What is the treatment for calculus cholecystitis in a male patient?

Calculus Cholecystitis in Males: Increased Surgical Risks and Treatment Approach

Male gender in acute calculus cholecystitis causes significantly higher rates of surgical complications (increasing from 10% to 15%) and a threefold increased risk of conversion to open cholecystectomy (from 16% to 48.5%), likely due to increased visceral abdominal fat, greater trunk skeletal muscle mass making laparoscopic surgery technically more difficult, and delayed presentation from reluctance to seek medical care. 1

Why Males Have Worse Outcomes

The mechanisms behind poorer outcomes in males with calculus cholecystitis are multifactorial 1:

• Anatomical factors: Males have increased visceral abdominal fat and greater skeletal muscle mass, particularly in the trunk, which creates technical challenges during laparoscopic surgery 1
• Behavioral factors: Males commonly delay seeking medical help due to misguided perceptions of masculinity, resulting in more advanced disease at presentation 1
• Combined effect: These factors work synergistically to increase both complication rates and the likelihood of requiring conversion to open surgery 1

Treatment Algorithm for Male Patients

Primary Treatment Approach

Early laparoscopic cholecystectomy within 24-72 hours after initial conservative management remains the treatment of choice, even in male patients with higher baseline risk. 2 This approach results in:

• Significantly fewer complications compared to delayed surgery or drainage procedures 2
• Better healthcare resource utilization 2
• Lower readmission rates for gallstone-related diseases 2

Risk Stratification Considerations

Male patients require careful preoperative assessment using Tokyo Guidelines (TG13/TG18) severity grading 1:

• TG13 Grade 3 (severe): Mortality risk increases from 1.3% to 6.5% compared to Grade 1 1
• Consider referral: High-volume and specialized centers may decrease complications and mortality in severe cases 1
• Surgical expertise matters: Experienced surgeons should perform laparoscopic cholecystectomy in male patients given the higher conversion risk 1

Intraoperative Safety Measures

Given the increased technical difficulty in males, specific safety steps are critical 3:

• Use of seven intraoperative safety steps to achieve critical view of safety (CVS) 3
• CVS can be achieved in 97.2% of complex cases when systematic safety protocols are followed 3
• Subtotal cholecystectomy should be performed when anatomical identification is difficult to prevent iatrogenic bile duct injuries 2

Alternative Management for High-Risk Males

When Surgery Is Not Immediately Feasible

Percutaneous transhepatic gallbladder drainage (PTGBD) should be reserved only for males who are truly non-surgical candidates or have sepsis from gallbladder empyema. 2 However, this approach has significant limitations:

• PTGBD has a 53% complication rate compared to 5% for laparoscopic cholecystectomy, even in high-risk patients 4, 2
• 49% one-year readmission rate in patients who undergo PTGBD without subsequent cholecystectomy 2
• Only 40% of PTGBD patients ultimately undergo delayed cholecystectomy 2

Predictors of Non-Operative Management Failure

Male patients with the following factors at 24 hours are at high risk for treatment failure 2:

• Age >70 years 2
• Diabetes 2
• Tachycardia 2
• Distended gallbladder 2

At 48-hour follow-up, additional predictors include 2:

• WBC count >15,000 cells/mm³ 2
• Persistent fever 2

Critical Pitfalls to Avoid

Do not delay surgery in male patients based solely on their higher baseline risk—this paradoxically worsens outcomes. 2 Common errors include:

• Overuse of drainage procedures: Males who could safely undergo surgery should not receive PTGBD, as this leads to higher mortality, longer hospital stays, and increased readmissions 2
• Age-based discrimination: Early laparoscopic cholecystectomy is safe and effective even in elderly male patients when performed by experienced surgeons 2
• Delayed intervention: Approximately 30% of males with mild acute cholecystitis who avoid cholecystectomy develop recurrent gallstone-related complications during long-term follow-up 1

Antibiotic Coverage

For males undergoing cholecystectomy, ceftriaxone provides appropriate prophylaxis 5:

• Single 1-gram dose preoperatively reduces postoperative infections 5
• Particularly indicated in high-risk males (>70 years, acute cholecystitis, obstructive jaundice, or common duct stones) 5
• Effective throughout the surgical procedure 5

Timing Considerations

Surgery should proceed within 24-72 hours regardless of male gender, as outcomes are similar across different timing intervals when proper protocols are followed. 3 The evidence shows:

• Outcomes are comparable whether surgery occurs <1 week, 2-5 weeks, or ≥6 weeks from symptom onset when systematic safety protocols are used 3
• However, earlier intervention (within 3 days) generally provides better overall outcomes in most populations 6