Prompted by our M&M yesterday, below are the data surrounding delayed vs early cholecystectomy in patients with acute calculous cholecystitis.
TL;DR: Current evidence supports early cholecystectomy provided the patient is medically stable for surgery. All sources I found recommended admission. I could not find any sources that recommended discharge from the emergency department.
Meta Analysis:
–Wu (2015): Meta-analysis comparing the cost-effectiveness, quality of life, safety and effectiveness of ELC (within 7 days of symptom onset) versus DLC. Results support early cholecystectomy associated with lower hospital costs, fewer work days lost, high patient satisfaction and quality of life, lower risk of wound infection, shorter hospital stay, longer duration of operation.
–Cao (2015): Meta-analysis of 15 randomised controlled trials. Found that early (during first admission) laparoscopic cholecystectomy in acute cholecystitis demonstrated decreased incidence of wound infections, a shorter total length of stay and decreased costs with no difference in the rates of mortality, bile duct injuries, bile leaks and conversions
–Cao (2016): Meta-analysis of 77 case-control studies published between 1985-February 2015. Found statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC (within 72 hours).
Other Data:
–Gutt (2013): Multicenter randomized trial of either early surgery shortly after hospital admission or delayed elective surgery after a conservative treatment with antibiotics. Early LC was shown to have lower morbidity, lower length of hospital stay, lower total hospital costs
–Blohm (2017): Administrative database study of over 15,000 cholecystectomies for acute cholecystitis. Found that bile duct injury, 30- and 90-day mortality risk, and intra- and postoperative AEs were significantly higher if the time from admission to surgery exceeded 4 days. The authors concluded “the optimal timing of cholecystectomy for patients with AC seems to be within 2 days after admission.”
–Roulin (2016): Randomized trial to compare clinical outcomes of early versus delayed laparoscopic cholecystectomy (LC) in acute cholecystitis with more than 72 hours of symptoms. Found that 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
Society Guidelines:
–Tokyo Guidelines 2018: surgical management of acute cholecystitis:
If a patient is deemed capable of withstanding surgery for AC, we propose early surgery regardless of exactly how much time has passed since onset. (Recommendation 2, level B)
–2016 WSES guidelines on acute calculous cholecystitis:
Statement 5.1 Early laparoscopic cholecystectomy is preferable to delayed laparoscopic cholecystectomy in patients with ACC as long as it is completed within 10 days of onset of symptoms (LoE 1 GoR A)
Statement 5.3 Early laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days of onset of symptoms. (Level 1 Evidence; Grade A recommendation). However, it should be noted that earlier surgery is associated with shorter hospital stay and fewer complications (LoE 2 GoR B)
–2010 SAGES: Guidelines for the clinical application of laparoscopic biliary tract surgery:
Early cholecystectomy (within 24-72 hours of diagnosis) may be performed without increased rates of conversion to an open procedure, without an increased risk of complications, and may decrease cost and total length of stay. (Level I, Grade A).
For patients who can tolerate the procedure, early cholecystectomy (within 24-72 hours of diagnosis) in cases of acute cholecystitis is increasingly advocated; when compared to planned open and/or delayed cholecystectomy, early laparoscopic cholecystectomy reduces the rate of symptom relapse, may be performed without increased rates of conversion to an open procedure, without an increased risk of complications, including bile duct injury, and early laparoscopic cholecystectomy may decrease cost and total length of stay.
Other:
