What are the considerations for cholecystectomy (gallbladder removal) in an adult patient with a history of gallbladder disease and persistent hyperthermia (high temperature) despite antibiotic therapy?

Cholecystectomy for Persistent Fever Despite Antibiotics in Acute Cholecystitis

In a patient with acute cholecystitis and persistent fever despite antibiotic therapy, proceed directly to early laparoscopic cholecystectomy rather than continuing conservative management, as this approach reduces mortality, morbidity, and hospital stay compared to prolonged antibiotic treatment or delayed intervention. 1

Immediate Surgical Intervention is Superior to Conservative Management

The 2020 World Society of Emergency Surgery guidelines, based on the landmark CHOCOLATE trial, definitively established that early laparoscopic cholecystectomy is superior to percutaneous drainage even in high-risk patients with acute calculous cholecystitis 1. In this randomized trial of critically ill patients (APACHE score 7-14), those who underwent early cholecystectomy had:

• 5% major complication rate versus 53% in the drainage group 1
• Significantly fewer recurrent biliary events 1
• Equal mortality but substantially better outcomes overall 1

Persistent fever despite antibiotics indicates failure of conservative management and is a clear indication for source control through cholecystectomy. 1

Optimal Timing: Within 10 Days of Symptom Onset

The evidence strongly supports performing cholecystectomy as soon as possible, ideally within 48 hours but acceptable up to 10 days from symptom onset. 1 Earlier surgery within this window is associated with:

• Shorter hospital stay 1
• Fewer complications 1
• Lower conversion rates to open surgery 1

Delaying surgery beyond 10 days or continuing antibiotics in the face of persistent fever increases morbidity and the risk of requiring intervention when the patient is in a more fragile state. 1

Laparoscopic Approach Should Be Attempted First

Even in elderly patients and those with persistent fever, laparoscopic cholecystectomy should be the initial approach unless absolute anesthetic contraindications or septic shock are present. 1 The 2019 WSES guidelines for elderly populations confirm:

• Laparoscopic cholecystectomy is safe and feasible in elderly patients with acute cholecystitis 1
• Low complication rates are achievable 1
• Shortened hospital stay compared to open surgery 1
• Age over 65 years alone does not contraindicate cholecystectomy 1

When to Consider Alternative Approaches

Percutaneous cholecystostomy should only be considered if the patient is truly unfit for surgery (ASA III/IV, performance status 3-4, or septic shock) and has failed medical therapy after 24-48 hours. 1 However, this is a bridge to eventual cholecystectomy, not definitive treatment:

• 49% readmission rate at 1 year without subsequent cholecystectomy 1
• High rate of recurrent gallstone-related disease 1
• Should be followed by delayed cholecystectomy once perioperative risk is reduced 1

Critical Pitfalls to Avoid

Do not continue antibiotics beyond 24-48 hours without surgical intervention if fever persists. 1 Predictors of conservative management failure include:

• Age over 70 years 1
• Diabetes 1
• Tachycardia 1
• Distended gallbladder on imaging 1
• WBC > 15,000 cells/mm³ 1
• Persistent fever 1

The presence of these factors, particularly persistent fever despite antibiotics, mandates proceeding to cholecystectomy rather than prolonging medical management. 1

Antibiotic Duration Post-Operatively

Once adequate source control is achieved through cholecystectomy:

• For complicated cholecystitis in immunocompetent patients: 4 days maximum of postoperative antibiotics 2, 3
• For immunocompromised or critically ill patients: up to 7 days based on clinical response 2, 3
• For uncomplicated cases: antibiotics can be discontinued within 24 hours post-operatively 2, 3

If signs of infection persist beyond 7 days of antibiotic treatment, further diagnostic investigation is warranted rather than prolonged empiric antibiotics. 2, 4

Conversion to Open Surgery

Conversion should be considered if the critical view of safety cannot be achieved, severe inflammation obscures anatomy, or bile duct injury is suspected. 1 Predictors of conversion include:

• Fever (the presenting complaint) 1
• Elevated serum bilirubin 1
• Gangrenous cholecystitis 1
• Extensive adhesions 1

However, conversion to open surgery does not inherently reduce bile duct injury risk—the critical view of safety technique is what matters most. 1