|Year : 2020 | Volume
| Issue : 6 | Page : 205-210
Laparoscopic cholecystectomy in acute cholecystitis: A feasible option regardless of timing
Ramya M Vishweshwara, Mallikarjuna Manangi, Dharini Dharini, CS Santhosh, Sunil V Kumar, MK Ramesh, K Seshagiri Rao
Department of General Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||23-May-2020|
|Date of Decision||12-Jun-2020|
|Date of Acceptance||28-Jul-2020|
|Date of Web Publication||19-Dec-2020|
Associate Professor, Department of General Surgery, Bangalore Medical College and Research Institute, Fort, K R Road, Bangalore - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The optimal timing of laparoscopic cholecystectomy (LC) in acute cholecystitis still remains a debate. Recent studies emphasize that LC can be done safely within the 1st week of onset of the disease process. However, not much data are available that defines the “early” period. We observed, in our institute that, patients presenting beyond 1st week with complications or unresolving symptoms. We aim to compare the outcomes of LC performed after 1st week versus interval LC.
Materials and Methods: A retrospective study of 64 patients who underwent LC from November 2017 to May 2018 was carried out. The study included one group of 32 patients who underwent LC after the 1st week (Group A) and another group of 32 patients who were operated after an interval of 6 weeks (Group B). Data were collected and compared.
Results: The mean duration of surgery (71.09 vs. 84.82 min, P < 0.05), total hospital stay (7.34 vs. 13.40 days, P < 0.05), and overall cost (USD 79.40 vs. 102.34 USD, P < 0.05) was significantly lesser in Group A. Intraoperative difficulty score (5.41 vs. 4.25, P < 0.05) was more in Group A. No complications, mortality, or conversion to open surgery occurred in both groups. A case of gall bladder perforation (at 3 weeks) and Mirizzi syndrome (at 4 weeks) were observed in patients who were in interval period. Four patients in Group B had readmission during the interval period due to biliary colic and were managed conservatively and operated at 6 weeks as planned.
Conclusion: LC performed even after 7 days of initial episode scores over interval LC in terms of total hospital stay, cost, morbidity and has the advantage of treating patients who would be lost to follow-up due to neglect, occupational, and financial concerns. Further studies are needed to validate our results.
Keywords: Acute cholecystitis, cost, hospital stay, interval cholecystectomy, laparoscopic cholecystectomy, timing
|How to cite this article:|
Vishweshwara RM, Manangi M, Dharini D, Santhosh C S, Kumar SV, Ramesh M K, Rao K S. Laparoscopic cholecystectomy in acute cholecystitis: A feasible option regardless of timing. Formos J Surg 2020;53:205-10
|How to cite this URL:|
Vishweshwara RM, Manangi M, Dharini D, Santhosh C S, Kumar SV, Ramesh M K, Rao K S. Laparoscopic cholecystectomy in acute cholecystitis: A feasible option regardless of timing. Formos J Surg [serial online] 2020 [cited 2021 Jan 27];53:205-10. Available from: https://www.e-fjs.org/text.asp?2020/53/6/205/304024
| Introduction|| |
Laparoscopic cholecystectomy (LC) is considered to be the definitive treatment for acute cholecystitis. However, the timing of cholecystectomy has been a source of debate. Earlier reports on the results of LC in patients with acute versus interval cholecystitis demonstrated increased morbidity and/or mortality in patients with acute cholecystitis and hence acute cholecystitis was considered a relative contraindication to LC initially. Although numerous studies in recent times have revealed convincing outcomes in terms of enhanced or similar safety when LC was performed in an acute setting.,,, The concern in subjecting patients with early cholecystitis to surgery (typically defined as <3 days) is the potential for increased complications, including common bile duct (CBD) injury as the acute inflammation may obscure the anatomy. The risk of performing cholecystectomy late (weeks after the diagnosis of cholecystitis) is that a proportion of patients develop recurrent symptoms during the interval period, which leads to recurrent hospital admissions, and/or urgent unplanned surgery, also delaying surgery allows inflammation to become more intense and neovascularized, with dense fibrotic adhesions at Calot's triangle, at times making gall bladder (GB) more shrunken and scarred, thus increasing the technical difficulty of LC. Finally, a proportion of patients would be lost to follow-up during the interval period. Furthermore, it is obvious that due to prolonged total hospital stay, there occurs an increase in the expenditure, absenteeism from work.
