Delayed Laparoscopic Cholecystectomy Group Research Articles

Early versus delayed laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography: A meta-analysis.

Patients with cholecysto- and choledocholithiasis usually undergo endoscopic retrograde cholangiopancreatography (ERCP)/-endoscopic sphincterotomy followed by laparoscopic cholecystectomy (LC). However, differences in the timing of LC after the ERCP may alter the post-operative outcomes. The aim of this study was to compare the effect of early (≤3 days) or delayed LC (>3 days) following ERCP on the post-operative outcomes. A comprehensive search of the 3 databases PubMed, EMBASE and the Cochrane Library was performed. Articles related to LC at different time-points after ERCP were retrieved. Dichotomous and continuous outcomes were analyzed by risk ratio (RR) and mean difference, and RevMan was used to analyze each group. A total of 7 studies, including 5 randomized controlled studies and 2 retrospective studies, involved a total of 711 patients. There were 332 patients in early LC group and 379 in delayed LC group. The conversion rate was lower in the early LC group compared to the delayed LC group (RR 0.38, 95% confident interval 0.19 to 0.74, P = .005, I2 = 0%). Early LC resulted in a shorter operation time (RR -6.2, 95% CI -27.2 to -5.2, P = .004, I2 = 97%) and fewer complications (RR 0.48, 95% CI 0.29 to 0.79, P = .004, I2 = 17%). Subgroup analysis found that there were no significant differences in the conversion rate (RR 0.61, 95% CI 0.25 to 1.45, P = .26, I2 = 0%) or complications between the early LC group and the delayed group who underwent LC after 1 month. Early LC after ERCP is the preferred treatment for patients with concurrent cholecysto- and choledocholithiasis due to improved clinical outcomes as compared to those who undergo delayed LC.

The Optimal Timing of Laparoscopic Cholecystectomy in Acute Cholecystitis: A Single-Center Study.

Introduction Early laparoscopic cholecystectomy (ELC) is a treatment option for acute cholecystitis (AC). However, the timing of ELC is controversial. Delayed laparoscopic cholecystectomy (DLC) continues to be a common practice. This study aims to determine the optimal timing of ELC in AC. Materials and methods Patients who underwent surgery for AC between 2014 and 2020 were divided into three groups: immediate laparoscopic cholecystectomy (ILC), prolonged ELC (pELC), and DLC. The demographic, laboratory, radiological findings, and postoperative results of all patients were retrospectively reviewed. Results The study included 178 patients, with 63 in the ILC group, 27 in the pELC group, and 88 in the DLC group. Postoperative outcomes, excluding hospital stay, were similar between the groups. The total hospital stay was significantly longer in the pELC and DLC groups (p<0.05). In addition, postoperative hospital stay was longer in the pELC group (p<0.05), and 17.7% of the patients who waited for delayed surgery experienced recurrent attacks during the interval period. Conclusion ILC is recommended in AC to minimize hospital stays.

EP-221 Outcome of early cholecystectomy compared to percutaneous drainage of gallbladder and delayed cholecystectomy for patients with acute cholecystitis: systematic review and meta-analysis

Abstract Aim Compare outcomes of ELC and PTGBD as an initial intervention for AC and to compare operative outcomes of ELC and delayed laparoscopic cholecystectomy (DLC). Methods English-language studies published until December 2020 were searched. Randomised controlled trials (RCTs) and observational studies compared EC and PTGBD with delayed cholecystectomy for patients presented with acute cholecystitis were considered. Main outcomes were mortality, conversion to open, complications and length of hospital stay. Results Out from 1347 records,14 studies were included. 205,361(94.7%) patients had EC and 11,565 (5.3%) patients had PTGBD as an initial intervention for AC. Risk of mortality was considerably higher in PTGBD compared to EC group; HR,95% CI: [3.68 (2.13, 6.38)]. In contrast, complication rate was significantly higher in EC group (47%) vs 8.7% in PTGBD group in patients admitted to ICU for sepsis related to AC; P-value=0.011. ELC group had more intra-operative blood loss than DLC group; MD (95%CI): 34.2 (4.15, 64.25) ml. There was no difference in mortality between the two groups; HR (95% CI): 1.30 [0.60, 2.83] Patients had ELC are at higher risk of post-operative complications compared to DLC; RR [95% CI]: 2.88 [1.78, 4.65]. Risk of bile leak or bile duct injury was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99]. Conclusion ELC should be considered for all patients with acceptable surgical risk admitted with AC regardless its severity. PTGBD can be considered for patients admitted to the ICU for organ support. Future studies needed to assess the validity of this approach.

