Acute cholecystitis: Delayed cholecystectomy has lesser perioperative morbidity compared to emergency cholecystectomy

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

A prospective randomized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates. It is not known whether there is a role for initial conservative treatment followed by interval elective operation. During a 26-month period, 99 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n = 49) or delayed interval surgery after initial medical treatment (delayed group, n = 50). Thirteen patients (four in the early group and nine in the delayed group) were excluded because of refusal of operation (n = 6), misdiagnosis (n = 5), contraindication for surgery (n = 1), or loss to follow-up (n = 1). Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n = 3) and persistent fever (n = 5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs. 11%; p = 0.174) and complication rate (29% vs. 13%; p = 0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p = 0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p < 0.001) and recuperation period (19 days vs. 12 days; p < 0.001). Initial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.

Reliable risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy would be extremely useful to optimize the clinical management. This study aimed to determine risk factors that can be used for predicting perioperative complications. Possible risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy for acute and chronic cholecystitis were analyzed by a stepwise logistic regression model using data from the Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS) database. A total of 22,953 patients with a mean (+/-SD) age of 54.5+/-16.1 years (range 17 to 89 years) and a male-to-female ratio of 1:2, underwent elective (85%) and emergency (15%) laparoscopic cholecystectomy. Multivariable analysis showed that male gender (odds ratio [OR]=1.16; p 90 kg versus 100 versus 11 to 100 interventions; OR=1.36; p 90 kg; OR=1.53; p<0.007), emergency surgery (OR=1.36; p<0.003), and duration of surgery (OR=1.28 per 30 minutes; p<0.0001) were found to be associated with a higher incidence of postoperative local complications. Higher postoperative systemic complications were encountered with conversion (OR=1.5; p<0.0002), ASA score (III/IV versus I/II: OR=1.54; p<0.0001), emergency surgery (OR=1.41; p<0.001), and a prolonged intervention time (OR=1.16 per 30 minutes; p<0.0001). For patients undergoing laparoscopic cholecystectomy (LC), the risk of possible perioperative complications can be estimated based on patient characteristics (gender, age, ASA score, body weight), clinical findings (acute versus chronic cholecystitis), and the surgeon's own clinical practice with LC. So in the likelihood of a case being a "difficult cholecystectomy," an experienced surgeon should be involved both in the decision-making process and during the operation. If LC lasts longer than 2 hours, the cumulative risk for perioperative complications is four times higher compared with an intervention that lasts between 30 and 60 minutes, independent of the surgeon's personal skills with LC.