HOW ACTIVE SHOULD BE SURGICAL TACTIC IN TREATMENT OF ACUTE CHOLECYSTITIS?

Cover Page

Abstract


Acute cholecystitis (AC) is one of the most common surgical diagnoses in emergency setting. Despite its high incidence there remains a range of treatment approaches. There is growing evidence in support of performing early cholecystectomy for acute cholecystitis but the definition of early operation varies from 0 through 10 days from onset or admission. The optimum time to perform cholecystectomy is still controversial. Aim. To determine the best practice for the patients presenting with AC focused on patients characteristics, timing of surgery, disease severity and intra- and postoperative complications. Materials and Methods. A multicentric retrospective study was conducted and included 754 patients operated for acute cholecystitis at 8 hospitals in 4 cities of Russian Federation (Moscow, Yekaterinburg, Volgograd, Kislovodsk) during 1 year period (from Jan 1, 2011 to Dec 31, 2011). Median time from symptoms onset to hospitalization varied from 15 to 72 hours, and median time spent at hospitals before operation was 9-71 hours. Results. We found that optimal time for cholecystectomy is 60 hours from the onset of symptoms in Grade I AC (TG18) and 36 hours for patients with Grade II of the disease. Delay of the operation beyond this time leads to more difficult cholecystectomies and higher complication rates. We compared results of the surgical treatment of AC in 2 groups of patients, operated in median 9 [4; 13] and 50 [29; 88] hours from admission using propensity score matching technique. Rate of Grade I AC in the 1st group was higher (59,8% vs 17,0%, p < 0,001) and incidences of gangrenous cholecystitis (15,3% vs 34,1%, p < 0,001) and difficult cholecystectomies (28,4% vs 41,5%, p=0,003) were lower. The Integral Complications Severity Index (based on Accordion classification and takes into account all intra- and postoperative complications and summarizes their respective severity) was also lower in the 1st group. Conclusions. The optimal time for cholecystectomy for mild (Grade I) acute cholecystitis is 60 hours of presentation of disease and for Grade II - 36 hours from symptoms onset. Cholecystectomy performed after short trial conservative treatment in 6-8 hours from admission yielded the best outcomes.


