From the Guidelines
Contraindications for cholecystectomy include inability to tolerate general anesthesia, uncorrected coagulopathy, end-stage liver disease with portal hypertension, and advanced pregnancy (particularly third trimester). Patients with severe cardiopulmonary disease may be poor surgical candidates due to their inability to withstand physiological stress 1. Uncontrolled sepsis should be addressed before proceeding with surgery. Extensive adhesions from previous abdominal surgeries may present a relative contraindication for laparoscopic approach, though open cholecystectomy might still be possible. Acute pancreatitis with gallstone etiology typically requires resolution of inflammation before cholecystectomy. Patients with gallbladder cancer may require more extensive surgery than simple cholecystectomy.
Key Considerations
- Inability to tolerate general anesthesia is a significant contraindication for cholecystectomy, as it poses a significant risk to the patient's life 1.
- Uncorrected coagulopathy is another critical contraindication, as it can lead to severe bleeding during and after surgery 1.
- End-stage liver disease with portal hypertension is a contraindication due to the high risk of liver decompensation and bleeding 1.
- Advanced pregnancy, particularly in the third trimester, is a contraindication due to the risk of preterm labor and other pregnancy-related complications 1.
Alternative Treatments
For patients with these contraindications, alternative treatments like percutaneous cholecystostomy tube placement may be considered for temporary biliary drainage 1. The decision to proceed with cholecystectomy should always involve careful risk-benefit analysis, particularly in high-risk patients, as the physiological stress of surgery can exacerbate underlying conditions.
Surgical Approach
The surgical approach should be individualized based on the patient's condition and the surgeon's experience. Laparoscopic cholecystectomy is the preferred approach for most patients, but open cholecystectomy may be necessary in certain cases, such as extensive adhesions or gallbladder cancer 1.
Preoperative Evaluation
A thorough preoperative evaluation is essential to identify potential contraindications and optimize the patient's condition before surgery. This includes assessing the patient's cardiac and pulmonary function, correcting coagulopathy, and addressing any other underlying medical conditions 1.
From the FDA Drug Label
Ursodiol will not dissolve calcified cholesterol stones, radiopaque stones, or radiolucent bile pigment stones. Hence, patients with such stones are not candidates for Ursodiol therapy. Patients with compelling reasons for cholecystectomy including unremitting acute cholecystitis, cholangitis, biliary obstruction, gallstone pancreatitis, or biliary-gastrointestinal fistula are not candidates for Ursodiol therapy. The contraindications for cholecystectomy are not directly stated, but the following conditions are listed as compelling reasons for the procedure, implying they are contraindications for alternative treatments like ursodeoxycholic acid:
- Unremitting acute cholecystitis
- Cholangitis
- Biliary obstruction
- Gallstone pancreatitis
- Biliary-gastrointestinal fistula 2
From the Research
Contraindications for Cholecystectomy
- Cardiovascular disease (CVD) is considered a contraindication for cholecystectomy, as it may increase the risk of complications during and after surgery 3.
- Severe cardiovascular disease, including valvular heart disease, ischemic heart disease, and heart failure, may be a contraindication for laparoscopic cholecystectomy 3.
- Patients with a history of open-heart surgery may be at higher risk for complications during cholecystectomy 3.
- Metabolic disorders, such as diabetes, hypertension, and dyslipidemia, may increase the risk of acute coronary syndrome (ACS) after cholecystectomy 4.
- Cholecystectomy may not be recommended for patients with certain metabolic conditions, as it may increase the risk of cardiovascular disease and mortality 5.
Relative Contraindications
- Advanced age and male predominance may be relative contraindications for cholecystectomy, as they may increase the risk of complications during and after surgery 3.
- High blood urea nitrogen (BUN) levels and a longer duration of hospitalization may be relative contraindications for cholecystectomy, as they may indicate underlying health issues 3.
- Patients with a history of cholecystectomy may be at higher risk for cardiovascular disease and mortality, especially if they have underlying metabolic disorders 5.
Special Considerations
- The decision to perform cholecystectomy should be made on a case-by-case basis, taking into account the patient's overall health and medical history 3, 4, 5.
- Patients with gallbladder disease and cardiovascular disease should be carefully evaluated and monitored before and after cholecystectomy to minimize the risk of complications 3, 4, 5.
- Cholecystectomy may be associated with an increased risk of cardiovascular disease and mortality, especially in patients with underlying metabolic disorders 5.