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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 197-200

Does timing of cholecystectomy in acute cholecystitis affect morbidity


1 Department of General Surgery, Malabar Institute of Medical Sciences Ltd., Kozhikode, Kerala, India
2 Department of Pediatric Surgery, NIKY Hospital, Gandhinagar, Gujarat, India
3 Department of Surgical Gastroenterology, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
4 Department of General Surgery, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India

Date of Submission30-Jul-2020
Date of Acceptance13-Aug-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Jinto Augustine Thomas
Department of General Surgery, Malabar Institute of Medical Sciences Ltd., Mini Bypass Road, Govindapuram P. O., Kozhikode - 673 016, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_8_20

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  Abstract 


Background: Laparoscopic cholecystectomy (LC) is the accepted treatment for acute cholecystitis (AC), presenting in the first 72 h. Delayed surgery after 6 weeks is the accepted norm in late presentations. Many studies have been done to find the ideal time for surgery in AC and assess complications of surgery in AC. LC after the initial 72 h of onset of symptoms has been associated with increased incidence of conversion to open surgery and also complications. The main was the technical difficulty of dealing with the inflammatory changes, when it becomes denser and fibrotic, thereby increasing chances of biliary and adjacent bowel injuries. Aims and Objective: To determine the relation between timing of surgery and the postoperative outcomes, and to determine the appropriate timing of surgical intervention in acute cholecystitis. Materials and Methods: We conducted a prospective cohort study of 2-year duration. One hundred patients who were diagnosed to have AC based on the clinical and the radiological features were divided into two groups based on the onset of their symptoms and were offered LC at the index admission. Results: Group A included 61 patients within 3 days of starting of symptoms and 42 days after the initial symptoms, and Group B had 39 presenting between 4th day and 41st day of symptoms. No statistical difference was seen between the groups regarding the duration of operation, need for conversion to open procedure and post operative complications. The length of hospital stay was longer in Group B, thus increasing expenditure (P = 0.015). Long term follow up showed no difference in recovery in both the groups. Conclusion: we conclude that LC at index admission is safe and the morbidity of LC remains the same irrespective of the timing of presentation.

Keywords: Acute cholecystitis, conversion rate, duration of hospital stay, laparoscopic cholecystectomy


How to cite this article:
Thomas JA, Ratani AA, Sahadevan S, Kuruvilla R, Nambiar R, George A, Akshay Viswanath U V. Does timing of cholecystectomy in acute cholecystitis affect morbidity. Kerala Surg J 2020;26:197-200

How to cite this URL:
Thomas JA, Ratani AA, Sahadevan S, Kuruvilla R, Nambiar R, George A, Akshay Viswanath U V. Does timing of cholecystectomy in acute cholecystitis affect morbidity. Kerala Surg J [serial online] 2020 [cited 2020 Nov 26];26:197-200. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/197/300247




  Introduction Top


Acute cholecystitis (AC) is defined as inflammation with oedema and subserosal haemorrhage of gall bladder (GB). Infection of the stagnant pool of bile is a secondary phenomenon, the primary pathophysiology being unresolved cystic duct obstruction.[1] Cholecystitis is divided into acute and chronic. Acute is further divided into acute calculous and acute acalculous cholecystitis. Acalculous cholecystitis usually occurs in critically ill patients, which accounts for approximately 10% of the cases of AC and is associated with high morbidity and mortality.[2]

Although there is consensus that incidentally discovered asymptomatic gallstones need not be treated [3],[4] once a patient develops related symptoms or complications (such as biliary colic or AC), treatment to eliminate the gallstones is recommended. There is growing evidence in support of early laparoscopic cholecystectomy (LC) for AC.[5],[6],[7],[8],[9] Patients receiving early intervention had shorter hospital stays and lower complication rates.[10],[11],[12],[13] The benefit of prompt surgical intervention was illustrated in patients with AC.[14] Compared to patients who underwent cholecystectomy, those who were discharged without surgery often had febrile spikes and chronic sepsis, requiring readmission (38% vs. 4%), and had higher mortality over the following 2 years.

