What is the recommended management for a patient with a contracted gallbladder (cholelithiasis)?

Management of Contracted Gallbladder with Lithiasis

Laparoscopic cholecystectomy is the definitive treatment of choice for contracted gallbladder with cholelithiasis and should be performed as soon as possible, ideally within 7 days of hospital admission and within 10 days from symptom onset. 1, 2

Surgical Approach

Laparoscopic cholecystectomy is the first-line treatment with high-quality evidence supporting its use, offering low complication rates and shortened hospital stays compared to open surgery or conservative management. 1

Timing of Surgery

• Early laparoscopic cholecystectomy (ELC) should be performed within 7 days of hospital admission and within 10 days from symptom onset when adequate surgical expertise is available. 1, 2
• If ELC cannot be performed within this timeframe, delayed laparoscopic cholecystectomy (DLC) should be scheduled beyond 6 weeks from initial presentation. 1
• The contracted gallbladder represents chronic inflammation, making early intervention particularly important to prevent recurrent complications and reduce technical difficulty. 1

Contraindications to Laparoscopic Approach

Avoid laparoscopic cholecystectomy only in cases of:

• Septic shock 1
• Absolute anesthesiology contraindications 1

Conversion to Open Surgery

• Conversion to open cholecystectomy is not a failure but represents a valid option when necessary for patient safety, particularly in difficult cases with severe inflammation or unclear anatomy. 1
• Risk factors predicting conversion include age >65 years, male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery. 3

Alternative Management for High-Risk Patients

For patients who are hemodynamically unstable, not responding to medical management, or at prohibitive operative risk:

• Percutaneous cholecystostomy can serve as bridging therapy until definitive cholecystectomy can be safely performed. 1
• This approach is particularly useful in critically ill patients with multiple comorbidities who are unfit for immediate surgery. 1
• Following stabilization, these patients should still be considered for eventual cholecystectomy rather than indefinite conservative management. 3

Assessment for Common Bile Duct Stones

Evaluate for common bile duct stones (CBDS) in all patients with contracted gallbladder and cholelithiasis, as this affects the treatment algorithm. 1

• Patients at high risk for CBDS should undergo preoperative ERCP, intraoperative cholangiography (IOC), or laparoscopic ultrasound (LUS), depending on local expertise and availability. 1
• If CBDS are identified, they should be removed either preoperatively, intraoperatively, or postoperatively according to local expertise. 1

Conservative Management: Why It Fails

Conservative management with antibiotics and supportive care is inadequate for contracted gallbladder with symptomatic cholelithiasis:

• Approximately 30% of patients treated conservatively develop recurrent gallstone-related complications during long-term follow-up. 2, 3
• Studies show that 60% of pregnant patients with gallstone disease treated conservatively experienced recurrent biliary symptoms, leading to multiple hospitalizations. 1
• Conservative management ultimately results in 60% of patients requiring cholecystectomy anyway, with accumulated morbidity from recurrent episodes. 3

Special Considerations

Pregnancy

• Laparoscopic cholecystectomy is safe during pregnancy and represents the standard of care regardless of trimester, though ideally performed in the second trimester. 1
• For symptomatic cholelithiasis presenting late in the third trimester, postponing surgery until delivery may be reasonable only if it does not pose risk to maternal or fetal health. 1

Surgical Expertise

• The procedure should be performed by surgeons with adequate experience in laparoscopic techniques, as bile duct injury remains a concern. 3
• When expertise in difficult laparoscopic cholecystectomy is ensured, conversion should be considered early rather than persisting with unsafe dissection. 1

Common Pitfalls to Avoid

• Do not delay surgery beyond the optimal window (7-10 days from symptom onset), as this increases technical difficulty and complication rates. 1
• Do not pursue indefinite conservative management in symptomatic patients, as this leads to recurrent complications in 30% and eventual surgery in 60%. 2, 3
• Do not assume the patient is too high-risk for surgery without formal evaluation—even high-risk patients should be considered for laparoscopic cholecystectomy rather than alternative treatments. 2, 3