Acute cholecystitis is a complication of biliary tract disease, which can be differentiated from chronic cholecystitis in its presentation. Patients with acute cholecystitis commonly have a sudden onset of symptoms that persists greater than 4 hours and causes them to seek consultation in the emergency room, urgent care center, or their physician's office. Symptoms develop from the presence of acute inflammation in the mucosa and wall of the gallbladder, leading to distention of the wall and eventual ischemia. The inflammatory response begins as sterile but can lead to secondary bacterial infection. Rarely, untreated acute cholecystitis can lead to perforation with abscess formation and peritonitis.
Gallstones are most commonly associated with biliary tract disease and can lead to the development of acute cholecystitis when the gallstones become lodged in the cystic duct, causing obstruction of the gallbladder's release of its bile into the common bile duct. Symptoms can improve if the stones become dislodged back into the gallbladder, but more serious illness can occur if the stones pass into the common bile duct, which can result in jaundice and pancreatitis. Acute acalculous cholecystitis can occur where the cystic duct is obstructed in the absence of gallstones and is less common in the general population but more often associated with critically ill patients in the intensive care unit (ICU) and in patients receiving total parental nutrition. Cholelithiasis is estimated to be present in 10% of the population, and one third has development of symptoms. The risk of asymptomatic stones becoming symptomatic is reported to be 1% to 2% per year. Once symptoms of acute cholecystitis develop, these symptoms should be treated immediately to prevent the risk of development of a more serious medical illness.
Patients with acute cholecystitis should be differentiated from patients with symptomatic biliary colic because they need immediate evaluation, workup, and treatment to prevent the deleterious progression of the disease. The classic right upper quadrant pain is accompanied by signs of the inflammatory response, which include fever, nausea, and vomiting and signs of peritoneal inflammation, causing pain radiating to the back and right scapulae regions. In contrast, patients with biliary colic often have intermittent pain that lasts less than a few hours and do not classically have fevers. The distinction is important because acute cholecystitis requires immediate treatment and biliary colic can be treated with cholecystectomy on a nonemergent elective basis.
Patients with acute cholecystitis commonly present with fever, tachycardia, and right upper quadrant tenderness on the physical examination. A positive Murphy's sign occurs when the pain in the right upper quadrant causes a sudden inspiratory arrest during deep palpation. Local peritoneal signs may also occur in acute disease, but diffuse peritonitis suggests a more advanced stage of disease and possible perforation. A palpable tender mass is indicative of a possible phlegmon, which can be a sign of advanced local inflammation indicating a more difficult surgical approach to cholecystectomy. If jaundice is noted on examination, this suggests common bile duct obstruction by choledocholithiasis or possibly Mirizzi's syndrome caused by a large cystic duct stone with inflammation compressing the common bile duct.
After a thorough history and physical examination, the next step in a workup includes laboratory evaluation. A complete blood count typically reveals an elevated white blood cell count (WBC). Although a complete metabolic profile typically reveals normal liver function, mild elevation of transaminase may occur from local inflammation to the liver and mild hyperbilirubinemia can be seen in severe infections. Markedly elevated transaminase values may be the result of hepatitis, whereas hyperbilirubinemia may be indicative of common bile duct obstruction and choledocholithiasis. Amylase and lipase levels should be tested to rule out the development of acute pancreatitis in any patient with abdominal pain.
A right upper quadrant ultrasound scan is the radiographic study of choice for its specific findings, easy availability, and inexpensive costs. Gallstones are commonly seen along with other findings highly suggestive of acute cholecystitis, including a lodged stone in the neck of the gallbladder, gallbladder wall thickening of 4 mm or greater, and pericholecystic fluid. In the unusual case in which ultrasound scan is not helpful or is inconclusive, a hepatobiliary iminodiacetic acid (HIDA) scan can determine whether cystic duct obstruction is present. A HIDA scan that shows nonvisualization of the gallbladder is consistent with acute cholecystitis from cystic duct obstruction, although false-positive studies can occur in fasting patients. Abdominal computed tomographic (CT) scan can also illustrate changes in patients with acute cholecystitis but is less sensitive in milder disease of the gallbladder and should not be used as the initial study in uncomplicated acute cholecystitis. The CT scan may show gallstones, a thickened gallbladder wall, or pericholecystic fluid as seen on ultrasound scan, but it is most beneficial to rule out other intraabdominal pathology if the diagnosis of acute cholecystitis is unclear. A magnetic resonance cholangiopancreatogram (MRCP) can also show signs of acute cholecystitis but is used in the authors' institution in the evaluation of hyperbilirubinemia to rule out choledocholithiasis or malignancy.
