LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS - PROSPECTIVE TRIAL

This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy (LC) following the onset of acu te cholecystitis. It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis. Having been es tablished as the procedure of choice for elective cholelithiasis, LC i s now also used for management of acute cholecystitis. Under these cir cumstances the procedure may be difficult and challenging. Certain fav orable and unfavorable conditions may be present that influence the co nversion and complication rates. Information about these conditions ma y be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided. We performed LC on an emergency basis a s soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995. All preoperative, o perative, and postoperative data were collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seve n patients found by laparoscopic intraoperative cholangiography to hav e choledocholithiasis were converted for common bile duct exploration and were excluded from the study. Altogether 93 patients (72%) underwe nt successful LC and 37 (28%) needed conversion to open cholecystectom y. The conversion rate of acute gangrenous cholecystitis (49%) was sig nificantly higher than that for uncomplicated acute cholecystitis (4.5 %) (p < 0.00001) and for hydrops (28.5%) and empyema of the gallbladde r (28.5%) (p = 0.004). The difference in conversion between the group with acute necrotizing (gangrenous) cholecystitis and the two groups w ith hydrops and empyema of the gallbladder was not statistically signi ficant (p = 0.07). The complication rates of acute cholecystitis, hydr ops, empyema of the gallbladder, and gangrenous cholecystitis were 9.0 %, 9.5%, 14.0%, and 20.0%, respectively (p = NS). Patients with an ope rative delay of 96 hours or Less from the onset of acute cholecystitis had a conversion rate of 23%, whereas a delay of more than 96 hours w as associated with a conversion rate of 47% (p = 0.022). The complicat ion rate was 8.5% in the laparoscopic group add 27% in the converted g roup (p = 0.013). Patients over 65 years of age, with a history of bil iary disease, a nonpalpable gallbladder, WBC count over 13,000/cc, and acute gangrenous cholecystitis were independently associated with a h igh LC conversion rate; male patients, finding large bile stones, seru m bilirubin over 0.8 mg/dl, and WBC count over 13,000/cc were independ ently associated with a high complication rate following laparoscopic surgery with or without conversion. Generally, LC can be performed saf ely for acute cholecystitis, with acceptably low conversion and compli cation rates. Different forms of cholecystitis carry various conversio n and complication rates in selected cases. LC for acute cholecystitis should be performed within 96 hours of the onset of disease. Predicto rs of conversion and complications may be helpful when planning the la paroscopic approach to acute cholecystitis.