SS Laparoscopic Cholecystectomy vs Open Cholecystectomy in the Treatment of Acute Cholecystitis A Prospective Study J-A Lujan, MD, PhD; P. Parrilla, MD, PRD; R. Robles, MD, PhD; P. Marin, MD, PRD: JA Torraiba, MD, PRD; J. Garcia-Ayllon, MD, PhD Objectives To compare the results of laparoscopic cho- lecystectomy (LC) with those of open cholecystectomy (OC) in the treatment of acute cholecystit Design: A prospective, nonrandomized trial. Settings “Virgen de la Arrixaca” University Hospital, EL Palmar (Murcia), Spain. Patients: Onc hundred fourteen patients underwent LC, Results: Conversion from LC to OC was necessary in 15% of the patients, The mean operating time was 77 min- utes for the OC group and 88 minutes for the LC group (P<.001). Complications occurred in 149% of the pa- jents in the LC group and in 23% of the p. jents in the OC group, with no significant differences between the 2 groups ( (06). The number of moderate or severe com- plications was similar in both groups, whereas mild com- plications were more common in the OC group (P<.02). The length of the hospital stay averaged 8.1 days for the and 110 underwent OC. The patients underwent sur gery within 72 hours ofthe onset of symptoms. The pa- tients were selected for LC or OC depending on the sur- _geon’s experience in laparoscopic surgery Main Outcome Measures: Operating ime, rte of con- version from LC 10 OC, complications, and length of hos- pital stay OC group and 3.3 days for the LC group (P<.001). Conelusions: Laparoscopic cholecystectomy is a safe, valid alternat fe 19 OC in patients with acute cholecys” tis. The technique has a low rate of complications, im- pliesa shorter hospital stay, and offers the patient a more comfortable postoperative period than OC. Arch Surg, 1998:133:173-175 From the Departamento de ‘Cirugia General, Hospital Universitario “Virgen de la Arrisaca,” El Palmar (Murcia), ‘Spain Downloaded From: on 08/08/2018 ApaROscOPICcholecystectomy (1.0) has clearly displaced open cholecystectomy (OC) inthe management of simple biliary lithiasis." However, the role of LC in the treatment of acute cholecystitis (AC) is somewhat contro- versial because some surgeons claim that the inflammation, edema, and necrosis ex- perienced by patients with AC make dis Section more dificult, which ean, ther fore, increase the rate of complications." Certain studies have recently found that LC is safe, efficient technique for cases of AC.” However, the patients are se- lected in some of these studies, and some are multicentrie;also, some ofthese stud- tes do not compare the results of LC with those of OC, Which is the safest tech- nique for managing AC. This study de- scribes series of patients with AC who were treated with LC oF OC and assesses the results of both techniques. (©1908 American Med Ls Cholecystectomy was performed in 100% of the patients. Intraoperative cholangi- ography was performed in 72 (63%) of the 114 patients who underwent LC and in 79 (72%) of the 110 patients who unde went OC, revealing 2 cases of choledo- cholithiasis in the former and 1 in the la- ter. Conversion from LC to OC was necessary in 17 (15%) of the L14 pa- ents: in 13 for inflammation or adbi sions that hampered dissection of the el- ements of the Calot triangle, in 2 for choledacholithiasis, and in 2 for bleed- ing of the cystic artery. The mean surgi- cal ime was 77 minutes for the OC group (eange, 30-165 minutes) and 88 minutes for the LC group (range, 30-180 min- utes), with statistically significant differ- ences (P<001) between groups. In the LC group, 18 complications occurred in 16 (1496) of the patients. In the OC group, Association, All rights reserved.PATIENTS AND METHODS Between June 1991 and December 1996, we con- ducted a nonrandomized, prospective study of 224 patients with AC: 114 patients underwent LC, and To underwent OC. The diagnosis of AC was estab- lished by (1) clinical and laboratory criteria, (2) an ultrasonographic indication of AC, 3) intragpera- tive findings of AC, or (4) pathological anatomical Features revealing the presence of AC. Patients in ‘whom choledacholithiasis was diagnosed preopera- tively were excluded from the study. Age, sex, and ‘operative findings are shown in Fable 1. An anti- biotic and antithrombotic prophylaxis was per formed