Sleeve Gastrectomy and Cholecystectomy are Safe in Obese Patients with Asymptomatic Cholelithiasis. A Multicenter Randomized Trial

BackgroundObesity is a severe health problem. Gallstones may symptomatize after sleeve gastrectomy (SG). Concomitant laparoscopic cholecystectomy (LC) with SG is controversial. The effects of SG and LC versus delayed LC following SG in obese patients with asymptomatic gallbladder stones were evaluated.MethodsA randomized trial of 222 morbidly obese patients with gallbladder stones divided them into two equal groups: SG + LC and SG-only. This multicenter study conducted from January 2016 to January 2019.ResultsExcept for operative time and postoperative hospital stay, there was no statistically significant difference between LSG + LC group and SG group (P < 0.001). In SG + LC group, LC added 40.7 min to SG, three patients (3%) required conversion, early postoperative complications occurred in 9 cases (9/111, 9%), three cases required re-intervention (3%). In SG group, the complicated cases required LC were 61 cases (61/111, 55%). Acute cholecystitis (26/61, 42.7%) was the most common gallstone symptoms. Most complicated cases occurred in the first-year follow-up (52/61, 85%). In the delayed LC group (61 patients), operative time was 50.13 ± 1.99 min, open conversion occurred in 2 cases (2/61, 3.2%), early postoperative complications occurred in four patients (4/61, 6.4%) and postoperative re-intervention were due to bile leaks and cystic artery bleeding (2/61, 3.2%).ConclusionsSG with LC prolongs the operative time and hospital stay, but the perioperative complications are the same as delayed LC; LC with SG minimizes the need for a second surgery. Concomitant LC with SG is safe.

English

BACKGROUND Acute cholecystitis is a pathology of inflammatory origin, usually associated with cholelithiasis, with a high incidence in the world. Its treatment involves an important socioeconomic impact. There are two surgical therapeutic options: early laparoscopic cholecystectomy (ELC) done within 72 hours of onset of pain or delayed laparoscopic cholecystectomy (DLC) done after 6 weeks of conservative treatment. The present study intends to compare between the effectiveness of ELC vs DLC in the management of acute cholecystitis in a tertiary care setup. METHODS The study sample included 65 patients who were clearly documented and radiologically proven cases of acute calculous cholecystitis, met the inclusion criteria, admitted to the surgery department of MKCG MCH, Berhampur, between August 2018 and July 2020. Out of 65 patients, 33 and 32 patients were selected randomly for ELC and DLC respectively. In ELC group surgery was done within 72 hours of the onset of pain while in DLC group surgery was done after 6 weeks of initial conservative treatment. The study was conducted using a case record proforma, prepared in their local language. The questionnaire included timing of cholecystectomy, duration of antibiotic coverage, mean duration of hospital stay, number of intraoperative and postoperative complications, conversion to open cholecystectomy, and follow-up. The data was compiled and tabulated in MS ® Excel and statistically analysed using IBM ® SPSS 22.0. RESULTS The overall morbidity and mortality were less in ELC compared to DLC. The mean duration of surgery was less in ELC (47.36 minutes) compared to DLC (65.75 minutes). The mean duration of antibiotic coverage was lesser in ELC (3.58 days) compared to DLC (5.50 days).The mean hospital stay was less in ELC (4.67 days) to DLC (6.50 days). The overall morbidity and mortality were less in ELC. CONCLUSIONS ELC is considered to be a safe modality of treatment in patients with acute cholecystitis and leads to an economical treatment. KEYWORDS Acute Calculus Cholecystitis, Early Laparoscopic Cholecystectomy, Delayed Laparoscopic Cholecystectomy

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis.

