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.

Laparoscopic Cholecystectomy for Symptomatic Cholecystic Disease in Children: Defining Surgical Timing

“…Gallstones can block the cystic duct causing GB distension and biliary colic. Prolonged obstruction results in inflammation, infection, and even ischemia, resulting in acute inflammation of GB; repeated episodes can result in chronic cholecystitis, in which a thickened GB wall, GB mucosal atrophy and scarring were detected (16). There is no consensus on the management of children with cholelithiasis and the risks of developing complications as a consequence of delaying surgery are well-known (17)(18)(19).…”

Think Like a Surgeon

“…Approximately 90% of patients with cholecystitis have gallstones 2 . Although most are silent, approximately 10% of patients with symptomatic gallstones will develop acute cholecystitis 3,4 . The remaining patients with acute cholecystitis have acalculous cholecystitis resulting from necrosis and inflammation of the gallbladder secondary to gallbladder ischemia, bile stasis, and subsequent infection.…”

Looking for the best practice for acute cholecystitis

“…Professor Stanley Ashley kindly delivered a special lecture titled ‘Advances in the management of acute cholecystitis’ at the 16th Annual Meeting of the Japanese Society of Gastroenterological Surgery. Based on that lecture, Prof. Ashley and his colleagues have written an informative review article in this issue of the Annals of Gastroenterological Surgery . Diagnostic and therapeutic strategies in acute cholecystitis (AC) are, indeed, continuing concerns.…”