At the acute inflammatory phase
(>72 to 96 hours), laparoscopic cholecystectomy becomes more difficult and
challenging because of oedema, fibrotic adhesions in Calot’s triangle
structures, friability of tissues, unclear ductal anatomy, gallbladder
distension, hypervascularity, congestion, and the spread of infection. All
these factors can cause suboptimal results leading to high conversion rates to
open surgery . (6,12,19)
Traditional medical management of
acute cholecystitis followed by late cholecystectomy (4 days to 6 weeks) was
correlated with a negative postoperative outcome. (4,10) Delayed
cholecystectomy actually increases the possibility of gallstone-related
complications during the waiting period and thus involves more hospital
admission. About 15–30% of patients discharged without surgery following acute
calculous cholecystitis were readmitted with recurrent clinical features and
had an unscheduled urgent cholecystectomy with gallstone-induced insults such
as biliary colic in 65%, biliary tract obstruction in 25%, and biliary
pancreatitis in 7% of cases. (5)
Further, these unscheduled procedures were associated with increased
complication rates, prolonged operation time, and increased conversion to open
surgery rates. (13,16)
Previously, early laparoscopic
cholecystectomy for acute cholecystitis was avoided in patients diagnosed with
acute cholecystitis because of the risk of increased operative complication and
high rates of conversion to open surgery that were considered to be
disadvantages of laparoscopic surgery. (7,15,19) Admittedly, the bile duct injury rate of 4.7%
during laparoscopic cholecystectomy for acute cholecystitis was a major issue. (6,8)
However, several new studies have shown that urgent early laparoscopic
cholecystectomy (within 3 days) for acute cholecystitis, when performed by
experienced hands, is safe and feasible and must be the first line treatment for
acute cholecystitis in fit patients. (14,18) The increased surgical difficulty of late
acute cholecystitis demands it is performed electively after 6–8 weeks. (8,19)
The goal of our study was to
evaluate the outcome of early urgent laparoscopic cholecystectomy (within 3
days) and to compare the results with delayed urgent laparoscopic
cholecystectomy (after 4 days to 2 weeks), paying attention to clinical outcome
to determine the optimal timing of laparoscopic cholecystectomy for patients
with acute calculous cholecystitis, and assessing the benefits in terms of
costs and hospital stay. (4,14,17)
Methods
This prospective study was
undertaken at Prince Rashid Military Hospital (Irbid) and King Talal Military
Hospital (Mafraq), Jordan, between November 2015 and March 2018 included 197
patients diagnosed with acute calculous cholecystitis. They were aged 31-66
years, of both genders, and scheduled for laparoscopic cholecystectomy. Written
informed consent was obtained from all patients, as was approval from the
ethical and research board review committee of the Royal Medical Services.
Patients with incomplete data, no gallstones, previous abdominal surgery, GB
tumours, or comorbid diseases were excluded. All our patients were selected
depends on first presentation of acute
onset of clinical picture of acute calculous cholecystitis and were admitted as
emergency cases via the Emergency/Out Patients Department.
Patients were divided into two groups after
admission. Patients in GI (GI, n = 98) underwent laparoscopic cholecystectomy
within 3 days of the establishment of the clear clinical picture. Patients in
GII (GII, n = 99) underwent laparoscopic cholecystectomy more than 3 days after
the establishment of the clear clinical picture. Laparoscopic
cholecystectomy in both groups was performed by senior general surgery
specialists. Data regarding the period between the establishment of the
clear clinical picture and surgery, rate of conversion from laparoscopic
cholecystectomy to open surgery, and complication after surgery (haemorrhage,
bile leak and chest infection) were recorded.
Follow-up was undertaken every week after discharge until patients were fully
recovered.
