Lap-Chole Best Done Within Two Days of Acute Cholecystitis

NEW YORK (Reuters Health) - Doing laparoscopic cholecystectomy within two days of onset of acute cholecystitis yields the best outcomes at the lowest costs, researchers say.

"I was not surprised by these findings, but we needed a large enough database to adequately support the findings," Dr. Daniel D. Tran from Howard University Hospital, Washington, DC, told Reuters Health by email.

Previous studies have shown that early laparoscopic cholecystectomy (LC) is at least as safe as delayed LC, but the definition of "early" varied from within 24 hours of presentation to 10 days later.

Dr. Tran and colleagues reviewed Nationwide Inpatient Sample data from 2005-2009 on 95,523 patients who underwent LC within 10 days after presenting with acute cholecystectomy.

Nearly two-thirds (64.5%) had LC within days 0 through 1. Most of the rest (32.3%) were performed within days 2 through 5, and 3.3% were performed within days 6 through 10 after presentation, according to the December 17 JAMA Surgery online report.

Conversion to open surgery, complications, and mortality all became more common as days to procedure increased.

When each day was analyzed separately, mortality rates were lowest for patients who underwent LC within days 0 through 2, with a sudden increase in mortality (from 0.37% to 0.45%) noted for day 3.

Risk-adjusted mean hospital costs nearly doubled from $8974 for days 0 to 1 to $17,745 for days 6 to 10, although there was no difference in risk-adjusted postoperative length of hospital stay by days to procedure.

"The practice of unnecessarily delaying cholecystectomy for acute cholecystitis should be discouraged," the researchers conclude.

"The main reason surgery should be delayed is if the patient is too ill from other concurrent diseases that must be addressed first," Dr. Tran said.

Dr. Aly Saber from Port-Fouad General Hospital in Egypt has published several studies of laparoscopic cholecystectomy. He told Reuters Health, "Early laparoscopic cholecystectomy within 72 hours of onset of symptoms has both surgical and patient's preference advantages and should be the preferred approach for patients managed by surgeons with adequate experience."

"The overall patient's satisfaction regarding surgical outcome, recurrent attacks of biliary pain, repeated readmission, and the length of hospital stay is in favor of patients with early surgical intervention," Dr. Saber said.

Another researcher who has published comparisons of early vs late laparoscopic cholecystectomy, Dr. Markus W. Buechler from University of Heidelberg in Germany, told Reuters Health by email that the results of this new review confirm his group's large randomized controlled trial that was published in Annals of Surgery.

His advice? "Treat acute cholecystitis as you treat acute appendicitis: early operation within 24 hours."

Finally, in email to Reuters Health, Dr. Sameer Padmakumar Junnarkar cited similar findings from Tan Tock Seng Hospital in Singapore: "Early cholecystectomy in patients with acute cholecystitis is a safe and a more efficient way of managing patients with acute cholecystitis, with lesser morbidity and healthcare costs than delayed cholecystectomy."

He, too, supports delayed cholecystectomy for "investigation or optimization of a patient's comorbidities, such as cardiac risks, etc. (Another) reason could be patient's preference."