A Decision Analysis of the Treatment for Uncomplicated Acute Cholecystitis

Abstract

Laparoscopic cholecystectomy has replaced an open procedure for elective treatment of symptomatic gallstone. However, its use in the management of acute cholecystitis is still controversial. The traditional approach of initial medical treatment followed by delayed laparoscopeic cholecystectomy has been challenged by many recent studies that demonstrated success with early laparoscopic cholecystectomy. In this report, a decision tree was used to analyze treatment alternatives for uncomplicated acute cholecystitis comparing between early and delayed laparoscopic cholecystectomy based on probability estimates and patient utilities data from current medical literature.
   From the decision tree, the expected value of delayed laparoscopic cholecystectomy in patients with acute cholecytitis was slightly higher than the expected value of early laparoscopic cholecystectomy (0.8634 versus 0.8520). Generally, delayed laparoscopic cholecystectomy seems to have a slight more preferable outcome than early laparoscopic cholecystectomy in patients with uncomplicated acute cholecystitis. However, this decision is sensitive to the change in the rate of conversion from a laparoscopic to an open procedure. Sensitivity analysis revealed that early laparoscopic cholecystectomy was a batter choice of treatment as long as its conversion rate was below 16.98%. From the conversion rates reported in current medical literature, early laparoscopic cholecystectomy should be done within 48-72 hours after the onset of symptoms. However, each surgeon should make appropriate decision for individual case based on individual laparoscopic experience, duration of patient's symptoms, and hospital policy in scheduling an emergency laparoscopic cholecystectomy. If early laparoscopic cholecystectomy can be performed with a conversion rate lower than 16.98%, it is a better choice of treatment for patients with uncomplicated acute cholecystitis. Otherwise, delayed laparoscopic cholecystectomy should be considered.