Is it Safe to Perform Laparoscopic Cholecystectomy for Acute Calculus Cholecystitis within 7 Days Following Symptom Onset?

ABSTRACT Introduction Although operation within “golden 72 hours” from the onset of symptoms has been suggested for acute calculus cholecystitis, such early surgery is hardly possible in clinical practice because of variable timing of presentation. The aim of this study is to compare the outcomes of patients undergoing laparoscopic cholecystectomy within 72 hours of symptom onset with patients undergoing surgery after 72 hours up to 7 days of symptom onset for acute calculus cholecystitis. Methods This is a descriptive cross-sectional study carried out from November 2016 to July 2018. Patients with acute calculus cholecystitis were divided in two groups according to the onset of symptoms. Main outcomes measured were conversion rate, duration of surgery, length of hospital stay and intraoperative complications. Results Total 64 patients were evaluated. Among which 18 (28.1%) underwent surgery within 72 hours of onset of symptom. Around 46 (71.9%) underwent surgery after 72 hours of symptom onset. On bivariate analysis there were no significant differences in mean duration of surgery, hospital stay and conversion to open surgery between two groups. Conclusions Early laparoscopic cholecystectomy is a safe procedure when done within 7 days of symptom onset. There were no significant difference in conversion rate, operative time, hospital stay, morbidity and mortality.


INTRODUCTION
The appropriate timing for laparoscopic cholecystectomy in the treatment of acute cholecystitis remains controversial. Early open cholecystectomy had previously been established as the preferred management of acute cholecystitis. 1 With the advent of laparoscopic surgery, the benefits of early surgery have been the subject of some contention. 2 Studies have indicated early laparoscopic surgery to be a safe option in acute cholecystitis. [3][4][5][6][7][8] Laparoscopic cholecystectomy is considered to be the standard of care if the patient is seen within 72 hours of the attack. 6 Although operation within the "golden 72 hours" from the onset of symptoms has been suggested, such early surgery is hardly possible in clinical practice because of variable timing of presentation.  9 All patients diagnosed with acute calculus cholecystitis were included in the study. Those patients who have symptoms >7 days, Pregnancy or Malignancy were excluded from the study.
After fulfilling the inclusion and exclusion criteria, patients were given adequate explanation about the study and assured of full confidentiality. Patients were divided in two groups according to the onset of symptoms. Patient with onset of symptoms less than 72 hours were kept in one group (Group A) and those patients whose symptom of onset is more than 72 hours but less than 7 days were kept in other (Group B). Patients' demographics, clinical characteristics, preoperative data, surgical intervention, intraoperative findings, biliary injury, intraoperative bleeding, conversion to open surgery, duration of operation, length of hospital stay, outpatient follow up, surgical complications and mortality were recorded. Outcomes measured were conversion rate, duration of surgery, surgical site infection, length of hospital stay. Other complications measured were bile duct injury, intractable bleeding, post-operative fever and mortality. The data were entered using SPSS software. Categorical variable were compared with Chi-Square or Fisher exact test and continuous variables were compared with independent samples T-test and Mann-Whitney U test, where appropriate. 95% confidence interval was taken and P value less than 0.05 was considered statistically significant.

RESULTS
Total of 64 patients were evaluated, among which 18 (28.1%) underwent surgery within 72 hours of onset of symptom. About 46 (71.9%) underwent surgery after 72 hours of symptom onset. Baseline characteristics of patients in two groups were compared. There were no significant differences in between these two groups in regard to mean age, sex, American Society of Anaesthesiologists' (ASA) grade and White Blood Cell (WBC) count preoperatively (Table 1).  There was one case of intraoperative bile duct injury and one intractable bleeding in group B and group A respectively. Two patients developed fever due to chest infection in group A. There was no mortality in any of the group (Table 3).  16 Although operation within the "golden 72 hours" from the onset of symptoms has been suggested, such early surgery is hardly possible. Presentation might be delayed because of various factors. We found that early laparoscopic cholecystectomy can safely be performed after 72 hours of symptom onset within seven days when compared to the patients who had undergone surgery within 72 hours of symptom onset.
There are several limitations to this study. Since this is single institutional study and all surgeries were performed by single surgeon, outcome might not be generalised. Long term follow up was not done, so incidence of late post-operative biliary stricture were not recorded.

CONCLUSIONS
Early laparoscopic cholecystectomy is a safe procedure when done within 7 days of symptom onset. There is no significant difference in conversion rate, operative time, hospital stay, morbidity and mortality.