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Annals of Emergency Surgery
Research Article *Corresponding author
Mohamed Samir Abou-Sheishaa, Department of

When to do Laparoscopic General Surgery, Mansoura University-Faculty of

Medicine, Mansoura city, Goumhoria street, Mansoura
university hospital, Main building, second floor,

Cholecystectomy in Mild Acute department 7, Ezypt, Tel: 002-01019623935; Email:

Biliary Pancreatitis, Early or

Submitted: 24 August 2018
Accepted: 07 September 2018
Published: 10 September 2018

Late? Copyright
© 2018 Abou-Sheishaa et al.

Mohamed Samir Abou-Sheishaa*, Waleed Ahmad Burham, ISSN: 2573-1017

Ashraf Elsayed Abbas, Ibrahim Elsayed Dawoud, Mahmoud OPEN ACCESS

Ahmed Shaker, Ahmed Negm Abdrahman Albany, Nashat Abd
Keywords
El Razek, Magdy Basher • Laparoscopic cholecystectomy; Mild acute
Department of General Surgery, Mansoura University-Faculty of Medicine, Egypt pancreatitis

Abstract
Background: Timing of cholecystectomy in acute biliary pancreatitis has always been a point of debate among surgeons. Our study has been conducted
aiming to compare the safety and efficacy of early versus delayed laparoscopic cholecystectomy in patients with mild acute biliary pancreatitis.
Objective: This study was conducted to compare the benefits and disadvantages of early versus delayed laparoscopic cholecystectomy in patients with
mild acute biliary pancreatitis.
Patients and methods: The 96 eligible patients were randomly distributed into two groups, Group I underwent cholecystectomy during index admission,
and group II underwent late laparoscopic cholecystectomy 25-30 days after discharge. The operative data were recorded for each patient in special sheets.
The patients were followed up for 3 months postoperatively to detect any complications.
Results: 125patients presented with acute biliary pancreatitis between November 2014 and June 2016, 25 patients were excluded because they
did not meet inclusion criteria and 4 patients refused to participate in this study. The remaining 96 patients were randomly distributed into 2 groups by
computer generated program. Group I (50 patients) underwent cholecystectomy during index admission, group II (46 patients) underwent late laparoscopic
cholecystectomy 25-30 days after discharge. There was no statistically significant difference between both groups regarding baseline characteristics including
age and sex. The overall hospital stay was significantly lower in group I than group II. No cases in both groups reported to have biliary injuries.
Conclusion: Early laparoscopic cholecystectomy is preferred over delayed laparoscopic cholecystectomy for cases of acute mild biliary pancreatitis
because it is associated with faster and easier operation, shorter hospital stay and lower recurrence rate with no significant difference regarding postoperative
complications.

INTRODUCTION the early 1990s. Laparoscopic cholecystectomy became the

standard of care for management of gall bladder stones with
Acute pancreatitis is a sudden inflammatory process in the faster recovery, and lower incidence of intra-operative or post-
pancreas which may have an effect on nearby as well as distant operative complications if compared to open surgery [6].
organs [1].
The major complications related to laparoscopic
The commonest 2 causes of acute pancreatitis are biliary and cholecystectomy include injury to bile duct (0.3%) [7], and other
alcoholism, accounting for more than 80% of acute pancreatitis rare complications such as injury to the bowel, and injury to
[2]. It is thought that the passage of a stone through the Ampulla major blood vessels, resulting in an overall mortality of 0.2% [8].
of Vater causes irritation of the pancreatic duct with activation of
pancreatic enzymes inside the pancreas [3]. Although the stone The appropriate timing of cholecystectomy in acute
itself passes into the duodenum, the damage has been done, and pancreatitis depends on the clinical course. Patients with
pancreatitis occurs. There is no major difference in the supportive severe acute biliary pancreatitis with associated multiple
care of biliary and non- biliary pancreatitis [4]. organs dysfunction are, definitely, logical choice for the
initial conservative approach with interval laparoscopic
Cholecystectomy remains the definitive treatment for cholecystectomy 6-8 weeks later after the resolution of the acute
prevention of further attacks of acute gallstone pancreatitis if attack. The major determinant in favor of this approach is the
the person is candidate for surgery [5]. The use of laparoscopic fear of added surgical stress to the morbidities associated with
technology for cholecystectomy has become widespread since severe pancreatitis.

