European Journal of Cardiovascular Medicine

Acute calculous cholecystitis, an inflammation of the gallbladder caused by gallstones, often requires surgery. Laparoscopic cholecystectomy has become the preferred method due to its minimally invasive nature and positive outcomes for patients.^[1,2] However, there is still debate over the best timing for the procedure-whether to perform it early (within 3–6 days after the onset of pain) or delay it (3–6 weeks following conservative treatment until the inflammation resolves).^[3] A key factor in this discussion is the rate of conversion from laparoscopic to open cholecystectomy, which can signal complications or technical challenges during the surgery. Several factors, including male gender, obesity, age over 65, previous abdominal surgeries, acute cholecystitis, choledocholithiasis, and unusual anatomy, have been identified as significant risk factors for requiring conversion to open surgery.^[4-7] This study aims to compare the rates of conversion between early and delayed laparoscopic cholecystectomy for acute calculous cholecystitis, with the goal of offering insights to guide clinical decisions and enhance patient care.

This was a prospective, randomized, two-arm clinical study of 462 patients. The sample size was based on a study conducted by Ozkardeş et al.^[3] in 2014. The study was conducted from December 2022 to June 2024 at the Department of General Surgery, ESIC Medical College and Hospital, Faridabad, Haryana, India.

Acute cholecystitis was diagnosed based on clinical signs and symptoms such as acute pain in the right upper abdomen or epigastric region, tenderness, a temperature of 37.5°C or higher, and a total leukocyte count of 10×10^9/L. Diagnosis was also supported by ultrasonographic findings including a thickened and edematous gallbladder, and the presence of gallstones with surrounding peri-cholecystic fluid. The study included patients aged 18 and older who were diagnosed with acute calculous cholecystitis. They were randomly assigned, using a computer-generated list, into two groups: the 'early' group (Group A) and the 'delayed' group (Group B). Group A underwent LC within 3 to 5 days, while Group B received intravenous hydration and antibiotics (cephalosporins, amikacin and metronidazole), followed by LC after 3 to 6weeks.

Exclusion Criteria

Patients with surgical jaundice and common bile duct (CBD) stones which were difficult to treat endoscopically before laparoscopic surgery, malignancies, acute biliary pancreatitis, previous surgery of the biliary tract, coagulopathy, spreading peritonitis, and those who were not fit for surgery were excluded from the study.

Statistical Analysis

Data were analyzed using IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA). The student t-test was employed to compare continuous variables between the two groups, and the chi-square test was used for categorical variables. A p-value of less than 0.05 was considered statistically significant in the analysis.

In this study, the mean age in group A was 45.67 ± 11.77 years; in group B, it was 45.20 ± 12.56 years (Table 1).

Ultrasonographic findings like gallbladder wall thickness and edema, peri-cholecystic fluid, CBD size, IHBRD and gallstone location were compared and group A was found to have significantly more gallbladder wall thickness and edema as well as pericholecystic fluid as compared to group B. Stone impaction at the neck of gallbladder was also more common in group A as compared to group B (Table 2).

Laboratory findings such as total leukocyte count, bilirubin (total, direct, and indirect) and ALP were found to be significantly higher in group A as compared to group B (Table 3).

The total rate of conversion of laparoscopic to open cholecystectomy was found to be 9.31% with 43 patients out of a total of 462 being converted to open surgery (Table 4).

In group A, 17 patients out of 231 (7.36%) had to be converted to open surgery while in group B, 26 patients out of 231 (11.26%) were converted. Thus, more patients in group B were converted to open surgery but the difference between the two was not statistically significant (Table 5).

Group A patients were further subdivided into those presenting within 3 days of onset of symptoms and those presenting after 3 days. In of the former subgroup, 7 patients (6.03%) were converted to open while in the latter subgroup, 10 patients (8.70%) were converted to open but the difference was not statistically significant (Table 6).

The mean duration of surgery was less in group A patients (40.38± 9.67) as compared with group B patients (48.52 ± 9.83). The mean hospital stay duration was also less in group A patients (4.90 ± 1.59) as compared with group B patients(6.89 ± 1.70) and it was significant statistically (Table 7).

In this prospective randomized study, we observed that early LC had the advantage in terms of shorter operation time and hospital stay with no significant difference in open conversion rate and intraoperative difficulty level.

Acute calculous cholecystitis is one of the most prevalent acute hepatobiliary disorders. Numerous studies have attempted to demonstrate less rigorous and cost-effective treatments. ^[8,9] The complexity of the structure and size, and multiplicity of stones are the factors limiting their nonsurgical management. These nonsurgical methods include oral desaturation of stones using ursodeoxycholic acid, contact disintegration, and extracorporeal lithotripsy techniques. But surgical treatment has become the gold standard for calculous cholecystitis because nonsurgical approaches have not yielded positive outcomes.^[10] LC has become the treatment of choice for gallstones during the past two decades.

Historically, acute cholecystitis due to stone was managed optimally with a span of 6 to 8 weeks with antibiotics in view of inflammatory resolution to avoid ductal and vascular injury. Acute cholecystitis was once considered a relative contraindication to LC in the early days of laparoscopic surgery. However, many clinical trials have shown the advantage of early LC over the delayed one in terms of short hospital stay and cost with a similar estimate of associated morbidity and mortality. ^[11-14]

In a 2014 study including 14,220 patients, de Mestral et al^[15] found that the early group’s hospital stay was 1.9 days shorter than that of the delayed group. In a 2015 trial of 502 participants, Pisano et al,^[16] observed a hospital stay of 2.5 days shorter in the early group, and no surgical complications were reported in the early group. This finding is in line with our study in terms of shorter mean postoperative and overall hospital stay in the early group. Thus, early LC has benefits over late LC when considering shorter operative time and hospital stay without significant difference in open conversion rates.

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