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Early Versus Delayed Laparoscopic Cholecystectomy, after Percutaneous Gall Bladder Drainage, for Grade II Acute
Mohamed Wael1,2, Mostafa Seif1,2, Mohamed Mourad1,2
1Liver and GIT unit, Alexandria University Main Hospital, Alexandria, Egypt.
Insights
Percutaneous transhepatic gallbladder drainage (PTGBD) offers safe initial decompression for high-risk acute cholecystitis (AC). Early laparoscopic cholecystectomy (LC) after PTGBD shortens hospital stays without increasing complications, making it a favorable option for selected patients.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Patient Management
Background:
- Increasing prevalence of acute cholecystitis (AC) in patients with cardiopulmonary comorbidities.
- Management of high-risk Grade II AC remains challenging, with laparoscopic cholecystectomy (LC) posing significant risks.
- Percutaneous transhepatic gallbladder drainage (PTGBD) is a minimally invasive option for initial gallbladder decompression.
Purpose of the Study:
- To evaluate the safety and efficacy of early versus late laparoscopic cholecystectomy (LC) following percutaneous transhepatic gallbladder drainage (PTGBD) in high-risk acute cholecystitis (AC) patients.
- To compare clinical outcomes, complications, and hospital stay between early and late LC groups.
- To establish an optimal treatment algorithm for high-risk AC patients managed with PTGBD.
Main Methods:
- Retrospective analysis of 58 high-risk Grade II AC patients with cardiopulmonary comorbidities.
- Initial management with PTGBD, followed by LC either within 7 days (early group, n=26) or 6-8 weeks (late group, n=32).
- Comparison of operative time, complication rates, inflammatory markers, and total hospital stay between the two groups.
Main Results:
- Procalcitonin and C-reactive protein levels were significantly higher in the late LC group.
- No significant differences in operative time, PTGBD-related, or major perioperative complications between early and late LC groups.
- Total hospital stay was significantly shorter in the early LC group.
Conclusions:
- PTGBD is a safe and effective initial treatment for high-risk AC, with low morbidity and high success rates.
- Early LC following PTGBD is a safe option for well-selected high-risk AC patients, offering a shorter hospital stay and reduced costs.
- Personalized timing of LC after PTGBD, based on patient's clinical status, is crucial, and early LC avoids potential risks associated with delayed surgery.
Abstract:
The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.
