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

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.

Keywords

• cute cholecystitis
• cholecystectomy
• complication score
• surgical timing
• multicenter trial