscopy era with a conversion rate of 42%, significantly higher than other forms of gall bladder diseases (P=0.002).

CONCLUSION

Empyema of the gall bladder is more often encountered in males and the elderly. The clinical picture is indistinguishable from other forms of acute cholecystitis and a preoperative diagnosis is difficult. Early laparoscopic cholecystectomy is advisable for all patients with acute cholecystitis. A higher conversion rate is expected for patients with empyema.

Laparoscopic reintervention for residual gallstone disease

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.

Increased laparoscopic experience does not lead to improved results with acute cholecystitis

BACKGROUND

As laparoscopic experience increases, ever more challenging cases are attempted. Enlarged surgeon experience, along with better technology, has been lauded as improving outcomes. The purpose of this study is to see if this applies to the management of acute cholecystitis.

METHODS

We reviewed our experience over a 7 and a half year period. Information was obtained from a prospectively maintained computer database containing patient presentation, demographics, workup, laboratory values, and outcomes. Diagnosis of gangrene was based on pathologic examination of the specimen.

RESULTS

There were 305 patients admitted to our institution with acute cholecystitis. Group I (n = 111) was admitted during the first half of the study and group II (n = 194) during the second half. Demographics were similar in the two groups. While slightly more patients were attempted laparoscopically in group II (90% versus 82%), conversion rates were virtually identical (27.1% versus 27.5%). There was a trend toward improved results with group II versus group I in mortality (3% versus 4%) and morbidity (14% versus 21%; P = not significant). Deaths were divided between sepsis and cardiac events. Gangrenous cholecystitis was less frequent in group II patients (29% versus 40%; P = 0.06). Analysis of gangrene versus non-gangrene patients within each group showed that conversion rates remained twice as high (40% versus 20%; P < 0.05) in those with gangrene. Interestingly, gangrene had no effect on morbidity or mortality.

CONCLUSIONS

Morbidity and mortality for acute cholecystitis remain relatively high. These seem to be determined by the degree of acute and chronic illness present at the time of diagnosis. As conversion rates remain unchanged, increased surgeon experience and further advances in laparoscopic technology are unlikely to dramatically affect results. Efforts to improve outcomes for this common disease should therefore focus on better and earlier identification of patients for operation.

Effect of timing of surgery, type of inflammation, and sex on outcome of laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND AND PURPOSE

Studies have shown the safety and effectiveness of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). Our aim was to establish the outcome of LC in patients with AC on the basis of duration of the attack before surgery took place, the type of gallbladder inflammation, and patient sex.

PATIENTS AND METHODS

All 204 patients at Princess Basma Teaching Hospital who underwent LC for AC by the authors between September 1994 and June 1999, were retrospectively reviewed. They were categorized into Group I, where surgery took place within 72 hours of the acute attack (N = 78; 54 women and 24 men), and Group II, if later than that (N = 126; 70 women and 56 men). Gallbladder pathology was classified as gangrenous, empyema, edematous, mucocele, or AC along with contracted fibrosed gallbladder.

RESULTS

Conversion to open cholecystectomy was needed in 12% of the total series. In Group I, 3.8% of the patients needed conversion compared with 16.7% in Group II patients (P = 0.01). Also, 4% of the female patients needed conversion compared with 24% of the male patients (P = 0.000). There was an association between the pathological type of AC and the likelihood of conversion (P = 0.002), conversion being least common in those with mucocele and most common in those with empyema and gangrene. The median operation time was 75 +/- 36 minutes, but the operation time for Group II patients was significantly longer (P = 0.001) than in Group I patients. Operation time in the male patients was significantly longer than in the female patients (P = 0.000). There was no statistically significant difference in the duration of hospital stay in the two groups or in men and women. There were no deaths or main bile duct injuries in the series. In successful LC, missed stones occurred in 3.3% of the patients. Bile collection, which was treated by open surgery, developed in one female patient.

CONCLUSION

Laparoscopic cholecystectomy is a reliable and safe modality for the management of AC. It was not associated with an increased incidence of bile duct injury in this series. It should be the first choice before resorting to open surgery. Factors associated with increased conversion include delay in surgery of more than 3 days from the acute attack and certain pathology, with conversion being more likely in empyema. Conversion also was more likely in male patients.

Laparoscopic cholecystectomy for gallstones: a comparison of outcome between acute and chronic cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (LC) is now a common method of treating symptomatic gallstones, and it is increasingly being requested by the informed general public. Our aim was to evaluate the role of LC for cholelithiasis and to establish its outcome and the effect of gender on the results.

PATIENTS AND METHODS

Between September 1994 and June 1999, all patients who underwent LC for cholelithiasis were retrospectively reviewed. They were classified as having acute or chronic cholecystitis (AC or CC).