Cite this article: Abou-Sheishaa MS, Burham WA, Abbas AE, Dawoud IE, Shaker MA, et al. (2018) When to do Laparoscopic Cholecystectomy in Mild Acute
Biliary Pancreatitis, Early or Late? Ann Emerg Surg 3(1): 1031.
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Recent evidence, with the introduction of laparoscopic Inclusion criteria

surgery, has suggested that patients with mild gallstone
Patients with the diagnosis of mild acute biliary pancreatitis
pancreatitis, which includes 80% to 90% of all patients with
with Ranson < 3 at admission and after 48 hrs evaluation, Age
gallstone pancreatitis [9], and do not have any associated organ
≥ 18 years, American Society of Anesthesiologists (ASA) I & II
dysfunction, are candidates to early laparoscopic cholecystectomy
patients and the patients being admitted to a non-monitored
during the index admission itself [10]. The most important value
ward bed.
for this is to prevent further attacks of acute pancreatitis, seen in
as many as 30-50% of these patients during the waiting period Exclusion criteria
for delayed laparoscopic cholecystectomy [11]. Necrotizing pancreatitis, Pancreatic infected collection,
Most surgeons agree that timing of the procedure is an Alcohol abuse or other causes of pancreatitis, ≥ 3 Ranson criteria,
important factor in determining prognosis. Debate about Concomitant acute ascending cholangitis, High suspicion for
the timing of cholecystectomy in patients with acute biliary retained common bile duct stone (total bilirubin ≥ 4 mg /dl on
pancreatitis still exists [12]. admission or ultrasound demonstration of common bile duct
stone stone), Pregnancy, need intensive care unit, American
AIM OF THE STUDY Society of Anesthesiologists (ASA) III patients and refusal of
This study was conducted to compare between early and participation.
delayed laparoscopic cholecystectomy in patients with mild A written informed consent from each patient was obtained
acute biliary pancreatitis. before study participation and after full explanation of the
PATIENTS AND METHODS technique and its possible complications. The study was approved
by our faculty ethical committee.
This is a prospective randomized controlled study conducted
All patients were informed about their bilio-pancreatic
at emergency surgery unit, Mansoura University.
pathology and the suggested treatment according to their
All Patients who were admitted to emergency surgery unit, diagnosis, Also the possibility of conversion to open.
Mansoura University, from November 2014 to June 2016, with
All cases were operated by dedicated team including senior
the diagnosis of mild acute biliary pancreatitis are potential
consultants in our university hospital and a specific operative
candidates to participate. Informed written & oral consent was
sheet including adhesions if present and their type fibrinous or
obtained from every patient according to ethical committee of
fibrous , degree difficulty of Calot dissection, gall bladder wall
Mansoura faculty of medicine.
oedema , and drain inserted or not.
Sample selection Pre-operative evaluation of the chest radiographs and
After exclusion of cases of sever biliary pancreatitis with electrocardiogram studies was performed. Patients’ ASA scores
Ranson ≥ 3 and patients who did not meet the inclusion criteria, were recorded.
patients with mild acute biliary pancreatitis proved by clinical, Discharge criteria
laboratory, radiological evaluation and Ranson score < 3 were
included in our study after getting an informed consent. Eligible Clinical (absence of fever, tolerance of oral feeding and
patients re-evaluated clinically, laboratory and radiologically removal of the drain if it was present)
if needed after 48h of hospital admission to confirm that all Laboratory: absence of abnormal liver functions or
admitted patients in our study followed these criteria (discharge leukocytosis
criteria): the patient could be discharged within 1 or 2 days, no
need to give the patient opioid analgesics, C-reactive protein The patients were followed up in outpatient clinic for 6
months. We have 2 types of complications, early within the
levels decreasing (< 100 mg/l), no local or systemic complications
admission or within 2 weeks of discharge, late which is up to 6
(for example, no fever) and the patient could resume oral intake.
months.
Randomization took place after confirmation and patients
Statistical analysis of the data
randomly divided using computer generated program into two
groups (Group I = early group and Group II = late group). Data were analyzed with SPSS version 21. The normality of
data was first tested with one-sample Kolmogorov-Smirnov test.
(Group I) were assigned to do early laparoscopic
cholecystectomy (within 72 hours of the randomization) while Qualitative data were described using number and percent.
patient still in initial hospital admission regardless of resolution Association between categorical variables was tested using Chi-
of abdominal pain or normalization of serum pancreatic enzyme square test while Fischer exact test was used when expected cell
levels. count less than 5.

