title: Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis.
abstract: OBJECTIVE
  To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis.
  
  
  BACKGROUND
  Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death.
  
  
  METHODS
  This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication.
  
  
  RESULTS
  From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR)=0.53, 95% confidence interval [CI]: 0.31-0.90], of major bile duct injury or death (1.36% vs 1.88%, RR=0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR=0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR=1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR=1.02, 95% CI: 0.93-1.13).
  
  
  CONCLUSIONS
  These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.
authors: *Sunnybrook Research Institute, Sunnybrook Health Sciences Center †Li Ka Shing Knowledge Institute, St Michael's Hospital; and ‡Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors: Charles
authors: C
authors: de Mestral
authors: Ori D
authors: OD
authors: Rotstein
authors: Andreas
authors: A
authors: Laupacis
authors: Jeffrey S
authors: JS
authors: Hoch
authors: Brandon
authors: B
authors: Zagorski
authors: Aziz S
authors: AS
authors: Alali
authors: Avery B
authors: AB
authors: Nathens
mesh_terms: D000328:Adult; D000368:Aged; D001649:Bile Duct Diseases / Q000453:epidemiology / Q000209:etiology; D001652:Bile Ducts / Q000293:injuries; D002763:Cholecystectomy / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D017081:Cholecystectomy, Laparoscopic / Q000706:statistics & numerical data; D041881:Cholecystitis, Acute / Q000453:epidemiology / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009864:Ontario; D057216:Propensity Score; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome