A multicentric, blinded, parallel clinical trial is proposed to compare early and late
cholecystectomy after percutaneous cholecystostomy (PC).
The primary objective of the present study is to determine the ideal time interval-early
versus late-for performing laparoscopic cholecystectomy (LC) in patients who underwent
PC. This includes assessing whether recurrence can be reduced. As a secondary aim, to
analyze the morbidity and mortality associated with the intervention.
Recruitment and Deadlines
Only surgical departments with an adequate number of patients will be included in the
trial to ensure the sample size objective. The selected recruitment period is 18 months.
Study Variables
Surgical sheets, laboratory reports, daily notes made by hospital staff, discharge
summaries, and outpatient clinic notes will be reviewed. Pre-operative characteristics,
including sex, age, body mass index (BMI), comorbidities (diabetes mellitus, asthma,
chronic obstructive pulmonary disease, malignant neoplasms, and immunosuppressive
therapy), the main procedure performed as well as secondary procedures such as endoscopic
retrograde cholangiopancreatography (ERCP) after confirming choledocholithiasis with
magnetic resonance cholangiopancreatography (MRCP), will be collected. Variables related
to the pre-operative context of the patient, such as Intensive Care Unit (ICU) admission,
the patient's hemodynamic status, the presence of septic shock, and the need for
vasoactive drugs, will also be collected. The characteristics studied for laparoscopic
cholecystectomy (LC) were as follows: type of prophylactic antibiotics used, details of
the LC surgical technique, intraoperative complications, assessment of technical
difficulty (as there are no quantitative scales, relied on previous studies adapted
according to our group's consensus) defined as: 1. Need for conversion, 2. Atypical
cholecystectomy (e.g., subtotal), 3. Strong adhesions on the gallbladder, 4. Difficult
dissection of the hilar region due to chronic inflammatory processes, and 5. Increased
average surgery time. Postoperative characteristics recorded included: hospital stay,
postoperative complications and treatments, bile cultures, subsequent complications, need
for reoperation, 30 and 90-day morbidity and mortality, and total follow-up time.
Interventions
Pre-operative Study
All participants with PC will undergo a preoperative study using MRCP or endoscopic
ultrasound (EUS) to rule out associated choledocholithiasis. A second MRCP or EUS will be
planned for the delayed group just before LC. If choledocholithiasis is confirmed,
preoperative endoscopic retrograde cholangiopancreatography (ERCP) will be performed.
Prophylactic Pre-operative Antibiotherapy
Prophylactic antibiotherapy will be administered according to hospital protocol
PC Catheter Removal
Various publications have proposed the removal of the PC catheter after confirming the
clinical resolution of acute cholecystitis (AC) following PC, performing percutaneous
cholangiography between the third and fourth day of the procedure to evaluate the patency
of the cystic duct. If continuity is confirmed, the catheter will be removed after the
completion of antibiotic treatment and 24 hours before clinical discharge; otherwise, it
will remain until the surgical intervention. In the present study, to avoid biases
related to the catheter's permanence between groups or complications associated with its
removal, the catheter will remain until the day of LC, and its removal will be performed
intraoperatively under direct vision. The tip of the PC catheter will be sent for
culture.
Randomization and Blinding
Prior to inclusion in the trial, the certified investigator from the Surgical Department
will perform the screening and gather patient information and informed consent. An online
tool will be provided to generate the sequence for group assignment, stratified by the
grade of AC at the time of PC placement.
According to the interval for surgical intervention:
Early LC group: Less than 2 weeks (within the first 2 weeks of diagnosis, after
confirming CA resolution or improvement of functional status and coagulation that
allows LC to be performed under optimal conditions), preferably within the first 10
days from the onset of CA symptoms.
Delayed LC group: From the 6th week (preferably between the 6th and 8th weeks of CA
diagnosis).
Randomization sheets will be kept outside the patient's medical records. The primary
objective (reduction of recurrence - in a previous study of the group it is up to 20% -
with this data and assuming a reduction from 20% to 5% for those cannot be operated, 73
patients per group will be needed) will be clinically evaluated by a local group member
who will not be part of the surgical team performing the intervention nor will have
access to the randomization results to maintain blinding. In case of risk to the patients
included in the study, access to randomization data will be allowed to the local
investigator.