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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 549-553

Laparoscopic for acute cholecystitis: an analysis for expanding the golden time


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of General Surgery, Kafr El-Dawar General Hospital, Kafr El-Dawar, Egypt

Date of Submission15-Feb-2018
Date of Acceptance17-Mar-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Ahmed AA El-Abd
Damanhour, Behaira
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_51_18

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  Abstract 


Objective
Our objective is to evaluate safety and efficacy of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in the first 7 days of acute attack.
Background
Gallstone disease constitutes up to 23% of AC, which is a common emergency. LC is the treatment of AC. There is confusion in the optimal timing for LC from the onset of symptoms.
Patients and methods
A total of 30 patients of AC at Menoufia University Hospital and Kafr El-Dawar General Hospital were selected based on clinical diagnosis, ultrasonographic finding, and laboratory finding for AC. They were divided into two groups: group A included 15 patients with AC who were managed conservatively and then surgically after 72 h and group B included 15 patients with AC assigned to LC within 72 h.
Results
There was no statistical significant difference between patients of both groups regarding age or sex. Operative time was significantly increased in group A than in group B, whereas there was no statistical significant difference between both groups regarding blood loss, intraoperative complications, conversion to open cholecystectomy, postoperative hospital stay, or follow-up period complications.
Conclusion
Extending the golden time for LC associated with the same hospital stay, cost-effectiveness, conversion rate, and complications, and therefore can be considered as a preferred approach in the treatment of AC.

Keywords: acute cholecystitis, delayed laparoscopic cholecystectomy, early laparoscopic cholecystectomy, gallstone disease, laparoscopic cholecystectomy, open cholecystectomy


How to cite this article:
Al-Batanony AA, Abdel-Aziz TF, El-Abd AA. Laparoscopic for acute cholecystitis: an analysis for expanding the golden time. Menoufia Med J 2019;32:549-53

How to cite this URL:
Al-Batanony AA, Abdel-Aziz TF, El-Abd AA. Laparoscopic for acute cholecystitis: an analysis for expanding the golden time. Menoufia Med J [serial online] 2019 [cited 2019 Sep 21];32:549-53. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/549/260895




  Introduction Top


The gallbladder is a saccular structure situated in the gallbladder fossa of the posterior right hepatic lobe[1].

Gallstone disease is prevalent in 10% of the population, and up to 23% can develop into acute cholecystitis (AC)[2].

AC is an inflammatory condition of gallbladder resulting from a spectrum of pathophysiologic processes[3].

The diagnosis of most cases of typical calcular AC can usually be achieved with a high degree of accuracy with the combination of clinical presentation and diagnostic imaging[4].

Surgery for AC could be time critical. According to previous studies, gallbladder inflammation during the first 72 h of onset of symptoms may not involve structures within the triangle of Calot[5]. Surgical dissection within this critical period therefore appears easiest owing to lack of organized adhesions. Cholecystectomy within this timeframe reduces the risk of injury to the structures within the triangle of Calot[6].

The optimal timing of surgery for patients with AC has been a topic of controversy in the past. Initially, patients were managed conservatively with the aim of 'cooling down' the inflammation, and then perform cholecystectomy weeks later. AC was once considered a relative contraindication for LC at the beginning of the laparoscopic era, mainly owing to high rates of complications and conversion. This trend, however, changed following growing expertise in laparoscopy[7].

The more recent meta-analysis of randomized trials published in 2013 by the Cochrane Collaboration showed no significant difference between early LC and delayed-interval LC in terms of bile duct injuries, other serious complications, rate of conversion, and operative time, with a 4-day shorter hospital stay in the early group compared with the delayed group. On the basis of these data, early LC is supported by many expert groups; however, the practice pattern differs significantly[8],[9].


  Patients and Methods Top


This prospective comparative study was carried out on 30 patients with AC at Menoufia University Hospital and Kafr El-Dawar General Hospital. The operations were done by two expert laparoscopic consultants. Patient's selection for this study was based on clinical diagnosis, ultrasonographic findings, and laboratory findings suggesting AC.

All of patients with AC within 7 days from the start of the attack were included in our study.

The following categories of patients were excluded from the studied groups: (a) patients with liver cirrhosis, (b) patients with choledocholithiasis, and (c) patients with gallbladder perforation.

Patients were divided into two groups: group A included 15 patients with AC who were managed by conservative measures initially followed by surgical intervention after 72 h but within 7 days of symptoms, and group B included 15 patients with AC assigned to early LC within 72 h of admission.

After approval of local ethics committee, all patients included in the study or their relatives were informed well about the procedure, and an informed written consent was obtained from them before carrying out the procedure.

All patients in the study were subjected to (a) clinical assessment in the form of complete history taking and clinical examination to confirm the acute illness of patients; (b) laboratory investigations in the form of complete blood picture, coagulation profile, liver function tests, kidney function tests, and blood chemistry, including blood glucose level, alkaline phosphatase, C-reactive protein, serum amylase, and lipase; and (c) imaging studies, which included (I) abdominal ultrasonography and (II) abdominal computed tomography examination.