(Group II) with symptoms that settle down completely and Continuous variables were presented as mean ± SD (standard
all the blood parameters suggestive of pancreatitis to return to deviation and the two groups were compared with Student t test.
normal levels underwent delayed laparoscopic cholecystectomy, Level of significance: For all above mentioned statistical
25-30 days after randomization following discharge from initial tests done, the threshold of significance is fixed at 5% level
hospitalization. (p-value). The results were considered:

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Non-significant when the probability of error is more than bladder wall edema were higher in early group than in late group
5% (p > 0.05), Significant when the probability of error is less (p=0.066 and p=0.088, respectively) but without significant
than 5% (p ≤ 0.05) and highly significant when the probability statistical difference between both groups due to concomitant
of error is less than 0.1% (p ≤ 0.001).The smaller the p-value acute cholecystitis, the statistical differences were markedly
obtained, the more significant are the results. Statistical power significant only in fibrous adhesion and difficult Calot’s triangle
for operative time was 89 % by using G Power program and effect dissection (p=.001in both), operation time was significantly
size was 59%. lower in early group than in late group (p=.043).

RESULTS Table 5: Postoperative hospital stay and Time from discharge to chole-
cystectomy.
Table 1: Demographic characteristics & associated co-morbidities Early Late
among the studied groups: Findings Measures P
(N=50) (N=46)
Early Late Time from dis- Mean ± SD -- 29.8 ± 2.3
Items Measure P
(N=50) (N=46) charge to chole-
Age Mean ± SD 38.4 ± 5.1 40.3 ± 5.6 Range -- 25.0-33.0
systectomy
^0.214
(years) Range 28.0-48.0 30.0-51.0 Postoperative Mean ± SD 2.12±0.43 2.17 ± 0.65
Male 6 (12.0%) 4 (8.6%) hospital stay 0.736
Sex §1.000 Range 2-4 2-5
Female 44 (88.0%) 42 (91.30%) (days)
DM 2 (4.0%) 3 (6.5%) §1.000 Total legnth of Mean ± SD 5.36 ± .81 8.78 ± 1.00
hospital stay <0.001*
HTN 6 (12.0%) 7 (15.0%) §1.000 Range 4-6 8-11
(days)
^Independent t-test, §Fisher’s Exact test
^Independent t-test, *Significant
Table 2: Admission clinical findings among the studied groups. There was no statistical difference between both groups as
Early Late regard post-operative duration of hospital stay (p=0.736).There
Items Measure P
(N=50) (N=46) was statistically significant difference between both groups
Abdominal pain 50 (100.0%) 46 (100.0%) -- regarding total length of hospital stay (p value<0.001).
Nausea 40 (80.0%) 38 (76.0%) #0.733
Vomiting 24 (48.0%) 20 (40.0%) #0.569 Table 6: Postoperative complications among the studied groups.
Jaundice 4 (8.0%) 2 (4.0%) §1.000 Early Late
Findings P
0 18 (36.0%) 20 (40.0%) (N=50) (N=46)
Ranson #0.771 Wound infection 2 (4.0%) 4 (8.7%) §1.0
1and2 32 (64.0%) 26 (56.50%)
I 38 (76.0%) 36 (72.0%) Pseudocyst formation 1 (0.0%) 3 (0.0%) -
ASA #0.747
II 12(24.0%) 10 (21.7%) Obstructive jaundice 0 (0.0%) 0 (0.0%) --
Cholangitis 0 (0.0%) 0 (0.0%) --
Table 3: Preoperative laboratory findings among the studied groups.
Early Late Biliary fistula 0 (0.0%) 0 (0.0%) --
Items Measure ^P
(N=50) (N=46) §Fisher’s Exact test
Amylase (U/L) Mean ± SD 938.6 ± 447.6 139.26 ± 30.3 <0.001*
Lipase (U/L) Mean ± SD 909.5 ± 456.1 75.1 ± 74.3 <0.001*
DISCUSSION
AST (U/L) Mean ± SD 50.24 ± 21.19 47.37 ± 14.21 0.636 There is no universally accepted definition for ‘early’
Total bilirubin
Mean ± SD 1.00 ± 0.37 0.82 ± 0.28 0.069
laparoscopic cholecystectomy [11]. PONCHO trial [16]
(mg/dL) suggested index laparoscopic cholecystectomy within the same
CRP (mg/dL) Mean ± SD 42.12 ± 13.53 24.39 ± 9.45 <0.001* hospitalization and interval cholecystectomy after discharge
from the index admission and we adopted the same concept.
Table 4: Intra-operative findings among the studied groups.
Early Late Traditionally, it is felt that patients should recover fully from
P pancreatitis before cholecystectomy being performed. Surgeons
(N=50) (N=46)
Fibrinous adhesions 14(28.0%) 4 (8.7%) 0.066 who recommended cholecystectomy 6 weeks after discharge
Gall bladder wall edema 16(32.0%) 6(13.0%) 0.088 argue that very early cholecystectomy is associated with a more
Fibrous adhesion 10 (20.0%) 34 (73.9%) #0.001* difficult dissection, potentially leading to more conversions and
Difficult Calot's triangle more complications, such as bile duct injuries. They accept the
10 (20.0%) 34 (73.9%) #0.001* risk of recurrent biliary events, arguing that these can usually be
dissection
Conversion 2 (4.0%) 0 (0.0%) §1.00 treated by simple cholecystectomy. It has also been suggested
Drain 32 (64.0%) 30(65.2%) #0.771 that patients should be given time to recover fully from an
Morbidity 0 (0.0%) 0 (0.0%) -- episode of acute pancreatitis [13].
Operative Mean ± Classic surgeons are not routinely performing early
47.7 ± 21.9 60.65 ± 21.1 0.043*
duration SD laparoscopic cholecystectomy after biliary pancreatitis, this
There was statistical difference between both groups can be explained that, early cholecystectomy may have three
regarding recorded intraoperative data. Fibrinous adhesions, gall potential drawbacks: a technically more difficult and demanding

