Filler POEM

Early surgery for acute calculous cholecystitis is better than delayed

BMJ 2004; 329 doi: (Published 21 October 2004) Cite this as: BMJ 2004;329:0-f

Question For patients with acute calculous cholecystitis, is it better to do surgery immediately or let them “cool off” first?

Synopsis The decision to perform open or laparoscopic surgery on patients with acute calculous cholecystitis, and whether that surgery is done during the initial hospital admission or later, after symptoms have “cooled down,” seems to depend largely on the surgeon. This meta-analysis with uncertain allocation, identified all available prospective randomised trials on the topic to try to provide a more solid evidence base for this decision. They identified nine studies with a total of 916 patients who underwent early or delayed open cholecystectomy, and three studies with a total of 228 patients who underwent early or delayed laparoscopic surgery. Most excluded patients with peritonitis, pancreatitis, or jaundice or who were otherwise at high risk. Patients in the early surgery group had surgery within seven days after onset of symptoms; those in the delayed surgery group typically had surgery about 6-12 weeks later. The exception was one of the laparoscopy studies, in which patients had early surgery within 72 hours or delayed surgery five days after admission. Analysis was by intention to treat, and most studies were of fair methodological quality (2 or 3 on the 5 point Jadad scale). Outcomes were consistent between studies for most variables. More patients in the open cholecystectomy group died than in the delayed surgery group (7/448 v 1/468), but this was not statistically significant (pooled rate difference −0.85%; 95% confidence interval −2.3% to 0.6%). The likelihood of complications was similar (1.4%; −3.8% to 6.5%). No deaths occurred in the studies of early versus delayed laparoscopic cholecystectomy, and the likelihood of complications was not significantly different (10.9% v 15.6%; difference −3.1%; −15 to 8.9%). Patients undergoing delayed surgery had longer total hospital stays (17.8 days v 9.6 days), although it is unclear whether this large a difference would occur in the United States, given the generally shorter length of stays.

Bottom line Early open or laparoscopic surgery for acute calculous cholecystitis was not associated with greater mortality or morbidity—in fact, trends were toward lower mortality and morbidity—and resulted in shorter hospital stays and lower costs.

Level of evidence 1a (see Systematic reviews (with homogeneity) of randomised controlled trials.


Papi C, Catarci M, D'Ambrosio L, et al. Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis. Am J Gastroenterol 2004;99: 147-55

©infoPOEMs 1992-2003


  • * Patient-Oriented Evidence that Matters. See editorial (BMJ 2002;325: 983

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