Acute Cholecystitis and Laparoscopic Cholecystectomy

Abstract

Objective:

To determine whether laparoscopic cholecystectomy (LC) should be the procedure of choice in treating acute cholecystitis.

Method:

A prospective study was conducted over a 4 1/2-year period. There were 187 patients with acute cholecystitis out of 1020 patients with gallbladder disease who required cholecystectomy. These patients were divided into three groups based on the time interval between the onset of pain and the time patients sought medical attention: Group 1, < 3 days; Group 2, 3 to 7 days; Group 3, > 7 days. All the patients underwent LC after a comprehensive preoperative workup. The parameters analyzed included operating time, hospital stay, and conversion rate. The comparison was made among the various groups and with those who had elective LC.

Results:

One hundred twenty patients (64.17%) presented for treatment within 3 to 7 days of the onset of an attack. Empyema of the gallbladder was seen in 106 (56.68%) patients and phlegmon of the gallbladder in 42 (22.46%) patients. Group 3 patients had an operative time of 56.2 min as opposed to 18.5 min in Group 1 and 17.5 min in the elective LC group. The conversion rate in Group 3 was 19.5% versus 3.8% in Group 1 and 3.48% in the elective LC group. The complication rate was 7.3% in Group 3, 3.8% in Group 1, and 3.7% in the elective LC group.

Conclusion:

Acute cholecystitis is better managed by laparoscopic cholecystectomy, except in the patients presenting with a gallbladder phlegmon later than 7 days after the onset of the attack.

INTRODUCTION

Although laparoscopic cholecystectomy (LC) has now been accepted as the gold standard for managing cholecystitis with or without cholelithiasis, a similar acceptance for the management of acute cholecystitis (AC) remains controversial because of technical difficulties.¹ With the acquisition of greater expertise, laparoscopic cholectystectomy is becoming an accepted procedure for acute cholecystitis. In acute cases, however, conversion to open cholecystectomy may be required in a larger percentage of patients.^{1, 2} This retrospective and prospective study was designed to analyze the results of LC in patients with acute cholecystitis.

MATERIALS AND METHODS

Over a period of 4 1/2 years starting in October 1994, 1020 patients underwent LC. Of these, 187 patients had acute cholecystitis. These 187 patients were age- and sex-matched and then assigned to one of the three groups according to the interval period (between the onset of acute attack and the time of presentation for treatment) < 3 days, 3 to 7 days, and > 7 days.

The diagnosis of acute cholecystitis was based on the clinical picture [which included acute right upper abdominal pain of more than 8 hours, with tenderness, temperature > 37.5°C, with or without mild jaundice, and a white blood cell (WBC) count of greater than 10⁹ /L] and supplemented by ultrasonographic evidence of dis-tended gallbladder with edematous wall, positive ultra-sonographic Murphy's sign +/- pericholecystic phlegmon +/- fluid in Morison's pouch). A postoperative histopathology study was performed on every gallbladder removed. Patients were excluded from the study if they had a significant medical illness that rendered them unfit for laparoscopic surgery.

RESULTS

Of the patients with acute cholecystitis, 70.5% were females mostly in the age group of 31 to 40 years. The minimum age was 8 years in one male patient. One hundred forty-six patients (78.07%) presented with an interval period of < 3 days or 3 to 7 days (Groups 1 and 2) (Table 1). Table 2 lists the anomalies present in patients with acute cholecystitis. Ten patients (5.35%) had patchy gangrene (Table 2). Jaundice of < 3 mg% was seen in 24 (12.83%) patients and acute pancreatitis was also present in 5 (2.67%) patients. Most of the patients with gallbladder phlegmon had Zuhlke³ type 1/2 omental adhesions (Table 3). In the 13 patients who were converted to open cholecystectomy, the major cause was adhesions.

Table 1.

Patient groups based on duration of symptoms.

Group	Duration	Total (%)	Male		Female
			No.	%	No.	%
1	< 3 days	26 (13.90)	8	14.55	18	13.63
2	3-7 days	120 (64.17)	36	65.45	84	63.64
3	7-14 days	41 (21.92)	11	20.0	30	22.73

Table 2.

Presentation characteristics of patients with acute cholecystitis. (n = 187) (Calculus = 181; Acalculus = 6)

Presentation	Number	Percentage
GB phlegmon	47	25.14
GB empyema/ mucocele	130(4)*	69.52
GB perforation	10	5.34

^*( ) indicates conversion. GB = gallbladder.

Table 3.

Types of gallbladder phlegmon. (n = 47) (Zulke type I/II) (Zulke Type III/IV)

Phlegmon	Fibrinous adhesions	Dense adhesions
With omentum	18	14 (2)
With omentum + bowel	9 (2)*	3 (3)
Pericholecystic pus collection	3	-

^*( ) Shows figures with conversion.

In those patients where tense empyema or mucocele existed, aspiration with a Veress needle was carried out to enable adequate grasper function. More than 3 ports were used in 36 patients (19.25%). The operating time tended to vary with the time of presentation, and the Group 3 patients had a mean operating time of almost 3 times that of Group 1 patients (56.2 min vs 18.5 min.) (Table 4). The hospital stay time was the same in patients of all groups. Conversion was required in 19.5% patients of Group 3 as opposed to 3.8% for Group 1 and 3.48% for the elective LC group. Similarly, the complication rate tended to be highest in Group 3 patients (7.3%) as opposed to 3.8% in Group 1 and 3.7% for the elective LC group. Common bile duct (CBD) injury occurred in only one patient (Table 5). Based on histopathological examination, all removed gallbladders were designated as having acute cholecystitis.

Table 4.

Comparative parameters.

Avg.	Group 1 n = 26	Group 2 n = 120	Group 3 n = 41	Elec.LC n = 833
Op. time 33.5 min.	18.5 min	32.5 min	56.2 min	17.5 min
	(16-21)	(17-60)	(28-90)	(10-70)
Number of ports > 3		36 (19.25% average grp 1-3)		71 (8.52%)
Hosp. Stay 2.4 day	2.4 days	2.4 days	2.4 days	2.4 days
Conversion (4.2%)	1/26 (3.8%)	4/120 (3.3%)	8/41 (19.5%)	20 (3.48%)
Complication rate	1/26 (3.8%)	5/120 (4.16%)	3/41 (7.3%)	31 (3.72%)

Elec. LC = elective laparoscopic cholecystectomy; Op. Time = operating time

Table 5.

Types of postoperative complications.

Postoperative complications	9 (4.81%)
Choleperitoneum
Localized - slipped cystic duct clips	1
- accessory cystic duct	1
- Generalized (CBD injury)	1
Wound granuloma/infection	4
Subcutaneous emphysema	2

CBD = common bile duct

DISCUSSION

Whether to perform early or elective standard cholecystectomy for acute cholecystitis has been an unresolved debate among surgeons, and the controversy continues even for the laparoscopic approach. Initially, acute cholecystitis was considered to be a relative contraindication for LC, but with the increase in general expertise, it is now considered an option albeit with certain reservations.⁴ LC in acute cholecystitis becomes progressively more difficult because of edema and adhesions and is best done within 48 hours of admission.^{4, 5} This technical difficulty has a direct bearing on the high and variable conversion rate which has been reported to be from 6% to 35%.^5–8 The high (35%) conversion rate may seem to be an argument against utilization of a laparoscopic approach, but consideration should be given that this is an abnormally high conversion rate, that delayed or interval cholecystectomy too has a higher than normal conversion rate (because of postinflammatory dense adhesions in and around the Calot's triangle^{9, 10}) and that a large number of patients fail to seek interval elective cholecystectomy.⁹ In addition, the possibility of having another attack of acute cholecystitis during the waiting period always exists. It would thus be wrong to assume that interval LC would always be a better option.⁸

Our conversion rate of 4.2% compares favorably with that of elective surgery (3.48%). It should be pointed out, however, that conversion to open surgery reached a maximum of 19.5% in Group 3 patients who had dense adhesions. The other causes requiring conversion in our series included the existence of completely gangrenous gall-bladders, an extremely edematous and friable gallbladder, Mirizzi's syndrome, and gallbladder perforation. These causes have also been cited by other authors as indications for open surgery.^{11, 12}

The operating time too for Group 3 patients, as compared with that for the elective LC group or for Group 1 patients, was 3 times higher. The increase in operative time was due to the extra time required to negotiate dense adhesions, the adoption of Veress needle aspiration of these gallbladders to enable adequate grasper function, and edema of the gallbladder which made grasping and retraction of the gallbladder difficult.^{8, 9} Complications included one patient (0.5%) with a CBD injury. Two other patients had a bile peritoneum due to slippage of the cystic duct clips and a missed accessory duct respectively. The CBD injury rate compared favorably with that of open cholecystectomy indicating that the operation is technically feasible.^{9, 10}

Group 3 patients did show a greater than normal rate of conversion to open surgery, a longer operating time (almost 3 times that for Group 1), and a higher complication rate. Should this be interpreted as: patients presenting after 7 days of attack (Group 3) should preferably be treated by elective LC as has been pointed out by various authors?^13,14 In our opinion, what is more important than considering the time interval of presentation as an absolute indicator of deciding for interval AC is the degree of perigallbladder adhesions involved in the phlegmon and their tenacity. Gallbladder phlegmon was the major cause of conversion in 7 out of 13 patients (Table 3), substantiating our contention. Thus, only those patients who present with gallbladder phlegmon of more than 7-days duration (when they are more likely to have Zuhlke's type 3 or 4 adhesions) may be candidates for elective cholecystectomy.