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procedure potentially resulting in more complications; poorer is 16 days. The ten admissions occurred within 3 weeks after
patient condition in early phase; and logistical obstacles [10]. discharge.
On the other hand, surgeons recommending cholecystectomy Previously, it was believed that, in the period immediately
during the index admission argue that recurrent biliary following the acute attack, the anatomy in the Calot’s triangle is
pancreatitis may be severe and potentially fatal [14]. Traditionally, difficult to assess and dissection is both dangerous and difficult.
early cholecystectomy has been suggested to be technically more However, our study as well as other studies like Sinha et al. [10],
demanding than interval cholecystectomy but data to support have totally shown different results. It was found that difficult
this statement are lacking. Notably, a recent study found that dissection of Calot’s triangle is a phenomenon of delayed surgery.
early cholecystectomy was technically less demanding, which Most of the patients in the early laparoscopic cholecystectomy
is matching with the nature of peritoneal healing and adhesion group had fibrinous omental adhesions where dissection was
formation [15]. very easy. In addition the edema in and around the CBD and
cystic duct in the initial stages that persists up to seven days
The reason for which we waited for reaching the discharge makes dissection easier rather than difficult [10]. The most
criteria before starting our study is that despite the growing fibrous adhesions is this study was found in delayed group 73.9%
evidence supporting the safety and efficacy of an early LC in the causing difficult dissection in these patients. These findings are
management of mild gallstone pancreatitis, concerns remain with consistent with the previous report.
regard to the safety of this approach. In a study by Dambrauskas
and his colleagues, they have suggested that from 5% to 10% Regarding the operative time, in Sinha and co-workers study
of patients with presumed mild pancreatitis progress to severe they have found no effect of timing of surgery on operating
pancreatitis during their hospitalization [17]. A policy of early time. the duration of surgery was shorter in early group median
LC might result in increased morbidity and mortality in a patient 80 minutes versus 85 minutes in delayed group but with no
misidentified as having mild pancreatitis who then progresses to significance p=0.752 [10].
more severe disease. For that in our study, the matter of timing Inconsistent with our findings in the present study that
was established after reaching a stable clinical situation that was has shown that early operation is associated with significantly
described as discharge criteria. It is important to note that, in shorter operative time (47.7 ± 21.9 minutes in Group I versus
the present study, no patient with mild pancreatitis progressed 60.65 ± 21.1 minutes in group II) (p=0.043).
to severe pancreatitis. We believe that the safety of an early LC
In our study, early cholecystectomy was associated with early
didn’t depend upon timing only, but also on the clinical state.
hospital discharge. This is consistent with findings of Sinha et al.
In a review of more than 59 articles discussing cholecystectomy [10], Papi et al. [30], in a meta-analysis, consistently, showed
in the context of gallstone pancreatitis, it was reported that for a longer hospital stay for patients of interval laparoscopic
mild gallstone pancreatitis, laparoscopic cholecystectomy within cholecystectomy group.
48 hours of presentation (without normalization of pancreatic
In the study of Ammori and his colleagues [27], despite
enzymes or absence of abdominal pain) has been shown to
increased age, co-morbidity and more frequent adhesions, their
