Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis: a meta-analysis of randomized clinical trials

Abstract

Background Early cholecystectomy for acute cholecystitis has proved to reduce hospital length of stay but with no benefit in morbidity when compared to delayed surgery. However, in the literature, early timing refers to cholecystectomy performed up to 96 h of admission or up to 1 week of the onset of symptoms. Considering the natural history of acute cholecystitis, the analysis based on such a range of early timings may have missed a potential advantage that could be hypothesized with an early timing of cholecystectomy limited to the initial phase of the disease. The review aimed to explore the hypothesis that adopting immediate cholecystectomy performed within 24 h of admission as early timing could reduce post-operative complications when compared to delayed cholecystectomy. Methods The literature search was conducted based on the Patient Intervention Comparison Outcome Study (PICOS) strategy. Randomized trials comparing post-operative complication rate after early and delayed cholecystectomy for acute cholecystitis were included. Studies were grouped based on the timing of cholecystectomy. The hypothesis that immediate cholecystectomy performed within 24 h of admission could reduce post-operative complications was explored by comparing early timing of cholecystectomy performed within and 24 h of admission and early timing of cholecystectomy performed over 24 h of admission both to delayed timing of cholecystectomy within a sub-group analysis. The literature finding allowed the performance of a second analysis in which early timing of cholecystectomy did not refer to admission but to the onset of symptoms. Results Immediate cholecystectomy performed within 24 h of admission did not prove to reduce post-operative complications with relative risk (RR) of 1.89 and its 95% confidence interval (CI) [0.76; 4.71]. When the timing was based on the onset of symptoms, cholecystectomy performed within 72 h of symptoms was found to significantly reduce post-operative complications compared to delayed cholecystectomy with RR = 0.60 [95% CI 0.39;0.92]. Conclusion The present study failed to confirm the hypothesis that immediate cholecystectomy performed within 24 h of admission may reduce post- operative complications unless surgery could be performed within 72 h of the onset of symptoms.

The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients

“…Importantly, this was not reflected in the complication severity as defined by Clavien-Dindo classification scores, mortality rates or re-operation rates. These findings are in harmony with the outcome of a 2021 meta-analysis by Borzellino et al showing that LC within 72 h of symptoms significantly reduces postoperative complications when compared to delayed cholecystectomy [21]. Conversely, Menahem et al concluded in a 2015 meta-analysis that while ELC and DLC are equivalent in terms of overall morbidity, major bile duct injury and mortality, ELC was significantly associated with postoperative bile leaks and a higher incidence of intraoperative insertion of drainage tubes [22].…”

The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis

“…In contrast, elective surgery allows maturation of the associated inflammation, leading to the organization of dense adhesions and scarring of the gallbladder 34 . Dissection of the gallbladder under chronic inflammatory conditions is often more difficult and can lead to more postoperative complications 35 . To date, emergency LC has not resulted in poorer outcomes than elective LC for the management of acute cholecystitis 36 .…”

“… 34 Dissection of the gallbladder under chronic inflammatory conditions is often more difficult and can lead to more postoperative complications. 35 To date, emergency LC has not resulted in poorer outcomes than elective LC for the management of acute cholecystitis. 36 Evaluating these outcomes more closely in the obese population is important as obesity was previously identified as a risk factor for conversion to open surgery in those undergoing emergency LC.…”

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies

“…50 Recent meta-analyses also suggested ELC as safe and effective against DLC for acute cholecystitis within 7 days from presentation 51 ; also, ELC should be preferred to DLC when feasible within 72 hours of the onset of symptoms. 52 In 2020, the World Society of Emergency Surgery recommended that ELC should be the standard of care whenever possible. 53 Previous Randomised control trials have reported quality improvements and cost savings through same-day surgery (ELC) over preoperative admission.…”

“…A systematic review of meta-analyses by Song et al suggested ELC as the standard treatment option and indicated a non-significant difference in mortality and complications, with a significant reduction in hospitalisation and improvement in quality of life when compared with DLC 50. Recent meta-analyses also suggested ELC as safe and effective against DLC for acute cholecystitis within 7 days from presentation51; also, ELC should be preferred to DLC when feasible within 72 hours of the onset of symptoms 52. In 2020, the World Society of Emergency Surgery recommended that ELC should be the standard of care whenever possible 53…”