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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 46  |  Issue : 4  |  Page : 288-291

Evaluation of laparoscopic cholecystectomy in treatment of acute cholecystitis


Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission26-Apr-2017
Date of Acceptance29-Nov-2018
Date of Web Publication02-Aug-2019

Correspondence Address:
MSc Mohamed Mousa
Department of General Surgery, Faculty of Medicine, Tanta University, El-Gharbia, Tanta, El-Nady Street from Ali Mubarak
Egypt
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DOI: 10.4103/tmj.tmj_52_17

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  Abstract 


Background There is a controversy for laparoscopic cholecystectomy (LC) in acute cholecystitis with higher morbidity rates in an emergency procedure and the higher conversion rate to open procedure. The main reason is inflammation obscuring the view of Calot’s triangle view, whereas in late phase it is fibrotic adhesion, which will be associated with the bile duct injury.
Aim This study was designed to evaluate the safety of LC for the treatment of acute cholecystitis.
Patients and methods This prospective study included 30 patients who were treated by LC after 24 h. The timing of intervention was within 7 days from the beginning of the symptoms.
Results All patients presented with elevated C reactive protein (CRP), which was higher in patients with high grade fever, who had palpable tender right hypochondrial mass and also in pyocele patients. Both CRP and total leukocyte count were noticed to be directly proportional to the amount of intraoperative hemorrhage. Males and pyocele patients had delayed time of intervention. Delayed timing of intervention was directly proportional to male and pyocele patients, intraoperative hemorrhage, and amount of drain postoperative. Total operative time was with mean 109.57 and blood loss was with mean 95. Longer operative time was associated with male sex, high-grade fever preoperatively, presence of palpable tender right hypochondrial mass, and higher total leukocyte count and CRP levels. Total hospital stay ranged from 4 to 6 days and increased with male sex and pyocele patients and delayed timing of intervention. Six patients had a postoperative superficial wound infection.
Conclusion It was found that early LC allowed significantly shorter total hospital stay and early return to work and avoided repeated admissions for recurrent symptoms with no added morbidity or mortality.

Keywords: acute cholecystitis, laparoscopic cholecystectomy, c-reactive protein


How to cite this article:
Mousa M, El-Shiekh M, Mohamed H, Nagy AE. Evaluation of laparoscopic cholecystectomy in treatment of acute cholecystitis. Tanta Med J 2018;46:288-91

How to cite this URL:
Mousa M, El-Shiekh M, Mohamed H, Nagy AE. Evaluation of laparoscopic cholecystectomy in treatment of acute cholecystitis. Tanta Med J [serial online] 2018 [cited 2020 Feb 29];46:288-91. Available from: http://www.tdj.eg.net/text.asp?2018/46/4/288/263920




  Introduction Top


Acute cholecystitis (AC) is a common cause of emergency admission and a high burden in surgical departments [1].

The surgical management of AC remains controversial. In the past, laparoscopic cholecystectomy (LC) in patients with AC was contraindicated due to higher rates of complications and conversion to open surgery. Early reports showed higher complication rates, a prolonged operation time, and a higher rate of conversion to open surgery [2].

With LC, there are concerns about higher morbidity rates in an emergency procedure and the higher conversion rate to an open procedure during the early phase.

The main reason for conversion to LC during the early phase is because of the inflammation obscuring the view of Calot’s triangle, whereas in LC during late phase it is fibrotic adhesions. Severe inflammation and fibrotic adhesions are associated with bile duct injuries [3].


  Aim and objective Top


The aim of the study was to evaluate LC in the treatment of AC.


  Patients and methods Top


Thirty patients diagnosed to have AC within 7 days from the beginning of symptoms were included and treated by LC after 24 h. The study was approved by Research Ethics Committee, Faculty of Medicine, Tanta University.

After dealing with intraoperative difficulties as taking adhesions down and decompression of tense gallbladder. Using a critical view of safety method for identification of cystic duct and artery was a must for safe cholecystectomy before clipping. A specimen bag was used for gallbladder extraction.


