What is the best practice management for patients with acute cholecystitis?

Koji Asai, MD, Manabu Watanabe, Hiroshi Matsukiyo, Tomoaki Saito, Tomotaka Ishii, Ryohei Watanabe, Toshiyuki Enomoto, Natsuya Katada, Yoshihisa Saida, Shinya Kusachi. Department of Surgery, Toho University Ohashi Medical Center

Introduction

We assessed the best practice management for patients with acute cholecystitis (AC) according to our own experience.

Patients and methods

We analyzed 273 patients who underwent surgery at our department.

Results

Impact of revised guidelines (Tokyo Guidelines 2007; TG07)

The therapeutic resulted obtained before and after the publication of TG07 were analyzed. Preoperative gallbladder drainage did not significantly differ; however, percutaneous transhepatic gallbladder aspiration was performed significantly more often than percutaneous transhepatic gallbladder drainage after the publication of TG07. The rate of performance early laparoscopic cholecystectomy (ELC) also significantly increased, rising from 28.2% to 83.7% and 42.5% to 75% in patients with mild and moderate AC, respectively. The rate of conversion to open surgery significantly decreased from 28.1% to 9.1% in patients with moderate AC. The rate of postoperative complications did not significantly differ. In addition, the duration of hospital stay was significantly shouter in both mild and moderate AC after the publication of the guidelines. 

Risk factor of conversion to the open surgery

The rate of conversion to open surgery was 12.9%, including 6.7% in mild AC and 18.5% in moderate AC. A duration of >72 h from symptom onset and a high C-reactive protein value were significant risk factor of conversion to the open surgery.

Analysis of data on elderly patients

We analyzed the data on patents between the age of <74 years and ≥75 years. When comparing data on ELC and delayed laparoscopic cholecystectomy, we did not find a significant difference in the rate of conversion to open surgery and postoperative complication. The duration of hospital stay showed significant shorter in elderly ELC group. 

Timing of surgery

We divided timing of surgery relative to the onset of symptoms into four groups, including A (<3 days), B (4–7 days), C (8– 21 days), and D (>22 days). The operative time and the duration of hospital stay were significantly shorter in group A; however, the rate of conversion to open surgery did not significantly differ across the four groups.

Conclusion

Early laparoscopic cholecystectomy was identified as the best practice management for all AC patients.