Acute cholecystitis is one of the most common presentations of gallstone disease in the emergency department and is a common reason for hospital admission in general surgical practice [1]. This is typically caused by the blockage of the cystic duct by gallstones, which results in inflammation, swelling, bacterial infection, ischemia, and, more rarely, empyema or gangrene of the gallbladder [2]. Laparoscopic cholecystectomy is now generally accepted as the definitive treatment for acute cholecystitis as it affords symptomatic relief, elimination of the disease focus, and minimises the risk of recurrence of further biliary events [3]. The timing of laparoscopic cholecystectomy (LC) in acute cholecystitis has been much discussed [4]. Laparoscopic cholecystectomy was performed on average within 72 hours of the onset of symptoms and was shown to lead to a decrease in the total hospital stay, earlier recovery, fewer recurrent attacks, and a reduction in the overall healthcare cost [5]. Delayed laparoscopic cholecystectomy is usually reserved for those who have tried initial conservative treatment with antibiotics and supportive treatment and proceed to surgery several weeks later when inflammation has settled [6]. Proponents of delayed surgery suggest that surgery can be performed after the acute inflammatory phase, which helps to minimize the technical difficulty, bleeding, damage to the bile duct, and the need for open surgery [7]. But, when the surgery is delayed, the patient is vulnerable to repeated biliary colic, recurrent cholecystitis, pancreatitis, cholangitis, repeated admissions, and prolonged disease burden before definitive surgery [8]. Furthermore, dense adhesions and chronic inflammatory changes can be present in delayed procedures, which could add to the complexity of the operation [9].

Laparoscopic to open cholecystectomy conversion is still a significant surgical outcome in cases of acute cholecystitis [10]. Some factors, such as severe inflammation, adhesions, and difficult Calot's triangle dissection, as well as empyema, gangrenous gallbladder, obesity, and late presentation, may increase the risk of conversion [11]. Postoperative complications such as wound infection, bile leak, intra-abdominal collection, bleeding, and prolonged ileus may also affect recovery and hospital stay [12]. Histopathological evaluation of the gallbladder is important and helps to give information about the severity and chronicity of the inflammation [13]. Different findings, such as acute suppurative cholecystitis, chronic cholecystitis, gangrenous change, empyema, fibrosis, and mucosal ulceration, can be associated with the difficulty of the surgery and the prognosis after surgery [14]. Histopathological differences between early and delayed surgery groups could provide an explanation for whether delay alters the course of the disease or surgical risk [15]. Although evidence for the benefits of early laparoscopic cholecystectomy continues to grow, there is still a divergence of opinion regarding the timing of surgery, which is related to the patient's presentation, surgeon preference, operating room availability, institutional protocols, and resource availability [16].

Objective

To compare the effects of early versus delayed laparoscopic cholecystectomy on surgical outcomes, conversion rate, postoperative morbidity, and histopathological findings in patients with acute cholecystitis

This was a comparative cross-sectional study conducted at Riphah international Hospital Islamabad from March 2024 to September 2025, including 175 patients diagnosed with acute cholecystitis who underwent laparoscopic cholecystectomy. Patients were categorized into two groups according to the timing of surgery: early laparoscopic cholecystectomy (performed within 72 hours of symptom onset or during the index admission) and delayed laparoscopic cholecystectomy (performed 6–12 weeks after initial conservative management). Patients aged 18 years and above with a clinical, laboratory, and radiological diagnosis of acute calculous cholecystitis based on the Tokyo Guidelines were included. Eligible patients had right upper quadrant pain, fever, leukocytosis, and ultrasonographic findings consistent with acute cholecystitis, including gallbladder wall thickening, pericholecystic fluid, or a sonographic Murphy’s sign. Patients who underwent either early or delayed laparoscopic cholecystectomy and provided informed consent were included. Patients with acalculous cholecystitis, gallbladder malignancy, concomitant choledocholithiasis requiring preoperative endoscopic intervention, severe pancreatitis, generalized peritonitis, previous upper abdominal surgery, pregnancy, significant coagulopathy, American Society of Anesthesiologists (ASA) class IV or higher, or incomplete clinical records were excluded.