Acute cholecystitis was diagnosed when
patients had at least two of the following: an acute right subcostal abdominal
pain and positive Murphy’s sign, fever (>37.5 °C), white blood cell (WBC)
count >10 × 109/L, and ultrasound findings of acute cholecystitis
(presence of gallstones, thick gallbladder wall (>0.4 cm), pericholecystic
fluid and positive probe Murphy’s sign). Acute calculous cholecystitis was
divided into 3 grades (I-III) according to TG13 (Tokyo guidelines 2013) as
follows: Grade I (mild): acute cholecystitis with mild gallbladder inflammation
without organ disturbance in a healthy patient; Grade II (moderate): acute
cholecystitis with one of the following: WBC count >18×109/L,
tender mass in the right hypochondrium, positive clinical picture established
for more than 3 days, biliary peritonitis, pericholecystic abscess, liver
abscess, gangrenous gallbladder, or emphysematous gallbladder; and Grade III
(severe): acute cholecystitis with complications presenting one of the
following : reduced level of consciousness, hypotension requiring vasopressors,
creatinine more than 2.0 mg/dl, oliguria, and PaO2/FiO2 ratio of 1.5 . (7,8)
For patients with high bilirubin
levels (>2 mg/ml), Magnetic Resonance Cholangiopancreatography (MRCP) was
performed before surgery to rule out common bile duct (CBD) stones. Endoscopic
retrograde cholangiopancreatography (ERCP) was performed before surgery because
of CBD stone and/or dilatation as shown by MRCP. In both Groups, laparoscopic
cholecystectomy was performed 24-48 h after ERCP.
All our patients received third
generation cephalosporin intravenously on admission, which continued at least
for one day after surgery.
Statistics
Data was evaluated statistically using
Wilcoxon’s test for unrelated data and χ2 test for numerical data. P
values less than 0.05 were considered statistically significant.
Results
There was no discrepancy in terms of
age, sex and BMI between the two groups. Median body temperature and the
occurrence of positive Murphy’s sign were markedly increased in GI compared
with GII (P >0.05), Overall, before
surgery direct bilirubin and BUN were significantly higher in GII patients than
in GI patients (P<0.05). ERCP was performed before surgery in 7 patients
(7.1%) in GI and in 19 patients (19.2%) in GII (P<0.05). The duration of
surgery and total hospital stay in GII was significantly longer compared with
GI (P<0.05), (Table I).
Table I. Patients’ clinical characteristics.
|
|
GI
|
GII
|
P-value
|
|
|
Surgery
within first 3 days
|
Surgery(3
days-2wks)
|
|
|
Number of patients (%)
|
98 (49.7)
|
99 (50.3)
|
|
|
Age: median (range)
|
44.2 (31-59)
|
46.6 (38-66)
|
|
|
Gender (%)
M
F
|
46 (46.9)
52 (53.1)
|
54 (54.5)
45 (45.5)
|
|
|
BMI(kg/m2): median(range)
|
32.4 (29-37)
|
33.6 (30-36)
|
|
|
Clinical picture:
Fever median(range)
Palpable tender mass, n (%)
Positive Murphy sign, n (%)
|
39.1(38.4-39.4)
17(17.3)
94(95.9)
|
38.5(37.3-38.8)
37(37.4)
85(85.9)
|
>0.05
<0.05
>0.05
|
|
Ultrasound results
|
|
|
|
|
Gallstones, n (%)
Thick wall gallbladder, n (%)
Pericholecystic fluid, n (%)
CBD
dilatation, n (%)
|
98(100)
84(85.7)
70(71.4)
7(7.1)
|
99(100)
86(86.9)
59(59.6)
19(9.2)
|
-
<0.05
>0.05
<0.05
|
|
ERCP, n (%)
|
7(7.1)
|
19(9.2)
|
<0.05
|
|
Laboratory: median(range)
|
|
|
|
|
WBCs(109/L)
|
17.4 (13.5-22.4)
|
16.8 (12.3-21.5)
|
>0.05
|
|
Total bilirubin(mg/L)
|
1.6 (1-3.7)
|
1.7 (1-4.6)
|
<0.05
|
|
Direct bilirubin(mg/L)
|
1.2 (0.1-3.3)
|
1.6 (0.4-4.2)
|
<0.05
|
|
BUN(mg/L)
|
18.1 (11-33)
|
20.8 (14-32)
|
<0.05
|
|
Operation duration (min)median (range)
|
79.3 (65-110)
|
125.1 (86-145)
|
<0.05
|
|
Total hospital stay (days)
|
4.7 (+,-
2.2)
|
8.2 (+,- 5.6)
|
<0.05
|
In GI, 52.04% of surgeries were performed
during the first day after establishment of the clear clinical picture, while
31.63% and 16.33% of surgeries were performed on the second and third days,
respectively. In GII, 54.5% of surgeries were performed between the fourth and
seventh days after the establishment of the clear clinical picture and 45.5%
were performed between the eighth and fourteenth days (Table II).
