What is the recommended treatment for a patient with chronic calculous cholecystitis?

Treatment of Chronic Calculous Cholecystitis

Laparoscopic cholecystectomy is the definitive treatment for chronic calculous cholecystitis and should be performed in all suitable surgical candidates. 1, 2

Primary Treatment Approach

Elective laparoscopic cholecystectomy is the standard of care for chronic calculous cholecystitis, as it provides definitive resolution of symptoms and prevents future complications. 1, 3 The surgical approach should be:

• Laparoscopic cholecystectomy as the operation of choice for uncomplicated chronic calculous cholecystitis, offering minimal postoperative morbidity and mortality 3, 4
• Surgery should be performed electively when the patient is optimized, rather than waiting for acute exacerbation 4
• Even high-risk patients benefit from surgical intervention rather than conservative management, as the 2020 World Society of Emergency Surgery guidelines demonstrate that age, cardiac disease, renal disease, and cirrhosis should not be absolute contraindications 1

Management of Difficult Cases

When anatomical identification is challenging during surgery:

• Subtotal cholecystectomy is a safe alternative to prevent iatrogenic bile duct injuries in cases of severe inflammation, cirrhosis with portal hypertension, or gallbladder empyema 1, 2
• This approach is particularly valuable when complete dissection of Calot's triangle is hazardous 1

Special Patient Populations

High-Risk Surgical Patients

Do not delay surgery based solely on age or comorbidities. 1, 2 The evidence shows:

• Laparoscopic cholecystectomy in patients over 65 years is associated with lower 2-year mortality (15.2%) compared with nonoperative management (29.3%) 5
• The World Society of Emergency Surgery confirms that elderly patients, those with cardiac disease, renal disease, and cirrhosis can safely undergo cholecystectomy 1

Patients with Complications

For chronic calculous cholecystitis complicated by choledocholithiasis or biliary obstruction:

• Endoscopic papillosphincterotomy (EPST) should be performed first, followed by cholecystectomy as a staged procedure 4
• This two-stage approach reduced postoperative mortality from 9.7% to 1.6% in patients with jaundice and severe comorbidities 4

Non-Surgical Candidates

For the rare patient who is truly not a surgical candidate:

• Percutaneous transhepatic gallbladder drainage (PTGBD) can temporize but has significant limitations, with 30-day mortality of 15.4% and morbidity rates of 8.2-62% 1, 2
• Endoscopic alternatives (transpapillary or EUS-guided drainage) should only be performed in high-volume centers by skilled endoscopists 1, 2
• Delayed cholecystectomy should still be pursued after risk reduction, as 49% of patients who never undergo definitive surgery experience readmission within one year 1, 2

Critical Pitfalls to Avoid

• Do not adopt a "wait and see" approach in symptomatic patients, as 20-40% of patients with gallstones will develop complications at a rate of 1-3% annually 1
• Avoid overusing drainage procedures in patients who could safely undergo surgery, as this leads to higher mortality, longer hospitalizations, and increased readmissions 2, 6
• Do not perform interval cholecystectomy between 7-45 days if early surgery is feasible, as this intermediate timing is associated with worse outcomes than either early (within 72 hours of acute presentation) or truly delayed (6-12 weeks) approaches 1
• Recognize that chronic cholecystitis can present with acute exacerbations requiring urgent rather than elective intervention—maintain a low threshold for expedited surgery in patients with recurrent symptoms 4, 7