early versus delay elective laproscopic cholecystecetomy for acute calculous cholecystitis

1. Early Versus Delayed Elective
Laproscopic Cholecystectomy for Acute
Calculous Cholecystitis
 M.B; B.Ch.; Faculty of Medicine
Benghazi University- Libya
 Master degree ; Faculty of Medicine
Benghazi University- Libya
 Libyan board
Thesis by

3. Cholecystitis simply means inflammation of the
gallbladder. This is most commonly due to
gallstones in the cystic duct, termed calculous
cholecystitis.
Compared to biliary colic, acute cholecystitis will
likely cause prolonged abdominal pain with
associated fever and leukocytosis. The feared
complication of untreated acute cholecystitis is
infection, chronic cholecystitis can occur if the
gallbladder undergoes repeated attacks of acute
cholecystitis.

4. The diagnosis of biliary colic is upgraded to acute calculous
cholecystitis if the pain does not resolve in six hours.
If no stone is identified, it is called acute acalculous
cholecystitis. Anyhow, the gallbladder wall edema may
eventually cause ischemia and become gangrenous then
infection with gas-forming organisms may occur, causing
acute emphysematous cholecystitis and become life-
threatening.
Rupture has a higher rate of mortality
Laparoscopic cholecystectomy is the most common surgery
performed worldwide

5. Before the Laparoscopic cholecystectomy for acute
cholecystitis was mainly performed after the acute episode
settled because of the fear of higher morbidity and the need
for conversion from laparoscopic to open cholecystectomy.
However, delaying surgery exposes the people to gallstone
related complications (cholecysto-pancreatitis , jaundice ,
cholangitis, ect.)
and here is the conflection .
Debates regarding the risks and benefits of early laparoscopic
cholecystectomy (ELC) versus delayed one (DLC) is still
occupying a part of research.

6. Aim of work

7.  To compare early and late laparoscopic
cholecystectomy in Tobruk Medical Center
surgical practice regarding:
1. Operation time.
2. Rate of conversion to open
cholecystectomy.
3. Intra-operative complications.
4. Post-operative complications.

8. Subjects & Methods

9. Patients Selection
This is a Case Control Study was conducted
on 88 patients in general surgery
Department of Tobruk medical center
(Tobruk, Libya) during the period from
(may 2017 to may 2019).

10. Inclusion Criteria:
•
Patients presented underwent laparoscopic
cholecystectomy including both gender
with clinically diagnosed acute
Cholecystitis.

11. Exclusion Criteria:
•
1. Patients with malignancy.
2. Patients with sepsis.
3. Patients With Medical Co-Morbidity
Factors.

12. Methods:
All included patients :
collected from the patients undergoing Laparoscopic
cholecystectomy divided into 2 groups
o Group of ELC: those who underwent laparoscopic
cholecystectomy within the first admission as a case of
acute cholecystitis.
o Group of DLC: those who underwent laparoscopic
cholecystectomy after planned appointment, mostly after 6
weeks when acute episode settled

13. All patients were subjected to
Full history taking ,
proper clinical examination and appropriate
radiological, hematological investigations,
operative findings,time of operation ,conversion to
open procedure, intra-operative complications ,
post-operative complications , outcomes and
follow-up of the cases .

15. Table (1): Gender of the participant according to study group :
Gender
Operation group
Total
DLC ELC
Males
8
(50.0%)
8
(50.0%)
16
(100.0%)
Females
36
(50.0%)
36
(50.0%)
72
(100.0%)
Total
44
(50.0%)
44
(50.0%)
88
(100.0%)

16. Table (2): Time of operation per participant according to study group:
Time of operation
Operation group
Total
DLC ELC
> 90 minutes
7
(50.0%)
7
(50.0%)
17
(100.0%)
60 – 90 minutes 27
(47.4%)
30
(52.6%)
57
(100.0%)
< 60 minutes
10
(58.8%)
7
(41.2%)
17
(100.0%)
Total
44
(50.0%)
44
(50.0%)
88
(100.0%)

17. Table (3): Conversion to open cholecystectomy rate according to
operation group:
Operation group
Conversion to open
cholecystectomy Total
Yes No
DLC
4
(9.1%)
40
(89.9%)
44
(100.0%)
ELC
3
(6.8%)
41
(93.2%)
44
(100.0%)
Total
7 81 88

18. FIGURE (1) : Distribution of post-operative complications across study groups :

19. Figure (2): Rates of composite complications according to study group:

20. Discussion

21. The results of the present study were concordant with
results presented by Menahem B, et al (2015) , Wu
XD, et al (2015) , Zhou MW, et al (2014) , Gurusamy
KS, et al (2013) and Ozkardeş AB, et al (2014)
regarding mortality, bile duct injury, bile leakage,
conversion to open cholecystectomy or overall
complications.
Anyhow, Wu XD, et al (2015) showed that ELC has
lower risk of wound infection and a longer duration
of operation.

22. Saber A, et al (2014) found that the number of
readmissions in DLC group was three times in
10% of patients, twice in 23.3%, and once in
66.7% while the number of readmissions was
once only in patients in ELC group. This outcome
was not evaluated in the current study but it
reflects post-operative complications. This
superiority of ELC described by authors might be
related to post discharge follow up which was
not feasible in the present study

23. Conclusion

24. No significant difference between delayed and early
cholecystectomy regarding time of operation, intra-operative
and post-operative complications rate.
Anyhow, cases of death, bile leakage and infection were only
reported with early laparoscopic cholecystectomy and cases
of pancreatitis were only reported with delayed one.

25. Recommendation

26. 1- Acute Cholecystitis with Diabetic patients should not
discharge before the operation because most of the cases
not improved.
2- Gallbladder stone even as accidental finding in diabetic
patients , operation should be considered in elective
appointment.
3- multiple tiny stones should be operated as soon as
possible.
4-Timing of the intervention in acute cholecystitis unless
there’s a mass or perforation could be in any time.

27. Thank you