Table II. Time (in days) between establishment of
clinical picture and surgery.
|
Time in days since start of clinical picture
and surgery
|
GI (n
= 98)
|
GII
(n = 99)
|
|
1
|
2
|
3
|
4-7
|
8-14
|
|
n (%)
|
51 (52%)
|
31 (31.6%)
|
16 (16.3%)
|
54 (54.5%)
|
45 (45.5%)
|
Regarding the Tokyo Severity Grading (TG13) of
acute calculous cholecystitis, the gallbladder was mildly inflamed (Grade I) in
87.8% of patients in GI and in 50.5% of patients in GII. In 12.2% of GI and
40.4% of GII, the gallbladder was moderately inflamed (Grade II). In addition,
0% of GI and 9.1% of GII had intense (Grade III) acute calculous cholecystitis
(P<0.05), (Table III).
Table II. Time (in days) between establishment of
clinical picture and surgery.
|
Time in days since start of clinical picture
and surgery
|
GI (n
= 98)
|
GII
(n = 99)
|
|
1
|
2
|
3
|
4-7
|
8-14
|
|
n (%)
|
51 (52%)
|
31 (31.6%)
|
16 (16.3%)
|
54 (54.5%)
|
45 (45.5%)
|
Regarding the Tokyo Severity Grading (TG13) of
acute calculous cholecystitis, the gallbladder was mildly inflamed (Grade I) in
87.8% of patients in GI and in 50.5% of patients in GII. In 12.2% of GI and
40.4% of GII, the gallbladder was moderately inflamed (Grade II). In addition,
0% of GI and 9.1% of GII had intense (Grade III) acute calculous cholecystitis
(P<0.05), (Table III).
Table III. Participants in terms of Tokyo intensity
grading (TG13) for acute cholecystitis
|
|
GI (n
= 98)
|
GII
(n = 99)
|
P-value
|
|
Grade I (mild) n (%)
|
86 (87.8%)
|
50 (50.5%)
|
<0.05
|
|
Grade II (moderate) n (%)
|
12 (12.2%)
|
40 (40.4%)
|
<0.05
|
|
Grade III (intense) n (%)
|
0
|
9 (9.1%)
|
<0.05
|
Table III. Participants in terms of Tokyo intensity
grading (TG13) for acute cholecystitis
|
|
GI (n
= 98)
|
GII
(n = 99)
|
P-value
|
|
Grade I (mild) n (%)
|
86 (87.8%)
|
50 (50.5%)
|
<0.05
|
|
Grade II (moderate) n (%)
|
12 (12.2%)
|
40 (40.4%)
|
<0.05
|
|
Grade III (intense) n (%)
|
0
|
9 (9.1%)
|
<0.05
|
There was a discrepancy between the
two groups in terms of complications of surgery and conversion rate. (Table
IV). In our investigation, overall peri- and postoperative complications were
more common in GII compared with GI (23 vs. 9, respectively). Five patients in
GI and eleven patients in GII experienced haemorrhage (via the abdominal drain)
during the first four days postoperatively and they were treated
conservatively. Two patients in GII had a biliary leak via the drain during the
first six days postoperatively, on the seventh day postoperatively, bile
leakage ceased completely. Hospital-acquired respiratory tract infection was
found in four GI patients and ten GII patients. Conversion rate to open surgery
was markedly low in GI in comparison with GII ( 3 vs. 7, respectively). (P<0.05), (Table IV).