The safety and feasibility of early laparoscopic cholecystectomy (LC) for acute cholecystitis with mild pancreatitis were explored. A total of 973 patients with acute pancreatitis, including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department. And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study, of which 328 patients underwent LC during the same-admission (early LC group), and 98 patients underwent LC a period of time after conservative treatment (delayed LC group). Clinical characteristics, operative findings and complications were recorded and followed up. The two groups were comparable in age, gender, the grade of American Society of Anesthesiologist (ASA), biochemical findings and Balthazar computer tomography (CT) rating (P>0.05). The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group (5.83±1.62 vs. 41.36±8.44 days; 11.38±2.43 vs. 16.49±3.48 days, P<0.01). There was no significant difference in the average operation time between the two groups. No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group (P<0.01). There was no significant difference in conversion rate (3.85 vs. 5.10%, P=0.41) and surgical complication rate (3.95 vs. 4.08%, P=0.95) between early LC group and delayed LC group. During the postoperative follow-up period of 375 cases, biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group (P=0.37). The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.

Application value of early and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage in 65 years of age or older patients with severe acute cholecystitis: a prospective analysis

Objective To investigate the application value of early and delayed laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGD) in 65 years of age or older patients with severe acute cholecystitis. Methods The prospective study was conducted. The clinical data of 80 patients with severe acute cholecystitis who were admitted to Shanxi Dayi Hospital of Shanxi Academy of Medical Sciences from May 2016 to January 2018 were collected. All patients were divided into two groups by random number table, including patients undergoing LC 72 h later after extubation of PTGD in the PTGD + early LC group, and patients undergoing LC 5-14 days later after extubation of PTGD in the PTGD + delayed LC group. Observation indicators: (1) surgical situations; (2) analysis of liver function before and after LC in the two groups; (3) analysis of serum-related inflammatory factors before and after LC in the two groups; (4) follow-up situations. Patients were followed up by outpatient examination or telephone interview to detect the postoperative complications in the postoperative three months up to April 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was done using the paired t test. Count data were represented as absolute number, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results Eighty patients were screened for eligibility, including 41 males and 39 females, aged from 65 to 70 years, with an average age of 67 years. There were 40 patients in the PTGD + early LC group and 40 in the PTGD + delayed LC group, respectively. (1) Surgical situations: the operation time, volume of intra-operative blood loss, and duration of postoperative hospital stay were (52±15)minutes, (29±11)mL, (18.9±1.6)days in the PTGD + early LC group, and (88±13)minutes, (69±11)mL, (27.7±4.8)days in the PTGD + delayed LC group, respectively, showing significant differences in the above indicators between the two groups (t=11.668, 16.219, 11.000, P 0.05), meanwhile, there were significant differences in the levels of AST, ALT, ALP, GGT, TBil after LC between the two groups (t=2.683, 10.067, 19.931, 6.508, 2.380, P 0.05), meanwhile, there were significant differences in the levels of IL-1, IL-6, high-sensitivity CRP, and TNF-α after LC between the two groups (t=24.844, 13.092, 4.833, 15.185, P<0.05). (4) Follow-up situations: 80 patients were followed up for 3 months. Two patients in the PTGD + early LC group had postoperative complications, including 1 of bile duct injury and 1 of incisional infection; 9 patients of PTGD + delayed LC group had postoperative complications, including 3 of bile duct injury, 3 of multiple organ failure, 2 of incisional infection, 1 of death. There was a significant difference in the postoperative complication between the two groups (χ2=5.165, P<0.05). Conclusion Early LC after PTGD can effectively shorten operation time, reduce volume of intraoperative blood loss, shorten duration of postoperative hospital stay, protect liver function, reduce the expression of serum inflammatory factors at 24 hours after surgery, and reduce postoperative complications. Key words: Severe acute cholecystitis; Percutaneous transhepatic gallbladder drainage; Cholecystectomy; Early surgery; Delayed surgery; Laparoscopy