Surgery for AC can be complicated by common bile duct injuries or excessive blood loss.[6],[15] Review of literature highlights the most common reason for conversion to open surgery as inflammation obscuring Calot's triangle in early surgery and fibrotic adhesions in delayed surgery.[16],[17]


  Materials and Methods Top


The aim of this prospective 2-year study was to determine the appropriate timing of surgical intervention in a case of AC, and the objective was to analyse the morbidity of the surgical intervention in a case of AC according to the timing of the presentation.

The patients diagnosed to have AC based on the clinical and the radiological features, fit for general anaesthesia and not on any anti-platelet drug were divided into two groups. The patients who presented within 3 days from the onset of symptom were grouped into Group A along with the patients who underwent an interval cholecystectomy after 42 days of onset of symptoms. The patients falling in the time period of 4–41 days of onset of symptoms were included in Group B. All the patients underwent a LC under general anaesthesia using standard 4 ports. All the patients were given antibiotic at the time of induction, and patients with signs of AC were started on antibiotics at the time of admission and continued for 3–5 days.

Variables in the study included duration of operation, suggesting difficult surgery, increased length of stay due to post-operative complications such as gangrenous GB, perforated GB, pyocele or a mucocele of GB, bile duct injuries and need for conversion to open surgery or subtotal cholecystectomy.


  Results Top


Data were analysed statistically using SPSS Inc. (1999). (SPSS for Windows, Version 11.0. Chicago, SPSS Inc.,) by t-test, Chi-square test and Fisher's exact test. One hundred patients were selected: 61 in Group A and 39 in Group B. The majority of the patients of Group A (19) were of the age group of 50–59 years. The majority of the patients in Group B (13) were between ages 40 and 49 years. A total of 32 females and 68 males were present in the study group.

29.5% in Group A and 41% in Group B were found to be having acute complicated cholecystitis (perforated GB, gangrenous GB, empyema GB or mucocele of GB). There was no significant difference found between the two groups (P = 0.236).

On comparing the duration of surgery, Group A was found to be having mean operating time of 104.8 min (standard deviation [SD] = 40.4) and Group B was found to be having mean operating of 117.7 min (SD = 51.2). There was no statistical difference (P = 0.166). None of the patients in both the groups had a bile duct injury. No signs or symptoms of bile leak were shown by the patients in the 6-month follow-up. There was no conversion to open cholecystectomy in either group. Group B had two patients (5.1%) who underwent a subtotal cholecystectomy due to dense adhesions in the Calot's triangle but was not statistically significant. Three patients in Group A and five in Group B suffered from post-operative complications. Paralytic ileus was the major complication reported in both the groups. On comparison, there was no statistical difference between the groups regarding the post-operative complications (P = 0.155), as shown in [Table 1].
Table 1: Post-operative complications

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The mean length of hospital stay was 4.5 days for Group A (SD = 2.2) and 5.8 days for Group B (P = 0.05). There was a significant statistical difference between the groups (P = 0.015). The patients in Group A had shorter stay [Figure 1].
Figure 1: Comparison of duration of hospital stay based on group

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  Discussion Top


This study found that there was no statistically significant difference in complication or conversion rates whether LC was performed at the index presentation or 6 weeks after the onset of symptoms as shown by previous studies.[6],[13]

The mean age of Group A patients was 51.3 years and that of Group B was 55.9 years. Another sociodemographic factor was sex; a total of 68 patients were males and rest females. In concordance with the previous studies, no statistical difference was found between both the groups regarding the age and sex factor.[6],[7],[18],[19]

In Group B, out of 39 cases, 13 patients were managed conservatively with antibiotics at other centres, but as their symptoms were not relieved or sepsis had set in, they were referred to our hospital. In the type of the AC, 29.5% of the patients had a complicated cholecystitis in Group A compared to 41% in Group B. Complicated AC included gangrenous GB, perforated GB, pyocele or a mucocele of GB. Gangrenous cholecystitis occurs in 2%–30% of the cases of AC.[20] It was the most common complicated type seen in Group B, whereas mucocele was the most common in Group A.