during the preoperative period and contin- uued until 24 to 48 hous postoperatively. all the patients underwent surgery within 72 hous of the ‘onset of symptoms. The patients underwent LC when thesurgeon (AL. PP.,or RR) responsible had ex- perience i laparoscopic surgery (ie. >100 LCs per- formed in patients with simple cholelithiasis). The surgeal technique used for OCs in all patients was a subcostal incision with removal of adhesions pls cho- lecystectomy. The surgical technique for LCs was per- formed according to the French school, as de- scribed previously." In all patients, intraoperative cholanglography was performed i the caliber of the ‘eystie duct and the amount of inflammation of the Calot triangle permited, The following data were re- corded: operating time; rate of conversion to OC in the LC group; postoperative complications, divided into 4 groups according to severity (Fable 2); and lengih of hospital say. The statistical analysis used for comparison was the x? test in an analysis of con- Lingency tables and in a subsequent analysis of the resides, When the expected frequency was less than, 5, we used the Fisher exact test. 29 complications occurred in 27 (23%) of the patients. [A list of the type and number of complications in each ‘group is provided (the grade of the complication is given in parentheses): osioperatv compications oc oroup Learup ‘dynamics (1) 9 3 Bilary stl} Pulmonary completions (1) Pris (1) Bie duct inury (2) ‘Margy (1) Fecegn by (2) Wound ition (1) Ir-abdoming intetion 2) Dias (1) Inr-bdominalleding (2) Pasa iis (2) 1 In the LC group, these complications included 1 mi- nor biliary fistula, which closed on the third postopera- Live day in a patient in whom the eystie duet was not iden- ified during surgery; 1 ease of choledochal stenosis caused by a burn from a coagulating erochet hook, which re- quired reoperation a month alter the cholecystectomy; 1 case of bleeding of the hepatic bed, which required Table 1. Patient Data rdentent Open vs choleytetomy” cholecystectomy” Pt ToulNe-ofpaions 0 18 Age y (ange) 6020-88) sr(i385) a8 Sexratio (MF) ar 1886 15 Operate atures Inismmaton @ ra 28 Gangiane az at 5 Epyema 5 10 2 ~All data ate gen a he uber of patents in each group unless tense specie, "elise inca dt not appeal Table2, Classification of Complications one concen ‘1 Davaton om del postoperative elton noes tothe ptr, spotanousreslution or minimum bt Procedwes, thou nereasing hosp 2 Taso patont it, possible ned for ina procedures 3 Grade2compleatons wth sal sequels, inluding resection of argans oa pts Me-hetning station 4 Dasth ofthe patent Table 3. Postoperative Complications ‘According to Severity” ationts Wo Patents we ‘Underset Unerwent open Lapaoseape rade __caoleeytectomy __choleystectomy PY 7 B 2 =a 2 a 4 ry 3 1 2 ” 4 ° 0 “Al daa are given asthe eumberof ates in each group uns otherwise sected elise inate dt not appeal blood transfusion; 1 intra-abdominal abscess, drained by radiological puncture; and 2 cases of residual lithiasis 9 and 12 months alter LC, which were resolved with en- doscopic papillotomy. In the OC group, these compli- cations included 2 cases of bleeding of the hepatic bed; 1 foreign body, which required reoperation in the im- mediate postoperative period: and I case of residual li thiasis 14 months alter the operation, which resolved with endoscopic papillotomy. Comparing the complications overall, we found a higher rate in the OC groulp than in the LC group, with no significant differences between groups (P=.00). Regarding severity (Fable 3), we see thatthe rate of grade 2, 3, and 4 complications was sim lar in both groups, whereas the rate of grade 1 compl cations was higher in the OC group (P*<.02). The mean length of the hospital stay was 8.1 days for the OC group (eange, +20 days) and 3.3 days for the LC group (range, (©1908 American Med Downloaded From: on 08/08/2018 Association, All rights reserved.1-12 days), with statistically significant differences (P<.001) between groups. Lees Laparoscopic cholecystectomy isa clear alternative in the management of uncomplicated biliary lthiasis."