Evaluation of management strategies in the surgical treatment of gallstone disease

Abstract

Introduction: In the surgical treatment of gallstone disease, different management strategies may result in different clinical outcome. In the case of acute cholecystitis the controversies are regarding the timing of surgery and the choice of surgical technique. For uncomplicated gallstone disease the surgical setting (day-care or overnight stay) is the focus of interest. The aim of the present thesis was to investigate differences in clinical outcome for the different management strategies.Material and methods: All studies were designed as randomized controlled trials. Different aspects of optimal timing for surgery in the case of acute cholecystitis, was studied by comparing laparoscopic cholecystectomy in the acute phase, to initial conservative treatment followed by elective laparoscopic cholecystectomy 6-8 weeks later (I-II). The third trial (III) was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis. The impact of choice of surgical setting (day-care versus overnight stay) in laparoscopic cholecystectomy for uncomplicated gallstone disease was also investigated (IV).Results: Regarding early or delayed laparoscopic cholecystectomy, there was no significant difference in conversion rates, operating times, or complications. Failure with the conservative treatment strategy was noted in 26% of these patients. Total hospital stay was significantly shorter in the early operation group, and they also showed a significant reduction of gastrointestinal symptoms during the first postoperative month. When operating in the acute phase, choice of procedure (open vs laparoscopic) showed no significant differences in complication rates, pain scores at discharge or sick leave. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group. Results from laparoscopic cholecystectomy for uncomplicated gallstone disease in day-care vs overnight stay showed no major significant differences in quality of life variables. Admission rate for day-care patients was 8%. There were no readmissions in either group, and there was no difference in complication rates.Conclusion: The main goal in the management of acute cholecystitis should be to perform a cholecystectomy in the acute phase of the disease. Acute laparoscopic cholecystectomy offers an advantage over a delayed operation strategy in terms of shorter total hospital stay, without an increase of complications or conversion rate. The acute operation strategy reduces gastrointestinal symptoms during the first postoperative month and provides a more rapid improvement of quality of life. The difference in clinical outcome between an open or laparoscopic approach is minor, and of no significant clinical importance. In the treatment of uncomplicated gallstone disease, laparoscopic cholecystectomy as a day-case procedure can be performed with a low rate of complications and admissions/readmissions. Regarding patient acceptance in terms of quality of life variables, no major differences between the groups could be demonstrated.