Timing and choice of intervention influences outcome in acute cholecystitis: a prospective study

Determine which management strategy is ideal for patients with acute cholecystitis.

Prospective enrollment between August 2009 and March 2011. Large academic center. Patients with acute cholecystitis. Laparoscopic cholecystectomy, intravenous antibiotics followed by laparoscopic cholecystectomy or percutaneous cholecystostomy. Primary endpoints were postoperative complications and 30-day mortality.

A total of 162 patients were enrolled, 53 (33%) with simple acute cholecystitis and 109 (67%) with complex acute cholecystitis. Of the 109 patients with complex cholecystitis, 77 (70.6%) underwent successful laparoscopic cholecystectomy during the same hospital admission and 6 patients (5.5%) had an unsuccessful laparoscopic cholecystectomy requiring conversion to cholecystostomy. Radiology performed cholecystostomy in 19 (11.7%) patients with complex acute cholecystitis and 4 (2.5%) patients with simple acute cholecystitis for a total 23 patients of the 162 patients in the study. Nine of the 23 patients had dislodged tubes (39.1%). Two of the 23 patients (8.7%) had significant bile leaks resulting in either sepsis or emergency surgery. One patient (4.3%) had a wound infection. Overall, patients with complex acute cholecystitis had a higher morbidity rate (31.2%) compared with patients with simple acute cholecystitis (26.4%).

A high complication rate seen with radiology placed percutaneous cholecystostomy tubes prompted our center to reevaluate the treatment algorithm used to treat patients with complex acute cholecystitis. Although laparoscopic cholecystectomy is considered to be the gold standard in the treatment of acute cholecystitis, if laparoscopic cholecystectomy is not felt to be safe due to gallbladder wall thickening or symptoms of >72 hours' duration, we now encourage the use of intravenous antibiotics to "cool" patients down followed by interval laparoscopic cholecystectomy approximately 6 to 8 weeks later. Patients who do not respond to antibiotics should undergo attempted laparoscopic cholecystectomy and if unable to be performed safely, a laparoscopic cholecystostomy tube can be placed under direct visualization for decompression followed by interval laparoscopic cholecystectomy at a later date.