Advances in the management of acute cholecystitis

Abstract

The diagnosis and management of acute cholecystitis (AC) continues to evolve. Among the most common surgically treated conditions in the USA, appropriate diagnosis and management of AC require astute clinical judgment and operative skill. Useful diagnostic and grading systems have been developed, most notably the Tokyo guidelines, but some recent clinical validation studies have questioned their generalizability to the US population. The timing of surgical intervention is another area that requires further investigation. US surgeons traditionally pursue laparoscopic cholecystectomy (LC) for AC patients with symptoms onset <72 hours, but for patients with symptoms over 72 hours, surgeons often elect to treat the patients with antibiotics and delay LC for 4-6 weeks to permit the inflammation to subside. This practice has recently been called into question, as there are data suggesting that LC even for AC patients with over 72 hours of symptoms confers decreased morbidity, shorter length of stay, and reduced overall healthcare costs. Finally, the role of percutaneous cholecystostomy (PC) needs to be better defined. Traditional role of PC is a temporizing measure for patients who are poor surgical candidates. However, there are data suggesting that in AC patients with organ failure, PC patients suffered higher mortality and readmission rates when compared with a propensity-matched LC cohort. Beyond diagnosis, the surgical management of AC can be remarkably challenging. All surgeons need to be familiar with best-practice surgical techniques, adjunct intra-operative imaging, and bail-out options when performing LC.

Keywords: cholecystectomy; cholecystitis; cholelithiasis; laparoscopic cholecystectomy; percutaneous cholecystostomy.

Figure 1

A 76‐year‐old man presented with minimal abdominal pain, nausea, emesis, and night sweats. Ultrasound showed cholelithiasis with thickened gall bladder (GB) walls (A) and 2.8 × 2.6 × 2 cm hypoechoic collection in the right hepatic lobe (B). Computed tomography scan showed thickened and irregular GB walls, pericholecystic stranding, and intraluminal membranes, suggestive of gangrenous cholecystitis (C,D). Fluid collection adjacent to GB (red arrows) is suggestive of pericholecystic abscess. The patient was successfully managed with percutaneous cholecystostomy