Acute mild gallstone pancreatitis: timing of cholecystectomy

Background: Cholecystectomy is essential to prevent recurrent attacks of mild acute gallstone pancreatitis, but the precise timing of cholecystectomy remains a subject of ongoing debate. The aim of this study is to address the optimal timing of cholecystectomy in patients with mild acute gallstone pancreatitis.Methods: From September 2013 to September 2018, patients with mild acute gallstone pancreatitis were prospectively randomized to either an early laparoscopic cholecystectomy (ELC) versus a delayed laparoscopic cholecystectomy (DLC) group. Recurrent biliary complications, success and failure rate, difficulty of cholecystectomy, operative time, cholecystectomy related complications, length of admission between the two groups were evaluated.Results: A total of 80 patients were randomized to the ELC (41 patients) and to the DLC group (39 patients). There were a statistically significant differences in the total length of hospital stay and recurrent biliary events (4.5±1.1 vs. 7.4±2.6 days, p&lt;0.01 and 4.9% vs. 41%, p&lt;0.001; respectively). There were no differences regarding success and failure rate, difficulty of cholecystectomy, operative time, cholecystectomy related complications, and length of index admission between both groups.Conclusions: In mild gallstone pancreatitis, ELC results in a shorter overall hospital stay with a significant reduction in the recurrent biliary events with no apparent impact on the safety and technical difficulty of the procedure or perioperative complication rate.

Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis

BackgroundThe timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP).MethodsWe systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom).ResultsThis meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78–1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67–1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42–3.86; p = 0.66), or OT (RR = 1.57; 95% CI, − 1.58–4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = − 2.08; 95% CI, − 3.17 to − 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = − 0.40; 95% CI, − 0.80–0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%).ConclusionThis study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.

RESULTS OF EARLY AND DELAYED LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH AN ACUTE CALCULUS CHOLECYSTITIS AND ISCHEMIC HEART DISEASE

Relevance. Determination of the optimal time for laparoscopic cholecystectomy (LCE) in patients with acute calculous cholecystitis (ACC) and ischemic heart disease (IHD) is still an actual and unresolved issue.&#x0D; Objective: to evaluate the results early versus delayed LCE in patients with ACC and IHD.&#x0D; Materials and methods. The study involved 107 patients with ACC and IHD: 56 (47,7 %) women and 51 (52,3 %) men aged 55 to 82 years, an average 70,2±0,6 years. The group with early LCE (ELCE) included 48 patients with LCE – up to 72 hours from the beginning of ACC (on average 41,9±2,1 hours), the group with delayed LCE (DLCE) – 59 patients, who were LCE for more than 72 hours (in average 90,2±1,6 hours) from the beginning of ACC. Groups of patients were representative according to the functional classes of heart failure, angina pectoris, severity and the histological form of ACC. All patients had a Charlson comorbidity index from 0 to 2 points. The endpoint of the study were: the frequency of conversion to open cholecystectomy, cardiac events in the intra – and early postoperative periods, the incidence of complications according to the Clavien-Dindo classification. Data analysis was performed using IBM SPSS Statistics.&#x0D; Results. The duration of LCE in the DLCE group was 45,2±2,1 minutes, in the ELCE group it was 40,9±1,4 min (p=0,115). Conversion to open cholecystectomy was required in 8 (13,6 %) patients of the DLCE group versus one (2,1 %) in the ELCE group, p=0,033. During the operation, myocardial ischemia occurred in 17 (28,8 %) patients of the DLCE group versus 6 (12,5%) the ELCE group, p=0,041, and a systolic blood pressure decrement lower than 70 mm hg. art. – in 24 (40,7 %) against 8 (16,7 %), p=0,007; saturation reduction episodes – in 33 (55,9 %) against 17 (35,4 %), p=0,034, respectively. In the early postoperative period, an increasing of HF class according to NYHA was observed in 12 (20,3 %) patients of the DLCE group versus one (2,1 %) in the ELCE group, p=0.004; the number of patients with complications according to Clavien-Dindo classification – 40 (67,8 %) versus 23 (47,9 %), p=0,038; pneumonia occurred in 26 (44,1 %) against 6 (12,5 %), p=0,001; exudative pleurisy – in 28 (47,5 %) against 9 (18,8 %), p=0,002, respectively. There were no lethal cases in the period up to 7 days in both groups.&#x0D; Conclusion. ELCE is a priority method of treatment patients with an acute calculous cholecystitis (ACC) and ischemic heart disease (IHD) with a different functional class (according to NYHA). Compared with DLCE, it is associated with reliable reduce of conversion (2,1 %), against 8 (13,6 %), intra- and early postoperative complications of the cardiovascular system and complications according to Clavien-Dindo classification – 23 (47,9 %) patients against 40 (67,8 %).

