Early Versus Delayed Cholecystectomy for Acute Cholecystitis

In This Article

Abstract and Introduction

Abstract

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[Euro sign] vs 12,361 [Euro sign], 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).

Introduction

If the definitive treatment of acute cholecystitis is laparoscopic cholecystectomy (LC), the timing of surgery remains controversial. A long-standing dogma stipulated that patients should be operated within 72 hours of symptoms. This was also based on anatomo-pathological observation: following edematous cholecystitis during the first 2 to 4 days of symptoms, necrotizing and then suppurative cholecystitis develops,^[1] making LC potentially more dangerous. In a retrospective study on acute cholecystitis, the conversion rate to laparotomy increased according to the delay from onset of symptoms until surgery.^[2]

Data however remain weak on the specific management of acute cholecystitis beyond 72 hours of symptoms, with only a few retrospective case-control studies reporting that LC can safely be performed after 72 hours of symptoms.^[3–5] A recently published meta-analysis reported that early LC for acute cholecystitis might be associated with shorter hospital stay, lower hospital costs, and higher patient satisfaction. However, all existing randomized studies included only patients with less than 72 hours of symptoms, or did not discriminate patients according to the length of symptoms.^[6] On the basis of the currently available literature, the updated Tokyo guidelines classify an acute cholecystitis as grade II/moderate with duration of complaints of more than 72 hours, and proposed delayed LC, or early LC when advanced laparoscopic technique was available.^[7] Therefore, prospective data were needed to establish the specific management of acute cholecystitis beyond 72 hours of symptoms.

The objective of the present prospective randomized trial was to compare clinical and surgical outcomes of early versus delayed LC in acute cholecystitis with more than 72 hours symptoms.

Table 1. Baseline Characteristics Comparing Patients With Early Versus Delayed Laparoscopic Cholecystectomy
	ELC (n = 42)	DLC (n = 44)	P
Age, mean (SD), yr	55.8 (16.8)	57.9 (16.6)	0.564
Male gender, n (%)	24 (57)	25 (57)	1.000
Body mass index, mean (SD), kg/m²	28.2 (5.5)	27.6 (4.3)	0.596
Hypertension, n (%)	15 (36)	12 (27)	0.488
Diabetes, n (%)	4 (10)	4 (9)	1.000
Cardiac disease*, n (%)	7 (17)	9 (20)	0.784
Pulmonary diseasey, n (%)	5 (12)	2 (5)	0.260
Chronic renal insufficiency, n (%)	0	2 (5)	0.236
Cerebrovascular attack, n (%)	2 (5)	0	0.494
Charlson comorbidity index, median (IQR)	0 (0–1)	0 (0–1)	0.413
ASA grade I–II, n (%)	40 (95)	42 (95)	1.000
Previous intrabdominal operation, n(%)	7 (17)	9 (20)	0.784
Length of symptoms, median (IQR), d	4 (3–7)	4 (3–5)	0.385

*Rythmic, valvular, or ischemic cardiopathy.
†Asthma, chronic obstructive pulmonary disease, obstructive sleep apnea.
ASA indicates American Society of Anesthesiologists.

Table 2. Overall Morbidity, Total Duration of Antibiotic Therapy, Length of Stay, and Hospital Costs
Outcomes	ELC (n = 42)	DLC (n = 44)	OR (95% CI)	P
Overall morbidity, n (%)	6 (14.3)	17 (38.6)*	0.26 (0.0–076)	0.015
Failure of initial treatment	0 (0)	3 (6.8)	0.14 (0–2.79)	0.242
Unplanned readmission/emergency consultation awaiting delayed cholecystectomy	0 (0)	10 (22.7)	0.04 (0–0.68)	0.001
Posoperative complications	6 (14.3)	7 (15.9)	0.88 (0.27–2.88)	1.000
Total antibiotic duration, median (IQR), d	2 (1–5)	10 (10–14)	—	<0.001
Total hospital length of stay, median (IQR), d	4 (3–4)	7 (5–11)	—	<0.001
Total hospital costs, mean cost per patient (95% CI), €	9349 (7865–11,142)	12,361 (10,753–14,253)	—	0.018

*Three patients with unplanned readmission while awaiting DLC also presented with postoperative complications.
CI indicates confidence interval; OR, odds ratio.

Table 3. Surgical Characteristics and Surgery-related Outcomes
	ELC (n = 41)	DLC (n = 41)	OR (95% CI)	P
Operative time, median (IQR), min	91 (70–114)	88 (71–118)	—	0.910
Peroperative cholangiography, n (%)	7 (17)	2 (4.9)	4.02 (0.8–20.7)	0.155
Pathological diagnosis			—	<0.001
Acute cholecystitis, n (%)	22 (53.7)	10 (24.4)
Acute on chronic cholecystitis, n (%)	15 (36.6)	0
Chronic cholecystitis, n (%)	4 (9.8)	31 (75.6)
Conversion to laparotomy, n (%)	1 (2.4)	0 (0)	3.07 (0.1–77.8)	1.000
Bile duct injury/leak, n (%)	0 (0)	1 (2.4)	0.33 (0–8.2)	1.000
Postoperative complications, n (%)	6 (14.6)	7 (17)	0.83 (0.3–2.7)	1.000
Grade I	2	3
Grade II	2	1
Grade III a/b	1	2
Grade IV a/b	1	1
Grade V	0	0
Postoperative length of stay, median (IQR), d	4 (3–4)	2 (2–3)	—	<0.001
Postoperative readmission, n (%)	0 (0)	2 (4.8)	0.19 (0–4.1)	0.494