What is the treatment for calculus cholecystitis?

Treatment for Acute Calculus Cholecystitis

Early laparoscopic cholecystectomy (ELC) is the first-choice treatment for acute calculus cholecystitis (ACC) in all patients, including high-risk patients, as it leads to significantly fewer complications and better healthcare resource utilization compared to other approaches. 1

Primary Treatment Algorithm

First-line Treatment

• Early laparoscopic cholecystectomy should be performed after 24-48 hours of initial conservative management (IV hydration, antibiotics covering enteric organisms, NPO status) 1, 2
• ELC is superior to percutaneous transhepatic gallbladder drainage (PTGBD) even in high-risk patients, with significantly lower complication rates (5% vs 53%) 1
• ELC results in shorter hospital stays, less pain, and quicker return to productivity compared to open cholecystectomy or delayed surgical management 2

Difficult Cases Management

• In cases where anatomical identification is difficult during surgery, laparoscopic or open subtotal cholecystectomy is recommended to prevent iatrogenic injuries 1
• Subtotal cholecystectomy is particularly useful in cases of severe inflammation, gallstones with liver cirrhosis/portal hypertension, or empyema/perforated gallbladder 1
• Intraoperative cholangiography may be helpful during difficult cases to prevent bile duct injury 3

Alternative Approaches for Non-Surgical Candidates

For patients who are truly not suitable for surgery (not just high-risk):

Gallbladder Drainage Options

• Percutaneous transhepatic gallbladder drainage (PTGBD) is recommended for non-surgical candidates with sepsis due to gallbladder empyema 1
• PTGBD has a high success rate (85.6%) with low procedure-related mortality (0.36%), though 30-day mortality remains high (15.4%) 1
• Endoscopic alternatives include:
  • Endoscopic transpapillary gallbladder drainage (ETGBD)
  • Ultrasound-guided transmural gallbladder drainage (EUS-GBD)
  • These should be performed in high-volume centers by skilled endoscopists 1

Delayed Cholecystectomy Considerations

• After gallbladder drainage and reduction of perioperative risks, delayed laparoscopic cholecystectomy should be considered to prevent readmission for ACC relapse 1
• Without delayed cholecystectomy after PTGBD, the 1-year readmission rate is approximately 49% 1

Special Considerations and Pitfalls

Risk Assessment

• Predictors of failure for non-operative management at 24 hours: age >70 years, diabetes, tachycardia, distended gallbladder 1
• Predictors of failure at 48 hours: WBC >15,000 cells/mm³, fever, age >70 years 1

Common Pitfalls to Avoid

• Delaying surgery in suitable candidates based solely on age or comorbidities - evidence shows ELC is safe and effective even in high-risk patients 1
• Overuse of gallbladder drainage procedures in patients who could safely undergo surgery - this leads to higher mortality rates, longer hospital stays, and increased readmissions 1, 4
• Performing complete cholecystectomy in difficult cases where anatomy is unclear - this increases risk of bile duct injury 1, 3

Evidence Quality Considerations

• The recommendation for ELC as first-line treatment is supported by high-quality evidence, including randomized controlled trials like the CHOCOLATE trial 1
• The evidence for gallbladder drainage in non-surgical candidates is of moderate quality 1
• The evidence for delayed cholecystectomy after drainage is of very low quality 1