What is the most appropriate surgical management for a critically ill patient with acute cholecystitis and sepsis?

Management of Acute Cholecystitis with Sepsis

Immediate cholecystectomy is the most appropriate surgical management for this critically ill patient with acute cholecystitis and sepsis.

Patient Assessment

This 65-year-old diabetic male presents with clear signs of acute cholecystitis complicated by sepsis:

• Clinical features: RUQ pain, nausea, vomiting, positive Murphy's sign
• Vital signs: Fever (39°C), tachycardia (P 115), hypotension (BP 88/60 mmHg)
• Laboratory findings: Leukocytosis (WBC 19,000/mm³)
• Imaging: Thickened gallbladder wall (7mm), air in gallbladder wall, pericholecystic fluid, gallstones

The presence of air in the gallbladder wall suggests emphysematous cholecystitis, which carries a significantly higher mortality risk (15-25%) than regular acute cholecystitis 1.

Surgical Management Options

Immediate Laparoscopic Cholecystectomy (Recommended)

Immediate laparoscopic cholecystectomy is superior to percutaneous cholecystostomy in high-risk patients with acute cholecystitis and should be the first-choice treatment in this group of patients. 2

Evidence supporting this approach:

• The 2020 World Society of Emergency Surgery guidelines strongly recommend immediate laparoscopic cholecystectomy as the first-choice treatment for high-risk patients with acute cholecystitis (high quality evidence) 2
• The CHOCOLATE trial demonstrated that patients who underwent early laparoscopic cholecystectomy had significantly fewer major complications (5%) compared to those who underwent percutaneous transhepatic gallbladder drainage (53%) 2
• Early laparoscopic cholecystectomy leads to significantly less utilization of healthcare resources 2

Percutaneous Cholecystostomy

Percutaneous cholecystostomy should be reserved for patients who are absolutely unfit for surgery 2. While it can be effective in decompressing the gallbladder and removing infected material 3, it has several limitations:

• Higher mortality rate, longer hospital stays, and more readmissions for gallstone-related diseases compared to cholecystectomy 2
• Often requires delayed cholecystectomy later, resulting in additional procedures 2
• Success rates vary widely (56-100%) depending on patient population 4

Conservative Management with Antibiotics Alone

This approach is inadequate for this critically ill patient with emphysematous cholecystitis and sepsis. Source control through definitive surgical intervention is essential 1.

Delayed Approach (Cholecystostomy followed by Cholecystectomy)

While this staged approach may be necessary in some cases, immediate cholecystectomy is preferred when feasible as it provides definitive treatment in a single procedure 2.

Decision Algorithm

1. First-line approach: Immediate laparoscopic cholecystectomy

   • Provides definitive source control
   • Associated with fewer complications and shorter hospital stays
   • Recommended by current guidelines for high-risk patients 2

2. If absolutely contraindicated for surgery (e.g., severe cardiopulmonary disease making general anesthesia impossible):

   • Perform percutaneous cholecystostomy for gallbladder drainage
   • Continue antibiotics and supportive care
   • Consider delayed cholecystectomy after clinical improvement

Important Considerations

• Ensure adequate resuscitation with IV fluids and vasopressors before surgery
• Continue broad-spectrum antibiotics covering biliary pathogens
• Monitor for clinical improvement (decreasing fever, abdominal pain, normalizing WBC)
• Be prepared for possible conversion to open cholecystectomy if severe inflammation, adhesions, or bleeding is encountered 2

Conclusion

Based on the highest quality and most recent evidence, immediate laparoscopic cholecystectomy is the most appropriate surgical management for this critically ill patient with acute cholecystitis and sepsis.