Does the timing of surgical intervention in case of Acute cholecystitis alter the Patient outcome ?

Dr. Aniz Ratani, DNB Trainee Dept. Of General Surgery. Dr. Sajeesh Sahadevan, Dr. Rajesh Nambiar, Dr. Rohit Ravindran . Department of Gastro Intestinal Surgery Dr. Rojan Kuruvilla , Dr. Sajan P , Dr. Subhash VC . Dept Of General Surgery.

Malabar Institute Of Medical Sciences,Kozhikode

Introduction
Laparoscopic cholecystectomy (LC) is the gold standard treatment
Optimal surgical timing is of major importance and still a debatable issue. Delayed presentation frequently encountered in a large urban hospital has therefore resulted in many surgeries performed within the period of subacute inflammation. Studies showed readmission of patients before interval cholecystectomy either due to recurrent biliary colics or underlying sepsis.

Aims and Objectives

The objective of the study is to see whether the timing of surgery in acute cholecystitis influences patient outcomes in terms of morbidity, mortality and duration of stay in the hospital.

Sample Size and Population

The study was carried out in Malabar Institute of Medical Sciences from the period of July 2012 to December 2012, obtaining a sample size of 100. The patients diagnosed to have Acute Cholecystitis were divided into 3 groups. Grp A Operated upon within 7 days of onset of symptoms. Grp B Operated between 8th day till 6 weeks. Grp C Operated after 6 weeks of duration.

Material and Methods

Diagnosis.
Grouping. Surgery performed with standard 4 ports. Interim-Analysis

Analysis and Results

Population
> 6 weeks(C) , 11

< 7 days( A ) < 7 days( A ), 50 8 to 6 weeks( B ) , 39

8 to 6 weeks( B )
> 6 weeks(C)

Mean Age Distribution

80 70 60 50

Age (in yrs )

57.85 44.7 48.23

40
30 20 10 0 A B C

Males Vs Females
60 50

40
30 20

13 11

Females Males

37 28

10
0 A B

4
7 C

Operative Period Time

Time in minutes
150

131.72 93.85 114.33

100

50 0 A B

Significance
Group A B C Mean Surgery time 93.85 131.72 114.33 Range 35 - 165 75- 224 58 - 181

There is a significant difference in the surgery time between groups. P value = 0.04 which is < 0.05. So average surgery time is high in Group B than in group A

Adhesions
20 15

17

9
10

8 0 6
Fibrinous Dense

5
0 A B C

Dense
Fibrinous

Demographic and perioperative Characteristics.

Characteristic Male / Female Age ( Median ) Complicated Cholecystitis Spillage Drain use Operative time * Group A 37 / 13 44.70 12 Group B 28 / 11 48.23 21 Group C 7/4 57.85 0

3 5 93.85

9 24 131.72

0 0 114.33

* p value < 0.05 , significant difference noted

Conversion Rates and CBD injury

1

0.8
0.6 0.4 0.2 0 A B C Conversion Rates CBD injury

No significant difference was found between the three groups in the parameters of conversion rates and CBD injury.

Complications
Complications Reoperation Sepsis Group A 0 0 Group B 0 3 Group C 0 0 Total 0 3

Bile Leak
CBD injury Wound infection Paralytic Ileus Others Readmission * Total

0
0 3 2 1 0

0
0 5 4 1 0

0
0 0 0 0 0

0
0 8 6 2 0 19

* till Jan 2013

Average Length of Stay ( days )

Days

7 6 5 4 3 2

6.17 5.19 4.57

Days

1
0

Significance
Group Mean length of stay ( in days ) Standard Deviation

A
B C

4.57
6.17 5.19

1.66
3.28 1.83

There was a significant difference in the length of stay between groups. P value = 0.008 < 0.05. The average length of stay was found to be lower in the Group A ( acute group )

Conclusion
The best timing for a cholecystectomy in Acute cholecystitis was within 7 days after the initial symptoms.

Safe cholecystectomy was possible even after 7 days though the operating time and the hospital stay was slightly more.
Timing of intervention did not increase the morbidity or the mortality.

Thank You