Early Versus Delayed Cholecystectomy for Acute Cholecystitis, Are the 72 hours Still the Rule?

The aim of this study was to compare clinical outcomes of early versus delayed laparoscopic cholecystectomy (LC) in acute cholecystitis with more than 72 hours of symptoms. LC is the treatment of acute cholecystitis, with consensus recommendation that patients should be operated within 72 hours of evolution. Data however remain weak with no prospective study focusing on patients beyond 72 hours of symptoms. Patients with acute cholecystitis and more than 72 hours of symptoms were randomly assigned to early LC (ELC) or delayed LC (DLC). ELC was performed following hospital admission. DLC was planned at least 6 weeks after initial antibiotic treatment. Primary outcome was overall morbidity following initial diagnosis. Secondary outcomes were total length of stay, duration of antibiotic therapy, hospital costs, and surgical outcome. Eighty-six patients were randomized (42 in ELC and 44 in DLC group). Overall morbidity was lower in ELC [6 (14%) vs 17 (39%) patients, P = 0.015]. Median total length of stay (4 vs 7 days, P < 0.001) and duration of antibiotic therapy (2 vs 10 days, P < 0.001) were shorter in the ELC group. Total hospital costs were lower in ELC (9349&OV0556; vs 12,361 &OV0556;, P = 0.018). Operative time and postoperative complications were similar (91 vs 88 min; P = 0.910) and (15% vs 17%; P = 1.000), respectively. ELC for acute cholecystitis even beyond 72 hours of symptoms is safe and associated with less overall morbidity, shorter total hospital stay, and duration of antibiotic therapy, as well as reduced cost compared with delayed cholecystectomy (NCT01548339).

MILD TO MODERATE ACUTE BILIARY PANCREATITIS;

