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Optimal time for early laparoscopic cholecystectomy for acute cholecystitis
Syed Nabeel Zafar1, Augustine Obirieze1, Babawande Adesibikan2
1Department of Surgery, Howard University Hospital, Washington, DC.
Insights
Performing laparoscopic cholecystectomy (LC) within 2 days of acute cholecystitis presentation improves patient outcomes and lowers costs. Delaying LC surgery is linked to increased complications, mortality, and expenses.
Area of Science:
- Gastroenterology
- Surgical Outcomes
- Health Economics
Background:
- Early laparoscopic cholecystectomy (LC) for acute cholecystitis is increasingly supported.
- The optimal timing for early LC remains undefined, with definitions varying between 0 and 10 days.
Purpose of the Study:
- To assess if outcomes of early LC for acute cholecystitis differ based on presentation-to-surgery time.
- To determine the optimal timing for performing LC in acute cholecystitis cases.
Main Methods:
- Retrospective analysis of prospectively collected Nationwide Inpatient Sample (NIS) data (2005-2009).
- Included 95,523 adult patients undergoing LC within 10 days of acute cholecystitis presentation.
- Patients categorized into 0-1, 2-5, and 6-10 day groups; incremental day analysis (0-5) also performed.
Main Results:
- Surgery within 2-5 days and 6-10 days showed progressively worse outcomes compared to 0-1 day.
- Increased odds of mortality (1.26 and 1.93) and postoperative infections (0.88 and 1.53) in later groups.
- Mean hospital costs rose significantly with delay, from $8974 (0-1 day) to $17,745 (6-10 days).
Conclusions:
- Laparoscopic cholecystectomy within 48 hours of presentation yields optimal outcomes and cost-effectiveness.
- Delayed LC is associated with higher complication rates, mortality, and costs, though causality is not definitively established.
Importance:
There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear.
Objectives:
To determine whether outcomes after early LC for acute cholecystitis vary depending on time from presentation to surgery and to determine the optimum time to perform LC for acute cholecystitis.
Design, Setting, And Participants:
We performed a retrospective review of prospectively collected data from the Nationwide Inpatient Sample (NIS) for 2005 through 2009. The population-based sample included 95,523 adults (18 years and older) who underwent LC within 10 days of presentation for acute cholecystitis.
Interventions:
Patients were categorized and analyzed in 2 ways based on length of time from presentation to surgery. First, patients were categorized into 3 groups: 0 through 1 day, 2 through 5 days, and 6 through 10 days. Second, we compared outcomes for each incremental preoperative day (days 0-5).
Main Outcomes And Measures:
Outcomes of interest were mortality, length of stay, complications, and cost. Propensity score matching and generalized linear modeling were used. The hypothesis being tested was formulated after data collection was complete.
Results:
A total of 95,523 patients were selected. After matching the 3 groups based on propensity scores, patients who underwent surgery during days 2 through 5 and days 6 through 10 had increasingly worse outcomes when compared with those undergoing surgery on days 0 through 1. The odds of mortality were 1.26 (95% CI, 1.00-1.58) and 1.93 (95% CI, 1.38-2.68), and the odds of postoperative infections were 0.88 (95% CI, 0.69-1.12) and 1.53 (95% CI, 1.05-2.23) for days 2 through 5 and days 6 through 10, respectively. Adjusted mean hospital cost increased from $8974 (days 0-1) to $17,745 (days 6-10). Analysis by each incremental day revealed the optimal time of surgery to be within the first 48 hours of presentation.
Conclusions And Relevance:
Laparoscopic cholecystectomy performed within 2 days of presentation of acute cholecystitis yielded the best outcomes and lowest costs. Although causality could not be established, delaying LC was associated with more complications, higher mortality, and higher costs.
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