Surg Endosc (2000) 14: 358361 DOI: 10.

1007/s004640020088

Springer-Verlag New York Inc. 2000

Laparoscopic cholecystectomy in acute cholecystitis

A prospective comparative study in patients with acute vs chronic cholecystitis
P. Pessaux, J. J. Tuech, C. Rouge, R. Duplessis, C. Cervi, J. P. Arnaud
Department of Visceral Surgery, 4 rue Larrey, Angers 49100, France Received: 13 May 1999/Accepted: 7 October 1999

Abstract Background: The aim of this prospective study was to compare the outcome of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis versus those with chronic cholecystitis and to determine the optimal timing for LC in patients with acute cholecystitis. Methods: From January 1991 to July 1998, 796 patients (542 women and 254 men) underwent LC. In 132 patients (67 women and 65 men), acute cholecystitis was confirmed via histopathological examination. These patients were divided into two groups. Group 1 (n 85) had an LC prior to 3 days after the onset of the symptoms of acute cholecystitis, and group 2 (n 47) had an LC after 3 days. Results: There were no mortalities. The conversion rates were 38.6% in acute cholecystitis and 9.6% in chronic cholecystitis ( p < 108). Length of surgery (150.3 min vs 107.8 min; p < 109), postoperative morbidity (15% vs 6.6%; p 0.001), and postoperative length of stay (7.9 days vs 5 days; p < 109) were significantly different between LC for acute cholecystitis and elective LC. For acute cholecystitis, we found a statistical difference between the successful group and the conversion group in terms of length of surgery and postoperative stay. The conversion rates in patients operated on before and after 3 days following the onset of symptoms were 27% and 59.5%, respectively ( p 0.0002). There was no statistical difference between early and delayed surgery in terms of operative time and postoperative complications. However, total hospital stay was significantly shorter for group 1. Conclusions: LC for acute cholecystitis is a safe procedure with a shorter postoperative stay, lower morbidity, and less mortality than open surgery. LC should be carried out as soon as the diagnosis of acute cholecystitis is established and preferably before 3 days following the onset of symptoms. Early laparoscopic cholecystectomy can reduce both the conversion rate and the total hospital stay as medical and economic benefits.

Key words: Acute cholecystitis Gallbladder Laparoscopic cholecystectomy Optimal timing

Since its introduction in 1987, laparoscopic cholecystectomy (LC) has increasingly been accepted as the procedure of choice for the treatment of symptomatic gallstones and chronic cholecystitis [22]. A successful LC is associated with a less painful postoperative course, a lower analgesic requirement, a shorter hospital stay, and less cosmetic disfigurement [15, 25]. Acute cholecystitis, which is generally found in 20% of all admissions for gallbladder disease [24], is no longer considered a contraindication for LC [4, 22]. However, the role and timing of LC in the management of acute cholecystitis remains controversial. In the prelaparoscopic era, prospective randomized studies [11, 18] demonstrated that the outcome for patients undergoing early open cholecystectomy within 7 days of the onset of symptoms was superior to delayed interval surgery. The aim of this prospective study was to compare the laparoscopic treatment of patients with acute cholecystitis to those with chronic cholecystitis. Our assessment of the results of attempted LC for acute cholecystitis paid particular attention to the interval from the onset of symptoms to the time of operation.

Materials and methods Patients

From January 1991 to July 1998, a total of 796 patients underwent laparoscopic cholecystectomy (LC). During that period, 132 patients (16.6%) had acute cholecystitis (68 phlegmonous and 64 gangrenous). They were admitted on an emergency basis with a diagnosis of acute cholecystitis based on the following symptoms: (a) acute upper abdominal pain with tenderness under the right costal margin, (b) fever >37.8C and/or leukocytosis >10 109/L (normal, <10 109/L), and (c) ultrasonographic evidence (thickened gallbladder wall, edematous gallbladder wall, distended gallbladder, presence of gallstones, ultrasonographic Murphys sign, and

Correspondence to: J. P. Arnaud

359 Table 1. Details of patients with acute cholecystitis (n 132) Symptom or finding Upper abdominal pain Right upper quadrant tenderness Leukocytosis >10 109/L Fever (>37.8C) Ultrasonographic evidence Histopathology n 116 108 91 65 118 132 % 87.8 81.8 68.9 49.2 89.4 100

pericholecystic fluid collection) [7, 19]. Histopathological examination of the excised gallbladder confirmed the presence of acute inflammation (Table I). All preoperative, intraoperative, and postoperative data were collected on standardized forms. We then analyzed the ultrasound findings, time of operation from the onset of symptoms, length of surgery, histologic gallbladder features, conversion rate to open laparotomy, postoperative mortality and morbidity, postoperative length of stay, and rate of early reintervention. The patients with acute cholecystitis were divided into two groups. Group 1 consisted of those who had an LC prior to 3 days after the onset of symptoms of acute cholecystitis; group 2 consisted of those who had an LC after 3 days following the onset of symptoms.

the procedure was converted to an open laparotomy. The average length of postoperative hospital stay for those who underwent successful LC was 6.1 days (range, 230). For patients in whom the procedure was converted to an open operation, the average length of stay was 10.5 days (range, 327). There was no statistical difference between the successful and the conversion groups in terms of morbidity (Table 5). When conversion to laparotomy in patients with acute cholecystitis was required, 11 of 51 patients (21.5%) developed postoperative complications, as compared to nine of 81 (11.1%) who had a successful LC. In particular, chest infections developed more frequently after conversion to open cholecystectomy (Table 6).

