Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis: a meta-analysis of randomized clinical trials.

Abstract

Background Early cholecystectomy for acute cholecystitis is reported in the literature to be performed up to 96 hours of admission or up to 1 week of the onset of symptoms. Based on the natural history of acute cholecystitis such timing may have missed some potential benefits that could have been expected by performing cholecystectomy in an earlier phase of the disease. The study aimed to explore the hypothesis that an immediate cholecystectomy performed within 24 hours of admission could reduce post-operative complications when compared with delayed cholecystectomy. Methods The literature search was conducted based on the Patient Intervention Comparison Outcome Study (PICOS) strategy. Randomized trials comparing post-operative complications at different timings of cholecystectomy for acute cholecystitis were included. The main outcome was the post-operative complication rate. Studies were grouped based on the timing of cholecystectomy which was defined immediate when performed within 24 hours of admission, early when performed up to 96 hours of admission and delayed when surgery was elective after medical treatment. Pooled data of studies comparing post-operative complications after immediate versus delayed and early versus delayed cholecystectomy were analysed within a sub-group analysis. The literature search finding allowed the performance of a second analysis in which immediate cholecystectomy did not refer to a cholecystectomy performed within 24 hours of admission but within 72 hours of the onset of symptoms. Results Immediate cholecystectomy performed within 24 hours of admission did not prove to reduce post-operative complications with relative risk (RR) 1.89 and its 95% confidence interval (CI) [0.76; 4.71]. When the timing was based on the onset of symptoms, immediate cholecystectomy performed within 72 hours of the onset of symptoms was found to reduce post-operative complications compared to delayed cholecystectomy with RR 0.57 [95% CI: 0.37;0.89]. Conclusion The present study did not confirm the hypothesis that immediate cholecystectomy performed within 24 hours of admission may reduce post- operative complications. However, the finding of studies in which timing referred not to admission but to the onset of symptoms, allows to favour immediate cholecystectomy if performed within 72 hours of the onset of symptoms.