Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Manuscript and Literature Review Committee Members Sumeet V. Jain, MD, MBA and Justin Hatchimonji, MD, EAST Member Brian Villa and Andrew Manhan, DO.
Thank you toHaemoneticsfor supporting the EAST Monthly Literature Review.
The body of research regarding management of gallbladder perforation remains low due to the low incidence. Additionally, there is little evidence to support whether early or delayed laparoscopic cholecystectomy is the more optimal treatment for gallbladder perforation. This study aimed to determine whether performing early laparoscopic cholecystectomy (within 2 days of admission) lead to decreased hospital length of stay and, overall, less morbidity than late cholecystectomy (greater than 2 days after admission). The primary outcome was total hospital length of stay. Secondary outcomes included 30-day postoperative complications, reoperation, and readmission.
The total study population included 266 patients with gallbladder perforation, of which 155 patients underwent early cholecystectomy and 111 patients underwent delayed cholecystectomy. The authors found that the total hospital length of stay was 3 days shorter in the early group (4 vs 7 days). Additionally, they found no statistically significant difference in their secondary outcomes. Limitations include the inability to obtain certain data from the NSQIP data set, such as conversion to open surgery or nonsurgical post operative procedures (such as IR drains or ERCP). Overall, this study suggests that early laparoscopic cholecystectomy leads to decreased total hospital length of stay and is safe, and therefore patients with gallbladder perforation should have surgery performed without delay.
In acute uncomplicated appendicitis there is little evidence on the effectiveness of antibiotics prior to surgical intervention with laparoscopic appendectomy. This paper aims to determine if antibiotic treatment vs no antibiotic treatment was necessary prior to surgery in acute uncomplicated appendicitis. This randomized control trial consisted of 1797 patients with uncomplicated acute appendicitis. The two comparison groups were those who received antibiotics (901 patients) and no antibiotics (896 patients) prior to the operating room for laparoscopic appendectomy. The antibiotics of choice were cefuroxime 1500mg and metronidazole 500mg q8 until surgery. The primary outcome was perforated appendicitis diagnosed during surgery.
The study found no significant difference in perforated appendicitis in patients who received antibiotics (66 patients, 8.4%) compared to those who did not (75 patients, 8.7%). The study appears to show that preoperative antibiotics did not decrease the risk of appendiceal perforation, and that therefore antibiotics do not need to be given. Importantly, this study was looking at patients who underwent surgery less than 24 hours after admission with uncomplicated acute appendicitis.
Although appendicitis is historically considered a surgical pathology, nonoperative management of the inflamed appendix appears to be increasing. In an exploration of downstream healthcare utilization of appendicitis management, Mathew et al. utilized a Medicare claims database to track the healthcare utilization (ED visits, hospitalizations, and abdominal computed tomography (CT) scans) up to one year after either operative (n=24,102) or nonoperative (n=2,486) management of uncomplicated appendicitis. After adjusting for baseline characteristics, patients treated nonoperatively experienced significantly higher rates of healthcare utilization within one year compared with those undergoing appendectomy.
These results take a non-clinical administrative approach in advocating for surgical management of the inflamed appendix. While meta-analyses such as de Almeida Leite et al. have reported comparable short-term complications to both management strategies, it is important to consider the expected progression and future utilization of healthcare resources in each treatment method. Together, these data highlight the trade-off: nonoperative management avoids surgery for some but increases the overall subsequent healthcare encounters.
This study benefits from a large dataset with robust one year follow-up, adjustment for baseline patient characteristics, and clinically meaningful outcomes such as utilization, imaging, and rehospitalization. However, its reliance on an administrative database limits insight into clinical presentation, imaging protocols, and physician decision-making. Additionally, unmeasured factors such as patient preference, socioeconomic status, and institutional practice patterns could not be accounted for, which may influence the observed outcomes.
These findings reinforce that while nonoperative management may avoid initial surgery, it carries a measurable burden of follow-up care and resource use. In the end, nonoperative management of uncomplicated appendicitis remains an option, but patients should be counseled that it carries higher likelihood of ED return, hospitalization, and repeat imaging over the following year.
This prospective study out of the Netherlands by Comes et al. aims to develop and externally validate a clinical decision tool for predicting long-term less pain after laparoscopic cholecystectomy (LC) in patients with symptomatic cholelithiasis. Using the SUCCESS cohort (n = 494) and then the SECURE trial (n = 1067) for external validation, the authors identified several independent predictors for pain at five years. Patients were more likely to have significant relief of pain if they were male, had a higher baseline VAS pain score, experienced radiation of pain to the back, and had associated nausea. The absence of functional gastrointestinal features such as obstipation, diarrhea, and postprandial bloating also predicted better outcomes. The model demonstrated good discrimination (C statistic 0.75) supporting its reliability in clinical practice.
The strengths of this paper include its prospective design, large sample size, and robust methodology, including external validation in a randomized trial cohort. This tool addresses a clinically relevant problem, with some studies citing nearly one-third of patients having persistent pain at long-term follow-up after LC. The authors provide an evidence-based framework that may assist surgeons and patients in shared decision-making by clarifying who is most likely to achieve lasting symptom relief from LC.
However, this tool was derived and validated in European cohorts, which may limit generalizability to other populations with different dietary, and healthcare factors. While predictors were statistically significant, some, such as sex, may not reflect modifiable mechanisms, and the model does not incorporate psychosocial factors known to influence postoperative pain.
In the broader context of emergency general surgery, this paper reinforces the growing recognition that cholecystectomy is not universally effective for all patients with abdominal pain found to have cholelithiasis on imaging. Prior studies have shown patients with typical biliary symptoms—severe episodic pain, radiation to the back, nausea—are more likely to benefit, while those with overlapping features of functional gastrointestinal disorders often continue to experience pain after surgery. This decision tool refines that understanding and provides a framework toward evidence-based patient selection.
In summary, the work by Comes et al. represents an important advance in tailoring surgical decision-making for symptomatic cholelithiasis. Its integration into practice should be cautious, with attention to validation across broader populations, but overall highlights a shift toward individualized rather than reflexive operative management.
This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed? Please email [email protected]. Previous issues available on the EAST website.