Most of the trials of early versus interval LC define “early” as within 72 h or within 7 days of onset of symptoms. However, the time frame of 72 h is rather impractical in all the patients due to various reasons. Furthermore, there exists a scarcity of promising publications with regard to outcomes of LC when performed in the period after 7 days time frame. Its worth noting that not the majority of patients within AC are operated within the early period of 72–96 h from the onset of symptoms and as expected this would result in drawbacks of interval cholecystectomy such as increased total hospital stay, cost, lost to follow-up, readmissions due to relapsing symptoms/complications. With these points in focus, this study was conducted to analyze the outcomes and to look for the feasibility of cholecystectomy when performed even beyond 7 days compared to that of delayed LC. Patients who remained symptomatic and toxic in the 2nd week even after conservative treatment, patients who were referred to our tertiary care center in view of unresolving symptoms and/or with complications were operated at index admissions. Data of these cases were retrospectively studied and analyzed.
| Methods|| |
A retrospective study of 64 LC cases who were operated between November 2017 to May 2018 was undertaken. The study included the patients who underwent LC for acute cholecystitis either 2nd week or at interval timing of 6 weeks at our institute. Patients were divided into Group A (after 1st week) and Group B (after 6 weeks). Group A included patients who did not respond to initial medical treatment in the 1st week of onset of symptoms and patients who were referred to our tertiary care hospital after the 1st week with unresolving symptoms and/or with complications. Group B included patients who were treated conservatively at the initial presentation of acute cholecystitis and were operated after an interval of 6 weeks.
The diagnosis of AC was based on the presence of at least 2 of the following criteria: (1) acute upper abdominal pain and Murphy's sign, (2) fever of 37.5°C and above and white blood cell count of 10 × 109/L and above, and (3) ultrasound findings of the thick-walled gallbladder, ultrasound Murphy's sign, and pericholecystic fluid, in the presence of gallstones. Exclusion criteria included: (1) patients who had no gallstones, (2) those who were not operated on, (3) those who had delay due to obstructive jaundice, ascending cholangitis, or biliary pancreatitis.
LC was performed in both groups by a team that included surgeon, two assistants, and a scrub nurse with anesthesiologists and OT technicians. Surgeries were performed as and when OR slot was available for our unit schedule (6 general surgical units are functioning in the hospital, with a specific day in a week scheduled for OT for each unit). The four-trocar technique was used (10 mm umbilical, 10 mm subxiphoid, 5 mm subcostal midclavicular line, 5 mm anterior axillary line). The critical view of safety was always identified, and Calot's triangle dissected, delineating cystic artery, and duct. GB specimens were sent for HPE. Patients were given postoperative intravenous second-generation cephalosporins as well as preoperative prophylactically. Patients were monitored postoperatively, treated with intravenous antibiotics, analgesics, and other supportive care and discharged after 2 days at the appropriate condition.
Data consisting of demographics, clinical/biochemical/ultrasonogram findings, time from admission to surgery, operative time, intraoperative difficulty score, conversion to open surgery or complications, postoperative and total hospital stay were collected and compared. An intraoperative difficulty score was formulated for the comparative purpose that was based on ease of port access to the abdomen, Adhesions around GB, difficulty in grasping the GB, time taken to identify cystic artery/duct, presence/absence of pericholecystic fluid, difficulty in extraction of GB.
As it is a retrospective study, consent of the study population, for participation in the study, and IRB approval was not needed for the study. However, written informed consent was always taken before surgery as a routine.
Data collected were entered into a standardized form and analyzed. Statistical analysis was performed using nonparametric score of Mann–Whitney U-test with significance set at P < 0.05.
Ethical committee clearance
As it was a retrospective study, ethical committee clearance was not taken. However, the consent of patients for surgery was always taken.
| Results|| |
Sixty-four patients had undergone LC, of which 67% were females, and the mean age was 42.4 years (range, 23–72). Patients were divided into two groups. Group A included patients (n = 32) who underwent LC after 1st week of onset of symptoms at index admission and Group B (n = 32) that included patients who underwent after 6 weeks. The mean duration of surgery (71.09 vs. 84.82 min, P < 0.05), total hospital stay (7.34 vs. 13.40 days, P < 0.05) and overall cost (USD 79.40 vs. USD 102.34, P < 0.05) was significantly lesser in Group A. Intraoperative difficulty score (5.41 vs. 4.25, P < 0.05) was more in Group A [Table 1].
There was no conversion to open cholecystectomy in either of the groups, despite higher intraoperative difficulty score with either more adhesions, difficulty in identifying cystic artery or duct.
