What is the urgency of gallbladder surgery?

Urgency of Gallbladder Surgery

Early laparoscopic cholecystectomy should be performed as soon as possible within 7 days from hospital admission and within 10 days from the onset of symptoms for patients with acute calculous cholecystitis. 1

Timing Recommendations Based on Clinical Presentation

Acute Calculous Cholecystitis

• Early laparoscopic cholecystectomy (ELC) is the preferred approach for acute cholecystitis and should be performed as soon as possible, ideally within 72 hours of diagnosis 1, 2
• If ELC cannot be performed within the initial window, surgery should be delayed until at least 6 weeks after the acute episode (delayed laparoscopic cholecystectomy or DLC) 1
• Intermediate laparoscopic cholecystectomy (performed between 7 days and 6 weeks) is associated with higher complication rates and should be avoided 1

Gallstone Pancreatitis

• Patients with gallstone pancreatitis who have associated cholangitis or persistent biliary obstruction should undergo biliary sphincterotomy and endoscopic stone extraction within 72 hours of presentation 1
• Following mild acute gallstone pancreatitis, cholecystectomy should be performed within 2 weeks of presentation, preferably during the same admission 1

Acute Cholangitis

• Patients with acute cholangitis who fail to respond to antibiotic therapy or who have signs of septic shock require urgent biliary decompression 1

Special Considerations for Elderly Patients

• Advanced age (>65 years) alone is not a contraindication to cholecystectomy for acute calculous cholecystitis 1
• In elderly patients, early laparoscopic cholecystectomy should still be performed as soon as possible but can be performed up to 10 days from symptom onset 1
• Earlier surgery in elderly patients is associated with shorter hospital stay and fewer complications 1

Risks of Delaying Surgery

• Waiting for interval operations is associated with multiple hospital readmissions, averaging one extra emergency department presentation per patient 3
• After long-term follow-up of 14 years, approximately 30% of patients with mildly symptomatic acute cholecystitis who did not undergo cholecystectomy developed recurrent gallstone-related complications 1
• Complication rates are higher in patients who undergo interval operations compared to early surgery 3

Alternative Approaches for High-Risk Patients

• Percutaneous cholecystostomy can be considered for patients deemed unfit for surgery (older than 65, with ASA III/IV, performance status 3-4, or septic shock) 1
• Percutaneous cholecystostomy may serve as a bridge to cholecystectomy in high-risk elderly patients, converting them to moderate-risk patients more suitable for surgery 1

Surgical Approach Considerations

• Laparoscopic approach should always be attempted first except in cases of absolute anesthetic contraindications or septic shock 1
• Conversion to open surgery should be considered in cases of local severe inflammation, adhesions, bleeding in Calot's triangle, or suspected bile duct injury 1
• Subtotal cholecystectomy (laparoscopic or open) is a valid option for advanced inflammation, gangrenous gallbladder, or difficult anatomy where bile duct injuries are highly probable 1

Common Pitfalls and Caveats

• Delaying surgery beyond the initial acute phase (>72 hours) but performing it before 6 weeks (intermediate period) is associated with higher complication rates and should be avoided 1
• The TG13 grade 3 acute cholecystitis has an increased risk of mortality compared to grade 1 (6.5% vs. 1.3%), and referral to high-volume specialized centers should be considered 1
• Male patients have an increased risk of complications (15% vs. 10%) and higher conversion rates to open surgery (48.5% vs. 16%) 1
• Observation alone is not recommended for symptomatic gallstone disease, as approximately 60% of patients will eventually require cholecystectomy 1

In conclusion, gallbladder surgery for acute calculous cholecystitis should be performed urgently within the first 72 hours of presentation when possible, and certainly within 7-10 days of symptom onset. If this window is missed, surgery should be delayed until at least 6 weeks after the acute episode to allow inflammation to subside.