Regarding the optimal timing of cholecystectomy, there have been some reports about patients after percutaneous transhepatic gallbladder drainage (PTGBD) (9–13), but there are very few reports on the optimal timing of surgery for cases after hospitalization and conservative treatment.
However, this study does not deny the benefit of conducting urgent cholecystectomy within 72 hours for acute cholecystitis. Instead, we examined the second-best timing of cholecystectomy for patients who had missed the best opportunity for surgery due to preoperative condition, complications, or re-hospitalization from other hospitals.
Ohta et al (17) reported that cholecystectomy for acute cholecystitis should be performed as soon as possible. They concluded that there were no significant differences in the conversion rate, operation time, blood loss, postoperative morbidity, or hospital stay length. These four groups were within 72 hours, within 4 days-2 weeks, 3–6 weeks, and 6 + weeks.
Therefore, we conducted our study simply in two groups, 4–89 days and 90 + days, focusing on the timing of surgery after conservative treatment, including readmission.
There were no significant differences in patient age, gender, height, body weight, or BMI, but preoperative data showed that the WBC and the value of CRP were significantly higher in the Early group, and the inflammatory response remained when the laparoscopic cholecystectomy was performed. Whereas there were no significant differences in total bilirubin, AST, ALT, PT, or preoperative liver function. Moreover, there were no significant differences in preoperative conditions or complications.
However, regarding surgical factors, our data showed that the operative time was significantly longer in the Early group. Furthermore, there was no significant difference in the amount of bleeding, but it was shown that it tended to be higher in the Early group. These seemed to indicate the difficulty of surgery in early cases where inflammation remained. These seemed to be the same tendency in the literature of cases in which PTGBD was inserted (12, 18). Furthermore, the conversion rate, length of hospital stay, and postoperative complications, tended to be more in the early group, especially the length of hospital stay was significantly longer. Similarly, these also seemed to indicate the difficulty of surgery in early cases where inflammation remains. In addition, as the progression of fibrosis made an adequate layer disappear, it could make LC more difficult after severe cholecystitis (19).
Some previous reports indicated that early surgery for acute cholecystitis shortened the length of hospital stay (20–22). However, our data revealed that the length of hospital stay was reduced in the Delay group. That could be because, in our data, almost all patients were readmitted, including from other hospitals. Therefore, the calculation of hospital stay was the same as for the first hospitalization, and the inflammation could be sufficiently relieved.
For postoperative complications, multivariate analysis did not extract independent risk factors. However, its analysis extracted high levels of CRP as independent risk factors for conversion. This fact could indicate that in early cases where the inflammatory reaction persists or prolongs, the difficulty of adhesion detachment and the risk of bleeding increases, resulting in a conversion.
In patients with cholecystitis who had undergone conservative treatment and missed the opportunity for cholecystectomy within three days, it is recommended that laparoscopic cholecystectomy is performed after 90 days or more.
The limitations of our study are sample size, that the analysis was limited to a single institution, and that the study had a retrospective design. Further analysis and more patients are needed to confirm our conclusion.