Table IV. Peri- and postoperative complications.
|
|
GI (n
= 98)
|
GII
(n = 99)
|
P-value
|
|
Conversion to open surgery, n (%)
|
3 (3.1%)
|
7 (7.1%)
|
<0.05
|
|
Hemorrhage (via abdominal drain), n (%)
|
5 (5.1%)
|
11 (11.1%)
|
<0.05
|
|
Bile
leak, n (%)
|
0
|
2 (2%)
|
<0.05
|
|
Chest
infection, n (%)
|
4 (4.1%)
|
10 (10.1%)
|
<0.05
|
Discussion
Previously, it was considered that
the appropriate time for laparoscopic cholecystectomy for acute calculous
cholecystitis was 6–8 weeks following clinical treatment of an acute episode. (11,15-19)
However, recently a review of the
literature has shown that early urgent (within 3 days) and delayed (6-8 weeks)
laparoscopic cholecystectomies for acute cholecystitis are safe, providing the same reduced operation time, conversion rates, and overall
complications. (4,14,18) However, early urgent laparoscopic
cholecystectomy results in a significantly shorter hospital stay and
prevents the risks of conservative treatment failing. (16) This development is making most
surgeons consider early laparoscopic cholecystectomy as the best treatment for
acute cholecystitis, which is well-supported by a recent international
consensus published as the Tokyo Guidelines.
(7,9-13,18)
With improved skills, new
instruments, and increased experience, the high rates of conversion to open
cholecystectomy, CBD injury, increased morbidity, and prolonged surgery time of
early urgent laparoscopic cholecystectomy for acute cholecystitis have been
significantly reduced. (6,13-15) However, acute cholecystitis is still the most
important risk factor for complications and conversion of laparoscopic
cholecystectomy. Furthermore, the timing of the surgery remains a highly
contested issue and a strong predictor of laparoscopic cholecystectomy success
for acute cholecystitis disease. (16,18)
The debate over relating the timing
of laparoscopic cholecystectomy for acute calculous cholecystitis to onset of
symptoms or admission has been exaggerated. (17-20) In our view, each clinical decision must be
individualized. However, we concur that patient-physician factors, such as
patient variable delay in diagnosis of more than 48 hours, influence surgical
decisions and timing of intervention. These tend to vary according to the
population’s attitude to illness and type of health care facility. (7,20)
According to international
guidelines and our results, we suggest that early laparoscopic cholecystectomy
within three days of admission with onset of clinical symptoms
for acute calculous cholecystitis is
safer. We also note that laparoscopic cholecystectomy within this early period
is technically less demanding because the oedema planes magnify the structures
and make dissection easier. So for those patients diagnosed after 3 days of
onset of acute calculous cholecystitis, it is recommended to postpone the
surgery for 6-8 weeks to avoid above mentioned complications. (14,18-20)
Overall, laparoscopic
cholecystectomy is cheaper than open surgery, mainly because the patient’s stay
in hospital is shorter. (18,19)
In our study early laparoscopic
cholecystectomy was performed during the first 3 days for Grade I and II acute
calculous cholecystitis. Urgent management of symptoms was concluded then late
elective laparoscopic cholecystectomy was performed on patients with Grade III
disorders. (7,8)
Decreasing operation duration and bleeding may
enhance both safety and outcomes. In our investigation, surgical duration was
significantly longer in GII compared with GI.
The conversion rate and number of
complications in GII were higher than in GI. This emphasises further that
laparoscopic cholecystectomy for acute calculous cholecystitis is safer than
late procedures. In GI, there is an oedematous plane near the gallbladder,
smoothing its dissection whereas in GII, there are firm adhesions with scarring
and contraction cementing with adjacent structures and distortion of normal
anatomy. These factors mean delayed laparoscopic cholecystectomy was associated
with longer surgical duration, more bleeding, more biliary insult, and a higher
conversion rate. (14,19)
Early laparoscopic cholecystectomy
is the best management procedure for acute calculous cholecystitis . (20) The management of acute calculous
cholecystitis should be limited to patients in good shape for urgent
surgery. (7,18)
Conclusion
The best time to perform
laparoscopic cholecystectomy for acute calculous cholecystitis is during the
same admission, within three days of the establishment of a clear clinical
picture. Early urgent laparoscopic cholecystectomy within three days is
feasible, safe and is associated with a decreased conversion rate to open
surgery, a lower complication rate, shorter operation time, and reduced total
hospital stay.
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