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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Wednesday, May 14, 2014
May, 2014 Journal Club
Moderator: Dr. Henry Pitt
 
Featured Articles:

1. Gutt CN, Encke J, Koninger J, et al. Acute cholecystitis: early versus delayed  cholecystectomy:  a multicenter randomized trial.  Ann Surg 2013; 258: 385-393.

2. DeMestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecytitis: a population-based propensity score analysis.  Ann Surg 2014; 259; 1-x.

Summary:

Debate regarding the pros and cons of early versus late cholecystectomy in patients with acute cholecystitis has raged for decades. In the open cholecystectomy era prospective randomized controlled trials (RCT’s) favored early surgery, primarily due to shorter overall length of stay and reduced likelihood of ongoing biliary disease.  Over the past 25 years following the introduction of laparoscopic cholecystectomy, RCT’s again have confirmed essentially the same conclusions.  In the 21st century meta-analyses, population studies, and cost-utility analyses also have favored early surgery.  However, despite the significant weight of these data, considerable variation in practice patterns exist within most countries as well as around the world.                                                                                                                                                                   In the September, 2013 issue of Annals of Surgery Gutt et al1 reported the largest RCT of early versus delayed cholecystectomy for acute cholecystitis.  This multicenter trial from Germany, which was presented at the American Surgical Association, documented that the 75-day morbidity was reduced by three-fold with early surgery (p<0.001). In addition, overall length of stay (LOS) was shortened by 4.6 days (p<0.001) and cost was diminished by one-third.  In the January 2014 issue of Annals of Surgery de Mestra et al2  have added  substantially to the literature by reporting a population-based propensity score analysis of more than 22,000 patients undergoing cholecystectomy for acute cholecystitis in Ontario, Canada from 2004-11.  This report is unique because the authors demonstrated, for the first time, that the risk of major bile duct injury (BDI) and early death are substantially reduced with early surgery.  They also confirmed earlier studies documenting reduced LOS with surgery performed early after presentation.  Taken together these two seminal reports document that patient value (quality/cost) is clearly superior with early surgery for acute cholecystitis.

Questions:

1. Do these seminal papers apply to patients with severe cholecystitis who present with septic shock and/or organ failure?

2. Should frail, very elderly patients with acute cholecystitis undergo early surgery?

3. Despite overwhelming evidence in the literature, why are many patients with acute cholecystitis not managed with early surgery?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

 

About the Author

Dr. David T Efron
Dr. Efron is an Associate Professor of Surgery, Anesthesiology & Critical Care Medicine and Emergency Medicine at the Johns Hopkins School of Medicine. He is the Director of Trauma and Chief of the Division of Acute Care Surgery (encompassing Trauma, Emergency Surgery and Surgical Critical Care) in The Johns Hopkins Hospital Department of Surgery. He is currently the Vice-Chair of the Maryland State Committee on Trauma. Dr. Efron’s current research interests are within the realm of regulation of inflammatory mediators of septic and post-injury states, particularly focusing on the role that statins play in this milieu. Dr. Efron carries additional interest in traumatic injury from interpersonal violence, measures of violence intensity, and trauma recidivism with an eye to prevention strategies.

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