Early cholecystectomy best option for acute cholecystitis

Last Updated: 2015-12-21

By Will Boggs MD

NEW YORK (Reuters Health) - Early cholecystectomy is more effective and less costly than delayed cholecystectomy or watchful waiting in patients with acute cholecystitis, researchers from Canada report.

Randomized trials have demonstrated the clinical and cost benefit of early over delayed surgical intervention, but these results may not have reflected real-world outcomes.

Dr. Charles de Mestral, from Sunnybrook Health Sciences Center, Toronto, Canada, and colleagues used a Markov cohort decision analytic model to compare three treatment strategies for patients admitted to hospital with a first presentation of acute cholecystitis: early cholecystectomy (performed within seven days of presentation); delayed cholecystectomy (performed electively eight to 12 weeks from presentation); and watchful waiting (cholecystectomy performed urgently if recurrent gallstone symptoms arise).

Costs were considered from the perspective of a third-party payer, the Ontario Ministry of Health and Long Term Care.

Early cholecystectomy was associated with the greatest quality-adjusted life-year gains over five years and the least expense.

Watchful waiting was associated with a higher rate of recurrent gallstone-related symptoms (47.7% vs 17.4% for delayed cholecystectomy), and delayed cholecystectomy was the most expensive option.

Modeled mortality at five years was 8.1% for elective cholecystectomy, 7.7% for delayed cholecystectomy, and 11.7% for watchful waiting, according to the November 24 Journal of the American College of Surgeons online report.

Probabilistic sensitivity analysis involving 10,000 model iterations yielded mean costs per person of $6,851 for early cholecystectomy, $7,282 for watchful waiting, and $8,505 for delayed cholecystectomy. Across all willingness-to-pay thresholds, early cholecystectomy remained the preferred alternative.

The researchers conclude that early cholecystectomy should be considered for most patients with uncomplicated acute cholecystitis.

Dr. Guillaume Passot, from CH Lyon Sud, Hospices Civiles de Lyon, Pierre Benite, France, recently investigated the optimal timing for early cholecystectomy in a French nationwide study (http://bit.ly/1mw6FBE). He told Reuters Health by email, "I would have expected such results according to previous data. However, the definition of early cholecystectomy was surprising. The authors defined early cholecystectomy as surgery <7 days after onset of symptoms; however, most authors and an international consensus (Tokyo Guidelines) defined early cholecystectomy as surgery within 72 or even 48 hours after the onset of symptoms."

"Early cholecystectomy should be advocated for patients who present uncomplicated mild or moderate (Tokyo Guidelines) calculous cholecystitis," Dr. Passot said. "Patients with main duct stones, pancreatitis, elderly patients, patients with high surgical risk, or patients presenting with acute nonlithiasis cholecystitis would definitely be managed with delayed cholecystectomy."

Dr. Jose M. Velasco, professor of surgery from Rush University, Chicago, told Reuters Health by email, "I believe that physicians should strive for early operation on noncomplicated acute cholecystitis patients unless the patient's risks are high due to comorbidities or the patient presents with bile duct obstruction or severe pancreatitis."

"I suspect that a lot of the patients included in the study may not have true acute cholecystitis, yet an argument should be made to cement the concept that cholecystectomy is the preferred treatment for patients with symptomatic cholelithiasis," Dr. Velasco concluded.

Dr. Michael Cox, from the University of Sydney, Penrith, New South Wales, Australia, who has also reported on the superiority of early over delayed cholecystectomy (http://bit.ly/1ZlfsnX), told Reuters Health by email, "All patients presenting with acute cholecystitis that are fit for a laparoscopic cholecystectomy should be managed with early laparoscopic cholecystectomy."

"When surgeons or institutions do not perform early laparoscopic cholecystectomy for acute cholecystitis, there needs to be an assessment of the reasons for this and those reasons addressed," Dr. Cox said.

"If it is related to the belief it is safer to perform delayed surgery, this is clearly incorrect when the data is assessed and the practice should change. Where the surgeons feel their skills are not up to performing laparoscopic cholecystectomy in acute cholecystitis, they need to acquire more skills or refer the patient on to surgeons that do. Where there are insufficient resources to perform early laparoscopic cholecystectomy the system of care needs to be reviewed and changed to provide for this group of patients," he said.

Dr. de Mestral did not respond to a request for comments.

The Canadian Surgical Research Fund, the Physician Services Inc. Foundation, and the Institute for Clinical and Evaluative Sciences supported this research. The authors reported no disclosures.

SOURCE: http://bit.ly/1NyepMo

J Am Coll Surg 2015.