Mangement of acute cholecystitis : surgery, drainage and gallbladder aspiration

Abstract: Background: Early laparoscopic cholecystectomy is considered the standard of care for patients admitted with acute cholecystitis. Nevertheless, a large proportion of patients admitted for acute cholecystitis are managed without acute surgery. The reasons for not opting on acute surgery include lack of resources, severe comorbidity, frailty, protracted history prior to admission or non-compliance with guidelines due to local routines. Even if early cholecystectomy remains the firsthand alternative for patients with acute cholecystitis, safe and effective management is needed in case this routine is not followed. Methods: For study one and two we retrospectively reviewed medical records of 1649 patients treated for acute cholecystitis in Stockholm County in the years 2003 and 2008. The aim was to study management and outcome after different treatment strategies. The primary focus for study one was to compare acute cholecystectomy with delayed surgery and for study two focus was on those treated with percutaneous cholecystostomy (PC). For study three we used the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) as well as the National patient register (NPR) to study the outcome after elective cholecystectomy for those patients treated initially conservatively for acute cholecystitis. The impact of time after discharge from hospital to elective surgery with focus on intra- and postoperative complications, bile duct injuries and leakage, operating time and surgeries completed laparoscopically was analyzed. Study four was a prospective safety feasibility pilot study of percutaneous gallbladder aspiration, (PGBA) as treatment of patients not suitable for emergency surgery. We performed PGBA on 25 high-risk patients. Study five was a retrospective review of 241 patients treated with cholecystostomy to evaluate maintenance of the cholecystostomy once in place. We studied when it is safe to remove a drainage and whether retrograde cholangiography adds to safety. Results: In study one and two we found that during the year 2003 42.9% and the year 2008 47.4% of patients were treated with acute cholecystectomy. Those receiving acute surgery tend to be younger and healthier. When adjusting for age, gender, severity of the inflammation, maximal white blood cell count and CRP we found no difference in complication rate between early and delayed surgery but in early surgery the operating time was shorter albeit with higher blood loss and delayed surgery had a lower conversion rate to open surgery. Between these groups there was no significant difference in intra- or and postoperative complication rates. In study two we found that patients treated with cholecystostomy tend to be older with higher co-morbidity and treatment with cholecystostomy for this group was a safe option with lower complication rate than for those treated with acute surgery, although with a longer hospital stay. In study three 8532 patients were divided into six different time intervals from discharge after acute cholecystitis to elective cholecystectomy. We found a reduction in the risk for cystic duct leakage and perioperative complications if surgery was performed more than 30 days after discharge and if surgery was performed more than one year after discharge there was an increased risk for bile duct injury. Study four was based on 25 high-risk patients treated with PGBA, showing that the procedure was successful in all patients, although one patient needed two aspirations. We registered one minor complication that did not require any intervention. Median hospital stay was 3 days (IQR 2-4 days). Recurrence rate of cholecystitis was 28%. In study five, 241 patients with a median age of 77 years, 82.6% with Tokyo grade 2 and 14.1 % grade 3 cholecystitis treated with cholecystostomy were included. Complications related to cholecystostomy Clavien-Dindo ≥ 2 were found in 19.5%. Recurrence rate following treatment with cholecystostomy was 12%. We found no significant difference in outcome if the drainage was removed based on clinical judgment or cholangiography finding. Time to drain removal did not have any impact on the complication rate either Management of the cholecystostomy had no impact on recurrence rate. Discussion: Although early cholecystectomy is considered the treatment of choice for acute cholecystitis, it is routinely applied. Rescue strategies should be evaluated for this patient group. PC seems to be a safe option for those with high risk for emergency surgery. We found that safety of cholecystectomy increases if performed more than 30 days after discharge after a conservatively treated cholecystitis. PGBA seems to be a safe treatment option in high-risk patients, although it should be evaluated in larger studies. A cholecystostomy can be safely removed early and performing a cholangiography does not seem to change the outcome.