acute cholecystitis as a major complication of gallstones is diagnosed in 10% to 35% of patients admitted for cholecystectomy .
the anatomy at calot 's triangle in acute cholecystitis is distorted due to adhesions . as such , cholecystectomy for this condition
is technically demanding , time consuming , and results in high morbidity . in the prelaparoscopy era , the traditional management of patients with acute cholecystitis included initial conservative treatment to  cool down  the inflamed gallbladder followed by delayed open cholecystectomy ( oc ) several weeks later .
this approach , however , was challenged by early oc , first advocated by essenhigh in 1966 . since then , several randomized studies have shown that early oc for acute cholecystitis is as safe as delayed oc with reduced morbidity and hospital stay , lower costs , and rapid recovery .
it appears that laparoscopic treatment of acute cholecystitis is following the same trend as oc .
initially , laparoscopic cholecystectomy ( lc ) was contraindicated in patients with acute cholecystitis because of the fear of increased morbidity and high rates ( 60% ) of conversion to oc that negate the advantages of laparoscopic surgery .
indeed , the bile duct injury of 5.5% during lc for acute cholecystitis was a major concern .
on the other hand , initial medical treatment for acute cholecystitis followed by delayed lc is associated with several shortcomings .
first , 20% to 26% of patients fail to respond to conservative treatment or develop early complications during the first admission and require an urgent and technically demanding cholecystectomy .
secondly , another 15% to 30% of patients are readmitted with recurrent symptoms and undergo an unplanned emergency cholecystectomy while waiting for their scheduled elective procedure .
thirdly , a small proportion ( 2.2% ) of patients is lost during the interval period . finally , at times the shrunken
, scarred gallbladder and dense fibrotic adhesions at calot 's triangle make interval lc extremely difficult and unsafe . as a result of these events and because of increasing experience and confidence in lc , the indications were extended to include patients with acute cholecystitis .
several randomized and nonrandomized studies have documented the feasibility and safety of early lc for acute cholecystitis in experienced hands . in our setting , we have offered lc for all patients with symptomatic gallstones , and our initial experience with early lc in 45 cases of acute cholecystitis showed a low conversion rate and no major bile duct injury or mortality .
the aim of this study was to determine the optimal timing of early lc for acute cholecystitis .
this study included all consecutive patients who underwent early lc for acute cholecystitis at king fahd hospital of the university , al - khobar , saudi arabia , between january 2001 and december 2006 .
the diagnosis of ac was based on the presence of at least 2 of the following criteria : ( 1 ) acute upper abdominal pain and murphy 's sign , ( 2 ) fever > 37.5c and white blood cell count > 10x10/l , and ( 3 ) ultrasound findings of thick - walled gallbladder , ultrasound murphy 's sign , and pericholecystic fluid , in the presence of gallstones .
exclusion criteria included ( 1 ) patients who had no gallstones , ( 2 ) those who were not operated on , ( 3 ) those who had incomplete data , ( 4 ) those who had an oc to start with , ( 5 ) those who had delay due to obstructive jaundice , ascending cholangitis , biliary pancreatitis , or comorbid diseases .
because previous reports , including our own experience , have shown that lc for acute cholecystitis is best performed within 72 hours of admission , the patients were divided into 2 groups , depending on the timing of lc after admission : group 1 within 72 hours and group 2 after 72 hours . on admission , all patients received intravenous second - generation cephalosporin plus metronidazole , which were continued for 24 hours after surgery .
laparoscopic cholecystectomy was performed in both groups by 5 surgeons with similar distribution of early and delayed lcs and the same technique described previously .
patients were followed up for 6 weeks and were discharged home unless they had postoperative complications .
patient demographics , white blood cell count , ultrasound findings , time from admission to surgery , operation time , conversion to oc , complications , postoperative stay , and total hospital stay were analyzed .
statistical analysis was performed using the t test , chi - square test , and fisher 's exact test , with significance set at p<0.05 .
there were 196 patients with acute cholecystitis ; 56% were females , and the mean age was 41.3 years ( range , 13 to 81 ) .
laparoscopic cholecystectomy was performed within 72 hours of admission in 82 patients ( group 1 ) and after 72 hours in 114 patients ( group 2 ) .
both groups were matched in terms of age , sex , body mass index , systemic manifestations , and ultrasound findings ( table 1 ) .
the mean operation time , including conversions , was 117.254.6 minutes ( range , 30 to 300 ) .
the mean postoperative stay was 3.72.5 days ( range , 1 to 17 ) , and the mean total hospital stay was 9.25.6 days ( range , 2 to 28 ) for all patients .
early laparoscopic cholecystectomy ( lc ) for acute cholecystitis : patient demographics * data are presented as mean  standard deviation unless otherwise indicated .
table 2 shows that there were 2 conversions ( 2.4% ) in group 1 and 8 in group 2 ( 7% ) ( p=0.3 ) .
obscure anatomy at calot 's triangle was the sole reason for conversion in group 1 .
the reasons for conversion in group 2 were obscure anatomy at calot 's triangle in 4 patients and difficulty to expose the gallbladder due to severe omental adhesions , inability to grasp the friable gallbladder , liver bleeding , and common bile duct injury in one case each .
results of early laparoscopic cholecystectomy ( lc ) for acute cholecystitis * data are presented as mean  standard deviation unless otherwise indicated .
however , 7 ( 6% ) complications occurred in group 2 ( p=0.02 ) and included 2 cases of respiratory infection , and a case each of cbd injury , retained cbd stone , subhepatic collection due to cystic duct leak , wound infection , and liver bleeding .
the cbd injury was managed with immediate conversion and hepatico - jejunostomy . the liver bleeding required conversion and blood transfusion
. retained cbd stone was managed with endoscopic retrograde cholangiopancreatography ( ercp ) and stone extraction .
the case of cystic duct leak required ercp and percutaneous drainage der ultrasound / ct guidance .
the mean operation time was 10549.5 minutes in group 1and 12656.9 minutes in group 2 ( p=0.008 ) .
the mean postoperative stay was 3.42.2 days in group 1 and 42.7 days in group 2 ( p=0.1 ) .
the mean total hospital stay in group 1 was 5.12.3 days compared with 12.25.3 days in group 2 ( p=0.001 ) .
there were 196 patients with acute cholecystitis ; 56% were females , and the mean age was 41.3 years ( range , 13 to 81 ) .
laparoscopic cholecystectomy was performed within 72 hours of admission in 82 patients ( group 1 ) and after 72 hours in 114 patients ( group 2 ) .
both groups were matched in terms of age , sex , body mass index , systemic manifestations , and ultrasound findings ( table 1 ) .
the mean operation time , including conversions , was 117.254.6 minutes ( range , 30 to 300 ) .
the mean postoperative stay was 3.72.5 days ( range , 1 to 17 ) , and the mean total hospital stay was 9.25.6 days ( range , 2 to 28 ) for all patients .
early laparoscopic cholecystectomy ( lc ) for acute cholecystitis : patient demographics * data are presented as mean  standard deviation unless otherwise indicated .
table 2 shows that there were 2 conversions ( 2.4% ) in group 1 and 8 in group 2 ( 7% ) ( p=0.3 ) .
obscure anatomy at calot 's triangle was the sole reason for conversion in group 1 .
the reasons for conversion in group 2 were obscure anatomy at calot 's triangle in 4 patients and difficulty to expose the gallbladder due to severe omental adhesions , inability to grasp the friable gallbladder , liver bleeding , and common bile duct injury in one case each .
results of early laparoscopic cholecystectomy ( lc ) for acute cholecystitis * data are presented as mean  standard deviation unless otherwise indicated .
no complications occurred in group 1 . however , 7 ( 6% ) complications occurred in group 2 ( p=0.02 ) and included 2 cases of respiratory infection , and a case each of cbd injury , retained cbd stone , subhepatic collection due to cystic duct leak , wound infection , and liver bleeding .
the cbd injury was managed with immediate conversion and hepatico - jejunostomy . the liver bleeding required conversion and blood transfusion .
retained cbd stone was managed with endoscopic retrograde cholangiopancreatography ( ercp ) and stone extraction .
the case of cystic duct leak required ercp and percutaneous drainage der ultrasound / ct guidance .
the mean operation time was 10549.5 minutes in group 1and 12656.9 minutes in group 2 ( p=0.008 ) .
the mean postoperative stay was 3.42.2 days in group 1 and 42.7 days in group 2 ( p=0.1 ) . the mean total hospital stay in group 1 was 5.12.3 days compared with 12.25.3 days in group 2 ( p=0.001 )
a review of the literature over the past decade shows that early and delayed lc for acute cholecystitis are safe with similar conversion rates , operation time , and overall complications .
however , early lc results in significantly shorter hospital stay and avoids the risks of failed conservative treatment .
this approach is well supported by a recent international consensus published as tokyo guidelines . with increased experience , improved skills , and new instruments ,
the high rates of conversion to oc , prolonged operation time , and increased morbidity , particularly cbd injury , of early lc for acute cholecystitis have been dramatically reduced . despite this acceptable level of outcome
, acute cholecystitis remains the most significant risk factor for conversion and complications of lc .
furthermore , the timing for the procedure is a hotly contested issue and in all probability a strong predictor of success of lc for acute gallstone disease . in this series , the overall conversion rate ( 5% ) to oc
conversion rates tend to have a wide range ( 0% to 39% ) with an overall rate of 16% .
these inconsistent results are attributed to differences in patient demographics , severity of inflammation , surgeon 's experience , and timing of early lc .
it is worth mentioning that the overall conversion rate of 5% in this study is similar to the 6.7% conversion rate reported in our initial experience and probably reflects a sustained experience of the team in the management of acute cholecystitis . as expected , the most common reason for conversion among our patients was distorted anatomy at calot 's triangle due to inflammatory changes . although our rate of complications is generally acceptable ( table 3 ) , all complications , including the single cbd injury , were limited to group 2 patients who had lc 72 hours after admission .
