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Thursday, March 1, 2012

Timing of Surgery for Acute Cholecystitis

Posted by Prahallad Panda on 1:13 PM Comments

When we were medical students in 1980s, the custom and teaching was not to operate upon cholecystic gall bladder during acute phase and defer it for at least six weeks; the inflammation to resolve.
Later on during 1990s, it was rather done during the same admission, after first week of acute attack; and sometimes operated upon in the acute stage, shortly after admission and work out. There were not many complications.
Later, when laparoscopic surgery for cholecystitis was considered as gold standard; still surgery was preferred after some weeks of acute attack.

Pictures of my cholecystectomy in progress tak...
Image via Wikipedia Laparoscopic Cholecystectomy

Now, it has been seen that surgery on admission in the acute stage does not give rise to many complications, and avoids conversion of closed (Laparoacopic) surgery to open one, if carried out on same day or after 1 day.
This may be due to absence of adhesion during the early hours and 1st day; and may also be due to better cleavage in tissue plane making easier to operate due to accompanying oedema of acute inflammation.
Researchers reviewed data from 4113 patients who were hospitalized and subsequently operated laparoscopically for acute cholecystitis.
Delaying surgery after the day of admission resulted in higher conversion rates from a closed to an open procedure (12% for patients operated upon admission vs 28% for patients operated on day 6, P < .001), a doubling of the risk for postoperative complications (6% vs 13%, P < .001), and a significantly longer period of postoperative hospitalization (P < .001).
Furthermore, the rate of reoperation was more than 4-fold greater in patients who were operated on or after day 6, compared with patients who were operated on the day of admission (P = .002).
This study shows that it appears to be as safe as, or safer, than postponing surgery. Approximately 70% of patients were operated either on the day of or 1 day after admission.
Because this is not a randomized trial, the authors do not know what the selection criteria were for early operation.
It is possible that patients with early intervention had milder disease than patients in whom operation was delayed.
However, if it is assume that patients with early surgery were similar to patients in whom surgery was postponed, then it seems reasonable to conclude from this report that early laparoscopic surgery is preferable to delayed surgery.

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