Operative time was one of the most important variables. The mean operative time was 104.8 min in Group A versus 117.7 min in Group B. The surgical timing varied from 35 min to 240 min depending on the presentation which was slightly longer than the previous studies (80 min).[13]

Bile duct injury, even though not so common, is the most dreadful complication of laparoscopic cholecystectomy in AC.[6],[15],[19] None of our patients suffered from a bile duct injury. Patients were followed up for a mean period of 6 months and were enquired about any readmissions. None of them reported any readmission.

In laparoscopic surgeries, difficulty with delineation of anatomy can lead to conversion of the surgery.[6] Conversion rates as high as 27% were reported in delayed presentations,[18] but in this study, all the cases were completed laparoscopically. The most difficult of cases took up to 4 h. This increased operative time in both the groups and a comparatively small sample size can be considered as a disadvantage of this study. The increased operative time may be the reason for the low conversion rates. Sometimes, due to dense adhesions in the Calot's triangle, defining anatomy was not possible, and in those cases, a subtotal cholecystectomy was done. Of the 39 patients in Group B, two patients underwent a subtotal cholecystectomy, whereas in Group A, all of them underwent a total cholecystectomy. Fisher's exact test was used to compare the two arms, and no statistical significance was found between the two groups (P = 0.150).

A total of 8 patients out of 100 had post-operative complications. Intraoperative bleeding, bile duct injuries and post-operative infection are the well-known complications of LC.[7],[18] However, in this study, the most common post-operative complication found was that of paralytic ileus and leak of the pus from the drain exit site in case of pyocele. The complications were higher in Group B in our study too as shown by previous studies.[7],[9] Pearson's Chi-square test was used to compare the post-operative complications, five patients in Group B and three patients in Group A, and no significance was found between the groups (P = 0.155).

The length of hospital stay was another important variable. The earlier the surgery from the day of onset of symptoms, the shorter was the hospital stay.[6],[9],[20] The mean stay in the hospital for Group A was of 4.5 days and that of Group B was of 5.8 days. In Group B, there were patients who had already developed sepsis due to prolonged illness and hence a longer recovery period. There was a statistical difference found between the two groups (P = 0.015). The patients in Group B had a longer hospital stay.

The only statistically significant difference between the two groups was noted in the length of the hospital stay. Group A had a short hospital stay than Group B. Even though increased hospital stay had increased the expenditure for these patients, in conservative treatment they may well have the expenditure associated with cholecystostomy, recurrent admissions, etc., as found out by previous studies.[13] None of the patients had a major complication of bile duct injury or conversion of the laparoscopic to open surgery. Two patients in Group B were managed by a subtotal cholecystectomy. Patients were followed up for a mean period of 6 months, and none had a readmission in the hospital to the complicated related to cholecystitis.


  Conclusion Top


It is found that morbidity of surgery was the same irrespective of the timing of surgical intervention. Long-term follow-up also showed no difference in recovery in both the groups. It is thus concluded that LC at index admission itself is a safe treatment option for all patients diagnosed with AC, if done by an experienced laparoscopic surgeon, irrespective of the time duration from onset of symptoms to presentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sabiston, David C, Courtney M Townsend. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 19th ed. Philadelphia, PA: Elsevier Saunders, 2012.  Back to cited text no. 1
    
2.
Barie PS, Fischer E. Acute acalculous cholecystitis. J Am Coll Surg 1995;180:232-44.  Back to cited text no. 2
    
3.
Thune A, Baker RA, Saccone GT, Owen H, Toouli J. Differing effects of pethidine and morphine on human sphincter of oddi motility. Br J Surg 1990;77:992-5.  Back to cited text no. 3
    
