When should patients with cholecystitis be admitted for surgery versus followed up as outpatients with a surgeon?

Management of Patients with Acute Calculous Cholecystitis: Admission vs. Outpatient Follow-up

Patients with acute calculous cholecystitis should be admitted for early laparoscopic cholecystectomy (ELC) within 7 days of hospital admission and within 10 days of symptom onset, as this approach results in significantly lower morbidity, shorter hospital stays, and reduced costs compared to delayed management. 1

Indications for Admission and Early Surgery

• Early laparoscopic cholecystectomy (within 7 days of admission and 10 days of symptom onset) is the gold standard treatment for acute cholecystitis in patients who are fit for surgery 1
• Immediate cholecystectomy (within 24 hours) has been shown to be superior to conservative management with delayed surgery in terms of morbidity and costs 2
• Surgery performed within the "golden 72 hours" window shows favorable outcomes with lower complication rates 3, 4
• Patients with moderate or severely symptomatic cholecystitis should be admitted for early surgical intervention rather than outpatient management 1

Patient Selection for Outpatient Management

Outpatient management with delayed follow-up should be limited to:

• Patients with mildly symptomatic acute cholecystitis (without peritonitis or worsening clinical condition) 1
• Patients who are poor surgical candidates due to high surgical risk 1
• Patients with severe comorbidities (Charlson Comorbidity Index ≥6 and ASA-PS ≥3) who fail conservative treatment 5

Risk Stratification

• TG13 grade 3 cholecystitis carries an increased mortality risk (6.5%) compared to grade 1 (1.3%) 1
• High-risk predictors for failure of non-operative management include:
  • Age over 70 years
  • Diabetes
  • Tachycardia
  • Distended gallbladder at admission
  • WBC >15,000 cells/mm³
  • Fever 1

Management Algorithm

1. For patients fit for surgery:

   • Admit for early laparoscopic cholecystectomy within 7 days of admission and 10 days of symptom onset 1
   • Early surgery results in shorter hospital stays (5.4 vs 10.0 days) and lower costs (€2919 vs €4262) compared to delayed surgery 2

2. For high-risk surgical patients:

   • If moderate acute cholecystitis with CCI ≥6 and ASA-PS ≥3 who fail conservative treatment: attempt laparoscopic cholecystectomy as first choice 5
   • If severe acute cholecystitis with high surgical risk: consider percutaneous cholecystostomy (PC) to relieve symptoms within 24-48 hours 5

3. For patients unsuitable for immediate surgery:

   • Consider gallbladder drainage (percutaneous cholecystostomy) for patients who fail conservative management after 24-48 hours 1
   • For patients with sepsis due to gallbladder empyema, percutaneous transhepatic gallbladder drainage (PTGBD) is effective 1
   • Alternative drainage options include endoscopic transpapillary gallbladder drainage (ETGBD) or ultrasound-guided transmural gallbladder drainage (EUS-GBD) in high-volume centers 1

4. For patients managed non-operatively initially:

   • Schedule delayed laparoscopic cholecystectomy at least 6 weeks after initial presentation 1
   • For patients with percutaneous cholecystostomy, consider interval cholecystectomy at least 6 weeks after PC placement 5
   • For patients not suitable for surgery (CCI ≥6 and ASA-PS ≥4), maintain percutaneous cholecystostomy for at least 3 weeks 5

Pitfalls and Caveats

• Observation alone without eventual cholecystectomy results in approximately 30% of patients developing recurrent gallstone-related complications over long-term follow-up 1
• Conversion from laparoscopic to open cholecystectomy should be considered in cases of severe local inflammation, adhesions, bleeding from Calot's triangle, or suspected bile duct injury 1
• Delaying surgery beyond the recommended timeframe increases the risk of recurrent biliary events and complications 1
• Patients with cholangitis or suspected common bile duct stones require additional management with ERCP 1

Follow-up After Discharge

• For patients who undergo delayed cholecystectomy, surgery should be performed no later than 6-8 weeks after the initial episode 1
• Patients discharged without cholecystectomy should be counseled about the high risk of recurrent gallstone-related complications (up to 49% readmission rate within 1 year) 1
• Ultrasound follow-up is indicated for patients who develop symptoms after cholecystectomy, such as abdominal pain, jaundice, fever, or abnormal liver function tests 6