Management of acute cholecystitis and the surgeon’s dilemma: the gun shoots both directions

 

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Cholecystectomy has been the gold standard treatment for gallbladder disease for a century, but minimal-invasive surgery has started a new era of management.

On a day-to-day basis, every medical treatment must consider benefit and risk, but the effects on quality of life and cost must also be kept in mind. As this editorial will show, controversy over the optimal management of acute cholecystitis still exists.

Due to increasing experience in laparoscopic techniques, which result in low mortality and morbidity, the laparoscopic approach could be considered the gold standard for patients with acute cholecystitis [1] [2], even though it has been suggested lately that open cholecystectomy might be as effective as laparoscopic cholecystectomy [3]. The timing of cholecystectomy has no clinically relevant influence on the conversion rate [2].

However, there have been numerous reports about non-operative treatment, such as percutaneous drainage, endoscopic sphincterotomy, antibiotic administration, and transpapillary gallbladder drainage, in patients suffering from acute cholecystitis and who are at increased operative risk, as suggested in the report by Kjaer et al. [4] [5]. The authors report on their personal experience with endoscopic gallbladder drainage, using a transpapillary drain, and resulting in a success rate of up to 89 %. Even though this series is truly remarkable and the authors should be congratulated for their excellent results, there are still some reservations concerning the interpretation of these data in order to establish therapeutic guidelines. The first statement (and the authors, too, leave no doubt about it) is that laparoscopic cholecystectomy it the gold standard therapy for acute cholecystitis. When we go into details, things get more interesting. What defines a patient with increased operative risk? The authors do not give an adequate answer to this hallmark question, and this is to be excused because the study was retrospective. But there is no indication whatsoever of the clinical appearance of the patients who were obviously considered high risk for laparoscopic cholecystectomy. What narrow path (from an anesthesiologic point of view) exists between an endoscopic retrograde cholangiopancreatography (ERCP) procedure (with deep sedation) and a laparoscopic cholecystectomy, nota bene with invasive monitoring and safe ventilation? Unfortunately the authors do not give a single hint as to why patients were thought to be fit to undergo time-consuming ERCP procedures but not to undergo simple laparoscopic cholecystectomy. What were the preoperative risks that prevented colleagues from Denmark from operating on these patients? This, however, is a key point that needs to be addressed.

Although seemingly effective, endoscopic gallbladder drainage as a therapeutic regimen, needs to be challenged. None of the cited reports offered the alternative: immediate cholecystectomy, either open or laparoscopic. But it is the sick, elderly, diabetic, heart-insufficient patient who, with conservative treatment, is at highest risk of developing “critical side effects”, such as liver abscess, gallbladder perforation, and peritonitis [6]. We would at least try to argue for a general indication pro cholecystectomy in patients with severe acute cholecystitis with associated operative risks. General anesthesia these days is safe, patients at high risk can be monitored closely (and, indeed, better than in the pure conservative group), and the infection focus is eliminated at once. Given that the risk of developing acute pancreatitis after ERCP intervention is not minimal (5 %), and that severe acute pancreatitis puts the sick patient at highest risk, operative treatment should not be excluded from the therapeutic armamentarium.

This is mirrored in the literature. An example is the study by Yi and co-workers in high-risk patients with acute cholecystitis. They report on 25 patients with ASA 3 scores who underwent laparoscopic cholecystectomy with the same results as patients with ASA 1 (n = 33) or ASA 2 (n = 79) scores [7]. In addition Salameh et al. report on their experience with 39 patients with coronary artery disease (ASA 3 and 4) who underwent laparoscopic cholecystectomy for acute cholecystitis, with no major morbidity or mortality. Of particular note is the report of one patient with unstable angina and acute cholecystitis, who underwent coronary angioplasty and stenting, immediately followed by laparoscopic cholecystectomy, with an uneventful course [8].

To draw an unequivocal solomonic conclusion to this editorial, we should like to expose the weakness of all cited studies on high-risk patients: there are no control groups. The “operative” studies only evaluated an operative strategy, with excellent results, and the “conservative” counterparts did likewise. As the number of patients with acute cholecystitis is low, a randomized trial would be hard to perform. In times of limited medical funding, favorable operative results constitute a strong argument for not excluding high-risk patients from a treatment that eliminates the infection focus at once, especially when considering that a large number of these patients need to undergo elective cholecystectomy anyway.

Therefore, a critique-less adoption of conservative treatment of acute cholecystitis seems not to be justified when the definition of “high-risk surgical patient” does not exist.

Competing interests: None

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J. R. Izbicki, MD

Department of General, Visceral and Thoracic Surgery
University Medical Center Hamburg Eppendorf

Martinistrasse 52
D-20246 Hamburg
Germany

Fax: +49-40-428034995

Email: izbicki@uke.uni-hamburg.de