Evaluating the 7-day barrier: early laparoscopic cholecystectomy for cholecystitis with prolonged symptom duration; a systematic review and meta-analysis.

backgroundThe gold standard for treating acute cholecystitis is an early laparoscopic cholecystectomy. However, whether this still applies for a > 7-day existing cholecystitis remains heavily debated. Therefore, this systematic review investigates the safety of early laparoscopic cholecystectomy for a > 7-day existing cholecystitis.

methodsPubMed and Embase were systematically searched for all studies comparing early laparoscopic cholecystectomy in patients with 0-7 versus > 7-day existing cholecystitis at time of surgery. Meta-analyses were performed on dichotomous and continuous outcomes with risk difference (RD) and mean difference (MD) as measures of effect.

resultsA total of 3007 studies were screened, resulting in the inclusion of 13 non-randomised studies comprising 5481 patients. Of these, 4690 received cholecystectomy within 7 days, and 791 after 7 days. Operating times (MD -11.8 min; 95% CI [-18.4; -5.2]) and total hospital stay (MD -2.7 days; 95% CI [-4.0; -1.4]) were longer in the > 7-day group. However, no significant risk difference was found for combined major complications: bile duct injury/leakage and bowel injury (RD -1.0%; 95% CI [-2.3; 0.3]), for complications graded Clavien-Dindo ≥ 3 (RD -0.3%; 95% CI [-2.5; 1.9]), or for conversions (RD -1.5%; 95% CI [-3.9; 0.9]).

conclusionEarly laparoscopic cholecystectomy for cholecystitis after the 7-day barrier might be harder, as reflected by longer operating times. However, a significant increase in complications or conversions was not found. Due to the risk of bias and lack of well-powered studies directly comparing early cholecystectomy after 7 days with alternative strategies, strong recommendations cannot be made. Meanwhile, it is advised to carefully weigh the treatment options in case of a > 7-day existing cholecystitis, based on patient's characteristics and surgeon's experience.