Acute Cholecystitis in High-Risk Patients. Surgical, Radiological, or Endoscopic Treatment? Brazilian College of Digestive Surgery Position Paper

Abstract

Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient’s desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

Ultrasound-Guided Interventions in the Biliary System

“…PGBD, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), and endoscopic transpapillary gallbladder drainage (ETGBD) are minimally invasive alternatives that can be considered [43][44][45]. While endoscopic approaches require equipment and expertise, PGBD is relatively easy to perform and is recommended for these patients in various guidelines [45][46][47][48][49][50]. Ultrasound is widely available, including in less specialised centres.…”

Bile Duct Injury Repair in a Patient With Situs Inversus Totalis

“…BDIs are a surgical challenge, impose significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life 3 , 8 , 16 , and should be managed in centers with expertise 23 . Risk factors that could contribute to a higher risk of BDI during cholecystectomy include acute cholecystitis, severe obesity, previous surgery on the biliary tract, underlying liver disease, and the several anatomical variants of the biliary tract 4 , 20 .…”

Acute Abdomen in Intensive Care Unit: Etiology, Comorbidity and Severity of 1,523 Patients

“…Clinical investigation of patients with AA are crucial for guiding further evaluation with laboratory tests and imaging 12,19,20 , in as much as benign non-specific abdominal pain (NSAP) still remains the most common subjacent diagnosis of AA [5][6][7]11,14 . Other common causes of non-traumatic AA include nephrolithiasis, cholelithiasis and/or cholecystitis (CC), acute appendicitis, acute pancreatitis (AP), acute diverticulitis, small (SBO) and large bowel obstruction (LBO), perforated hollow viscus and mesenteric ischemia 1,[5][6][7]10,15,17,26,31 .…”