Conversations in Acute Cholecystitis Management Include Treatment Timing, Robotics

Around the world, gallstones and subsequent cholecystitis are among the most common gastrointestinal disorders and a leading cause of hospitalization. Surgeons of any discipline are likely to be familiar with the condition, as cholecystectomy is one of the most common operations, with hundreds of thousands performed each year in the US alone.¹

Indeed, cholecystectomy is widely considered the ultimate solution for acute calculous cholecystitis. Unlike other common conditions, such as appendicitis, in a typical case of acute cholecystitis, there is little debate about whether surgery, antibiotics, or some other treatment modality is the preferred course of care. Cholecystectomy, especially laparoscopic cholecystectomy, is the gold standard.²

Because the disease and treatment are common, there is an ongoing need to evaluate and reevaluate evidence of best practices for acute cholecystitis management to ensure that each patient receives the best care possible, particularly when the gold standard is unachievable. This article reviews recent ongoing trends, shifts, and potential future directions for managing acute cholecystitis.

The Gold Standard

As noted, laparoscopic cholecystectomy has become the accepted treatment for acute cholecystitis, with up to 90% of gallbladders removed laparoscopically.³

One of the current conversations is not about what to do, but when to do it. Evidence suggests that early laparoscopic cholecystectomy (within 2 days of cholecystitis episode onset, by most definitions) is the preferred timing, even if the acute disease episode is still taking place.⁴

“Research shows that if you take a gallbladder out during the acute admission you will save the patient a lot of time, you will save the hospital a lot of money, and the patient can return to their work and life faster. There are a lot of benefits to taking the gallbladder out right away,” said Clancy J. Clark, MD, FACS, a hepatobiliary and pancreatic surgeon and associate professor of surgery at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

And with the emergence of acute care surgeons who have 24-hour availability, a patient often can be operated on in a timely fashion during a period that cholecystectomy will be an easier, less complex operation, Dr. Clark noted.

Nonoperative Alternatives

While most patients can have their gallbladders removed early, not all patients can have surgery in that timeframe due to a variety of factors. The large volume of patients experiencing acute cholecystitis virtually guarantees that thousands of individuals each year will not fall into the standard or ideal treatment paradigm—thus, other options such as interval, or delayed, cholecystectomy need to be considered.

“If a surgeon finds that the patient is in a severe episode of inflammation or experiencing a secondary health condition that may affect their candidacy for surgery, you would give serious consideration to delaying cholecystectomy several weeks, if not a few months, after initial presentation,” explained Benjamin K. Poulose, MD, FACS, chief of the Division of General and Gastrointestinal Surgery at The Ohio State University Wexner Medical Center in Columbus. Therefore, surgeons and patients must consider other options to alleviate symptoms while final treatment decisions are made.

One of the primary options historically has been percutaneous cholecystostomy (PC) tube placement to drain the gallbladder of bile, which is intended to get the patient past the acute episode of cholecystitis. Then, if the medical condition improves and the patient is more stable, surgery can be delayed. In such scenarios, PC tubes have proven to be an effective temporizing measure before surgery.⁵

While there is some evidence that PC tubes can act as definitive treatment in select, complicated cases of acute cholecystitis,⁶ they are generally considered a bridge to cholecystectomy when possible. A more recent emerging technology that could provide alternative resolution to acute cholecystitis is internal drainage using endoscopic techniques.

“Endoscopists are now starting to access the gallbladder through the common bile duct, place a drain through the cystic duct, or under ultrasound, they can bridge a stent into the gallbladder so that it drains into the duodenum,” said Trang K. Nguyen, MD, FACS, associate professor of surgery in surgical oncology at the Washington University Center for Advanced Medicine in St. Louis, Missouri.

Research has shown that endoscopic approaches can produce positive results in patients who cannot undergo cholecystectomy.⁷

Endoscopic techniques, such as transduodenal luminal apposing metal stent placement and transpapillary drainage of the gallbladder, have seen more regular use in countries like South Korea and Japan, but they are not a standard treatment option in the US.

“We haven’t quite reached the point where they’re commonly used procedures, and not all hospitals are doing them,” Dr. Nguyen said. “We don’t know how safe or not safe it is, and it is important to have surgeons involved as part of the multidisciplinary team for appropriate indications using this emerging technology for those patients who can’t undergo an operation.”

