When is emergent cholecystectomy (surgical removal of the gallbladder) indicated?

From the Guidelines

Emergent cholecystectomy is indicated in cases of acute cholecystitis with signs of gangrene, perforation, or emphysematous cholecystitis, as well as in patients with sepsis or peritonitis due to gallbladder disease, and should be considered when patients show clinical deterioration despite conservative management. The decision to perform an emergent cholecystectomy is based on the severity of the patient's condition and the risk of complications, as outlined in the 2017 WSES and SICG guidelines on acute calculous cholecystitis in the elderly population 1.

Indications for Emergent Cholecystectomy

• Acute cholecystitis with signs of gangrene, perforation, or emphysematous cholecystitis
• Acute cholangitis not responding to antibiotics
• Gallstone pancreatitis with persistent obstruction
• Patients with sepsis or peritonitis due to gallbladder disease
• Clinical deterioration despite conservative management, including worsening pain, fever, increasing white blood cell count, or signs of systemic inflammatory response syndrome

Preoperative Management

Patients requiring emergent cholecystectomy should receive:

• Appropriate fluid resuscitation
• Broad-spectrum antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours
• Adequate pain control

Surgical Approach

The procedure typically involves removing the gallbladder, preferably laparoscopically when possible, though open surgery may be necessary in complex cases, as stated in the guidelines 1. The choice of surgical approach depends on the patient's condition and the surgeon's expertise.

Alternative Treatments

Percutaneous cholecystostomy can be considered as a bridge to cholecystectomy in acutely ill, high-risk elderly patients deemed unfit for surgery, in order to convert them into moderate-risk patients more suitable for surgery 1. However, this approach should be reserved for patients who are not candidates for immediate surgery due to severe comorbidities or other high-risk conditions.

Timing of Surgery

Early laparoscopic cholecystectomy should be performed as soon as possible, but can be performed up to 10 days after the onset of symptoms, as recommended by the guidelines 1. Earlier surgery is associated with shorter hospital stays and fewer complications.

In summary, emergent cholecystectomy is a life-saving procedure that should be performed promptly in patients with severe acute cholecystitis or those who show clinical deterioration despite conservative management, with the goal of reducing morbidity and mortality by eliminating the source of infection and inflammation before further complications develop.

From the Research

Indications for Emergent Cholecystectomy

• Emergent cholecystectomy is indicated in patients with acute cholecystitis who do not respond to nonoperative treatment 2
• It is also considered in high-risk patients, although percutaneous cholecystostomy may be an alternative treatment option in these cases 3, 4
• The timing of cholecystectomy is important, with early laparoscopic cholecystectomy (within 1-3 days) associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 5
• In patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis, while others should undergo a laparoscopic cholecystectomy 5

Patient Selection

• Patient selection is crucial in determining the best treatment approach for acute cholecystitis
• Factors such as age, surgical risk, and comorbidities should be taken into account when deciding between emergent cholecystectomy and percutaneous cholecystostomy 3, 4
• The American Society of Anesthesiologists (ASA) score can be used to estimate surgical risk, with higher scores indicating a higher risk of complications and mortality 3

Outcomes and Complications

• Emergent cholecystectomy is associated with a higher conversion rate to open cholecystectomy, as well as increased morbidity and mortality rates compared to elective cholecystectomy 6
• Percutaneous cholecystostomy is a safe and effective procedure, but may be associated with higher rates of postprocedural complications compared to laparoscopic cholecystectomy 5, 4
• The timing of percutaneous cholecystostomy insertion does not affect the outcome of acute cholecystitis, but may influence the likelihood of undergoing an elective cholecystectomy 4