Researchers urge shakeup to laparoscopic cholecystectomy timing

The tradition of delaying laparoscopic cholecystectomy (LC) after hospital admission for mild gallstone pancreatitis may be unnecessary, say the authors of a US study.

Darin Salzman (University of California Los Angeles Medical Center, Sylmar, USA) and colleagues found that patients who underwent LC within 48 hours of admission had significantly shorter hospital stays compared with those whose surgery was delayed until normalization of pancreatic and liver enzymes, with no difference in complication rates.

They say: "Provided patients are carefully selected, this strategy will not increase the rates of complications, the rates of readmission, the need for conversion to an open cholecystectomy, or the need for ERCP [endoscopic retrograde cholangiopancreatography]."

The retrospective study included 303 patients who were admitted with mild gallstone pancreatitis (<3 Ranson signs) over a 5-year period. In all, 117 patients underwent early LC and 186 had delayed LC. There were no significant differences in characteristics between the two groups on hospital admission apart from that the early LC group was slightly older (median 40 vs 35 years).

The median length of stay was 3 days in the early LC group compared with 6 days in the delayed LC group.

The authors found no differences between the groups in mortality, readmission within 30 days, or in conversion from LC to open cholecystectomy. However, those who underwent delayed LC were more likely to require ERCP than early LC patients.

The authors say that the practice of delaying surgery until lab values have normalized is a throwback to the era of open cholecystectomy. However, despite growing evidence that this is unnecessary with a laparoscopic approach, surgeons have been reluctant to abandon the tradition.

A major concern is that early surgical intervention is known to trigger disease exacerbation in some patients diagnosed with mild pancreatitis.

However, the authors argue that, with careful screening, patients at risk for developing severe pancreatitis can be identified. For example, they excluded those with tachycardia, elevated serum urea nitrogen level, or evidence of cholangitis. None of the patients developed severe pancreatitis during the study.

Reporting in the Archives of Surgery, the authors say that as the largest study into the timing of LC yet, they hope their results will help give surgeons confidence to reduce delays to surgery.

In an accompanying critique, Michael West (University of California, San Francisco, USA) agrees: "Based on this study, surgeons should feel more comfortable proceeding with an early laparoscopic cholecystectomy to shorten hospital length of stay without sacrificing outcomes."

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