Early 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.

Efficacy of early laparoscopic cholecystectomy compared with percutaneous transhepatic gallbladder drainage in treating acute calculous cholecystitis in elderly patients

Background Acute calculous cholecystitis is a common acute disease in elderly patients. This study aimed to evaluate the efficacy of early laparoscopic cholecystectomy (ELC) compared to percutaneous transhepatic gallbladder drainage (PTGD) for treating acute calculous cholecystitis in elderly patients. Methods This retrospective study compared the clinical outcomes of two groups of elderly patients treated with ELC (group A) and PTGD (group B) from January 2018 to December 2021. Preoperative clinical characteristics and postoperative treatment outcomes were analyzed for both groups. Results There were no statistically significant differences in preoperative clinical characteristics between the ELC and PTGD groups. ELC took longer to perform (69.8 ± 15.9 min vs. 29.6 ± 5.3 min, p < 0.001) but resulted in a significantly shorter duration of pain (1.9 ± 0.9 days vs. 3.9 ± 1.0 days, p < 0.001) and hospital stay (6.3 ± 2.5 days vs. 9.9 ± 3.6 days, p < 0.001), and a lower rate of sepsis (3.4% vs. 16.9%, p < 0.019). Time to soft diet was faster in the ELC group (1.5 ± 0.9 days vs. 3.0 ± 1.6 days, p < 0.001). Fewer patients in the ELC group experienced surgical reintervention than in the PTGD group (0% vs. 5.6%, p = 0.043). The incidence of postoperative complications and readmission rates in the ELC group were significantly lower than those in the PTGD group (ELC, 3.6%; PTGD, 25.4%, p = 0.001). Conclusions ELC is an effective treatment option for acute calculous cholecystitis in elderly patients, and has the added benefits of low postoperative complication rates, rapid recovery, shorter duration of pain, and excellent curative effects as compared to PTGD.

Comparison between percutaneous transhepatic gallbladder drainage and upfront laparoscopic cholecystectomy in patients with moderate-to-severe acute cholecystitis: a propensity score-matched analysis.

In the Tokyo Guidelines 2018 (TG18), emergency laparoscopic cholecystectomy is recognized as a crucial early treatment option for acute cholecystitis. However, early laparoscopic intervention in patients with moderate-to-severe acute cholecystitis or those with severe comorbidities may increase the risk of complications. Therefore, in the present study, we investigated the association between early laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) in moderate-to-severe acute cholecystitis patients. We retrospectively analyzed 835 TG18 grade II or III acute cholecystitis patients who underwent laparoscopic cholecystectomy at 4 tertiary medical centers in the Republic of Korea. Patients were classified into 2 groups according to whether PTGBD was performed before surgery, and their short-term postoperative outcomes were analyzed retrospectively. The patients were divided into 2 groups, and 1:1 propensity score matching was conducted to establish the PTGBD group (n = 201) and the early laparoscopic cholecystectomy group (n = 201). The PTGBD group experienced significantly higher rates of preoperative systemic inflammatory response syndrome (24.9% vs. 6.5%, P < 0.001), pneumonia (7.5% vs. 3.0%, P = 0.045), and cardiac disease (67.2% vs. 57.7%, P = 0.041) than the early operation group. However, there was no difference in biliary complication (hazard ratio, 1.103; 95% confidence interval, 0.519-2.343; P = 0.799) between the PTGBD group and early laparoscopic cholecystectomy group. In most cases of moderate-to-severe cholecystitis, early laparoscopic cholecystectomy was relatively feasible. However, PTGBD should be considered if patients have the risk factor of underlying disease when experiencing general anesthesia.

Is early laparoscopic cholecystectomy after clearance of common bile duct stones by endoscopic retrograde cholangiopancreatography superior?: A systematic review and meta-analysis of randomized controlled trials.

