Proactive emergency laparoscopic cholecystectomy for complex acute cholecystitis: a prospective cohort at a national...

While emergency laparoscopic cholecystectomy (ELC) is the standard treatment for acute cholecystitis (AC), optimal management of complex cases, particularly those with symptom duration ≥7 days or severe inflammation, remains controversial.

To assess the feasibility and safety of a proactive protocol for ELC in patients with complex AC, including high-risk cases defined by advanced age, prolonged symptoms, or severe inflammation (Tokyo Guidelines grade II/III).

From 1 August 2020 to 1 February 2024, the emergent surgical teams at Peking Union Medical College Hospital (National Emergent Surgery Center in North China) prospectively implemented proactive ELC for AC patients, irrespective of symptom duration and inflammatory severity. Intraoperative indocyanine green cholangiography (ICG-C) was selectively employed based on the surgeon's discretion. Clinicopathological data and perioperative outcomes were analyzed to assess safety and efficacy. Logistic regression and multi-way ANOVA were employed to assess the effects of multiple independent variables.

Among 721 enrolled patients, 576 (79.9%) were interprovincial referrals, and 342 (47.7%) were transferred from external hospitals. More than half of the patients suffered from at least one comorbidity. The median age was 60 ± 16.7 years, with 11.5% aged >80 years. Symptom duration exceeded 3 days in 343 (47.6%) and 7 days in 190 (26.4%) of cases. Most patients had advanced disease (334 (46.3%) grade II, 199 (27.6%) grade III). Mean operative time was 64 ± 36.5 minutes, with intraoperative blood loss (IBL) of 65.0 ± 177.4 ml. Seven cases (1%) required conversion to open surgery, 39 (5.4%) underwent partial cholecystectomy, and 3 (0.4%) experienced iatrogenic colon injuries. Reoperation occurred in 2 cases (0.3%). The overall postoperative complication rate was 6.9%, with severe complications (Clavien-Dindo grade ≥III) at 1.2%. Patients older than 80 years did not have a higher rate of complications (P = 0.14). Patients with symptom duration ≥ 7 days had similar rates of partial resection and overall complications to those with 4-6 days. Although grade II/III had substantial adverse intraoperative and postoperative effects (all items, P ≤ 0.001), the overall rate of complications remains low (8.4%). ICGC correlated with reduced partial resection rates (0.7% vs. 6.3%, P = 0.005) and lower intraoperative blood loss (44.7 ± 82.8 mL vs. 69.4 ± 194.0 mL, P < 0.001).

Proactive ELC could be safe and effective for complex AC, even in elderly patients (≥80 years), prolonged symptom duration (≥7 days), and severe disease (grade II/III), when performed in high-volume centers. ICGC enhances precision, mitigating incomplete resections and bleeding.