Follow-up of patients was done by clinical observation of abdominal pain, the color of sclera, asking about the color of urine and stool, serum bilirubin, alkaline phosphatase, white blood cell count, and monthly ultrasonography for 3 months.

Complications were defined during 30 days postoperatively, even those that altered the clinical course such as bile duct lesions, bleeding, abdominal collection, pneumonia, additional procedures, and readmissions.

Later on, patients were followed up in the outpatient clinic monthly intervals for 3 months; liver function tests, serum bilirubin, and abdominal ultrasonography were performed to exclude missed stones or other long-term complications.

Data were analyzed using IBM SPSS software package version 20.0 (Belmont, Calf, 2013) IBM in Armonk, New York, USA. Data were collected in tables and then analyzed using χ2, and P value less than 0.05 was considered statistically significant.


  Results Top


The age of the patients of group A ranged between 38 and 68 years, with a mean age of 53.27 ± 8.9 years whereas that of the group B ranged between 37 and 66 years, with a mean age of 53.6 ± 8.97 years, and the statistical analysis revealed that there was no statistical significant difference between patients of both groups regarding age.

Three cases in group A (3/15, 20%) were male and 12 (12/15, 80%) were female, whereas in group B, five (5/15, 33.3%) patients were male and 10 (10/15, 66.7%) were females, and the statistical analysis revealed that there was no statistically significant difference between patients of both groups regarding sex.

The operative time in group A ranged between 80 and 100 min with a mean value of 88.30 ± 18.15 min, whereas that of group B ranged between 70 and 90 min with a mean value of 77.2 ± 12.2 min, and the statistical analysis revealed that the operative time is significantly increased in group A than in group B [Table 1], [Figure 1].
Table 1: Operative data of the studied groups

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Figure 1: Bleeding and the operative time in our groups.

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The amount of blood to be lost in group A ranged between 100 and 210 ml with a mean value of 155.3 ± 30.1 ml whereas that of group B ranged between 90 and 190 ml, with a mean value of 150.09 ± 28.2 min, and the statistical analysis revealed that there is no significant difference between both groups.

Six cases of group A (40%) experienced intraoperative complications in the form of bleeding (4/15, 26.7%) and common bile duct injury in two cases (2/15, 13.3%) and the remaining cases of this group passed without complications, whereas in group B, five cases (5/15, 33.3%) experience complications: three of them were complicated by bleeding (3/15, 20%), one experience bile leak owing to injury to the gallbladder bed (1/15, 6.7%), and the remaining case experience injury to the common bile duct (1/15, 6.7%). Moreover, the statistical analysis revealed that there was no significant difference between both groups regarding rate of intraoperative complications.

A total of six (40%) of 15 cases of group A were converted to open cholecystectomy, which was owing to excessive bleeding in four (26.7%) cases and common bile duct injuries in two (13.3%) cases, whereas in group B, five (33.3%) of 15 cases were converted to open cholecystectomy: three (20%) of them owing to excessive bleeding, one (6.7%) owing to bile leak from the gallbladder bed, and the one (6.7%) owing to injury to the common bile duct. The statistical analysis revealed that there was no statistical significant difference between both groups regarding the rate of conversion to open cholecystectomy.

The hospital stay in patients of group A ranged between 6 and 15 days with a mean value of 10.8 ± 2.4 days, whereas in group B, the hospital stay ranged between 7 and 17 days, with a mean value of 10.3 ± 2.7 days, and the statistical analysis revealed that there was no statistical significant differences between both groups regarding the period of postoperative hospital stay [Table 2].
Table 2: Postoperative follow-up data of the studied groups

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Early follow-up of cases of group A showed that two (40%) cases had complications, which were simple and in the form of superficial wound infection in four (26.7%) cases, persistent bile leak in one (6.7%) case, and common bile duct injury in one case (6.7%).

Early follow-up in cases of group B showed that five (33.3%) patients had complications: three of them owing to wound infections, one case of persistent bile leak, and one case presented late in the follow-up period, and complication was because of narrowing of the common bile duct [Figure 2].
Figure 2: Intraoperative complications in our groups.

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The statistical analysis revealed that the rate of complications during the follow-up period was fairly the same in both groups without statistical significant difference.


  Discussion Top


The statistical analysis revealed that there was no statistical significant difference between patients of both groups regarding age. Ferreres et al.[10] stated similar results to ours. In addition, De Mestral et al.[11] and Ambe et al.[6] showed in their study that there was no significant difference between groups of their study regarding age.

In cases of our study, there was no statistical significant difference between patients of both groups regarding sex. In agreement with our results, Minutolo et al.[9] and Ambe et al.[6] found in their studies that there was no significant difference between groups of their study regarding sex.