With medical advancement, common bile duct stones were treated by endoscopic retrograde cholangiopancreatography (ERCP), considered the standard treatment. However, ERCP might induce complications including pancreatitis and cholecystitis that could affect a subsequent laparoscopic cholecystectomy (LC), leading to conversion to open cholecystectomy perioperative complications. It is not yet known whether or not the time interval between ERCP and LC plays a role in increasing conversion rate and complications. Bides, in the traditional sense, after ERCP, for avoiding edema performing LC was several weeks later. Even no one study could definite whether early laparoscopic cholecystectomy after ERCP affected the prognosis or not clearly. Comparing some different surgical timings of LC after ERCP. Searching databases consist of all kinds of searching tools, such as Medline, Cochrane Library, Embase, PubMed, etc. All the included studies should meet the demands of this meta-analysis. In all interest outcomes below, we took full advantage of RevMan5 and WinBUGS to assess; the main measure was odds ratio (OR) with 95% confidence. Moreover, considering the inconsistency of the specific time points in different studies, we set a subgroup to analyze the timing of LC after ERCP. For this part, Bayesian network meta-analysis was done with WinBUGS. In the pool of conversion rate, the result suggested that the early LC group was equal compared with late LC (OR = 0.68, I2 = 0%, P = .23). Besides, regarding morbidity, there was no significant difference between the 2 groups (OR = 0.74, I2 = 0%, P = .26). However, early LC, especially for laparoscopic-endoscopic rendezvous that belonged to performing LC within 24 hours could reduce the post-ERCP pancreatitis (OR = 0.16, I2 = 29%, P = .0003). Considering early LC included a wide time and was not precise enough, we set a subgroup by Bayesian network, and the result suggested that performing LC during 24 to 72 hours was the lowest conversion rate (rank 1: 0%). In the present study, LC within 24 to 72 hours conferred advantages in terms of the conversion rate, with no recurrence of acute cholecystitis episodes.

EP-617 Early vs delayed laparoscopic cholecystectomy for acute cholecystitis: A systemic review

Abstract Background Gallstones are present in approximately 10% to 15% of the adult western population with 1% to 4% of patients becoming symptomatic each year. Laparoscopic cholecystectomy for acute cholecystitis is usually performed after the acute cholecystitis episode settles because of the perceived fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery may expose the individual to gallstone-related complications. Aims &amp; objectives To compare early laparoscopic cholecystectomy, defined as less than seven days of clinical presentation with acute cholecystitis, versus delayed laparoscopic cholecystectomy more than six weeks after index admission and conservative treatment for acute cholecystitis. Search Criteria Clinical databases were searched for suitable studies. Randomised and non-randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis published after 1994 were included. Results 16 studies were identified for this review and the outcomes measured were operation time, conversion to open surgery, postoperative complication, post operative pain and analgesia use, length of hospital stay, and duration of antibiotic therapy. For all but one of the criteria it has been found that early and delayed laparoscopic surgery were equivalent for these end points. The endpoint antibiotic duration post-surgery still remains an area of contention. Conclusion Early and delayed cholecystectomy for the treatment of uncomplicated acute cholecystitis is both safe and feasible. Early laparoscopic cholecystectomy is preferred over delayed laparoscopic cholecystectomy mainly because of decreased length of hospital stay in the early laparoscopic cholecystectomy group. This is a clear advantage.

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

Safety of early same-admission laparoscopic cholecystectomy for acute mild biliary pancreatitis. A retrospective study for acute pancreatitis.