  Results Top


All patients presented with right side abdominal pain, elevated C reactive protein (CRP) with mean 44.6 while 21 patients had elevated total leukocyte count (TLC) with mean 22 700.48. Higher levels of CRP were found in patients with high-grade fever who had palpable tender right hypochondrial mass and pyocele patients (P=0.001, 0.001, 0.005, respectively). Both CRP and TLC were noticed to be directly proportional to the amount of intraoperative hemorrhage (P=0.034). Male sex had a delayed time of intervention (P=0.031) and also patients of pyocele (P=0.005). Delayed timing of intervention was directly proportional to the intraoperative hemorrhage and the amount of drain postoperative (P=0.006 and 0.035, respectively). Total operative time was with mean 109.57 and blood loss was with mean 95. Longer operative time was associated with male sex, high-grade fever preoperatively, presence of palpable tender right hypochondrial mass, higher TLC, and higher CRP levels (P=0.03, 0.001, 0.001, 0.001, 0.002, respectively). It was noted that delayed timing of intervention had no effect on operative time (P=0.145). No conversion to open surgery or bile duct injury. The amount of postoperative drain was estimated in the 20 patients in whom drains were inserted with a mean of 102.5. Drain insertion was statistically correlated with preoperative high-grade fever, presence of palpable tender RUC mass, higher ranges of CRP, long operative time, and more amount of intraoperative hemorrhage (P=0.004, 0.001, 0.035, 0.007, 0.004, respectively). Total hospital stay ranged from 4 to 6 days with mean 4.97. It was noted that hospital stay increased with male sex and pyocele patients and delayed timing of intervention (P=0.035, 0.016, 0.011, respectively). Six (20%) patients had postoperative superficial wound infection of epigastric port site.


  Discussion Top


All patients presented with elevated CRP with mean 44.6 while 21 patients had elevated TLC with mean 22 700.48, seven (23.3%) and five (16.7%) patients showed elevated serum glutamic pyruvic transaminase and serum glutamic oxaloacetic transaminase, respectively, and two (6.7%) patients showed elevated bilirubin level.

Ciftci et al. [4] reported that CRP ranged from 55 to 301 mg/dl and TLC with mean 13±3 while the mean TLC in Özkardes et al. [5] was 11.93. Rouf Gul et al. [6] reported that 13 (43.3%) patients had elevated TLC, six (20%) patients showed elevated serum bilirubin, and five (16.7%) patients showed elevated serum glutamic pyruvic transaminase and serum glutamic oxaloacetic transaminase. Preoperative CRP in Shinke et al. [7] was slightly higher in the late phase group (4–7 days) compared with the early phase group (first 3 days).

The timing of intervention in our study was within 7 days from the symptom day with a mean 4.37. The term of the timing of intervention had no definite starting and end point until now. As seen in the literature, every study had its own timing. Some studies started from the symptom day as in Al-Qahtani [2], Verma et al. [8], and Gurusamy et al. [9]. However, other studies started from the day of presentation or admission as in Agrawal et al. [10], Ciftci et al. [4], and Rouf Gul et al. [6]. Many studies agreed with us, as their interference was within 7 days of symptom day as Al-Qahtani [2], Siddiqui et al. [11], Gurusamy et al. [12], Gurusamy et al. [9], Zhou et al. [3].

In our study, males had a delayed time of intervention and this may be due to high pain threshold of males and pyocele patients. Delayed timing of intervention was directly proportional to the intraoperative hemorrhage and the amount of drain postoperative and hospital stay, however, had no significant effect on operative time.

Teckchandani et al. [13] reported that among patients with varying intraoperative severity of AC, there was a significant difference in the mean values of duration of symptoms before surgery (P=0.006). Shinke et al. [7] compared clinical features and perioperative outcomes between patients who underwent LC within 3 days (early phase group) and 4–7 days after symptom onset. The rate of conversion to open surgery and blood loss were slightly higher in the late-phase group (8% and 140 ml) compared with the early phase group (3% and 69 ml) but were still acceptable.

Almost, all the studies had reported that LC for early AC has a longer operative time but the mean operative time had a wide range in between studies in the level of surgical expertise. Total operative time, in our study, was ranging from 42 to 180 min with a mean 109.57. Agrawal et al. [10] reported that the mean operative time was 60 min (range: 35–150 min) in the early group. In Özkardes et al. [5] the mean operative time was 67.00±28.515; Al-Qahtani [2] the mean operative time was 85.1±1.9; Rouf Gul et al. [6] the mean operative time in the early group was 98.83 min; Ciftci et al. [4] the mean operative time in the early group was 105±28 (49–163) min.