Timing of surgery in acute cholecystitis In 85 (64.4%) of 132 patients, the LC was performed prior to 3 days after the onset of symptoms (group 1), whereas 47 (35.6%) underwent the operation after 3 days (group 2). There were 23 patients (27%) in whom the surgical procedures was converted to an open operation in group 1 and 28 (59.5%) in group 2 (p 0.002). There was no statistical difference between early and delayed surgery in terms of operative time and postoperative complications. However, the total hospital stay was significantly shorter in group 1 (Table 7). Six patients (12.7%) in the delayed group either failed conservative treatment or developed a recurrent attack of acute cholecystitis, requiring emergency LC.

Statistical analysis
Statistical analysis was performed by the chi-square test, exact Fishers test, or students t-test, as appropriate. Statistical significance was set at p < 0.05.

Results Elective LC vs LC for acute cholecystitis The patient population was comprised of 542 women and 254 men with a mean age of 54.5 years (range, 1495). In our series of patients with acute cholecystitis, there were 67 women and 65 men with a mean age of 58.7 years (range, 1490). The average age of these patients was significantly different from that of the 664 patients (475 women and 189 men) who underwent elective cholecystectomy (mean age, 52.7 years; p < 0.001; range, 1995). Fifty-one patients (38.6%) with acute cholecystitis and 64 (9.6%) who had elective LC were converted to open surgery (p < 108) (Table 2). The length of the surgery (150.3 vs 107.8 min), postoperative length of stay (7.9 vs 5 days), and morbidity (15% vs 6.6%) were significantly different between acute cholecystitis and elective LC. There were no mortalities in either group (Table 3). The most common reason for conversion in patients with acute cholecystitis (n 30) was an inability to complete the procedure due to difficulties with exposure and dissection associated with the inflammatory reaction. The most common reason for conversion in patients with elective LC was adhesions (n 29). The other indications for conversion to an open procedure are summarized in Table 4. Acute cholecystitis The average length of the operative procedures was 141 min (range, 65380) for 81 patients who underwent successful LC and 170 min (range, 45350) for 51 patients in whom

Discussion Laparoscopic cholecystectomy is the treatment of choice for most patients with symptomatic cholelithiasis. Initially, acute cholecystitis was a contraindication for this procedure [4, 22]. The laparoscopic management of acute cholecystitis is a logical progression from elective LC. LC patients with acute cholecystitis have significantly higher rates of conversion to open cholecystectomy, longer operating times, longer hospital stays, and an increased morbidity rate compared with elective LC. The conversion rate reported in the literature varies from 7 to 60% [8, 10, 20, 22]. The total conversion rate in our series was high (38.6%). Our study was performed over a long period, and the existence of a learning curve was clearly demonstrated by the fact that the conversion rate decreased from 80% to 20% from the beginning to the end of the study (Table 2). An inability to define the anatomy of the cystic duct due to inflammation was the most common reason for conversion in all reported series (58.8% in our series). Conversion may be required if the operation progresses poorly, if there are pathologic conditions best dealt with by open surgery, or if complications arise. Conversion to an open procedure after an adequate attempt by an experienced laparoscopic surgeon should not be regarded as a complication or an operative failure but as a means of preventing complications. Our complication rate of 15% compares favorably to the 17.439.9% morbidity rate reported for traditional open cholecystectomy in patients with acute cholecystitis [2, 13, 21]. There were no mortalities. In cases where the operation

360 Table 2. Conversion rate during the study in laparoscopic cholecystectomy for acute cholecystitis 1991 LC for acute cholecystitis Conversions (n) Conversion rate (%) 4 3 75 1992 7 6 85 1993 11 7 63.6 1994 19 8 42.1 1995 21 8 38.1 1996 27 9 33.3 1997 29 7 24.1 1998 14 3 21.4

Table 3. Results for patients undergoing elective LC and patients with acute cholecystitis Elective LC (n 664) Mean age (yr) Operative time (min) Conversions Mortality Morbidity Early reinterventions Postoperative stay (days) 52.7 107.8 64 (9.6%) 0 44 (6.6%) 4 (0.6%) 5 Acute cholecystitis (n 132) 58.7 150.3 51 (38.6%) 0 20 (15%) 3 (2.2%) 7.9

Table 6. Postoperative complications Successful group (n 81) Conversion group (n 51) 4 1 2 1 0 3 0 11 (21.5%) NS

p <0.001 <109 <108 NS 0.001 NS <109

Chest infection Subhepatic collection Biliary fistula Hernia Bile duct injury Retained CBDS Others Total