Introduction: Acute biliary pancreatitis is a serious complication of biliarycalculous disease and is associated with significant morbidity and mortality. Incidence is moreoften in females and cause is the gall stones in majority of the cases. Definitive treatment ischolecystectomy and with the advancement of minimal invasive surgery, laparoscopiccholecystectomy has been considered as a gold standard for the management of acute BiliaryPancreatitis. The optimal timing when to perform laparoscopic cholecystectomy is still underdebate. Many surgeons recommend early surgery whereas others are in favor of delayedsurgery. This study is carried out to compare the timing of laparoscopic cholecystectomy in casesof acute biliary pancreatitis. Objective: To compare the frequency of conversion fromlaparoscopic to open cholecystectomy in early versus delayed laparoscopic cholecystectomy inmild to moderate acute biliary pancreatitis. Study design: Randomised Control trial (RCT).Setting: Department of surgery, Holy Family Hospital, Rawalpindi. Duration: Six months, fromJanuary 2010 to June 2012. Material and methods: 306 patients, diagnosed as mild tomoderate acute Biliary Pancreatitis were randomly allocated into two groups for laparoscopiccholecystectomy. Those who were operated within two weeks of index hospital admission werelabeled as Early laparoscopic cholecystectomy (EC) group whereas those undergoing surgeryafter 02 weeks of index hospital admission were considered as Delayed laparoscopiccholecystectomy group(DC). Conversion rate from laparoscopic to open cholecystectomy wascompared in two groups. Results: Out of 153 patients enrolled as EC group, 138 were female and15 were male patients. Mean age was 39.19 ± 11.25years where as in DC group , there were 134female and 19 male patients in a total of 153 patients, and the mean age was 39.54 ±10.37 years.Conversion from laparoscopic surgery to open cholecystectomy was 8.5%(13 patients) and13.1%(20 patients) in EC and DC groups respectively. The overall conversion rate was 10.8%.There was no statistical significance between conversion rate of the two groups. (p = 0.197)Conclusions: Acute Biliary Pancreatitis should be managed by laparoscopic cholecystectomyregardless of the time elapsed since the start of symptoms. There is no statistical significance ofconversion rate from laparoscopic to open cholecystectomy associated with the timing ofsurgical intervention in the case of acute Biliary Pancreatitis.

Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis

Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% of these adults become symptomatic in a year (the majority due to biliary colic but a significant proportion due to acute cholecystitis). Laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery exposes the people to gallstone-related complications. The aim of this systematic review was to compare early laparoscopic cholecystectomy (less than seven days of clinical presentation with acute cholecystitis) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission with acute cholecystitis) with regards to benefits and harms. We searched the Cochrane Hepato-Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and World Health Organization International Clinical Trials Registry Platform until July 2012. We included all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis. We used standard methodological procedures expected by The Cochrane Collaboration. We identified seven trials that met the inclusion criteria. Out of these, six trials provided data for the meta-analyses. A total of 488 participants with acute cholecystitis and fit to undergo laparoscopic cholecystectomy were randomised to early laparoscopic cholecystectomy (ELC) (244 people) and delayed laparoscopic cholecystectomy (DLC) (244 people) in the six trials. Blinding was not performed in any of the trials and so all the trials were at high risk of bias. Other than blinding, three of the six trials were at low risk of bias in the other domains such as sequence generation, allocation concealment, incomplete outcome data, and selective outcome reporting. The proportion of females ranged between 43.3% and 80% in the trials that provided this information. The average age of participants ranged between 40 years and 60 years. There was no mortality in any of the participants in five trials that reported mortality. There was no significant difference in the proportion of people who developed bile duct injury in the two groups (ELC 1/219 (adjusted proportion 0.4%) versus DLC 2/219 (0.9%); Peto OR 0.49; 95% CI 0.05 to 4.72 (5 trials)). There was no significant difference between the two groups (ELC 14/219 (adjusted proportion 6.5%) versus DLC 11/219 (5.0%); RR 1.29; 95% CI 0.61 to 2.72 (5 trials)) in terms of other serious complications. None of the trials reported quality of life from the time of randomisation. There was no significant difference between the two groups in the proportion of people who required conversion to open cholecystectomy (ELC 49/244 (adjusted proportion 19.7%) versus DLC 54/244 (22.1%); RR 0.89; 95% CI 0.63 to 1.25 (6 trials)). The total hospital stay was shorter in the early group than the delayed group by four days (MD -4.12 days; 95% CI -5.22 to -3.03 (4 trials; 373 people)). There was no significant difference in the operating time between the two groups (MD -1.22 minutes; 95% CI -3.07 to 0.64 (6 trials; 488 people)). Only one trial reported return to work. The people belonging to the ELC group returned to work earlier than the DLC group (MD -11.00 days; 95% CI -19.61 to -2.39 (1 trial; 36 people)). Four trials did not report any gallstone-related morbidity during the waiting period. One trial reported five gallstone-related morbidities (cholangitis: two; biliary colic not requiring urgent operation: one; acute cholecystitis not requiring urgent operation: two). There were no reports of pancreatitis during the waiting time. Gallstone-related morbidity was not reported in the remaining trials. Forty (18.3%) of the people belonging to the delayed group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy in five trials. The proportion with conversion to open cholecystectomy was 45% (18/40) in this group of people. We found no significant difference between early and late laparoscopic cholecystectomy on our primary outcomes. However, trials with high risk of bias indicate that early laparoscopic cholecystectomy during acute cholecystitis seems safe and may shorten the total hospital stay. The majority of the important outcomes occurred rarely, and hence the confidence intervals are wide. It is unlikely that future randomised clinical trials will be powered to measure differences in bile duct injury and other serious complications since this might involve performing a trial of more than 50,000 people, but several smaller randomised trials may answer the questions through meta-analyses.

