Laparoscopic versus open treatment of patients with acute cholecystitis

The studies published so far mention a high rate of complication and conversion in laparoscopic surgical treatment of acute cholecystitis. Considering the relatively high conversion rate in cases of acute cholecystitis, it is necessary to pre-operatively estimate the chance of successful laparoscopic cholecystectomy. One of the aims of this study was to determine the factors that influence the chance of success of this technique. Another aim was to define possible advantages of the method.

From 1991 through to 1995, a total of 295 patients in whom acute cholecystitis had been diagnosed on the basis of clinical examination, laboratory data, ultrasonography and pathohistological examination, underwent operative therapy. The laparoscopic approach was attempted in 49 of these patients. Since the patients who underwent primary open surgery were markedly handicapped with regard to severity of inflammation and co-morbid factors, we identified a sub-group of these patients who were comparable to those who underwent laparoscopic cholecystectomy in accordance of the above-mentioned criteria.

The rate of conversion (44.9%) correlated with the severity of inflammation, which was determined on the basis of leukocytosis > 10 x 10(9)/l (p = 0.004) and the pathohistological diagnosis (p = 0.005). Hence, the rate of conversion was 71.4% in cases of empyema of the gallbladder but only 29.2% in cases of edematous cholecystitis. In patients whose leukocyte count decreased within 4 days of conservative treatment, a successful laparoscopic cholecystectomy (LC) was performed in 91.7% (11/12) of cases, while 8 patients whose leukocyte count increased or showed no reduction during this time required conversion to open cholecystectomy (p = 0.0001). In cases of acute cholecystitis, the complication rate after LC is lesser in respect of wound infection (p = 0.07) and pneumonia (p = 0.04). In all patients, obesity was a risk factor for wound infection (p = 0.04). Injury to the small intestine was registered in 1 case but in no case was LC associated with injury to the bile duct.

The degree of inflammation and its response to conservative treatment, which are determined on the basis of leukocytosis and clinical improvement, are clear indications of the chance of successful delayed laparoscopic cholecystectomy within the first week. Hence, all patients whose leukocyte count does not decrease after antibiotic treatment should be treated with open cholecystectomy (OC). The complication rate following LC is less than that following OC. Although no injury to the bile duct has been observed in cases of acute cholecystitis, major complications are possible and should not be excluded.