Comment On: The Importance of Surgical Timing in Acute Cholecystitis and Postoperative Intravenous Tramadol Consumption

Dear Editor, We read with great interest the article titled “The Importance of Surgical Timing in Acute Cholecystitis and Postoperative Intravenous Tramadol Consumption” by Aydın et al. published on pages 1-6 of issue 3(1) of the 2024 Atatürk Uni Fac Med J Surg Med Sci. The article addresses an extremely important clinical situation. However, we are writing to respectfully add an aspect that has not been sufficiently focused on in the article, along with our current clinical results and experiences. Acute cholecystitis is a common surgical emergency. Effective management of cholecystitis is planned taking into operating room resources and the expertise of the surgical team, and outcomes vary accordingly.1 The timing of surgery is a significant factor influencing postoperative outcomes and has been studied in relation to the distribution of complications.2 Long-term clinical outcomes may include a number of symptoms that do not fully overlap with gastrointestinal symptoms described as Postcholecystectomy Syndrome, and this is an entity used to describe the persistence of gallbladder colic or right upper quadrant abdominal pain with various gastrointestinal symptoms.3 Another entity is Sump Syndrome, a long-term complication. Sump Syndrome, which is confused with cholangitis and requires a high degree of suspicion for diagnosis, has been noted in several studies, particularly in patients with a history of open cholecystectomy, especially those migrating from developing countries where alternative biliary interventions may be limited.4 In Sump Syndrome, sludge can accumulate in the bile duct and act as a focus for bacterial proliferation, leading to cholangitis or pancreatitis-like outcomes, and this condition can sometimes appear decades after large cystic sumps.5 In recent years, following due to migration from the Middle East, and after the earthquake centered in Kahramanmaraş on February 6, 2023, we observed that cholecystectomies were delayed for years among the local population. In these cases, in addition to an increase in the size of the stones and the thickness of the gallbladder wall due to delayed surgery, the diameters of the gallbladder and cystic ducts were significantly widened, even without sludge. We frequently encountered a clinical picture similar to Sump Syndrome, which we suspect may be related to a widened cystic stump after cholecystectomy. Based on these experiences, we would like to emphasize that changing social and demographic conditions affect the timing of cholecystectomy, and that the timing of cholecystectomy brings with it various clinical outcomes that cannot be fully defined by a single complication.