shorten hospital stay without increased morbidity or mortality
data showed no evidence that intraoperative or postoperative
[19]. This was matching with our study as there was significant
complications were more frequent in patients with biliary
difference in overall hospital stay of both groups of early and late
pancreatitis underwent early laparoscopic cholecystectomy. They
cholecystectomy. consider that a policy of ‘‘same admission’’ cholecystectomy is
Several recent studies concluded that interval cholecystectomy appropriate for patients with acute pancreatitis due to gallstones.
carries a substantial risk of recurrent bilio-pancreatic events Unlike our present study, Bedirli and his colleagues [28] have
after discharge and before interval cholecystectomy after mild found that early surgery is associated with significantly higher
gallstone pancreatitis [24]. This risk is high even when the interval morbidity rate versus delayed surgery. This can be attributed
cholecystectomy takes place within 2 weeks after discharge that they included patients with severe form of disease unlike our
from the acute pancreatitis [25]. Early cholecystectomy may be study. The operation on patients with severe disease has resulted
indicated to prevent such biliary events, which are associated in mortality rate of 5.1% with early surgery and 4.3% with
with patient discomfort, hospital admission and additional costs. delayed surgery [28] while in our study there was no mortality.
Re-admission rate of 21% has been reported with delayed The possibility of development of postoperative pseudocyst
cholecystectomy group in a study by Cameron and Goodman [26]. or infected pancreatic necrosis is another factor which has
In our study, In the 50 patients of the early group (group I), been considered in the literature as a reason for deferring
there was no recurrent biliary event in the short interval between surgery until 6-8 weeks after the attack so interval laparoscopic
the attack of pancreatitis and cholecystectomy. 16 patients out of cholecystectomy advocated in all patients of ABP because of the
46 (34.7%) in the delayed group (group II) had gallstone-related possibility of a Pseudocyst developing later [29]. But we should
symptoms prior to cholecystectomy. The difference between the remember that mild ABP does not result in any pancreatic
two groups is significant (0% vs. 32%, p < 0.002). Ten of the 16 necrosis and usually pseudocyst does not form. And even if the
pseudocyst develops, the incidence is low and intervention may
patients (21%) required hospital readmission due to severity of
be required in a smaller percent of these patients and can be
the biliary events. No incidence of cholangitis occurred in our
carried out laparoscopically [10]. In the present study, pseudocyst
study. The median time between discharge and readmission

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formation was reported among 4 patients (3 patients of group B 5. Laparoscopic cholecystectomy in mild acute biliary
and one patient of group A). They were treated conservatively pancreatitis has no added risks in comparison with
with complete resolution. delayed interval laparoscopic cholecystectomy and is
recommended in the same admission guided by clinical
None of the operated cases in this study (96 cases) showed
criteria of improvement (discharge criteria ) not only the
post-operative mortality or morbidity except 2 cases (4.0%) in
issue of definitive time schedule.
the Group I and four cases (8.7%) in the group II after follow-up
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Cite this article

Abou-Sheishaa MS, Burham WA, Abbas AE, Dawoud IE, Shaker MA, et al. (2018) When to do Laparoscopic Cholecystectomy in Mild Acute Biliary Pancreatitis,
Early or Late? Ann Emerg Surg 3(1): 1031.

Ann Emerg Surg 3(1): 1031 (2018)

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