Laparoscopic cholecystectomy, one of the most commonly performed and straightforward operations for the general surgeon, usually comes off without a hitch. But difficult cases of acute cholecystitis can quickly turn morbid, and management varies dramatically from patient to patient.
“Cholecystitis is thought to be a disease process that all general surgeons can take care of—there’s an expectation that it should go well every time,” said Michael Martyak, MD, an assistant professor of surgery at Eastern Virginia Medical School, in Norfolk. “But with the increasing number of patients with comorbidities such as obesity and diabetes, and patients who struggle with access to care who present for evaluation in a delayed fashion, sometimes surgical management can be difficult.”
At the 2021 virtual American College of Surgeons Clinical Congress, Dr. Martyak and other experts in the treatment of acute cholecystitis discussed alternative approaches to difficult gallbladders, considerations for the sickest patients, and how to manage the most dreaded complication: common bile duct injury (CBDI).
To Drain or Not to Drain
Percutaneous cholecystostomy has historically been used as either a bridge to surgery or a definitive treatment in patients who are too frail to undergo surgery. Mortality related to the procedure is less than 0.5%, and percutaneous cholecystostomy is successful from a clinical point of view, relieving fever, pain and inflammatory markers in 85% to 90% of patients.
“When you look at our population of high-risk surgical patients, [percutaneous cholecystostomy] is superior to conservative management followed by delayed laparoscopic cholecystectomy,” said Raul Coimbra, MD, PhD, a professor of surgery at Loma Linda School of Medicine, in California. There are a couple of algorithms that can help guide what to do with patients after drain placement (Front Surg 2021;8:616320; Abdom Radiol 2020;45[4]:1193-1197). The second and simpler one advises following up on all patients at two weeks with cholangiography (Figure). “If the patient is a surgical candidate, they should undergo cholecystectomy; if they are not a surgical candidate, one option is percutaneous cholecystolithotomy, though that’s performed in the minority of patients,” Dr. Coimbra said.
A novel alternative to percutaneous cholecystostomy worth watching is endosonography-guided gallbladder drainage. “You locate the gallbladder through the stomach or duodenum, perform a cholecystogastric or cholecystoduodenal fistula through a stent, and remove the stones,” Dr. Coimbra said.
A recent multicenter, randomized controlled trial found this technique resulted in lower rates of recurrence, and fewer 30-day reinterventions, unplanned admissions, and 30-day and one-year adverse events than percutaneous cholecystostomy (Gut 2020;69[6]:1085-1091).
“Both are technically and clinically successful procedures, so both work. But it seems that the performance of the novel technique is much superior,” Dr. Coimbra noted.
Subtotal Cholecystectomy: A Safer Bailout
When a CBDI appears imminent during a difficult cholecystectomy, the default has been converting from laparoscopic to open surgery. But it might be counterintuitive for the most recent generation of surgeons, well trained in laparoscopy, to turn to a less familiar option when surgery becomes challenging.
“The truth of the matter is that inflammation doesn’t vanish when it’s exposed to air; a difficult gallbladder laparoscopically is a difficult gallbladder open,” said Sharmila Dissanaike, MD, the Peter C. Canizaro Chair of the Department of Surgery at Texas Tech University, in Lubbock.
Enter subtotal cholecystectomy, a relatively new approach that is gaining traction. “It’s probably accepted these days as the safest option to prevent severe bile duct injury,” Dr. Dissanaike said.
The two types, reconstituting and fenestrating, are both easy to perform laparoscopically and open, Dr. Dissanaike said. “The key is staying high, away from the danger zone; opening into the gallbladder antero-laterally; leaving only about 1 cm of infundibulum; taking as much of the posterior wall as you safely can; and clearing all the stones.”
How do you choose between the two? It’s a bit of a toss-up, weighing potential complications. “Fenestrating will usually give you a bile leak and it has slightly more reinterventions, but reconstituting seems to have more recurrent biliary symptoms,” Dr. Dissanaike said.
Finally, she recommended reserving subtotal cholecystectomy for the most difficult cases, when dissection is truly dangerous. “If we drop the threshold to perform subtotal cholecystectomy too low, we might have unacceptably high rates of patients needing reoperation,” Dr. Dissanaike said.
Cholecystitis and Cirrhosis: Managing the Sickest Patients
Patients with cirrhosis and cholecystitis are at increased risk for a number of complications and difficult surgery. The decision to proceed with surgery begins with an assessment of the patient’s capacity to tolerate it.
“Clearly there is a large spectrum of cirrhosis, and stratifying the perioperative mortality is important,” said Kristin Ellen Raven, MD, a transplant surgeon at Beth Israel Deaconess Medical Center and faculty member at Harvard Medical School, both in Boston.
For example, patients classified as Childs A are likely to survive surgery; similarly, those with a Model for End-stage Liver Disease (MELD) score less than 15 who have not been decompensated also have a relatively low mortality risk of 10% to 15%.
To further determine surgical risk in cirrhotic patients, Dr. Raven uses a calculator available on Mayo Clinic’s website that takes into account age and American Society of Anesthesiologists physical status in addition to MELD score (https://mayocl.in/ 32ICYIo). “I find this calculator extremely valuable to discuss risk with patients and family, and to provide solid data to nonsurgical colleagues who may be pushing for an operation.”
When surgery is deemed feasible, Dr. Raven advocates for the least invasive operation possible, noting that risk rises with procedure length. “The cumulative risk for perioperative complications is four times higher past two hours than it is for a 30- to 60-minute laparoscopic cholecystectomy. I have a low threshold to open.”
For decompensated patients, she recommends starting initial nonoperative management with NPO order and IV antibiotics. “I require that decompensated cirrhotics really force me to operate, meaning they’ve failed several days of conservative management,” Dr. Raven said.
But surgery is only part of the challenge in managing patients with cirrhosis. Postoperative care requires hemodynamic monitoring, possible ICU admission, optimal coagulopathy, management of ascites and other considerations.
“The ability of your institution to care for these patients postoperatively should weigh heavily in your decision to operate,” Dr. Raven said.
Managing Common Bile Duct Injury
Despite such precautionary measures as achieving a critical view of safety and bailing out to subtotal cholecystectomy, common bile duct injuries still occur in up to 0.4% of all laparoscopic cholecystectomies. Katherine Morgan, MD, suggested steps for managing this daunting complication.
“The first step, to quote my hilarious partner, is to take your own pulse; it’s terrifying to see an unexpected bile leak, which can compromise your judgment, so take pause,” she said.
Second, call a senior partner or phone an accessible hepato-pancreatico-biliary (HPB) surgeon for help, said Dr. Morgan, a professor of surgery and the head of the Division of Hepato-Pancreatico-Biliary Surgery, Medical University of South Carolina, in Charleston. Although she was trained to convert to open when laparoscopic cholecystectomy becomes difficult, like Dr. Dissanaike, Dr. Morgan thinks this approach may no longer be the safest option for surgeons trained more in minimally invasive surgery than open procedures. “Opening does not make this operation any easier,” she said.
Third, and most important, obtain drainage. “Controlling the bile leak will prevent sepsis and allow for the inflammatory physiology to resolve to allow the patient to be prepared for a more definitive repair later on,” Dr. Morgan said.
Finally, consider an early referral to an HPB center. “Management of CBDI really is a multidisciplinary effort. It involves the therapeutic endoscopist, interventional radiology and HPB surgery,” she said, noting that attempting CBDI repair at the primary hospital has been identified as an independent risk factor for poor outcomes.