* Thead- vantages and inconveniences of this new procedure are well documented for uncomplicated biliary lithiasis but not so well defined for the treatment of AC. The data pub- lished about patients with AC are usually multicentric studies or personal series reviewed retrospectively, and they are sometimes of tle value because of the wide varia- tion in the definition of AC and because they include cases with a histological rather than a clinical diagnosis. Our study included patients who were admitted to the emer gency department for clinical, analytic, and ultrasono- [graphic manifestations of AC; all the patients had signs ‘of acute inflammation when LC was performed, The operative ime in our series was significantly longer in the LC group (P.01). This is because the sur- _geon and the emergency department team must get used to managing the laparoscopic material and need time to master the laparoscopic technique; also, LC is more la- borious than OC im patients with AC. The rate of conversion depends, on the one hand, ‘on the surgeon's experience (in fact, most conversions ‘occurred in each surgeon's initial patients) and, on the ‘other hand, on the time when the patient undergoes sur~ gery.” All the patients with AC in this series were oper ated on within 72 hours of the onset of symptoms be- ‘cause at this stage of the disease inflammation is, widespread andit is easy to perform dissection ofthe struc- tures. Ata later stage, there is induration, hypervascu- larity, and the formation of abscesses and necrosis, fac- tors that make dissection difficult. One factor to remember regarding conversion is that it must never be consid- ‘ered a complication but rather a wise move on the part fof the surgeon. In our opinion, «low rate of conversion, is directly related to an increase in major complications. The treatment of choice for AC for many surgeons is OC because it has an acceptable morbidity and mor- tality rate" Any alternative lo this treatment must im- prove the results obtained with this technique, The in- ‘idence of complications in our series was greater with, (OC than with LC, although not significantly (P=.06). IF we classify these complications according to severity, we see that mild complications (grade 1), which usually oc- cur in any postoperative period (eg, phlebitis and ady- namic ileus), were more frequent in patients who un- derwent OC than in those who underwent LC because the postoperative period was significantly (P<.01) longer for these patients (8.1 vs 3.3 days). Conversely, the amount of moderate or severe complications (grades 2, 3, and 4), usually related to surgical technique, was simi lar in both groups of patients We believe that LC is safe, valid alternative to OC {im patients with AC. The procedure has a low rate of com- plications, implies a shorter hospital stay, and offers the patient a more comfortable postoperative period than OC. The threshold for conversion to OC must be low so that the rate of complications is also low. Reprints: J. A. Lujan, MD, PhD, Departmento de Cirugia General, Hospital Universitario “Virgen de la Arrixaca, 30120 El Palmar (Murcia), Spain. Es} 4. Cuchi A Oboe F, Maui tl The European experiance with pt Scope elecjtcony- An. Su 19116138 Datos Fett, Lev H. Laparoscopic cblestcomy stor pe spec and pesca experience. Suy Laas Enos 109115257. ‘Sj AT. Reds, On DO, Lagwescniclase chleysecomy nas 1550 procadres. Surg Laparse Enos. 1001127 Cameron JC, GafacrTA.Laparseope hls, Aon Sug. 1861.24 a Fried 6, Sigman HH, Mens J et Managment of acute lest by laparoscope choccy. Sry Ese. 1002538 lr RE: Kimi FM, Lapa eolestecty or acu choles te, Sup Ens 10087206700 Pris EH, Carol, alls MU. Laparoscopy gud cholestrom2 erate pao es 153 cases pane yon sup eam. A Sug. Sones0 285202 Lujan, Pail, Rls, tal Liprseapi choleystecony inte wa met of ecole. JCal Sug. 1805187377. Clava PR, Sarai JR, Sastry SD. Popased cassia of comps nsf sugary wih ramps of uy in chester. Suen 18211 siesae 10. Rater OW, Ferguson 0, Warshaw AL. Fas aso wth success laparoscopic coleeystecomy of aut holes. Aan Sur, 1093.21 a2 1. Nery 5, Horn, Holnin.Sjdl A TapessonO aro dada tet in sete choles acne ta Br Surp G3 70408-11 clinical research, he Archives of Surgery will give priority review and early publication to seminal ‘works. This policy will include baste science advancements in surgery and critically performed (©1908 American Med Downloaded From: on 08/08/2018 Association, All rights reserved.