Acute cholecystitis is most often associated with gallstones or cystic duct obstruction in calculus disease. The differential diagnosis in patients with acute right upper quadrant pain includes gastric, colonic, renal, pancreatic, liver, lung, cardiac, and appendiceal disease processes. These include peptic ulcer disease, gastritis, gastroenteritis, colitis, right or transverse colon diverticulitis, nephrolithiasis, renal infarction or infection, pancreatitis, hepatitis, liver abscess, pneumonia, myocardial ischemia, and appendicitis. A common consult occurs in patients who are admitted to rule out cardiac disease and who after a negative cardiac workup are found to have acute biliary tract disease.
Once the diagnosis of acute cholecystitis is determined, the patient's condition is stabilized, comorbid risk factors are managed, and broad-spectrum antibiotics are given. More than 50% of patients with acute cholecystitis have positive bile cultures, with Escherichia coli, Klebsiella, Enterobacter, and Bacteroides species the predominant isolates, and antibiotic coverage should be broad enough to cover these organisms. Except in the instance of the patient with sepsis or immunocompromise, antibiotics are discontinued in the early perioperative period.
The debate over the timing of surgery in the patient with acute cholecystitis is one of mainly historic interest; it is now widely accepted that cholecystectomy should be performed within the first 72 hours of diagnosis. In the nonseptic, high operative risk case with reversible or improvable comorbid risk factors, it is often prudent to manage with supportive care, optimizing the clinical situation as best as possible and performing an elective cholecystectomy in 6 to 12 weeks.
Multiple studies have clearly shown the safety and the advantage of early cholecystotomy in the management of this process. No demonstrable difference is found in mortality rate, major bile duct injury, postoperative pain, or other significant complications in patients treated with early or delayed cholecystectomy. Early cholecystectomy halts the progressive inflammatory response and coincident tissue fibrosis that complicates tissue dissection and vital structure identification, allowing for the increased opportunity for a safe laparoscopic procedure and reducing the chances of open conversion. In addition, early cholecystectomy in patients with cholecystitis and systemic toxicity, emphysematous cholecystitis, and acute acalculous cholecystitis reduces the known tendency towards gangrene and perforation in this subset of patients.
Laparoscopic cholecystectomy is now considered the procedure of choice in the operative management of acute cholecystitis. Multiple studies have confirmed that the overall morbidity rate, length of hospital stay, cost, and time to return to function are lower in the patient treated laparoscopically when compared with the standard open technique. That said, the variable and often severe inflammatory response seen in the patient with acute cholecystitis adds special technical challenges to the laparoscopic technique, potentially leading to devastating and lethal vascular and ductal injuries. Severe inflammation limiting the safe conduct of the laparoscopic procedure requires open conversion in up to 20% of these patients. Dramatic and ongoing improvements in optics, instrumentation, and laparoscopic skills have reduced the absolute contraindications of the technique to patients with adhesive hostile abdomens and those who cannot tolerate abdominal insufflation.
The primary guiding principle of laparoscopic cholecystectomy in the patient with acute cholecystitis is the safe removal of the gallbladder without vital biliary structure injury. Inherent challenges in this subset of patients include a lack of tactile sensation, a two-dimensional view of a three-dimensional field, lateral retraction techniques that distort the normal alignment of critical biliary tract structures, periodic difficulties in maintaining a dry field, and abnormal dissecting angles created by atypical and challenging body habitus. These limitations, combined with an often robust inflammatory response and the known frequent anatomic anomalies of the biliary structures, result in an inherently dangerous procedure of varying proportion. It is therefore essential to follow, without deviation, the time-honored proven techniques of laparoscopic cholecystectomy to avoid complications in these patients. Good visualization provided with a clear laparoscope with adequate illumination often aided by a 30-degree or directed device is essential. As in all operations, good exposure through adequate retraction is a fundamental requirement for success. The standard four-port approach is usually adequate; however, in more challenging cases, never hesitate to add more trocars and retractors to optimize exposure. Superolateral retraction on the dome of the gallbladder combined with inferolateral retraction of the infundibulum usually provides an adequate field to begin the dissecting process. In situations where the gallbladder is tensely distended, the retraction process can be greatly aided with needle drainage. Dissection is begun high on the gallbladder infundibulum with a goal of safely exposing and identifying the infundibular-cystic duct junction. The surgeon should avoid initial dissection efforts low on the gallbladder because it is very easy to become confused and lost in this area, creating a higher chance of vital structure injury. In cases of severe inflammation, it is often helpful to divide the inflamed or fibrotic gallbladder rind along the superior and