ESTES PARK, COLO. – Patients hospitalized for prolonged biliary colic cholecystitis should be medically stabilized and then undergo cholecystectomy during the same admission, Dr. David Tanaka advised at a conference on internal medicine sponsored by the University of Colorado.
"I think that’s one of the big changes in the way we do things now. There’s really no benefit to cooling them off and sending them home and having them see the surgeon later. In fact, their outcomes are worse if you do that," according to Dr. Tanaka, a general internist at the university.
Dr. David Tanaka
A major influence on this change in thinking was a meta-analysis involving five randomized clinical trials of early versus delayed laparoscopic cholecystectomy, with the delayed procedures being performed 6-12 weeks after symptoms settled. The analysis included 451 randomized patients with cholecystitis.
The incidence of bile duct injury was 36% lower and the conversion rate to open cholecystectomy was 12% lower in the early-surgery group, although neither of these differences achieved statistical significance.
However, the early-surgery group also averaged a mean 4.12-day shorter total hospital stay than did patients undergoing late cholecystectomy, and that difference was highly significant. Also, 17.5% of patients randomized to delayed laparoscopic surgery wound up undergoing emergency surgery as a consequence of incomplete resolution or recurrence of their cholecystitis during the waiting period. Fully 45% of these emergency laparoscopic cholecystectomies required conversion to open procedures (Br. J. Surg. 2010;97:141-50).
Ten to 15% of adults in Western countries have gallstones, and each year 1%-4% of these individuals become symptomatic. In the United States, historically only about 30% of patients with acute cholecystitis have undergone cholecystectomy during the acute episode.
It’s particularly important that patients admitted with gallstone pancreatitis undergo cholecystectomy prior to discharge. Otherwise they are at risk for frequent recurrences, Dr. Tanaka noted. Surgeons won’t want to operate on them when they have pancreatitis, though, so it’s necessary to treat that condition first. Preoperative endoscopic retrograde cholangiopancreatography is not indicated in all patients with gallstone pancreatitis, but it has been shown to be beneficial in those with persistent obstructive jaundice and/or biliary sepsis, he continued.
Most patients with gallbladder and common bile duct stones undergo preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy. However, a recent meta-analysis demonstrated that intraoperative endoscopic sphincterotomy carried out during laparoscopic cholecystectomy is just as safe and effective as preoperative endoscopic sphincterotomy. And in this meta-analysis involving four randomized trials with 532 patients, intraoperative endoscopic sphincterotomy was associated with a mean 3-day shorter hospital stay (Br. J. Surg. 2011;98:908-16).
"So if you can get your gastroenterologist to coordinate with the surgeons to do it at the time of surgery, you’re probably going to save some hospital days," Dr. Tanaka said.
He reported having no financial conflicts.