What is the recommended management for patients with a history of acute cholecystitis or biliary colic who are candidates for interval cholecystectomy?

Management of Interval Cholecystectomy in Patients with History of Acute Cholecystitis or Biliary Colic

For patients with a history of acute cholecystitis or biliary colic, laparoscopic cholecystectomy should be performed during the index admission rather than delayed as an interval procedure to prevent recurrent biliary complications. 1

Timing of Cholecystectomy Based on Disease Severity

Mild Acute Gallstone Pancreatitis/Cholecystitis

• Laparoscopic cholecystectomy during index admission is strongly recommended (Level 1A evidence) 1
• Can be performed as early as the second hospital day if the patient is clinically improving 1
• Same-admission cholecystectomy significantly reduces:
  • Mortality and gallstone-related complications (OR 0.24; 95% CI 0.09-0.61)
  • Readmission for recurrent pancreatitis (OR 0.25; 95% CI 0.07-0.90)
  • Pancreaticobiliary complications (OR 0.24; 95% CI 0.09-0.61) 1

Moderate to Severe Cases with Peripancreatic Fluid Collections

• Cholecystectomy should be deferred until:
  • Fluid collections resolve or stabilize
  • Acute inflammation ceases (Level 2C evidence) 1
• Early cholecystectomy in these cases has been associated with more complications 1

Special Considerations

Post-ERCP Management

• Even when ERCP and sphincterotomy are performed during index admission:
  • Same-admission cholecystectomy is still advised
  • Risk for recurrent pancreatitis is diminished but not eliminated
  • Increased risk for other biliary complications persists (Level 1B evidence) 1
• A meta-analysis showed that wait-and-watch strategy after ES is associated with:
  • Higher rates of recurrent cholecystitis (RR 9.82; 95% CI 4.27-22.59)
  • Higher rates of cholangitis and recurrent jaundice (RR 2.16; 95% CI 1.14-4.07) 2

High-Risk Patients

• For patients unfit for surgery (elderly >65 years with ASA III/IV or septic shock):
  • Percutaneous cholecystostomy (PC) is recommended as:
    • Bridge to interval cholecystectomy
    • Or definitive treatment in very high-risk patients 3
  • PC has a high success rate (91-98.5%) for resolving acute episodes 4, 5
  • However, PC has notable drawbacks:
    • Tube dysfunction in up to 46% of patients
    • Re-intervention required in 28% of patients
    • Procedure-related complications in 7% 4
    • Recurrent biliary events in 41% of patients without subsequent cholecystectomy 5

Surgical Approach for Interval Cholecystectomy

• Interval cholecystectomy after PC reduces risk of recurrent biliary events from 21% to 7% 4
• Laparoscopic completion is more likely with interval cholecystectomy (45%) compared to urgent surgery for PC failure or recurrent biliary events (22%) 4
• For difficult cases (advanced inflammation, gangrenous gallbladder, difficult anatomy):
  • Subtotal cholecystectomy (laparoscopic or open) is a valid option 3

Perioperative Management

• Antibiotic therapy:
  • After adequate source control (cholecystectomy): 4 days for immunocompetent, non-critically ill patients 3
  • No post-operative antibiotics needed if procedure is uncomplicated 3
• Pain management:
  • Oral NSAIDs are recommended as first-line therapy
  • Acetaminophen as an alternative or adjunct 3

Pitfalls and Caveats

1. Delayed intervention risks:

   • A multicenter RCT showed interval cholecystectomy resulted in more gallstone-related complications, especially recurrent pancreatitis and biliary colic, without increased cholecystectomy-related complications 1

2. Misperception about surgical difficulty:

   • Same-admission cholecystectomy does not differ from delayed cholecystectomy with respect to rates of conversion from laparoscopy to open approach or surgical difficulty 1

3. Acalculous cholecystitis considerations:

   • For acalculous cholecystitis, interval cholecystectomy may be safely avoided in patients who recover, as they are typically high-risk surgical candidates 6
   • Mortality in acalculous cholecystitis is higher (45.2%) compared to calculous cholecystitis (21.2%) 3

4. Bile duct injury awareness:

   • Bile duct injuries are among the most serious complications of laparoscopic cholecystectomy and require careful technique 3