Data Collection

After obtaining ethical approval, data were collected using a structured proforma from patient interviews, medical records, operative notes, and histopathology reports. Demographic variables included age, gender, body mass index, comorbidities, symptom duration, and ASA classification. Clinical variables included white blood cell count, liver function tests, ultrasonographic findings, and severity grading according to the Tokyo Guidelines. Operative variables included timing of surgery, operative duration, intraoperative blood loss, identification of difficult Calot’s triangle anatomy, presence of adhesions, gallbladder perforation, need for drain placement, and conversion to open cholecystectomy. Postoperative outcomes included duration of hospital stay, surgical site infection, bile leak, intra-abdominal collection, postoperative pain score, readmission, and overall morbidity. Histopathological examination of the excised gallbladder specimens was performed by experienced pathologists. Histopathological findings including acute inflammatory changes, chronic cholecystitis, gangrenous cholecystitis, empyema, fibrosis, mucosal ulceration, xanthogranulomatous changes, and incidental malignancy were recorded.

Statistical Analysis

Data were analyzed using SPSS version 26.0. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Independent t-tests or Mann–Whitney U tests were used to compare continuous variables between the early and delayed surgery groups. Chi-square tests or Fisher’s exact tests were used to compare categorical variables. Multivariable logistic regression analysis was performed to identify factors independently associated with conversion to open surgery and postoperative morbidity. A p-value ≤0.05 was considered statistically significant.

Both groups were clinically comparable at baseline. Mean age was 45.8 ± 13.2 years in the early LC group and 47.1 ± 12.8 years in the delayed LC group (p=0.51). BMI, diabetes, hypertension, ASA class, Tokyo grade, WBC count, and gallbladder wall thickness were also similar between groups, showing no significant baseline imbalance.

Table 1: Baseline Demographic and Clinical Characteristics of Patients with Acute Cholecystitis (N = 175)

Early LC showed better intraoperative outcomes. Operative time was shorter in early LC compared with delayed LC (78.4 ± 21.6 vs. 92.7 ± 25.4 minutes; p<0.001), with lower blood loss (68.5 ± 34.7 vs. 84.2 ± 39.8 mL; p=0.005). Dense adhesions, difficult Calot’s dissection, drain placement, and conversion to open surgery were all more frequent in delayed LC, with conversion significantly higher in delayed cases (17.2% vs. 6.8%; p=0.034).

Table 2: Intraoperative Outcomes of Early Versus Delayed Laparoscopic Cholecystectomy

Postoperative recovery was better after early LC. Postoperative stay was shorter in early LC (2.4 ± 1.1 vs. 3.8 ± 1.6 days; p<0.001), and total hospital stay was also markedly lower (3.9 ± 1.8 vs. 8.6 ± 2.7 days; p<0.001). Early LC patients had lower pain scores (3.8 ± 1.2 vs. 4.4 ± 1.5; p=0.004), fewer readmissions (4.5% vs. 13.8%; p=0.031), and lower overall morbidity (13.6% vs. 26.4%; p=0.033).

Table 3: Postoperative Outcomes and Morbidity

Histopathology showed acute cholecystitis was more common in early LC specimens (65.9% vs. 24.1%; p<0.001), while delayed LC showed more chronic cholecystitis with fibrosis (32.2% vs. 10.2%; p<0.001). Xanthogranulomatous changes were also higher in delayed LC (10.3% vs. 2.3%; p=0.029), suggesting more chronic inflammatory remodeling with delayed surgery.

Table 4: Histopathological Findings of Gallbladder Specimens

Delayed LC independently increased the odds of conversion to open surgery (AOR=2.89, 95% CI: 1.08–7.74; p=0.035) and overall morbidity (AOR=2.34, 95% CI: 1.12–4.88; p=0.024). Difficult Calot’s triangle was the strongest predictor of conversion (AOR=4.28), followed by dense adhesions.

