Why not perform a cholecystostomy (gallbladder drainage) followed by cholecystectomy (gallbladder removal) in 3 months?

Management of Acute Cholecystitis: Cholecystostomy vs. Early Cholecystectomy

Early laparoscopic cholecystectomy is superior to percutaneous cholecystostomy followed by delayed cholecystectomy for most patients with acute calculous cholecystitis, resulting in significantly fewer major complications and better outcomes. 1

Evidence-Based Decision Algorithm

First-Line Treatment

• Early laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days from symptom onset 1
• This approach has demonstrated:
  • Lower major complication rates (5% vs 53% with cholecystostomy) 1
  • Shorter hospital stays 1
  • Less utilization of healthcare resources 1
  • Lower readmission rates for gallstone-related diseases 1

When to Consider Percutaneous Cholecystostomy

Percutaneous cholecystostomy followed by delayed cholecystectomy should be reserved for:

1. Patients truly unfit for surgery with:

   • Sepsis due to gallbladder empyema 1
   • Strict contraindications to surgery after failed conservative management (24-48 hours) 1
   • ASA III/IV patients with severe comorbidities 1
   • Frail elderly patients with poor performance status 1

2. Predictors for failure of non-operative management requiring drainage:

   • Age over 70 years
   • Diabetes
   • Tachycardia
   • Distended gallbladder
   • WBC >15,000 cell/mm³
   • Fever 1

Outcomes and Complications

Cholecystostomy Followed by Delayed Cholecystectomy

• Technical success rate: 85.6% 1
• Procedure-related mortality: 0.36% 1
• 30-day mortality: 15.4% (high) 1
• In-hospital mortality: 4-50% (variable) 1
• Morbidity: 8.2-62% (variable) 1
• Readmission rate: 49% at 1 year for patients who don't undergo subsequent cholecystectomy 1
• Recurrent cholecystitis: High incidence if tube removed without subsequent cholecystectomy 2

Early Laparoscopic Cholecystectomy

• Significantly fewer major complications compared to cholecystostomy 1
• Lower mortality rate 1
• Shorter hospital stays 1
• Lower readmission rates 1

Important Considerations

Timing of Delayed Cholecystectomy

• If cholecystostomy is performed, delayed laparoscopic cholecystectomy is suggested after reduction of perioperative risks 1
• The standard 3-month interval is not specifically supported by high-quality evidence
• Removal of cholecystostomy tube without subsequent cholecystectomy leads to high recurrence rates of cholecystitis (62% in one study) 2

Conversion to Open Surgery

• Conversion from laparoscopic to open cholecystectomy should not be viewed as a failure but as a valid option for patient safety 3
• Predictors of conversion include:
  • Fever
  • Leukocytosis
  • Elevated serum bilirubin
  • Extensive upper abdominal surgery
  • Local severe inflammation
  • Adhesions
  • Bleeding in Calot's triangle
  • Suspected bile duct injury 1

Alternative Drainage Options

For patients truly unfit for surgery, endoscopic alternatives to percutaneous cholecystostomy can be considered:

• Endoscopic transpapillary gallbladder drainage (ETGBD)
• Ultrasound-guided transmural gallbladder drainage (EUS-GBD)
• These should be performed in high-volume centers by skilled endoscopists 1

Common Pitfalls to Avoid

1. Delaying definitive treatment unnecessarily

   • Delaying cholecystectomy in suitable candidates increases risk of recurrent biliary events 1

2. Removing cholecystostomy tubes without subsequent cholecystectomy

   • High risk of recurrent cholecystitis with potentially devastating consequences 2

3. Using age alone as a contraindication to surgery

   • Patient frailty and comorbidities, not age alone, should guide decision-making 1, 3

4. Failing to perform risk stratification

   • Use frailty scores and surgical risk assessment tools (ASA, P-POSSUM, APACHE II) 1

The evidence strongly supports early laparoscopic cholecystectomy as the preferred treatment for acute cholecystitis in most patients, with cholecystostomy reserved for those truly unfit for surgery. When cholecystostomy is performed, subsequent cholecystectomy should follow once the patient's condition improves to prevent recurrent cholecystitis.