What is early cholecystectomy (surgical removal of the gallbladder within 24 hours of symptom onset) compared to delayed cholecystectomy associated with?

Early Cholecystectomy vs. Delayed Cholecystectomy in Acute Cholecystitis

Early cholecystectomy (<24hrs) compared to delayed cholecystectomy is associated with shorter hospital stay and fewer complications, without any increase in mortality, biliary system injury, or overall morbidity. 1

Evidence for Early vs. Delayed Cholecystectomy

Hospital Stay

• Early laparoscopic cholecystectomy (ELC) results in a significantly shorter total hospital stay compared to delayed laparoscopic cholecystectomy (DLC), with approximately 4 days shorter hospitalization 1
• Multiple randomized controlled trials consistently show reduced length of stay with early intervention 2, 3
• Even in elderly patients, early laparoscopic cholecystectomy is associated with shortened hospital stay 1

Complications and Morbidity

• Early cholecystectomy is associated with fewer overall complications compared to delayed cholecystectomy 4, 5
• The number of serious adverse events was significantly less with ELC compared to DLC in trials reporting this outcome 1
• Early intervention reduces the risk of recurrent gallstone-related complications that can occur during the waiting period for delayed surgery 1

Mortality and Biliary System Injury

• There are no significant differences in mortality between early and delayed cholecystectomy approaches 1
• No evidence shows increased biliary system injury rates with early cholecystectomy 1, 5
• Conversion rates from laparoscopic to open cholecystectomy are not significantly different between early and delayed approaches in most studies 1

Other Benefits of Early Cholecystectomy

• Patients undergoing early cholecystectomy return to work approximately 9 days sooner than those with delayed surgery 1
• Early cholecystectomy is associated with shorter duration of antibiotic therapy 4
• Total hospital costs are lower with early cholecystectomy compared to delayed approaches 4, 3

Timing Recommendations

• The World Society of Emergency Surgery strongly recommends early laparoscopic cholecystectomy within 7 days of hospital admission and within 10 days of symptom onset 1
• Even beyond the traditional 72-hour window, early cholecystectomy remains beneficial compared to delayed cholecystectomy 4, 6
• In elderly patients, early laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days of onset of symptoms 1

Special Considerations

• For patients with high surgical risk (ASA III/IV, performance status 3-4, or septic shock), percutaneous cholecystostomy can be considered as an alternative when patients are deemed unfit for surgery 1
• In cases of severe local inflammation, gangrenous gallbladder, or difficult anatomy, subtotal cholecystectomy (either laparoscopic or open) is a valid option 1
• Conversion to open surgery should be considered in cases of local severe inflammation, adhesions, bleeding in Calot's triangle, or suspected bile duct injury 1

Clinical Practice Recommendations

• Laparoscopic approach should always be attempted first for acute cholecystitis, except in cases of absolute anesthetic contraindications or septic shock 1
• Early cholecystectomy should be performed by experienced surgeons due to potentially greater technical complexity 1
• If early cholecystectomy cannot be performed, delayed cholecystectomy (after 6 weeks) is preferable to intermediate cholecystectomy (between 7 days and 6 weeks) 1

The evidence strongly supports early cholecystectomy as the preferred approach for acute cholecystitis, with clear benefits in terms of hospital stay and complications without increasing risks of mortality or biliary injury.