There were no complications in both groups. Bile duct injury/cystic duct leak or retained CBD stone or hepatic/bowel injury were not observed. There were no admissions to high dependency/intensive care unit, or no mortality occurred.
The mean duration of surgery was 71.09 min in Group A and 84.82 min in Group B (P < 0.05).
The total hospital stay was estimated including the number of days of hospitalization at index admission when managed conservatively and at admission for interval cholecystectomy in case of Group B and that of the number of days from admission to surgery to date of discharge in case of Group A. The mean total hospital stay was 7.34 days in Group A compared to 13.40 in Group B (P < 0.05).
The overall expenditure incurred was estimated based on the cost of laparoscopic surgery (USD 34.86), hospital bed charges (USD 0.35/day), cost of investigations, and drugs (USD 20.50). It was USD 79.40 in Group A compared to USD 102.34 in Group B (including expenses of index admission) and was significantly lesser in Group A (P < 0.05).
Intra operative difficulty score
An intraoperative difficulty score [Table 2] was designed based on adhesions around GB, time taken to identify cystic artery/duct, difficulty in grasping GB, distended/contracted GB. Scores were given as depicted in [Table 3]. It was observed to be significantly higher (5.41) in Group A as that of (4.25) in Group B (P < 0.05).
During the interval period among Group B patients, a case of GB perforation and Mirizzi syndrome presenting at 4 weeks were noted. Four patients in Group B had another admission [Table 3] during the interval period due to biliary colic and were managed conservatively and operated at 6 weeks as planned.
| Discussion|| |
Cholecystectomy is considered the treatment of choice for acute cholecystitis. The timing of operative intervention in acute cholecystitis has long been a source of debate. In the past, many surgeons advocated for delayed cholecystectomy, with patients managed nonoperatively during their initial hospitalization and discharged home with the resolution of symptoms. An interval cholecystectomy was then performed at approximately 6 weeks after the initial episode. Recent studies have demonstrated that early in the disease process (within the 1st week), the procedure can be performed laparoscopically with equivalent or improved morbidity, mortality, and length of stay as well as a similar conversion rate to delayed cholecystectomy. A review of the literature over the past decade shows that early and delayed LC for acute cholecystitis are safe with similar conversion rates, and overall complications.,,, However, early LC might be associated with lower hospital costs, fewer workdays lost, and greater patient satisfaction. Though possible that technically more demanding and time-consuming, early LC has shown to reduce the risk of repeat cholecystitis. This approach of early LC is well supported by an international consensus published as Tokyo Guidelines. With increased laparoscopic experience, improved skills, and new instruments, the pitfalls of early LC for acute cholecystitis like high rates of conversion to open cholecystectomy, prolonged operation time, and increased risks, particularly CBD injury, have been dramatically reduced.,, A gripping proposition favoring early LC for acute cholecystitis is that of morbidity in view of readmissions pertaining to recurrent attacks of cholecystitis and escalating expenses of prolonged waiting time for surgery following conservative treatment at index admission.,, Johner et al. in their study “Cost utility of early versus delayed LC for acute cholecystitis” in North America found that early LC was estimated to cost approximately $2000 (Canadian dollars) less than delayed LC per patient, with an incremental gain of approximately 0.03 quality-adjusted life years (QALYs). de Mestral C et al. in their study “Early Cholecystectomy for Acute Cholecystitis Offers the Best Outcomes at the Least Cost: A Model-Based Cost-Utility Analysis.” derived that Early cholecystectomy was less costly (C$6905 per person) and more effective (4.20 QALYs per person) than delayed cholecystectomy (C$8511; 4.18 QALYs per person) or watchful waiting (C$7274; 3.99 QALYs per person) and also early cholecystectomy was the preferred management in 72% of model iterations, given a cost-effectiveness threshold of $50,000 per QALY. In the study, “Costs of waiting for GB surgery” by Somasekar et al., observed that the patients who were included in the waiting list after an episode of acute cholecystitis were admitted more frequently with recurrent symptoms (14 of 24 patients, 58%) when compared with patients who were listed after an episode of biliary colic (23 of 127 patients, 18%) requiring biochemical and radiological investigations thereby escalating the cost of health care. The main element in the economics of LC is the overall hospital stay as endpoint. Analysis of literature including our study shows that the total hospital stay is significantly less when LC for acute cholecystitis is performed early irrespective of the conversion. Saber et al. observed that the number of readmissions in delayed treatment group B was thrice in 10%, twice in 23.3%, and once 66.7% of patients. Therefore, the mean total hospital stay in days for patients in Group B were 5.7 ± 2.32 days compared with 2.4 ± 1.1 days in Group A in their study. Patient's satisfaction was measured based on recurrent attacks of