Cholecystitis: Surgery works best at an early stage and with laparoscopic technique

The main issue in cases of acute gallstone disease is whether to operate or wait. After having reviewed available studies, SBU concluded that researchers have not found any conclusive evidence one way or the other.

“As opposed to our expectations, the scientific basis is insufficient to make a determination,” says Dr Johanna Österberg, Senior Consultant for the Surgical Department of Mora Hospital, Sweden – one of SBU's experts in the project.

The assessment showed that many patients never experienced a relapse over a period of 14 years when they choose to wait on surgery following acute gallstone disease.

“We need randomised studies of acute gallstone pain,” Dr Österberg says.

She adds that no evidence seems to discord the principle that many Swedish practitioners follow: wait after a single uncomplicated gallbladder attack, but consider operating without delay in the case of acute cholecystitis.

The SBU review still identified potential for improvement. Surgery for acute cholecystitis works best within a few days. Patients don’t have to endure waiting, risking relapse. Acute phase surgery does not increase the risk of complications, and resources are freed up.

Approximately 60% of Swedish patients currently undergo surgery during the acute phase. SBU found that some 3,300 days of convalescence and SEK 26 million would be freed up every year if the figure increased to 90%.

Laparoscopic technique instead of open surgery for acute cholecystitis substantially reduces the risk of complications, particularly wound infections and pneumonia. The majority of operations already use laproscopic technique, but there is latitude for more.

Finally, SBU points out that the Swedish national quality register enables monitoring of surgical practice for gallstone disease. [RL]

SBU’s conclusions

• It is unclear whether patients experiencing a gallstone attack should receive surgical treatment or not. The scientific basis to assess this is insufficient and better studies are needed.
• The body of evidence is currently insufficient to determine whether it is better to always surgically treat acute inflammation of the gallbladder. More well-conducted studies are needed.
• Patients with acute inflammation of the gallbladder can be surgically treated in the acute phase, within a few days of symptom debut, without increasing the risk for complications (compared to when the surgery is done later in an asymptomatic stage). Increasing the number of surgeries performed during the acute phase could free resources for the health care system. Just over 60% of surgeries for acute inflammation of the gallbladder are currently performed during the acute phase. SBU estimates that increasing acute phase surgeries to 90% could free three in-hospital days per patient, or about 3,300 days per year (corresponding to nearly 26 million Swedish crowns yearly). What is more, patients who receive acute phase surgery are spared experiencing additional pain and suffering while they wait for their operation.
• The risk for complications is reduced when patients with acute inflammation of the gallbladder are treated using laparoscopic surgical techniques compared to open surgery techniques.