What is the most appropriate surgical management for a critically ill patient with acute cholecystitis and signs of sepsis, including fever, tachycardia, hypotension, and elevated white blood cell count?

Management of Acute Cholecystitis in a Critically Ill Patient

For this 65-year-old diabetic male with acute cholecystitis and septic shock, percutaneous cholecystostomy (Option A) is the most appropriate surgical management.

Patient Assessment and Diagnosis

This patient presents with:

• Classic symptoms of acute cholecystitis (RUQ pain, nausea, vomiting)
• Signs of septic shock (fever 39°C, tachycardia 115, hypotension 88/60 mmHg)
• Positive Murphy's sign
• Leukocytosis (WBC 19,000/mm3)
• Ultrasound findings consistent with acute cholecystitis (thickened gallbladder wall, pericholecystic fluid, gallstones)
• Emphysematous cholecystitis (air in gallbladder wall)

Rationale for Percutaneous Cholecystostomy

1. Critical Illness and Septic Shock

   • The patient is critically ill with septic shock requiring ICU admission, IV fluids, and vasopressors
   • The 2023 WSES guidelines specifically recommend percutaneous cholecystostomy for "critically ill patients with multiple comorbidities and unfit for surgery" 1
   • The 2019 WSES guidelines state: "Percutaneous cholecystostomy can be considered in the treatment of ACC patients with septic shock who are deemed unfit for surgery" 1

2. Patient Risk Factors

   • Advanced age (65 years)
   • Diabetes mellitus
   • Septic shock
   • These factors place the patient at high risk for surgical complications 1, 2

3. Emphysematous Cholecystitis

   • The presence of air in the gallbladder wall indicates emphysematous cholecystitis, a severe form of acute cholecystitis with high mortality
   • This finding further supports urgent decompression via percutaneous cholecystostomy 2

Procedural Considerations

• Percutaneous transhepatic approach is preferred to minimize bile leak risk 1
• The procedure should be performed under ultrasound guidance with local anesthesia 3
• Technical success rates are high (94%) with clinical response in most patients 4
• The catheter should remain in place for 4-6 weeks, with a cholangiogram at 2-3 weeks to confirm biliary tree patency 1

Post-Procedure Management

• Continue broad-spectrum antibiotics covering biliary pathogens 2
• Monitor for clinical improvement (decreasing fever, abdominal pain, normalizing WBC) 2
• Once the patient stabilizes, interval cholecystectomy can be considered after 4-6 weeks 1
• Percutaneous cholecystostomy serves as a bridge to definitive cholecystectomy once the patient's condition improves 1

Why Other Options Are Less Appropriate

1. Immediate cholecystectomy (Option B)

   • Contraindicated in this patient with septic shock and critical illness
   • High mortality risk (14-30%) in elderly critically ill patients with comorbidities 1
   • The patient requires stabilization before considering definitive surgical treatment

2. IV antibiotics alone for one week (Option C)

   • Insufficient for source control in emphysematous cholecystitis
   • Source control is essential in septic shock 1

3. Cholecystostomy and cholecystectomy in 3 months (Option D)

   • While percutaneous cholecystostomy is appropriate initially, the timing of interval cholecystectomy should be based on clinical improvement, typically 4-6 weeks after cholecystostomy 1
   • Delaying for 3 months is unnecessarily long if the patient stabilizes sooner

Conclusion

Percutaneous cholecystostomy is the most appropriate surgical management for this critically ill patient with acute cholecystitis and septic shock. It provides urgent source control while avoiding the high risks of immediate surgery in an unstable patient.