Early Laparoscopic Cholecystectomy After Endoscopic Common Bile Duct Stone Extraction

The optimal timing of laparoscopic cholecystectomy (LC) after endoscopic common bile duct stone extraction remains controversial. The aim of this China-based retrospective study was to investigate the outcomes of patients who underwent early LC after endoscopic procedures. The retrospective study enrolled patients who underwent LC after endoscopic common bile duct stone extraction between January 2007 and February 2010. On the basis of intervals between LC and endoscopic procedures, patients were classified into 2 groups: early LC group, including patients receiving LC within 3 days; and delayed LC group, including patients receiving LC after 3 days. Operation time, surgical complications, postoperative hospital stay, and the cost of hospitalization were compared between 2 groups. There were 92 patients in the early LC group and 115 patients in the delayed LC group. The characteristics and endoscopic procedures of the 2 groups were similar. There were no differences between the 2 groups in operative duration, incidence of surgical complications, restoration of bowel motion, postoperative hospital stay, and LC-related cost. However, total hospital cost of early LC was less than that of delayed LC. Early LC after endoscopic common bile duct stone extraction in developing countries is feasible and safe. Moreover, it can reduce the total hospital cost effectively. Thus, early LC after endoscopic procedures should be recommended in developing countries.

Laparoscopic cholecystectomy for acute cholecystitis

From October 1991 to March 1994, 35 patients (20 men and 15 women) with acute cholecystitis (AC) underwent laparoscopic cholecystectomy (LC). They ranged in age from 17 to 82 years (mean, 51.7 years). Nine of the 35 patients (25.7%) had either percutaneous transhepatic gallbladder drainage (PTGBD) or percutaneous transhepatic gallbladder aspiration (PTGBA) performed preoperatively. The mean operative time was 183.7 min. Four of the 35 patients (11.4%) required conversion to open laparotomy. The mean postoperative hospital stay was 11.2 days and postoperative morbidity rate was 2.9%. There were no major complications and no deaths. In this retrospective study, we divided the patients into three groups according to the surgical timing of LC in relation to onset. Two of the three groups had LC performed more than 7 days after onset; these groups were termed, collectively, the delayed LC group. The group that had LC performed within 7 days of onset we termed the early LC group. The early LC group had a shorter operative time, less blood loss, and a shorter postoperative hospital stay than the delayed LC group, but the differences were not significant. Nevertheless, we suggest that early LC for AC should be employed for patients who are in a stable condition and who have no preoperative associated medical problems. In the delayed LC group, there were no significant differences in findings between patients who received or did not receive either PTGBD or PTGBA. PTGBD and PTGBA are useful procedures for the relief of acute severe symptoms in patients whose condition is refractory to treatments such as i.v. antibiotic infusion and no oral feeding. We conclude that a laparoscopic procedure for patients with AC, when performed by experienced surgeons, is safe, technically feasible, and useful.