1. Delaying cholecystectomy in the setting of acute cholecystitis doubles the morbidity rate.
2. Immediate surgery within 24 hours of admission for acute cholecystitis results in shorter hospital stays and lower costs than antibiotic treatment followed by elective surgery a week or more later.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Although laparoscopic cholecystectomy is among the most common procedures in general surgery, debate remains on whether surgical intervention should be immediate or delayed for patients presenting with acute cholecystitis. Concern for operating in an area of high inflammation is weighed against the risk of delaying intervention. This multicenter randomized control trial demonstrated a significant doubling in morbidity associated with the delayed approach (antibiotics followed by surgery 7 to 45 days later) compared to immediate surgery (within 24 hours of admission). While this study boasts strong enrollment and good randomization methodology, a discrepancy of rare comorbidities was seen between the two treatment arms. Sensitivity analysis confirmed that the imbalance of comorbidities had no causative relationship with the improved outcomes seen in the immediate surgery group. Overall, this trial provides strong evidence that the optimal treatment for acute cholecystitis should be cholecystectomy within 24 hours of presentation.
In-Depth [randomized controlled trial]: This study enrolled 618 patients presenting with acute cholecystitis to one of 35 centers in Germany. Patients were randomized to either immediate surgery within 24 hours or to receive conservative therapy with moxifloxicin followed by elective laparoscopic cholecystectomy within 7 to 45 days. The primary outcome was morbidity at 75 days. Analysis demonstrated a morbidity rate for the immediate surgery group half that experience by the delayed procedure group: 11.6% compared to 31.3%, with a 95% CI of 12.5 to 25.7. These reported morbidity rates excluded patients with unassessed morbidity scores, however inclusion of these patients resulted in similar rates with a similar 95% confidence interval. Immediate laparoscopy patients also spent half the days in the hospital compared to delayed laparoscopy patients: mean total length of stay was 5.4 days compared to 10.0 days respectively, with a corresponding 46% increased cost in the delayed group. The majority of adverse events (81%) in the immediate surgery group occurred postoperatively, while the majority of adverse events (67%) in the delayed procedure group happened prior to cholecystectomy.
By Asya Ofshteyn and Chaz Carrier
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