IntroductionAs the standard procedure for the surgical treatment for gallbladder stones, we investigated the controversy surrounding the optimal time for laparoscopic cholecystectomy (LC) for acute mild biliary pancreatitis (AMBP).AimTo further address the optimal timing of LC, we conducted a retrospective study comparing early (< 72 h, group I) with delayed (> 72 h, group II) LC for AMBP during the same admission.Material and methodsThis retrospective study included medical records of all patients who were admitted with a diagnosis of acute mild biliary pancreatitis at Dongyang People’s Hospital from July 2011 to June 2019.ResultsA total of 119 patients were divided into an early LC group (group I; 52 patients) and a control group (group II; 67 patients). Conversion to open cholecystectomy (COC) was performed in 17 patients (6 patients in group I and 11 patients in group II, p = 0.62). There were no significant differences in terms of estimated blood loss and duration of surgery (p = 0.08 and p = 0.64, respectively). The overall hospital stay in group I was significantly shorter than in group II (10.86 ±3.21 vs. 13.29 ±4.51 days, p = 0.001). Compared with postoperative bile leakage (p = 0.72) and postoperative morbidity (p = 0.97) and mortality, there were no significant differences between the groups.ConclusionsEarly LC during the same admission is safe for acute mild biliary pancreatitis and has the advantage of shortening overall hospital stay. There was no significant increase in COC, bile duct injury, and complications.

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.

Early Laparoscopic Cholecystectomy Has an Advantage over Antecedent Drainage for Grade II/III Acute Cholecystitis

Early laparoscopic cholecystectomy (LC) after gallbladder drainage is recommended in cases with acute cholecystitis (AC); however, the safety of LC after gallbladder drainage is still controversial, and it is not clear whether the drainage contributes to prevent bile leakage during operative procedure. A single institutional retrospective cohort study was performed to assess the safety of LC after gallbladder drainage as well as the frequency of bile leakage during LC. Twenty-four patients that had gallbladder drainage (Drainage group) and 67 patients that had early LC (Early LC group) were treated for AC. Charlson comorbidity index was significantly higher in the Drainage group (P = 0.015). Early LC group had a shorter operative time than Drainage group (P = 0.020) and tend to have less bile leakage rate than Drainage group. In cases when the initial treatment was started within a day after the onset of symptom, no bile leakage was observed in either group. LC after gallbladder drainage can be performed safely; however, it does not reduce the bile leakage rate. Early laparoscopic cholecystectomy with immediate admission as possible might help to prevent the postoperative bile leakage.

Early versus late laparoscopic cholecystectomy in the management of acute cholecystitis: a retrospective study

Background: Early laparoscopic cholecystectomy (LC) is a life-saving procedure in the management of acute cholecystitis as it helps in prevention of late complications like development of adhesions, haemorrhage and sepsis. The study aims at comparing the outcomes of early versus late laparoscopic cholecystectomy in the management of acute cholecystitis.Methods: A retrospective study was done by analyzing the past 5 years medical records of 250 patients admitted to the emergency department with diagnosis of acute cholecystitis established according to the Tokyo criteria. The relevant clinio-social demographic data of the patients, clinical and radiological parameters, intra-operative and post-operative findings and follow-up data were compared between early and late LC group of patients.Results: The study included 125 middle aged patients who underwent early LC (within 24 hours) and 125 patients who underwent late LC (after 24 4hours). The complication rate, conversion to open cholecystectomy and duration of surgery showed no significant differences between early and late laparoscopic cholecystectomy except for an increased duration of stay among the late LC group.Conclusions: Early LC is an efficient procedure for acute cholecystitis but it has risks of complications which can be minimized by careful selection of patients after clear clinical and radiological evaluation.

The optimal timing of laparoscopic cholecystectomy in patients with mild gallstone pancreatitis: A meta-analysis.

Background:The optimal timing of laparoscopic cholecystectomy (LC) in patients with mild acute gallstone pancreatitis (MAGP) is controversial. The aim of this study was to systematically evaluate and compare the safety and efficacy of early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) in patients with MAGP.Methods:A strict search was conducted of the electronic databases, including PubMed, MEDLINE Embase, the ISI Web of Science, and Cochrane Library for all relevant English literature and RevMan5.3 software for statistical analysis was used.Results:A total of 19 studies comprising 2639 patients were included. There was no significant difference in intraoperative complications [risk ratio (RR) = 1.46; 95% confidence interval (CI) = 0.88–2.41; P = .14)], postoperative complications (RR = 0.81; 95% CI = 0.58–1.14; P = .23), rate of conversion to open cholecystectomy (RR = 1.00; 95% CI = 0.75–1.33; P = .99), operative time (MD = 1.60; 95% CI = −1.36–4.56; P = .29), and rate of readmission (RR = 0.63; 95% CI = 0.19–2.10; P = .45) between the ELC and DLC groups. However, the ELC group was significantly correlated with lower length of hospital stay (MD = −2.01; 95% CI = −3.15 to −0.87; P = .0006), fewer gallstone-related events rates (RR = 0.17; 95% CI = 0.07–0.44; P = .0003), and lower endoscopic retrograde cholangiopancreatography (ERCP) usage (RR = 0.83; 95% CI = 0.71–0.97; P = .02) compared with the DLC group.Conclusion:Early laparoscopic cholecystectomy is safe and effective for patients with MAGP, but the indications and contraindications must be strictly controlled.

