Acute cholecystitis: We can drain it!

Abstract

Introduction

Acute cholecystitis (AC) is one of the most common gastrointestinal diseases encountered in the emergency department.1 Cholecystectomy (CCY) is regarded as the standard treatment for AC patients.2–7 The major role of percutaneous transhepatic gallbladder drainage (PTGBD) is temporary stabilization of the patient’s acute debilitating condition prior to CCY.8–12 However, PTGBD can be a permanent treatment for patients who are not candidates for surgery (Figs. 1–3). Moreover, in some patients, there may be a possibility of undergoing unnecessary surgery when it can be managed alternatively via conservative management with or without PTGBD. In this article, the author restates the role of PTGBD in patients with AC in the era of minimally invasive medicine.

Controversies

Traditionally, patients are prepared to proceed to cholecystectomy whenever they are ready. However, there is some controversy as to which patients PTGBD is indicated. Another controversy is whether CCY is mandatory after PTGBD because CCY is not free of complications.13

As for the first controversy, there is as yet no clear evidence for which is the best treatment for AC patients. Abi-Haidar et al compared the outcomes of PTGBD with those of CCY for AC patients and concluded that PTGBD should be reserved only for patients with prohibitive risks for surgery due to its high association with higher morbidity rates.14 However, as are with many other comparative studies, this study lacks good randomization between two comparative groups. PTGBD was performed for more debilitated and high-risk patients than those who underwent CCY. Kortram et al, however, conducted a randomized controlled study between two groups of high-risk AC patients.15 According to this, there was a consensus that patients with an Acute Physiology and Chronic Health Evaluation (APACHE)-II score <7 should undergo emergency laparoscopic CCY, whereas patients with a score >14 would be better to undergo PTGBD. In patients with an APACHE II score 7–14, opinions differ and no consensus was reached regarding which treatment was better. According to Kortram et al, PTGBD has obviated the need for emergency operations in high-risk patients, and has helped to save time for patients conditioning for elective surgery and general anesthesia.

As for the second controversy, once PTGBD is performed, an interval CCY seems to be mandatory, and the only exceptions are the selected high-risk patients with acalculous AC in whom the PTGBD can be considered as a definitive treatment. For this matter, there has not been a well-designed randomized controlled study as to whether the PTGBD group is inferior to the delayed CCY group in longer-term mortality and morbidity. In some patients, PTGBD may obviate unnecessary CCY if patients are left well without significant complications. The cost-effectiveness evaluation for the two groups should also be performed in order to conclude whether or not CCY must be followed after stabilization of the AC patient’s general conditions.

McGillicuddy et al analyzed the data of 185 AC patients without operative treatment.16 Out of 67 PTGBD patients, 44 had subsequent CCY with a complication rate of 23%. No deaths or major complications occurred among those with recurrent AC. Therefore, they concluded that medical management with or without PTGBD may be appropriate for select patients. Interval CCY is needed only for recurrent AC.

Rimkus and Kalff followed acalculous AC patients and according to their observations, more than 90% of the patients treated by PTGBD showed no recurrence of symptoms during a period of more than 1 year.17 Thus, it is unclear as to whether delayed CCY is still justified for these patients who were previously treated by PTGBD.

By contrast, Morse et al evaluated the clinical course and outcomes of critically ill AC patients (n = 50) who underwent PTGBD and subsequent CCY. They concluded that the removal of the PTGBD tube without subsequent CCY is associated with a high recurrence of AC and devastating consequences.8

However, it cannot be concluded that CCY must be performed for AC patients who have been stabilized in general conditions after PTGBD. In some patients, such as hemodialysis patients, patients in intensive care, and pregnant women, CCY seems to be unnecessary after PTGBD.18

Recommendations from an interventional radiologist’s viewpoint

Laparoscopic CCY may be the standard treatment for AC whenever indicated. PTGBD may be indicated for high-risk patients for surgery. However, the role of medical treatment with or without PTGBD should not be ignored. When AC patients are stabilized in general conditions, delayed CCY is not mandatory; selected patients can be managed cautiously without surgery. A possible schematic treatment is shown in Fig. 4, reflecting the viewpoint of an interventional radiologist. A well-designed prospective randomized trial is warranted comparing between the medical treatment group with or without PTGBD and the CCY group for proper management guidelines of AC patients.

Figure 4

Suggested treatment flow chart for acute cholecystitis patients from an interventional radiologist’s viewpoint.

Article information

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