Table 5: Multivariable Logistic Regression Analysis of Predictors of Conversion to Open Surgery and Postoperative Morbidity

This study found that early laparoscopic cholecystectomy in patients with acute cholecystitis was better at achieving good surgical outcomes and had fewer conversion rates, fewer post operative complications and fewer hospital stays, and better histopathological results. The results are consistent with the increasing number of studies which have promoted laparoscopic gallbladder removal as the treatment of choice for acute cholecystitis. Demographic and clinical parameters were similar in both groups and were not significantly different with respect to age, sex, BMI, comorbidities, disease severity or gallbladder wall thickness. The mean age was 45.8 ± 13.2 years in the early group and 47.1 ± 12.8 years in the delayed group. The observed differences in outcome were likely due to a difference in timing of surgery, and not due to differences in patient factors because of similar baseline characteristics. Similar baseline characteristics have been previously reported between early and delayed intervention groups as well [17]. The intraoperative outcomes of early laparoscopic cholecystectomy were shown to be significantly better. Operative time was shorter in the early group (78.4 ± 21.6 vs. 92.7 ± 25.4 minutes), and estimated blood loss was lower (68.5 ± 34.7 vs. 84.2 ± 39.8 mL). Higher rates of dense adhesions and difficult dissection of Calot's triangle at the operation were found to be associated with delayed surgery. These results indicate that postpone surgery, inflammation becomes chronic and adhesions develop, making it more difficult. Other studies have also demonstrated that the delay in cholecystectomy is correlated with higher operative complexity, associated with chronic inflammatory changes and changes in the anatomy [18]. Open surgery continues to be an important determinant of both the difficulty of the operation and patient safety. The conversion rate in the early surgery group was significantly lower (6.8 vs. 17.2) in this study. Multivariable analysis showed that delayed surgery increased the nearly 3-fold the odds of conversion to open surgery (AOR=2.89). The factors associated with the highest rate of conversion were dense adhesions and difficult Calot's triangle anatomy. Previous studies have found similar results, highlighting that when lesions are not treated early, fibrosis and/or anatomical changes occur leading to the need for conversion for surgical safety.

Patients who had surgery in the early phase experienced significantly better recovery after surgery. The early group had a shorter length of hospital stay (2.4 ± 1.1 days vs 3.8 ± 1.6 days), and total stay in the hospital was cut in more than half (3.9 ± 1.8 days vs 8.6 ± 2.7 days). The use of early surgery was also related to reduced postoperative pain, reduced overall morbidity, and reduced readmission. Early laparoscopic cholecystectomy has been proven to have a significant impact on reducing the cumulative hospitalization, reduce healthcare costs, and reduce recurrent biliary events requiring readmission [19]. The early group had fewer surgical sites infections, bile leak and intra-abdominal collection, although these differences were not statistically significant. But the overall morbidity-rate was much lower in patients who were operated upon early (13.6% compared with 26.4%). There was an independent association between delayed surgery and postoperative morbidity that was greater than twofold. The previous studies have also shown better outcomes after early intervention, presumably because of the prevention of the progression of the disease and the absence of recurrent inflammatory episodes [20]. Histopathology was also used to gain insight into disease evolution. Acute cholecystitis was more common in the early surgery group (65.9% vs 24.1%), while chronic cholecystitis with fibrosis was significantly more common in delayed surgery (32.2% vs 10.2%). There was also an increased incidence of xanthogranulomatous changes in delayed surgery specimens. The results indicate that delay of surgery could cause inflammatory responses to become fibrotic, which could lead to increased difficulty of surgery and complications. Previous studies have also shown a higher degree of fibrosis, chronic inflammation and xanthogranulomatous transformation in the specimens of delayed cholecystectomy [21].

LIMITATIONS

Several limitations of this study are noted. First, the cross-sectional design of comparison used in the study makes it difficult to draw definite conclusions about the relationship between the timing of surgery and postoperative results. Second, the study took place at a single institution, which may hamper the generalizability of the results to other centers with different patient populations, surgical skills and resources. While baseline parameters were similar, selection bias may have affected distribution of patients across early vs. delayed surgery cohorts. The different experience levels, operating techniques, and peri-operative management protocols of the surgeons could not be completely standardized and could have influenced the surgical results. Multi-center randomized controlled trials with longer follow-up periods are recommended to confirm these results and further define the best time to perform laparoscopic cholecystectomy.

In patients with acute cholecystitis, early laparoscopic cholecystectomy was shown to have better surgical and postoperative results. Early intervention was correlated with decreased blood loss, shorter operating time, lower conversion rate, less postoperative pain, less hospital length of stay, fewer readmissions and lower overall morbidity. The histopathological changes were more severe in the chronic inflammatory and fibrotic changes, which were also more severe in those undergoing delayed surgery; difficult Calot's triangle dissection and greater adhesions were also associated with delayed surgery.

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