Early cholecystectomy for acute cholecystitis in a low income setting: a myth?

Abstract

Laparoscopic cholecystectomy is the gold standard surgical management for acute cholecystitis (AC). Controversy exists regarding the optimal timing to perform laparoscopic cholecystectomy in AC. The Tokyo consensus guidelines 2013 (TCG13) are the most widely used and accepted management guidelines in acute cholecystitis. These guidelines advocate early laparoscopic cholecystectomy (ELC) in patients presenting within 72 hours of onset of symptoms of acute cholecystitis. This has several advantages such as sorting the patient's problem during the first admission, decrease in overall hospital costs by avoiding a second admission and averting po sible occmrence of gallstone related complications whilst awaiting delayed cholecystectomy. Traditionally a delayed cholecystectomy has been the preferred approach in acute cholecystitis with a theoretical advantage of avoiding a cholecystectomy in acutely inflamed tissues thereby avoiding complications of major ductal or vascular injuries. It has been shown in several studies however that morbidity, m01tality and conversion rates are similar in early laparoscopic cholecystectomy and in delayed laparoscopic cholecystectomy.

There are only a handful of studies from the developing world regarding management and the timing of intervention in acute cholecystitis. ·We therefore studied our profile of patients and compare these to the patient populations commonly cited in literature mostly from first world countries. Late presentation outside the window for early intervention, limited availability of transport to a health care facility with expertise to perform laparoscopic cholecystectomy, limited diagnostic modalities like ultrasound and limited laparoscopic services are amongst the common challenges faced by developing countries. This may potentially exclude a large number of patients for consideration for early laparoscopic cholecystectomy.

This is a retrospective chart review looking at all adult patients who were 18 years and older who presented to King Edward VIII in South Africa between 01 January 2013 and 31 December 2013, who have a confirmed diagnosis of acute cholecystitis and had a cholecystectomy. Data was retrieved from the patients' admission and in-patient files and theatre records. Diagnosis was established using clinical and laboratory criteria and a confirmatory ultrasound, as per the TCG13. We looked at the time of presentation to the health care facility from the initial onset of symptoms of acute cholecystitis, patient demographics, type of operation i.e. laparoscopic or open surgery, reasons and rate of conversion from laparoscopic to open surgery, time taken from initial presentation to time of operation. All patients meeting the inclusion criteria were included in this study. A total of 176 files were evaluated and 139 of them had complete records for inclusion in the study.

Findings from this study showed that the majority of patients present late i.e. after 72 hours and after 7 days of onset of symptoms when using the two commonest definitions of early presentation. A delayed laparoscopic cholecystectomy was the most commonly performed surgical intervention for acute cholecystitis. It was shown to be a safe option and was associated with low morbidity and mortality. In low income settings DLC still has a significant role in the management of acute cholecystitis despite the cun-ent recommendations ofELC in acute cholecystitis. Clinicians in low income settings with limited radiologic and laparoscopic services can use the results of this study in managing patients who present outside the window for ELC.

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