Operative Management of Cholecystitis and Cholelithiasis


With an annual rate of greater than a quarter of a million hospital admissions and an associated cost of greater than two billion dollars, cholelithiasis and cholecystitis have a tremendous impact on the health care system. Their diagnosis and associated symptoms are one of the most common reasons for clinic visits and the second most common reason for gastrointestinal-related hospital admissions in the United States. Minimally invasive surgery has revolutionized the way these patients are managed. This technique provides a safe and effective therapy that also results in reduced wound-related complications compared with open cholecystectomy. This enhanced recovery has made the laparoscopic cholecystectomy one of the most commonly performed abdominal surgeries in the Unites States, with more than 500,000 performed each year.

Cholelithiasis

The incidence of cholelithiasis varies greatly (10% to 70%) and is influenced by ethnicity, gender, age, genetic predisposition, obesity, and the presence of certain diseases, such as hemolytic anemia and cirrhosis. The vast majority of gallstones (90%) result from the crystallization and precipitation of excess biliary cholesterol from endogenous and dietary lipids. Most patients diagnosed with gallstones present without symptoms or with mild symptoms, and the majority resolve spontaneously. Expectant management is recommended for these patients because the majority will remain without clinically significant symptoms (78%). Patients with symptomatic cholelithiasis who are surgical candidates should undergo cholecystectomy due to its safe and definitive resolution of symptoms and prevention of future gallstone-related complications. A select group of patients (15%) who are either unable or unwilling to undergo a surgical intervention may be managed nonoperatively with oral gallstone lytic therapy (hydrophilic ursodeoxycholic acid), as long as they present with mild symptoms and small, noncalcified cholesterol gallstones in a functioning gallbladder with a patent cyst duct.

The main symptom of uncomplicated cholelithiasis is biliary colic, which is characterized by sporadic pain localized in the epigastrium or right upper abdomen. This is caused by the intermittent obstruction of the cystic duct by a gallstone. It is usually preceded by a fatty meal, which stimulates gallbladder contraction. This pain may radiate to the back and may be accompanied by nausea and vomiting. Ultrasonography (US) detects cholelithiasis in most patients (98%). These patients benefit from an elective laparoscopic cholecystectomy because their symptoms are likely to persist and surgery will avoid future bouts of cholecystitis and gallstone-related complications, such as pancreatitis, cholangitis, and gallstone ileus.

Pancreatitis that progresses into infected pancreatic necrosis may require pancreatic débridement. Simultaneous cholecystectomy at the time of pancreatic débridement should be considered because gallstones are the most common etiology in these patients (41%), and patients who undergo the combined procedure do not incur an increased incidence of intraoperative biliary ductal injury or postoperative morbidity or mortality. One-third of patients who do not undergo simultaneous cholecystectomy develop biliary-associated complications within a year of the necrosectomy.

Cholangitis may develop in the setting of biliary obstruction secondary to stone impaction within the common bile duct (CBD). Stones in this location are amenable to extraction via endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. Gallstones may also cause major biliary obstruction from impaction within the gallbladder or cystic duct by external compression or “Mirizzi syndrome.” This requires cholecystectomy with possible reconstruction or bypass of the extrahepatic biliary tract. Although few patients undergoing cholecystectomy present with this entity (0.18%), most of these patients present with abdominal pain and jaundice. Preoperative ERCP is used to define the biliary anatomy. Most favor an open approach due to the high rate of conversion associated with a laparoscopic approach (67%). There is a significant postoperative morbidity (31%) and a prolonged length of hospitalization associated with this entity. Preoperative biliary stenting and the enhanced dexterity provided by robotic assistance may reduce conversion rate. This technique provides the advantage of minimally invasive surgery such as shorter length of hospitalization but comes at the expense of a longer operative time.

Gallstones may also erode through the gallbladder into the duodenum and then lodge themselves in the distal small bowel. This creates a mechanical bowel obstruction or “gallstone ileus” requiring an emergent laparotomy. This rare condition is associated with a significant morbidity (35%) and mortality rate (6%). The obstruction is typically addressed via stone extraction alone, whereas bowel resection is less often required. Simultaneous cholecystectomy is associated with increased operative time and increased length of postoperative stay, but because there is no significant increase in major postoperative morbidity this option may be considered in select patients.

Cholecystitis

The inflammation in cholecystitis is for the most part (90%) due to cystic duct obstruction secondary to prolonged gallstone impaction. As this inflammatory process progresses, secondary infection may develop and result in emphysematous cholecystitis and even gangrenous cholecystitis and perforation. These advanced stages of cholecystitis are associated with a significant increase in morbidity and mortality compared with earlier stages of cholecystitis.

Acute cholecystitis usually presents as biliary colic that persists and localizes in the right upper quadrant. Physical findings reflect this level of local inflammation, and patients demonstrate “Murphy sign” with cessation of inspiration with palpation of the right upper abdomen. Diagnosis is confirmed radiologically by US, which has been proven to be safe, widely available, and highly sensitive for the diagnosis of acute cholecystitis. Findings on US include gallstones, gallbladder wall thickening (≥5 mm), and pericholecystic fluid. When the diagnosis is in doubt, a hepatoimino diacetic acid (HIDA) scan can aid in the diagnosis by identifying cystic duct obstruction with the absence of gallbladder filling within 60 minutes after the radiotracer administration. HIDA has a significantly higher sensitivity and specificity than US in the setting of acute cholecystitis.

There are cases of severe inflammation during cholecystitis in which no obstruction from stone impaction is found (acalculous cholecystitis) and is thought to be related to bile stasis and/or systemic hypoperfusion, as seen in critically ill patients. Patients who develop acalculous cholecystitis may require a percutaneous cholecystostomy tube for immediate decompression with or without an interval cholecystectomy depending on their overall status. Subsequent cholecystectomy in this patient cohort is associated with a significantly increased operative time, open conversion rate, biliary-related complications, surgical site infections (both superficial and deep), and total length of hospitalization compared with those who undergo cholecystectomy without the need for preoperative tube placement.

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