Laparoscopic Cholecystectomy in Acute Cholecystitis: Refining the Best Surgical Timing Through Network Meta-Analysis of Randomized Trials

Background: Acute cholecystitis (AC) is largely diffused among population worldwide. Laparoscopic cholecystectomy is the treatment of choice. Current evidence suggests a clinical benefit of early cholecystectomy. The aim of the present study was to evaluate the different "timing" ("early" vs. "delayed" cholecystectomy), through the application of network meta-analyses, to define the most adequate interval associated with the best outcomes. Materials and methods: A network meta-analysis of randomized controlled trials was conducted. Results: Early cholecystectomy ≤72 hours from symptoms reduced conversion rate in comparison to: cholecystectomy ≤7 days from symptoms ( P =0.044), delayed cholecystectomy within 1 to 5 weeks from first admission ( P =0.010) and 6 to 12 weeks from symptoms resolutions ( P =0.009). Delaying cholecystectomy to 6 to 12 weeks reduces operating time in respect to early cholecystectomy ≤72 hours from symptoms ( P =0.001), within 24 hours from admission ( P =0.001), ≤72 hours from admission ( P =0.001) and ≤7 days from symptoms ( P =0.001). Cholecystectomy ≤24 hours from admission was the best strategy to reduce total in-hospital stay, whereas delaying cholecystectomy to 6 to 12 weeks was the worst strategy. The same applied when cholecystectomy was performed ≤72 hours from symptoms in respect to both delayed strategies ( P =0.001 for both comparisons) or when it was performed ≤72 hours from admission ( P =0.001 for both comparisons). Cholecystectomy ≤72 hours from symptoms onset was the best strategy to reduce postoperative complications, the worst was represented by delayed cholecystectomy at 1 to 5 weeks from first admission. Conclusion: AC should be operated as soon as possible. AC surgical management should be considered in a dynamic time conception to optimize clinical, organizational, and economical outcomes.