pain, number of readmissions, length of hospital stay, and morbidity pertaining to surgery. The overall patient's satisfaction was 92.66 ± 6.8 in Group A compared with 75.34 ± 12.85 in Group B, and this distribution was significant (P ≤ 0.0001) and obvious that delayed LC results in absenteeism from work due to increased total hospital stay or recurrent admissions due to relapsing symptoms. As stated, early cholecystectomy in 1st week for AC is well established by numerous studies not just by similar safety outcomes but also due to shorter hospital stay, lessened morbidity, and reduced cost. However, as Tzovaras et al. points it, How early is “early” is not clear in the literature, as this parameter has not been effectively tested in controlled randomized trials. Most of the publications define early as 72–96 h in their study, and hence, the group of patients presenting late to the hospital were not considered. Practically, not the majority of patients get treated surgically during a short period due to many factors. Patients often are referred to late. On the other hand, few patients who are on oral anti-coagulants or anti-platelet agents entails stoppage before surgery. All these factors practically play a role in procrastinating surgery beyond 72 h. In our study, 25 out of 32 (78%) patients in Group A were referred late to our setup. The major concern of performing LC in acute cholecystitis after the early edematous process (72 h) has elapsed is that, the risk of bile duct injury, which was found to be nil in our study. A school of thought proposes that when inflammation matures over several weeks before the operation, the pericholecystic tissue planes may get obliterated by thick, woody tissues, and delaying surgery allows inflammation to become more intense and neovascularized, thus increasing the technical difficulty of LC. Though intervention during the early phase often reveals an inflamed, edematous, thick-walled, and tensely distended organ, LC is still technically feasible, as long as the inflammation is limited to the gallbladder and not involving Calot's triangle. Chronic inflammation may scar and distort the critical view of safety, making dissection more difficult and prone to bile duct injuries. A prospective study by Tzovaras et al. studied the effect of timing of surgery with respect to time since onset of symptoms and divided 129 patients into three groups regarding the timing of their surgery from symptom onset: within 3 days, between 4 and 7 days, and after 7 days and suggested no significant difference in conversion rate, morbidity, or postoperative hospital stay and thus recommended that the benefits of early cholecystectomy are not limited to patients who present within 72 h of symptom onset.
Our study was conducted on LC performed after 7 days as these were the patients who did not respond to initial medical treatment and remained toxic even after antibiotic therapy; patients who were referred to tertiary care hospital after 7 days of treatment with unresolving symptoms and/or with complications. Irrespective of the timing of operative intervention, the overall conversion rate to open cholecystectomy was nil. This improved conversion rates can be attributed to enhancing expertise in laparoscopy, ability to delineate the operative planes effectively. It is also worth noting that there were no complications like bile duct injury observed in our study. A wealth of literature emphasizes the timing of LC for acute cholecystitis.,,, In our view, timing should not be a criteria and 72 h should not pose a rigid barrier in considering LC for acute cholecystitis as timing does not seem to have much bearing on the procedure and its outcomes. We believe that clinical decision should be individualized on a case to case basis with preference provided to early intervention of acute cholecystitis at index admission regardless of the timing of presentation as delaying surgery would result in increased absenteeism from work, increased cost. Also worth mentioning, the possibility of lost to follow-up of patients either due to ignorance about the gravity of their condition or limited accessibility to healthcare or financial concerns. We do, however, concur that many factors bear an impact on surgical judgment of operating at index admission such as patient apprehension for surgery on an emergency basis, associated comorbidities preventing anesthetic fitness and requiring optimization of the condition, variable delay in diagnosis, influence surgical decisions as well as the timing of intervention. These tend to vary considerably according to the population attitude to illness and type of health care facility. Our data support early laparoscopic intervention even after 7 days of onset of symptoms for acute cholecystitis. Nonetheless, further studies are needed to validate our results. An effort to perform LC in acute cholecystitis even beyond 7 days should be considered in an optimized set up with the availability of laparoscopic expertise.
| Conclusion|| |
LC performed even after 7 days of initial episode scores over interval LC in terms of total hospital stay, cost, overall morbidity and has an advantage of treating patients who would be lost to follow up due to neglect, limited accessibility to healthcare, occupational and financial concerns. Less number of cases being the limitation of our study, further studies are needed to validate our results.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]