Part of the issue is that if the endoscopic intervention fails, patients may find themselves requiring surgery.

“I hesitate to add endoscopy as a primary treatment, because if it goes wrong, the bailout is much more challenging,” Dr. Clark said. “If you’re choosing a technique that is meant to avoid surgery, you’re in a potentially dangerous situation if surgery is ultimately required for management of an unexpected complication.”

Identifying a Difficult Gallbladder

Patients with a known high risk of morbidity and mortality from cholecystectomy must be offered alternative treatment options preoperatively. But not all higher-risk patients are identified before surgery—sometimes, the difficulty of a cholecystectomy becomes apparent only after an incision is made and a laparoscope is inserted.

Despite its prevalence as the site of a common surgical disease, the gallbladder and its surrounding anatomic structures are subject to a wide variety of presentation, both from variable genetics, disease presentation, and environmental factors.

“There are factors just from the disease process itself that can make for a more difficult cholecystectomy. Severe inflammation in the hepatocystic triangle can make it difficult or even impossible to dissect out the important structures for identification,” Dr. Poulose said.

He added that biliary anatomy in the hepatocystic triangle is naturally one of the most varied anatomies from patient to patient, which can make capturing the critical view of safety more difficult.

In addition, there are growing differences in the ability to visualize the gallbladder and its structures due to rising obesity and obesity-related surgeries, which can limit visualization.

“In the last decade or two, there has been a rise of patients who have altered intestinal anatomy after gastric bypass, which may prevent our endoscopic colleagues from accessing the biliary tree to identify gallstones that are in the common bile duct,” Dr. Nguyen said.

In such cases, the difficult gallbladder can present a patient safety issue because of the risk of common bile duct injury, as well potential injury to other surrounding vascular structures.

Subtotal Cholecystectomy

To avoid operative complications, including the hazardous common bile duct injury, one of the key conversations taking place around acute cholecystitis is determining the correct bailout procedure if a laparoscopic total cholecystectomy is deemed too high risk to continue.

One option is conversion to open cholecystectomy. The rate of open procedure as an initial operation has decreased significantly in the last 30 years as laparoscopic cholecystectomy has become the surgical treatment of choice,² but it remains a potential option when the critical view of safety cannot be achieved due to reasons such as cirrhotic liver or adhesions.

Practicing surgeons, however, advise a subtotal or partial gallbladder removal, which provides better patient outcomes and a superior method to achieve surgical goals if traditional laparoscopic cholecystectomy is not possible. Recent research suggests that subtotal cholecystectomy is associated with fewer complications than an open procedure, such as biliary injury and bleeding.⁸

“At the end of the day, we’re trying to make sure that we avoid a common bile duct injury in these challenging cases where there is so much inflammation and you can’t visualize the critical view of safety with the cystic duct and cystic artery away from the common bile duct,” Dr. Nguyen said.

Common bile duct injury is an omnipresent threat with laparoscopic cholecystectomy, and Dr. Nguyen explained that these injuries can be devastating, or even fatal, and require other surgeries with concomitant lengthy hospital stays.

Subtotal cholecystectomy has been recognized as a critical bailout procedure to avoid bile duct injury while achieving the best-possible surgical outcomes, which was detailed in the “Safe Cholecystectomy Multi-Society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury during Cholecystectomy,” released in 2020.⁹

There is some debate regarding the ideal subtotal cholecystectomy, which comes in two forms: fenestrating, wherein the gallbladder is left “open” but the cystic duct is sutured internally; and reconstituting, wherein the lower end of the gallbladder is closed. Data suggest that both are feasible and safe, although the fenestrated version may have higher incidence of bile leakage, while recurrence of biliary events was higher in the reconstituting form.¹⁰

Regardless of which technique is chosen, this alternative to standard laparoscopic cholecystectomy means that a patient may be left feeling that the surgery “went wrong”—which presents an opportunity, if not a mandate, for surgeons to counsel their patients about what this means for their future.

“I think from a public point of view, it can be difficult to understand why a person would require a partial cholecystectomy when a majority of a patients who have acute cholecystectomies will have their whole gallbladders removed,” Dr. Clark said.