0 1 2 1 1 0 4 9 (11.1%)

CBDS, common bile duct stones

Table 4. Reasons for conversion to laparotomy Elective LC (n 664) Inflammatory reaction Technical difficulty Adhesions Common bile duct stones Biliary injury Bleeding Cholecystoduodenal fistula Bilio-biliary fistula Intolerance to pneumoperitoneum Others Total 0 15 29 8 1 4 0 1 3 3 64 (23.5%) (46%) (12.5%) (1.5%) (6%) (1.5%) (4.5%) (4.5%) (9.6%) Acute cholecystitis (n 132) 30 0 6 9 2 1 1 0 0 2 51 (58.8%) (11.7%) (17.5%) (4%) (2%) (2%) (4%) (38.6%)

Table 7. Results of early versus delayed LC for acute cholecystitis Early surgery (group 1) (n 85) Operative time (min) Conversion Mortality Morbidity Total hospital stay (days) 149.7 23 (27%) 0 12 (14%) 7.6 Delayed surgery (group 2) (n 47) 158.4 28 (59.5%) 0 6 (12.7%) 11.4

p NS 0.0002 NS NS p < 0.001

Table 5. Comparison of successful and conversion groups in patients with acute cholecystitis Successful group (n 81) Mean age (yr) Operative time (min) Postoperative stay (days) Morbidity 57.7 141 6.1 9 (11.1%) Conversion group (n 51) 60.4 170 10.5 11 (21.5%)

p NS <0.02 <107 NS

was performed successfully, the patients enjoyed a shorter surgical time and a briefer postoperative hospital stay (6.1 vs 10.5 days; p < 107). Many modifications in the surgical technique have been described, including the use of additional cannulas, more versatile angled or side-viewing laparoscopes, sterile specimen bags to retrieve lost stones or extract infected tissue, decompression of the gallbladder, routine intraoperative cholangiography, and liberal use of sutures to control the cystic duct and artery [26]. Most of them were developed in an attempt to facilitate exposure of the biliary anatomy and diminish the incidence of gallstone or bile spillage.

The results of earlier studies aimed at defining preoperative factors that would predict conversion to open cholecystectomy have been contradictory. Lo et al. [16] found that the only factors predictive of conversion were advanced patient age, larger gallstones in the gallbladder, and severe adhesions. Although several authors claimed that male sex does not affect conversion rate [6, 16, 23], others found a positive correlation [1,9]. Other authors reported that severity of the inflammation was an important prognostic factor for a successful laparoscopic approach in acute cholecystitis [1, 3, 10] and that the intraoperative finding of empyema of gallbladder or gangrenous cholecystitis increased the odds for conversion. Perhaps the most important predictor of the success of attempted LC in patients with acute cholecystitis was the timing of surgery. Previous reports [11, 18] on patients undergoing conventional open cholecystectomies suggested that cholecystectomy should be performed early in the course of the disease, preferably in the first 72 h after the onset of symptoms. Is there an optimal timing for the performance of laparoscopic cholecystectomy? The conversion rates in patients operated on before and after 3 days after the onset of symptoms were 27% and 59.5%, respectively, and were significantly different (p 0.0002). Other laparoscopic studies [12, 15, 20] have also found that patients with prolonged preoperative illnesses had higher conversion rates. The most common reason for conversion was the severity of inflammation, along with the existence of severe

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adhesions. In the early phase of acute inflammation, adhesions are easily separated, and there is usually an edematous plane around the gallbladder that facilitates dissection. After a period of conservative treatment, the inflammation and edema are replaced by fibrotic adhesions between the gallbladder and surrounding structures, which occasionally render laparoscopic dissection extremely difficult. Postoperative complications were similar in both groups. The absence of major complications, such as bile duct injury, suggests that LC can be performed safely in both early or delayed settings. The major advantage of early LC is the reduction of the total hospital stay. One of its main benefits is the potential for an earlier return to work; however, the relative recuperation periods were not compared in this study. Early LC offers a definitive treatment during the same admission and avoids the problems associated with failed conservative management (12.7% in our series). Two recent prospective randomized studies [14, 17] showed that initial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rates of laparoscopic cholecystectomy for acute cholecystitis. But early operation before 3 days of admission yields both medical and socioeconomic benefits, in terms of a briefer hospital stay and an accelerated recuperation period. In summary, laparoscopic intervention appears to be a safe and beneficial option in the management of selected patients with acute cholecystitis. Higher rates of conversion and morbidity were observed, as compared with those for elective laparoscopic cholecystectomy. The complication rate compares favorably with that of open cholecystectomy. Laparoscopic cholecystectomy should be carried out soon as the diagnosis of acute cholecystitis is established and preferably within 3 days after the onset of symptoms. Early laparoscopic cholecystectomy allows a reduction in both the conversion rate and the total hospital stay as significant medical and economic benefits. References
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