RESULTS

There were 791 patients with CC (633 females, 158 males) and 204 patients with AC (124 females, 80 males). Conversion to open cholecystectomy was needed in 0.76% and 11.8% of the patients with CC and AC, respectively (P<0.00). Four percent of the female patients with AC needed conversion as compared to 23.8% in the males (P<0.00). The low conversion rate in CC limited gender comparison. Median operation time in the patients with CC was 53+/-16 minutes as compared to 74.5+/-35.7 minutes in those with AC (P<0.00). Operation time in the male patients with CC and AC was significantly higher than in the female patients, even after excluding the converted cases (P<0.00). Median postoperative stay for patients with CC was 1.33+/-0.9 days as compared to 1.9+/-1.34 days in patients with AC (P<0.00). No statistical significance in the hospital stay was found between males and females (in CC and AC). There was no mortality in the series. There were three bile duct injuries in the patients with CC. In patients with successful LC, gallbladder perforation occurred in 18% and 31% of CC and AC patients, respectively (P<0.003). Missed stones occurred in 1.4% and 3.3% of the patients with successful LC for CC and AC, respectively. Bile collection, which was treated with open drainage, occurred in four patients with CC and one patient with AC.

CONCLUSION

LC for symptomatic cholelithiasis is safe and feasible; it should be the first choice before resorting to open surgery. In patients with AC as compared to CC, there is an increased conversion rate, longer operation time, longer hospital stay, and higher incidence of gallbladder perforation without an increase in the incidence of bile duct injuries (BDI). Male patients have a longer operation time and higher conversion rate than female patients.

Surgical Treatment of Biliary Tract Infections

Despite major advances in surgical and nonsurgical therapy, biliary tract infections remain a significant cause of morbidity and mortality. The two classic biliary tract infections most commonly encountered are acute cholecystitis (either calculous or acalculous) and acute cholangitis. In addition, bile leakage associated with bile duct injuries during laparoscopic cholecystectomy has become a problem not infrequently encountered by surgeons. Acute calculous cholecystitis results from a combination of mechanical, biochemical, and infectious mechanisms, initiated by stone impaction in the cystic duct. After instituting empiric antibiotics, early laparoscopic cholecystectomy should be performed. Although conversion to open cholecystectomy is more common than in chronic cholecystitis, there appears to be no increased morbidity or mortality in that setting. Acute acalculous cholecystitis usually occurs in critically ill patients and may present both a diagnostic and therapeutic dilemma. Aggressive management, however, is warranted, both because of the critical nature of illness in these patients and the high incidence of perforation. Percutaneous cholecystostomy is indicated, particularly in high-risk patients both for diagnosis and treatment. Acute cholangitis results from a combination of bactibilia and biliary obstruction. The majority of patients can be successfully managed with intravenous antibiotics and fluid resuscitation. In those patients in whom initial management is not successful, biliary drainage, which is best accomplished nonoperatively, should be instituted. There is a very limited role for early surgical intervention in acute suppurative cholangitis. Biliary leaks resulting in bile “peritonitis” or bilomas are common sequelae of laparoscopic bile duct injury. Although surgeons may feel it is necessary to operate urgently, delineation of the proximal biliary anatomy via percutaneous transhepatic cholangiography and biliary stent placement is the appropriate first step in management. This procedure will usually control the bile leak and allow delineation of the anatomy and opportune timing of definitive reconstruction.

Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

The aim of this prospective randomized study was to define the optimum management between early and delayed laparoscopic cholecystectomy for patients with acute cholecystitis.

METHODS

Patients were randomized to receive either early laparoscopic cholecystectomy within 24 h of randomization or initial conservative treatment followed by delayed laparoscopic cholecystectomy 6-8 weeks later.

RESULTS

There were 53 patients in the early group and 51 in the delayed group. There was no significant difference in conversion rate (early 21 per cent versus delayed 24 per cent), postoperative analgesic requirement (1 versus 2 doses) and postoperative complications. However, the early group had significantly longer operating time (122.8 versus 106.6 min, P = 0.04) and shorter total hospital stay (7.6 versus 11.6 days, P < 0.001).

CONCLUSION

Early laparoscopic cholecystectomy is safe and feasible for acute cholecystitis with the additional benefit of shorter total hospital stay. Apart from a shorter operating time, treating patients with delayed laparoscopic cholecystectomy does not offer additional benefit.

Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

OBJECTIVE

A prospective randomized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis.

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates. It is not known whether there is a role for initial conservative treatment followed by interval elective operation.

METHOD

During a 26-month period, 99 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n = 49) or delayed interval surgery after initial medical treatment (delayed group, n = 50). Thirteen patients (four in the early group and nine in the delayed group) were excluded because of refusal of operation (n = 6), misdiagnosis (n = 5), contraindication for surgery (n = 1), or loss to follow-up (n = 1).

RESULTS

Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n = 3) and persistent fever (n = 5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs. 11%; p = 0.174) and complication rate (29% vs. 13%; p = 0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p = 0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p < 0.001) and recuperation period (19 days vs. 12 days; p < 0.001).

CONCLUSIONS

Initial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.