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

Evidence-based Reviews in Surgery: Early Cholecystectomy for Cholecystitis.

What are the clinical outcomes of early versus delayed laparoscopic cholecystectomy (LC) in acute cholecystitis with more than 72 hours of symptoms? A randomized controlled trial. Single center at the University Hospital of Lausanne, Switzerland. Eighty-six patients were enrolled in the study that had symptoms of acute cholecystitis lasting more than 72 hours before admission. Patients were randomly assigned to early LC or delayed LC. Primary outcome was overall morbidity following initial diagnosis. Secondary outcomes included total length of stay, duration of antibiotic used, cost, and surgical outcome. Overall morbidity was lower in early laparoscopic cholecystectomy (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 minutes; 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.

Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a comparative study

Background: Laparoscopic cholecystectomy is now the procedure of choice for patient presenting with acute cholecystitis unless it is contraindicated for technical reason or safety. An attempt was made to compare the outcome and postoperative complications of early vs delayed laparoscopic cholecystectomy in acute cholecystitis.Methods: Fifty patients aged 18 to 64 years having acute cholecystitis admitted for laparoscopic cholecystectomy were included. They were divided into two groups, early (less than 72 hours) and delayed (more than 72 hours up to 6 weeks) laparoscopic cholecystectomy. The patients were followed for three months after the surgery. The primary outcome measures were conversion to open surgery and postoperative complications whereas secondary outcome measures were hospital stay and return to full activity. Comparison of quantitative variables and qualitative variables was done using unpaired student’s “t” test and chi-square test/ Fisher’s exact test respectively.Results: Conversion to open cholecystectomy (p = 0.007) and post-operative complications (p = 0.032) were significantly less in early laparoscopic cholecystectomy group compared to delayed laparoscopic cholecystectomy group. Mean days of hospital stay (4.9 versus 7.4 with p = 0.001) and mean days of return to full activities (12.6 vs 16.3 days with p = 0.001) was significantly less in early laparoscopic surgery group compared to delayed laparoscopic cholecystectomy group. Mean duration of surgery was significantly less in early laparoscopic surgery group as compared to delayed laparoscopic surgery group (69.3 versus 108.5 minutes, with p = 0.001).Conclusions: Early laparoscopic cholecystectomy is better choice than delayed laparoscopic cholecystectomy in acute cholecystitis.

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 %).

Is postponed laparoscopic cholecystectomy justified for acute cholecystitis appearing early after onset?

Early laparoscopic cholecystectomy (ELC) is considered the standard treatment for acute cholecystitis for patients who can tolerate surgery. The ideal time for performing ELC is reported to be 72 h from onset. However, many patients undergo surgery on or after the fourth day from onset, even if they presented early after onset. A few reports have investigated the feasibility and disadvantages of this so-called "postponed laparoscopic cholecystectomy" (PLC). This study consisted of 215 patients who had undergone laparoscopic cholecystectomy for acute cholecystitis within 6 days of onset between July 2006 and December 2017. Patients were divided into an ELC group (patients who underwent LC within 3 days of symptom onset, n = 172) and a PLC group (patients who underwent LC 4-6 days from symptom onset and on or after 3 days from admission, n = 43). Comparisons were made between these groups. Perioperative outcomes between the PLC and ELC groups were not significantly different, except for the requirement of subtotal cholecystectomy (SC) (16.2% vs 5.2%, P = 0.013). In the PLC group, persistent fever after admission was significantly associated with the need for SC (P = 0.036). PLC for acute cholecystitis performed within 6 days of onset gave acceptable perioperative outcomes, except for an increased requirement for SC. Surgeons should keep in mind that PLC may increase the need for SC. A persistent fever after admission may be a risk factor for SC in the PLC group.