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Ransohoff DF, Gracie WA. Treatment of gallstones. Ann Intern Med 1993;119:606-19.  Back to cited text no. 4
    
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Yamashita Y, Takada T, Kawarada Y, Nimura Y, Hirota M, Miura F, et al. Surgical treatment of patients with acute cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg 2007;14:91-7.  Back to cited text no. 5
    
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Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2010;97:141-50.  Back to cited text no. 6
    
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Banz V, Gsponer T, Candinas D, Güller U. Population-based analysis of 4113 patients with acute cholecystitis: Defining the optimal time-point for laparoscopic cholecystectomy. Ann Surg 2011;254:964-70.  Back to cited text no. 7
    
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Papi C, Catarci M, D'Ambrosio L, Gili L, Koch M, Grassi GB, et al. Timing of cholecystectomy for acute calculous cholecystitis: A meta-analysis. Am J Gastroenterol 2004;99:147-55.  Back to cited text no. 8
    
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Barcelo M, Cruz-Santamaria DM, Alba-Lopez C, Devesa-Medina MJ, Diaz-Rubio M, Rey E. Advantages of early cholecystectomy in clinical practice of a terciary care center. Hepatobiliary Pancreat Dis Int 2013;12:87-93.  Back to cited text no. 9
    
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Gurusamy KS, Samraj K. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005440. doi: 10.1002/14651858.CD005440.pub2. Update in: Cochrane Database Syst Rev. 2013;6:CD005440. PMID: 17054258.  Back to cited text no. 10
    
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Johansson M, Thune A, Blomqvist A, Nelvin L, Lundell L. Management of acute cholecystitis in the laparoscopic era: Results of a prospective, randomized clinical trial. J Gastrointest Surg 2003;7:642-5.  Back to cited text no. 11
    
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Lau H, Lo CY, Patil NG, Yuen WK. Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: A metaanalysis. Surg Endosc 2006;20:82-7.  Back to cited text no. 12
    
13.
Gutt CN, Encke J, Köninger J, Harnoss JC, Weigand K, Kipfmüller K, et al. Acute cholecystitis: Early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg 2013;258:385-93.  Back to cited text no. 13
    
14.
Papi C, Catarci M, D'Ambrosio L, Gili L, Koch M, Grassi GB, et al. Timing of cholecystectomy for acute calculous cholecystitis: A meta-analysis. Am J Gastroenterol 2004;99:147-55.  Back to cited text no. 14
    
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Bernard HR, Hartman TW. Complications after laparoscopic cholecystectomy. Am J Surg 1993;165:533-5.  Back to cited text no. 15
    
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Strasberg SM. Acute calculous cholecystitis. N Engl J Med 2008;358:2804-11.  Back to cited text no. 16
    
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Panni RZ, Strasberg SM. Preoperative predictors of conversion as indicators of local inflammation in acute cholecystitis: Strategies for future studies to develop quantitative predictors. J Hepatobiliary Pancreat Sci 2018;25:101-8.  Back to cited text no. 17
    
18.
Blohm M, Österberg J, Sandblom G, Lundell L, Hedberg M, Enochsson L. The sooner, the better? The importance of optimal timing of cholecystectomy in acute cholecystitis: Data from the national Swedish registry for gallstone surgery, gallriks. J Gastrointest Surg 2017;21:33-40.  Back to cited text no. 18
    
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McGillicuddy EA, Schuster KM, Barre K, Suarez L, Hall MR, Kaml GJ, et al. Non-operative management of acute cholecystitis in the elderly. Br J Surg 2012;99:1254-61.  Back to cited text no. 19
    
20.
Indar AA, Beckingham IJ. Acute cholecystitis. BMJ 2002;325:639-43.  Back to cited text no. 20
    


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