What is the management of a nonfunctioning gallbladder (cholecystectomy) on imaging?

Management of Nonfunctioning Gallbladder on Imaging

Cholecystectomy is strongly recommended for patients with a nonfunctioning gallbladder on imaging, particularly when symptomatic, as these patients face increased risk of biliary complications and bile duct injury during delayed surgery. 1

Clinical Context and Risk Assessment

A nonfunctioning gallbladder represents a high-risk anatomical condition that warrants definitive surgical management:

• Nonfunctioning gallbladders are associated with significantly higher rates of bile duct injury during cholecystectomy, particularly in cases of scleroatrophic gallbladder which occurs in approximately 4.1% of patients with chronic calculous cholecystitis 2
• Long-term nonfunctioning gallbladders lead to cicatricial and adhesive processes in the gallbladder wall and surrounding tissues, substantially complicating surgical dissection 2
• Complete transection of the common bile duct occurred in 10 cases in one series, with 6 of these involving scleroatrophic (nonfunctioning) gallbladders 2

Recommended Management Algorithm

For Symptomatic Patients with Nonfunctioning Gallbladder

Proceed with cholecystectomy using the following approach:

• Laparoscopic cholecystectomy is the preferred initial approach, even in high-risk anatomy 3
• Ensure achievement of the Critical View of Safety (CVS) before dividing any structures, which minimizes iatrogenic complications 3
• If CVS cannot be achieved due to inflammation or fibrosis, immediately convert to bailout procedures such as fundus-first approach or subtotal cholecystectomy rather than risking bile duct injury 3
• Consider intraoperative cholangiography (IOC) in cases where biliary anatomy cannot be clearly defined or CVS cannot be obtained 3
• Maintain a low threshold for conversion to open surgery if laparoscopic visualization is inadequate 3

For Patients with Gallbladder Stones and Common Bile Duct Stones

Cholecystectomy is recommended for all patients with common bile duct stones (CBDS) and gallbladder stones unless surgery is deemed prohibitive 3:

• Patients with residual gallbladder stones after endoscopic duct clearance have recurrent CBDS rates of 15-23.7% compared to 5.9-11.3% in those with empty gallbladders 3
• Meta-analysis demonstrates mortality is higher in the "wait and see" group (14.1%) versus prophylactic cholecystectomy group (7.9%) with relative risk 1.78 (95% CI 1.15-2.75) 3
• Recurrent pain, jaundice, and cholangitis are significantly more common without cholecystectomy 3

For High-Risk Surgical Candidates

When operative risk is prohibitive:

• Biliary sphincterotomy and endoscopic duct clearance alone is an acceptable alternative for patients with prohibitive surgical risk 3
• Age and comorbidity do not significantly impact ERCP complication rates, making this a reasonable option for elderly or frail patients 3
• Percutaneous cholecystostomy may serve as a bridge procedure in critically ill patients who do not improve with antibiotic therapy, though it is inferior to cholecystectomy in terms of major complications 3

Special Considerations

Timing of Surgery

• Early cholecystectomy (within 7-10 days of symptom onset) is preferred for acute cholecystitis to avoid progression of inflammation that increases surgical difficulty 3
• Delays beyond this window are associated with disease progression and unfavorable surgical conditions 3

Empty Gallbladder on Imaging

• For patients with an empty gallbladder following duct clearance, surgeons may discuss a wait-and-see approach as recurrence rates are lower (5.9-11.3%) 3
• However, several reports suggest lower risk of cholecystitis and subsequent cholecystectomy with prophylactic removal even in empty gallbladders 3

Contraindications to Immediate Surgery

Biliary stenting should be restricted to patients with limited life expectancy or prohibitive surgical risk 3:

• Short-term biliary stenting followed by further endoscopy or surgery is recommended for adequate drainage 3
• Clearance of bile duct stones remains the standard of care; refer to specialist centers if standard extraction techniques fail 3

Key Pitfalls to Avoid

• Never proceed with cholecystectomy without achieving CVS or converting to a bailout procedure when anatomy is unclear, as this is when most bile duct injuries occur 3
• Do not delay surgery excessively in symptomatic patients, as chronic inflammation increases technical difficulty and complication rates 3, 2
• Avoid leaving gallbladder stones in situ after endoscopic duct clearance in surgical candidates, as this significantly increases recurrent biliary events 3, 4