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 Acute Cholecystitis: A Prospective, Randomized Study

We aimed to compare the clinical outcome and cost of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Sixty patients with acute cholecystitis were randomized into early (within 24 hours of admission) or delayed (after 6-8 weeks of conservative treatment) laparoscopic cholecystectomy groups. There was no significant difference between study groups in terms of operation time and rates for conversion to open cholecystectomy. On the other hand, total hospital stay was longer (5.2 ± 1.40 versus 7.8 ± 1.65 days; P = 0.04) and total costs were higher (2500.97 ± 755.265 versus 3713.47 ± 517.331 Turkish Lira; P = 0.03) in the delayed laparoscopic cholecystectomy group. Intraoperative and postoperative complications were recorded in 8 patients in the early laparoscopic cholecystectomy group, whereas no complications occurred in the delayed laparoscopic cholecystectomy group (P = 0.002). Despite intraoperative and postoperative complications being associated more with early laparoscopic cholecystectomy compared with delayed intervention, early laparoscopic cholecystectomy should be preferred for treatment of acute cholecystitis because of its advantages of shorter hospital stay and lower cost.

Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis

The management of people at high risk of perioperative death due to their general condition (high-risk surgical patients) with acute calculous cholecystitis is controversial, with no clear guidelines. In particular, the role of percutaneous cholecystostomy in these patients has not been defined. To compare the benefits (temporary or permanent relief of symptoms) and harms (recurrence of symptoms, procedure-related morbidity) of percutaneous cholecystostomy in the management of high-risk individuals with symptomatic gallstones. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to December 2012 to identify the randomised clinical trials. We also handsearched the references lists of identified trials. We included only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue. Two review authors collected data independently. For each outcome, we calculated the P values using Fisher's exact test or mean difference (MD) with 95% confidence intervals (CI). We included two trials with 156 participants for this review. The comparisons included in these two trials were percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy (1 trial; 70 participants) and percutaneous cholecystostomy versus conservative treatment (1 trial; 86 participants). Both trials had high risk of bias. Percutaneous cholecystostomy with early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy: There was no significant difference in mortality between the two intervention groups (0/37 versus 1/33; Fisher's exact test: P value = 0.47). There was no significant difference in overall morbidity between the two intervention groups (1/31 versus 2/30; Fisher's exact test: P value = 0.61). This trial did not report on quality of life. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy between the two intervention groups (2/31 percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus 4/30 delayed laparoscopic cholecystectomy; Fisher's exact test: P value = 0.43). The mean total hospital stay was significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -9.90 days; 95% CI -12.31 to -7.49). The mean total costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -1123.00 USD; 95% CI -1336.60 to -909.40). Percutaneous cholecystostomy versus conservative treatment: Nine of the 44 participants underwent delayed cholecystectomy in the percutaneous cholecystostomy group. Seven of the 42 participants underwent delayed cholecystectomy in the conservative treatment group. There was no significant difference in mortality between the two intervention groups (6/44 versus 7/42; Fisher's exact test: P value = 0.77). There was no significant difference in overall morbidity between the two intervention groups (6/44 versus 3/42; Fisher's exact test: P value = 0.49). The number of participants who underwent laparoscopic cholecystectomy was not reported in this trial. Therefore, we were unable to calculate the proportion of participants who underwent conversion to open cholecystectomy. The other outcomes, total hospital stay, quality of life, and total costs, were not reported in this trial. Based on the current available evidence from randomised clinical trials, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for adequately powered randomised clinical trials of low risk of bias on this issue.