About the authors

I. G. Natroshvili

Stavropol State Medical University

Author for correspondence.
Email: surgery.kislovodsk@gmail.com
Stavropol, Russia

M. I. Prudkov

Ural State Medical University

Email: surgery.kislovodsk@gmail.com
Yekaterinburg, Russia

References

  1. Okamoto K, Suzuki K, Takada T, и др. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. doi: 10.1002/jhbp.516.
  2. Natsional'nye klinicheskie rekomendatsii «Ostryj kholetsistit». [National clinical recommendations “Acute cholecystitis”] 2015. Available from: http://xn----9sbdbejx7 bdduahou3a5d.xn--p1ai/upload/acute_cholecystitis.pdf. Accessed: Dec 28, 2018. (In Russ).
  3. Loozen CS, Oor JE, van Ramshorst B, van Santvoort HC, Boerma D. Conservative treatment of acute cholecystitis: a systematic review and pooled analysis. Surg Endosc. 2017;31(2):504-515. doi: 10.1007/s00464-016-5011-x.
  4. Hatzidakis AA, Prassopoulos P, Petinarakis I, и др. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol. 2002; 12(7):1778-1784.
  5. Yermolov AS, Gulyayev AA. Ostryj kholetsistit: sovremennye metody lecheniya. [Acute cholecystitis: modern methods of treatment]. Lechashhij vrach. 2005;(2):16-18. (In Russ).
  6. Gutt CN, Encke J, Köninger J, и др. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013; 258(3):385-393. doi: 10.1097/SLA.0b013e3182a1599b.
  7. Ozkardeş AB, Tokaç M, Dumlu EG, и др. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective, randomized study. Int Surg. 2014; 99(1):56-61. doi: 10.9738/INTSURG-D-13-00068.1.
  8. Gul R, Dar RA, Sheikh RA, Salroo NA, Matoo AR, Wani SH. Comparison of early and delayed laparoscopic cholecystectomy for acute cholecystitis: experience from a single center. N Am J Med Sci. 2013;5(7):414-418. doi: 10.4103/1947-2714.115783.
  9. Saber A, Hokkam EN. Operative Outcome and Patient Satisfaction in Early and Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis. Minim Invasive Surg. 2014;2014:1-4. doi: 10.1155/2014/162643.
  10. Kolla SB, Aggarwal S, Kumar A, и др. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial. Surg Endosc. 2004; 18(9):1323-1327. doi: 10.1007/s00464-003-9230-6.
  11. Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2010;97(2):141-150.
  12. De Mestral C, Rotstein OD, Laupacis A, и др. Comparative Operative Outcomes of Early and Delayed Cholecystectomy for Acute Cholecystitis. Ann Surg. 2014; 259(1):10-15. doi: 10.1097/SLA.0b013e3182a5cf36
  13. Kerwat D, Zargaran A, Bharamgoudar R, и др. Early laparoscopic cholecystectomy is more cost-effective than delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis. Clinicoecon Outcomes Res. 2018; 10:119-125. doi: 10.2147/CEOR.S149924
  14. Wu X-D, Tian X, Liu M-M, Wu L, Zhao S, Zhao L. Meta-analysis comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2015;102(11):1302-1313. doi: 10.1002/bjs.9886.
  15. Johner A, Raymakers A, Wiseman SM. Cost utility of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Surg Endosc. 2013;27(1):256-262. doi: 10.1007/s00464-012-2430-1.
  16. Goh JC, Tan JK, Lim JW, Shridhar IG, Madhavan K, Kow AW. Laparoscopic cholecystectomy for acute cholecystitis: an analysis of early versus delayed cholecystectomy and predictive factors for conversion. Minerva Chir. 2017;72(6):455-463. doi: 10.23736/S0026-4733.17. 07412-0.
  17. Brooks KR, Scarborough JE, Vaslef SN, Shapiro ML. No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database. J Trauma Acute Care Surg. 2013;74:167-174. doi: 10.1097/ TA.0b013e3182788b71.
  18. De Mestral C, Hoch JS, Laupacis A, и др. Early Cholecystectomy for Acute Cholecystitis Offers the Best Outcomes at the Least Cost: A Model-Based Cost-Utility Analysis. J Am Coll Surg. 2016;222(2). doi: 10.1016/ j.jamcollsurg.2015.10.015.
  19. Kohga A, Suzuki K, Okumura T, и др. Outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis performed at a single institution. Asian J Endosc Surg. апрель 2018. doi: 10.1111/ases.12487.
  20. Banz V, Gsponer T, Candinas D, Güller U. Population-based analysis of 4113 patients with acute cholecystitis: Defining the optimal time-point for laparoscopic cholecystectomy. Ann Surg. 2011;254(6):964-970. doi: 10.1097/SLA.0b013e318228d31c.
  21. Koti RS, Davidson CJ, Davidson BR. Surgical management of acute cholecystitis. Langenbeck’s Arch Surg. 2015;400(4):403-419. doi: 10.1007/s00423-015-1306-y.
  22. Papi C, Catarci M, D’Ambrosio L, и др. Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis. Am J Gastroenterol. 2004;99(1):147-155.
  23. Blohm M, Österberg J, Sandblom G, Lundell L, Hedberg M, Enochsson L. The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg. 2017;21(1). doi: 10.1007/s11605-016-3223-y.
  24. Yu H, Chan EE-H, Lingam P, и др. Index admission laparoscopic cholecystectomy for acute cholecystitis restores Gastrointestinal Quality of Life Index (GIQLI) score. Ann hepato-biliary-pancreatic Surg. 2018;22(1): 58-65. doi: 10.14701/ahbps.2018.22.1.58.
  25. Kuznetsov NA, Aronov LS, Kharitonov SV, Brontvein AT, Ziniakova MV. Vybor taktiki, srokov i metoda provedeniya operatsii pri ostrom kholetsistite. [Choice of the policy, terms, and method of surgery in acute cholecystitis]. Khirurgiia (Mosk). 2003;(5):35-40. (In Russ).
  26. Kohga A, Suzuki K, Okumura T, и др. Is postponed laparoscopic cholecystectomy justified for acute cholecystitis appearing early after onset? Asian J Endosc Surg. март 2018. doi: 10.1111/ases.12482.
  27. Roulin D, Saadi A, Di Mare L, Demartines N, Halkic N. Early versus delayed cholecystectomy for acute cholecystitis, are the 72 hours still the rule?: A randomized trial. Ann Surg. 2016;264(5):717-722. doi: 10.1097/ SLA.0000000000001886
  28. Catani M, Modini C. Laparoscopic cholecystectomy in acute cholecystitis: a proposal of safe and effective technique. Hepatogastroenterology. 2007;54(80):2186-2191.
  29. Catani M, De Milito R, Romagnoli F, и др. The best timing of surgery in laparoscopic cholecystectomy for acute cholecystitis: when and how is to be performed. Hepatogastroenterology. 2008;55(88):1993-1996.
  30. Polo M, Duclos A, Polazzi S, и др. Acute Cholecystitis - Optimal Timing for Early Cholecystectomy: a French Nationwide Study. J Gastrointest Surg. 2015;19(11): 2003-2010. doi: 10.1007/s11605-015-2909-x.
  31. Kozlov VA, Airapetov DV, Makarochkin AG. Vsegda li nuzhno kupirovat' pristup ostrogo kal'kuleznogo kholetsistita metodami konservativnoj terapii? [Is Always Necessary to Arrest Conservatively an Acute Cholecystitis Attack?] Аnnaly khirurgicheskoy gepatologii [Annals of Surgical Hepatology]. 2002;2(3):51-57. (In Russ).
  32. Wu JX, Nguyen AT, De Virgilio C, и др. Can it wait until morning? A comparison of nighttime versus daytime cholecystectomy for acute cholecystitis. В: American Journal of Surgery. Т 208; 2014. doi: 10.1016/ j.amjsurg.2014.09.004.
  33. Cuschieri A, Berci G. Laparoscopic Biliary Surgery. Oxford, London, Edinburgh: Blackwell Scientific Publication; 1992.
  34. Natroshvili I, Prudkov M, Shulutko A. Integral assessment of risk and severity of complications of surgical treatment for acute cholecystitis. Georgian Med News. 2018;(282):7-11. (In Russ).
  35. Grjibovski AM, Ivanov SV, Gorbatova МA, Dyussupov AA. Propensity Score Matching as a Modern Statistical Method for Bias Control in Observational Studies with Continuous Outcome Variable. Ekologiya cheloveka [Human Ecology]. 2016, 7:51-60. (In Russ).
  36. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1):41-55. doi: 10.1093/biomet/ 70.1.41.

Statistics

Views

Abstract - 378

PDF (Russian) - 181

Cited-By


PlumX

Dimensions


Copyright (c) 2019 Natroshvili I.G., Prudkov M.I.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies