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

Background: Early cholecystectomy for acute cholecystitis has proved to reduce hospital length of stay but with no benefit in morbidity when compared to delayed surgery. However, in the literature, early timing refers to cholecystectomy performed up to 96 h of admission or up to 1 week of the onset of symptoms. Considering the natural history of acute cholecystitis, the analysis based on such a range of early timings may have missed a potential advantage that could be hypothesized with an early timing of cholecystectomy limited to the initial phase of the disease. The review aimed to explore the hypothesis that adopting immediate cholecystectomy performed within 24 h of admission as early timing could reduce post-operative complications when compared to delayed cholecystectomy.

Methods: The literature search was conducted based on the Patient Intervention Comparison Outcome Study (PICOS) strategy. Randomized trials comparing post-operative complication rate after early and delayed cholecystectomy for acute cholecystitis were included. Studies were grouped based on the timing of cholecystectomy. The hypothesis that immediate cholecystectomy performed within 24 h of admission could reduce post-operative complications was explored by comparing early timing of cholecystectomy performed within and 24 h of admission and early timing of cholecystectomy performed over 24 h of admission both to delayed timing of cholecystectomy within a sub-group analysis. The literature finding allowed the performance of a second analysis in which early timing of cholecystectomy did not refer to admission but to the onset of symptoms.

Results: Immediate cholecystectomy performed within 24 h of admission did not prove to reduce post-operative complications with relative risk (RR) of 1.89 and its 95% confidence interval (CI) [0.76; 4.71]. When the timing was based on the onset of symptoms, cholecystectomy performed within 72 h of symptoms was found to significantly reduce post-operative complications compared to delayed cholecystectomy with RR = 0.60 [95% CI 0.39;0.92].

Conclusion: The present study failed to confirm the hypothesis that immediate cholecystectomy performed within 24 h of admission may reduce post- operative complications unless surgery could be performed within 72 h of the onset of symptoms.