What is the role of cholecystectomy in the treatment of cholecystitis?

Updated: Jan 18, 2017
  • Author: Peter A D Steel, MBBS, MA; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Answer

Historically, cholecystitis was operated on emergently, resulting in increased mortality. The current practice is to cool off the gallbladder and perform a cholecystectomy after several days or to readmit the patient at a later date.

Indications for urgent surgical intervention include patients with complications such as empyema, emphysematous cholecystitis, or perforation. Emergent cholecystectomy is usually performed in 20% of such cases.

Cholecystectomy

In approximately 30% of patients with uncomplicated cholecystitis, medical therapy is not sufficient and these patients usually need cholecystectomy within 24-72 hours. Cholecystectomy may be performed after the first 48 hours or after the inflammation has subsided. Unstable patients may need more urgent intervention with endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage, or cholecystectomy.

Laparoscopic cholecystectomy is very effective and has few complications. Approximately 5% of cases must be converted to an open cholecystectomy; in acute cholecystectomy, the conversion rate can be as high as 30%. The rate of conversion is higher for acute cholecystitis compared with uncomplicated cholelithiasis, in both acute or delayed intervention. [29, 30, 31, 32] Predictors of the need for open conversion include a white blood cell (WBC) count of more than 18,000 cells/µL at the time of presentation, a duration of symptoms longer than 72-96 hours, and an age older than 60 years. [33]

Immediate laparoscopic cholecystectomy (within 24 h) has been increasingly performed by surgeons, because it has been shown to be safe, is not more difficult than laparoscopic cholecystectomy performed later, and shortens the hospital length of stay. [1, 34, 35, 36]  Similarly, Zafar et al reported the best outcomes and lowest costs were achieved when laparoscopic cholecystectomy was performed within 2 days of presentation of acute cholecystitis. [37]

In a large randomized trial by Gutt et al, laparoscopic cholecystectomy performed within 24 hours of hospital admission was found to be superior to conservative management followed a week or more later by surgery in terms of morbidity and costs. In the study, 304 patients underwent laparoscopic cholecystectomy within 24 hours of hospital admission, while 314 patients underwent antibiotic treatment initially, with laparoscopic cholecystectomy performed after 7-45 days. The morbidity rate in the group of patients receiving immediate surgery was 11.8%, compared with 34.4% in the delayed-surgery group. [38]


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