If a patient assumes that the entire gallbladder was removed and then develops symptoms of a remnant cholecystitis 5 years later, the assumption may be poor surgical care at the first operation. Following partial cholecystectomy, patients and their families should be informed that a partial cholecystectomy was the safest option available and that there is a small risk of remnant cholecystitis in the future.

“Since hundreds of thousands of cholecystectomies are performed each year, it is inevitable that thousands will have a subtotal cholecystectomy. It is critical that we share freely with our patients that this bailout maneuver is common and for their safety,” he said.

It is worth noting that subtotal cholecystectomy of either is a technique that must be learned and executed correctly, and few training programs make it a point to teach how to perform these techniques safely and effectively, Dr. Poulose added. There is an opportunity for improvement in this space as this bailout becomes more common.

Ongoing Questions about Robotic Cholecystectomy

Robotic cholecystectomy has emerged as a potential next step for managing acute cholecystitis. Much like laparoscopic cholecystectomy in its nascent stages 30 years ago, robotic procedures face questions about effectiveness, quality, and value.

In recent years, research has shed light on the positives and negatives of robotic cholecystectomy, with sometimes opposing findings. Some smaller case studies of elective cholecystectomy have found that the technique is safe and effective, allowing superior means of visualization and manipulation of the operative field,¹¹ while a larger study of Medicare claims data found that robotic cholecystectomy led to a notably higher number of bile duct injuries.¹²

Unlike the elective setting, however, robotic cholecystectomy in an emergency general surgery setting has more positive results. A recent study showed that robotic cholecystectomy in an emergency setting was associated with a significantly lower risk of conversion to open surgery.¹³

As a relatively new platform, there is an expectation that robotic cholecystectomy will require time to show its potential value—and that the additional upfront costs may make it prohibitive early on.

“As a new technology for removing a gallbladder, robotics will have a learning curve, as well as arguably higher costs,” Dr. Nguyen said. “Even if some institutions can lower the costs by managing the supply chain, it will require a dedicated team that is used to the robot, versus most operating room staff who are used to laparoscopic procedures by now.”

On the other side of the cost equation is the potential one where performing robotic surgery on a common surgical disease such as acute cholecystitis can provide downstream benefits for other procedures.

“You need to start with some simpler operations like the cholecystectomy or inguinal hernia repair before you move on to more advanced operations on the robotic platform,” Dr. Nguyen said, adding that “there is some utility in that, even if it may not be cost effective right now.”

As with any surgical innovation, there is a balance to be struck between using the technology or technique in real cases while still in its exploratory stage versus prioritizing patient safety, especially, in this situation, when faced with a difficult gallbladder.

“The challenge is recognizing that it is a different enough technique where we may need to rethink some of the assumptions that we held true for laparoscopic cholecystectomy,” Dr. Poulose said.

“Some data suggest that there may be an increased risk of bile duct injury, even if it appears small. Whether or not this is true or not still begs the question—should we alter our technique to minimize injury in those situations that we know are difficult?” he asked.

Ultimately, the global surgeon and healthcare community need to reach a consensus on what is an acceptable bile duct injury rate.

Another potentially significant challenge related to robotic cholecystectomy is how it may only be available, as of now, to a subset of patients, which could further contribute to a healthcare system struggling with inequity.

“The accessibility of the robot is currently limited, whether that’s to the hospital itself or an individual patient, so it might widen the gap of healthcare disparities,” Dr. Clark said. “Inadvertently, if we start saying everyone should perform a cholecystectomy robotically, even if it is because it might be safer or more easily done, we might widen the gap between the haves and the have-nots.”

A Surgeon’s Judgment

Management of acute cholecystitis can occupy a unique space for general surgeons, hepatobiliary surgeons, gastrointestinal surgeons, and other medical team members who interact with these patients.

It is a common ailment, but because of variation in patient status, disease process at presentation, organ anatomy, availability of hospital resources, and training of personnel, among other aspects, a surgeon’s individual judgment is important.

“We know that certain patients clearly should proceed to cholecystectomy early, and we know that some patients clearly should have something else done other than cholecystectomy, like a PC tube,” Dr. Poulose said. “It’s the middle ground where there is often a lot of variation between general surgeons themselves, as well as different surgical disciplines.”

While laparoscopic cholecystectomy is the current gold standard of treatment for acute cholecystitis, surgeons must continue to be leaders in defining that middle ground so that all patients have access to the safest, most effective treatment available.

Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.

References

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