Our results showed prolonged operative time with delaying interference similar to Cao et al.[12] whereas Minutolo et al.[9] found no difference between their groups regarding the operative time. The prolonged time in our study was owing to number of cases and massive adhesion that needed more time for dissection.

In our study, there was no difference in blood loss in both groups early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC), and this result was in disagreement with Cao et al.[12], the reason of this difference in our and their results may be due to massive adhesion and obscured anatomy in their study.

During our study, the intraoperative complications did not differ in both groups and explained on the bases of the presence of massive fibrous adhesions and its vascular nature. Minutolo et al.[9] agreed with our results. However, Blohm et al.[13] and Cao et al.[12] found low risk of intraoperative adverse events with early interference, because the inflammatory process was not so severe.

The conversion rate in our results showed no difference between both groups because intraoperative difficulties can be managed, and this was similar to Degrate et al.[14] and Minutolo et al.[9]. However, De Mestral et al.[11] showed increased complication rate with DLC owing to the development of excessive fibrosis in and around the Calot's triangle.

Yamashita et al.[8] found no difference between ELC and DLC regarding bile duct injuries, other serious complications, and rate of conversion, whereas disagree with us on operative time and postoperative hospital stay. Moreover, Ambe et al.[6] agree with our results regarding conversion rate and complications but disagree with us regarding operative time. In addition, Menahem et al.[15] have similar results regarding conversion rate.

There was no difference in postoperative hospital stay in our groups, which is similar to Minutolo et al.[9] and Gurusamy et al.[16]. However, De Mestral et al.[11] and Cao et al.[12] showed prolonged hospital stay with delayed interference owing to evident rate of difficulties during and after operation.

There was no difference regarding delayed complications in our groups, which is similar to Degrate et al.[14] and Özkardes et al.[17]; however, Gurusamy et al.[16], Gutt et al.[18], and Cao et al.[12] found increase delayed complications with DLC.


  Conclusion Top


From our study, we can conclude that early LC and delayed LC can be regarded as safe procedures for the treatment of AC, with a comparable operative time, major and minor complication rate, conversion rate, and postoperative stay. Moreover, extending the golden time for intervention by LC is associated with the same total hospital stay and cost-effectiveness, conversion rate, and complications and therefore can be considered as a preferred approach in treatment of AC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Chuang SH, Chen PH, Chang CM, Lin CS. Single-incision vs three-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis. World J Gastroenterol 2013;19:7743–7750.  Back to cited text no. 3
    
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Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, et al. Surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20:89–96.  Back to cited text no. 8
    
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Minutolo V, Licciardello A, Arena M, Nicosia A, Di Stefano B, Calì G, et al. Laparoscopic cholecystectomy in the treatment of acute cholecystitis: comparison of outcomes and costs between early and delayed cholecystectomy. Eur Rev Med Pharmacol Sci 2014; 18(Suppl 2):40–46.  Back to cited text no. 9
    
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Ferreres AR, Asbun HJ. Technical aspects of cholecystectomy. Surg Clin North Am 2014; 94:427–454.  Back to cited text no. 10
    
11.
De Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorasky B, Alali AS, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population based propensity score analysis. Ann Surg 2014; 259:10–15.  Back to cited text no. 11
    
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Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case–control studies. Surg Endosc 2016; 30:1172–1182.  Back to cited text no. 12
    
13.
Blohm M, Österberg J, Sandblom G, Lundell L, Hedberg M, Enochsson L. The sooner, the better? the importance of optimal timing of cholecystectomy in acute cholecystitis: data from the National Swedish Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg 2017; 21:33–40.  Back to cited text no. 13
    
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Degrate L, Ciravegna AL, Luperto M, Guaglio M, Garancini M, Maternini M, et al. Acute cholecystitis: the golden 72-h period is not a strict limit to perform early cholecystectomy. Results from 316 consecutive patients. Langenbecks Arch Surg 2013; 398:1129–1136.  Back to cited text no. 14
    
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Menahem B, Mulliri A, Fohlen A, Guittet L, Alves A, Lubrano J. Delayed laparoscopic cholecystectomy increases the total hospital stay compared to an early laparoscopic cholecystectomy after acute cholecystitis: an updated meta-analysis of randomized controlled trials. HPB (Oxford) 2015; 17:857–862.  Back to cited text no. 15
    
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Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev 2013; 6:CD005440.  Back to cited text no. 16
    
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Özkardes AB, Toka M, Dumlu EG, Bozkurt B, Çiftçi AB, Yetisir F, et al. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective, randomized study. Int Surg 2014; 99:56–61.  Back to cited text no. 17
    
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Gutt CN, Encke J, Köninger J, Harnoss JC, Weigand K, Kipfmüller K, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC Study, NCT00447304). Ann Surg 2013; 258:385–393.  Back to cited text no. 18
    


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