Surgical timing in biliary tract disease.

Based on 991 cases of biliary tract disease managed in a recent four-year period, the authors contrast an elective operative mortality rate of 0.6% against 4.4% for acute cholecystitis. Because in 21 of 28 patients with acute cholecystitis symptoms and signs subsided within 48 hours of conservative management in hospital, they recommend a two-day trial of conservative management for patients with acute cholecystitis and operation only for those who are not definitely improving under optimal conditions. The incidence and expected mortality from acute cholecystitis increased with age. Where possible, elective operation should be done when stones are first diagnosed because in patients over 65 years of age the rate of complications was four times and the mortality rate three times that in patients under 65. The incidence of cancer in cholelithiasis was sufficiently high that it is a significant factor in the consideration of prophylactic cholecystectomy. Patients with ruptured gall-bladders can present a trap for the unwary diagnostician; they should have minimal emergency surgery.