Also, longer operative time was associated with male, high-grade fever preoperatively, presence of palpable tender right hypochondrial mass, higher TLC, higher CRP levels, pyocele patients, presence of intraoperative adhesions, and more intraoperative hemorrhage.

Ambe and Köhler [14] reported that surgery lasted significantly longer in the male group (P=0.008). Bansal et al. [15] reported that the possible causes of the longer duration of surgery in the early group include the time required for removal of the inflammatory pericholecystic adhesions, intraoperative gallbladder decompression and a longer learning curve associated with the surgery in AC.

Total hospital stay ranged from 4 to 6 days. It was noted that hospital stay increased with male sex, patients of pyocele, and delayed timing of intervention with a significant difference of 0.035, 0.016, and 0.011, respectively. Also, hospital stay increased with delayed timing of intervention with significant difference 0.011. The mean duration of total hospital stay of early group in agrawal et al. was 4.16 (range: 4–8 days). Al-Qahtani [2] reported that the length of hospital stay for ELC was significantly less (4.4±1.2). Total hospital stay in Özkardes et al. [5] was longer (5.2±1.40). The mean postoperative length of hospital stay was 2 days (range: 1–3 days) in Ciftci et al. [4]. Mean hospital stay in the early group of Rouf Gul et al. [6] was 4.77 days. The mean duration of total hospital stay in the early group of Bansal et al. [15] was 5.08 days. Ambe and Köhler [14] reported that the length of postoperative hospital stay was significantly longer in the male group (P=0.007). Performing LC, as reported in the late phaseby Shinke et al. [7], did not influence postoperative complications or postoperative hospital stay. In our study, the drains were inserted in 20 patients and it was statistically significant, which correlated with high-grade fever preoperatively in presence of palpable tender right hypochondrial mass, higher CRP levels, longer operative time, and more amount of intraoperative hemorrhage (P=0.004, 0.001, 0.035, 0.007, and 0.004, respectively).

Rouf Gul et al. [6] inserted drain in 19 of 30 patients, which was removed after 24 h. However, in Bansal et al. [15] drains were not placed in any of the patients who underwent successful LC. Agrawal et al. [10] reported that drains were inserted in 28% of patients underwent LC. Senadhipan et al. [16] reported that drains were inserted in 20 of 30 patients who underwent LC within 48 h of onset of symptoms and 36 of 60 patients underwent surgery between 48 h and 6 weeks of onset of symptoms.

A total of 193 patients who needed LC due to acute inflamed gallbladder were included in the study of Kim et al. [17]. After the operation, the patients were randomly assigned to undergo drain insertion (94 patients, 48.7%, group A) or not (99 patients, 51.3%, group B). The study suggested that routine drain use in LC for acute inflamed gallbladder should be avoided, except in unusual patients that have a high risk of postoperative bleeding or bile leakage.


  Conclusion Top


LC is found to be superior for AC as a definitive treatment without added morbidity in experienced laparoscopic hands. Although, with its longer operative time and more blood loss, it was found that LC allows significantly shorter total hospital stay and reduction in days away from work and avoids repeated admissions for recurrent symptoms.

LC should be preferred as a treatment for AC in the early phase. It should be done, as soon as possible, within 7 days from the beginning of symptoms..

Acknowledgements

All authors had equal roles in design, work, statistical analysis, and manuscript writing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Al-Qahtani HH. Laparoscopic cholecystectomy within one week from the onset of acute cholecystitis: a 6-year experience. J Taibah Univ Med Sci 2013; 8:38–43.  Back to cited text no. 2
    
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Zhou MW, Gu XD, Xiang JB, Chen ZY. Comparison of clinical safety and outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis. ScientificWorldJournal 2014; 2014:1–8.  Back to cited text no. 3
    
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Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2010; 97:141–150.  Back to cited text no. 12
    
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Teckchandani N, Garg PK, Hadke NS, Jain SK, Kant R, Mandal A et al. Predictive factors for successful early laparoscopic cholecystectomy in acute cholecystitis: a prospective study. Int J Surg 2010; 8:623–627.  Back to cited text no. 13
    
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