it is worth noting that we had no single case of cbd injury in our initial experience with lc performed during the first 72 hours of admission for acute cholecystitis .
results of trials addressing timing of early laparoscopic cholecystectomy for acute cholecystitis lc = laparoscopic cholecystectomy ; ot = operation time ; ns = not significant ; nr = not reported .
the question of relating the timing of lc for acute cholecystitis to admission or onset of symptoms has been overemphasized . in our view
we do , however , concur that patient - physician factors , such as patient delay of more than 48 hours and a variable delay in diagnosis , influence surgical decisions and timing of intervention .
these tend to vary considerably according to the population attitude to illness and type of health care facility . based on international experience and our own results ,
it is our observation that lc within this period is technically less demanding because the edema planes magnify the structures and facilitate dissection 
a compelling argument in favor of early lc for acute cholecystitis is the morbidity and escalating cost of prolonged waiting time for surgery following conservative treatment at index admission .
somasekar and colleagues in the united kingdom found that 58% of patients were readmitted as emergencies , some with biliary pancreatitis , necessitating laboratory and x - ray investigations , thereby escalating the cost of emergency care by as much as  1544 per patient .
lawrentschuk et al in australia found that the cost per patient for emergency readmission while on the waiting list was $ a 6129 compared with $ a 3725 for an uncomplicated elective lc .
in addition , these findings do not take into account the  patient suffering , loss of work hours and income , and the effect on the community as a whole .  in the realm of cost - benefit analysis , lc has been evaluated , and the overall cost of the procedure is cheaper than oc , mainly because the patient 's stay in the hospital is shortened .
the key question in the economics of lc is the overall hospital stay as end point .
analysis of 5 recent studies including our series ( table 3 ) shows that the total hospital stay is significantly less when lc for acute cholecystitis is performed early irrespective of the conversion .
stevens and colleagues reported a mean total stay as low as 2.6 days , and this is achievable now that the role of clinical pathways and specialist - led services are available in some countries .
caplan et al in australia prospectively studied the effect of reengineered surgical service ( consisting of a perioperative unit , preadmission anesthetic assessment , day of surgery admissions , enhanced patient education , clinical pathways , and postacute care ) on total costs , patient satisfaction , time off work , and pain score in 224 patients .
they concluded that besides high patient satisfaction with the treatment , the cost savings to the hospital outweighed the cost of increased services in the community .
mercer and colleagues listed similar clinical and economic benefits in their specialist - led service for the management of acute gallstone disease in the united kingdom .
in addition , uchiyama et al in japan highlighted the role of clinical pathways in reducing hospital stay and cost of laparoscopic surgery .
our overall mean total hospital stay of 9 days is considerably longer than that reported in the current literature .
then ours is not an lc - specific facility , and lc for acute gallstone disease has to fit in with the rest of the operating room schedule . besides
we also have to satisfy cultural and social demands of the population . as yet , there is no insurance - related scheme in our institution that would trigger the development and introduction of specialist - led or reengineered service with suitable clinical pathways .
our future plan of reorganization is on the drawing board , and we already have some of the components of a dedicated and specialist - led unit , ie , a short - stay / outpatient facility , and preadmission anesthesia clinic
. we are hopeful that in future reporting the current halfway facility would evolve into a dedicated and internationally comparable laparoscopic unit .
laparoscopic cholecystectomy for acute cholecystitis performed within the same admission is safe and associated with a low conversion rate and no mortality .
however , lc should be performed as early as possible , preferably within the golden period of 72 hours after admission , to decrease the morbidity rate , operation time , and total hospital stay .
 objective : although many surgeons advocate early laparoscopic cholecystectomy ( lc ) in acute cholecystitis , debate still exists regarding its optimal timing . this study compares the outcome of lc performed within and after 72 hours of admission in patients with acute cholecystitis.methods:between january 2001 and december 2006 , lc was performed in 196 consecutive patients with acute cholecystitis . 
 laparoscopic cholecystectomy was performed within 72 hours of admission in 82 patients ( group 1 ) and after 72 hours in 114 patients ( group 2 ) . 
 data were collected prospectively.results:both groups were matched in terms of age , sex , body mass index , fever , white blood cell count , and ultrasound findings . 
 the overall conversion rate was 5% . 
 no significant difference existed in conversion rates between group 1 ( 2.4% ) and group 2 ( 7% ) ( p=0.3 ) . the operation time ( 105 versus 126 minutes , p=0.008 ) , complications ( 0% versus 6% , p=0.02 ) , and total hospital stay ( 5 versus 12 days , p<0.001 ) 
 were significantly reduced in group 1 . 
 no deaths occurred in this study.conclusion:early lc can be performed safely in most patients with acute cholecystitis , but we recommend intervention within 72 hours of admission to minimize the complication rate and shorten the operation time and total hospital stay . 
INTRODUCTION
METHODS
Statistics
RESULTS
Overall Results
Conversion Rates
Complications
Operation Time
Hospital Stay
DISCUSSION
CONCLUSION