inferior margins of the infundibulum before dissection, allowing for better mobilization and retraction of the infundibulum and, hence, safer dissection of the infundibular-cystic area. The top-down dissection should cautiously continue until the critical infundibular-cystic duct junction view is obtained. Dissection is only considered satisfactory when a complete and unobstructed 360-degree view of the infundibular-cystic junction is obtained, a clear space between the superior distal margin of the gallbladder and liver is seen, and the surgeon is absolutely certain that only two definite structures (cystic duct, cystic artery) are left entering the gallbladder. In no circumstance are any structures in this critical area to be clipped, cauterized, or divided until the surgeon has achieved this critical and certain level of dissection and exposure. In the circumstance when this cannot be achieved, an intraoperative cholangiogram through the distal infundibulum can sometimes clarify the anatomy. If this is not possible or not completely helpful, a dome-down dissection technique can be used. However, the surgeon must be very cautious in avoiding injury to the hepatic artery or the right hepatic duct while dissecting the distal superior edge of the gallbladder away from the liver. If the appropriate dissection techniques have not resulted in a certain and critical view of the anatomy, it is imperative to abort the laparoscopic procedure and convert to an open operation. Remember that the goal is the safe and uncomplicated removal of the gallbladder, and in this circumstance, conversion to an open procedure is not only the appropriate approach but is also the mark of a safe and mature surgeon. Finally, independent of the techniques used, the critically defined structures are individually ligated and the gallbladder is removed with the surgeon's energy source of choice.
One final note of caution involves the case of a short cystic duct. Injudicious dissection or cholangiography in the presence of a short cystic duct can lead to common duct injury or cystic duct postoperative bile leak. In this circumstance, it is better to perform cholangiography through the infundibulum and terminate the distal dissection by dividing the distal infundibulum by ligation or endostapling.
There has been an evolution in the use of intraoperative cholangiography from a routine standard to a more selective approach. Most surgeons today reserve cholangiography to situations of anatomic uncertainty or when choledocholithiasis is suspected. The overall incidence rate of common duct stones reported in conglomerate series of laparoscopic cholecystectomies is 4% to 11%; however, in patients with acute cholecystitis, the reported incidence rate has been as high as 18%. With use of cholangiography to help elucidate anatomic uncertainties, it is important to understand that the images can be misleading, especially when the right hepatic duct arises off of the cystic duct. Therefore, it cannot be overemphasized that intraoperative cholangiography, albeit often very helpful, should never be substituted for a definitive dissection creating the critical view of the vital biliary tract structures. In keeping with the noted increased incidence of ductal stones in patients with acute cholecystitis, some surgeons have advocated the routine preoperative use of MRCP or endoscopic retrograde cholangiopancreatography (ERCP). It is fair to say, however, that this practice is not mainstream, and most surgeons reserve this strategy for patients with hard signs of choledocholithiasis such as significant jaundice, cholangitis, ductal dilation, or radiologic findings of intraductal calculi.
When ductal stones are discovered during laparoscopic cholecystectomy, the growing consensus is that they should be definitively addressed at the time of the initial surgery. This is obviously more satisfactory to the patient and more cost effective and saves the patient from a potentially failed ERCP. Current options include laparoscopic common duct exploration and laparoscopic transcystic basket choledocholithotomy. Both procedures are difficult and require expertise that is not often available in every hospital. In such a situation, which is more common than not, it is well within the standard of care to plan for a postoperative ERCP choledocholithotomy.
Despite the mainstream acceptance of laparoscopic cholecystectomy as the procedure of choice in the management of acute cholecystitis, open cholecystectomy remains an important part of the surgical armamentarium in the treatment of this disease. The procedure is indicated when laparoscopy is contraindicated or when the laparoscopic procedure cannot be completed safely. The operation is performed through either a subcostal or a midline incision, both of which provide excellent exposure. Dissection is achieved through either a fundus-down or an infundibulum-down technique. In situations of severe inflammation, especially when the infundibular technique is too hazardous, the fundus-down technique is safer and advisable. As noted in the description of this technique done laparoscopically, it is important to proceed cautiously in the lower superior area of the gallbladder to avoid damaging the hepatic artery and duct, which can be retracted up in this dissection plane because of the inflammatory process often encountered in this situation. The principles of the rest of the operation are no different than those of the previously described laparoscopic procedure, with the exception of the situation where ductal stones are encountered. In this circumstance, the authors believe that definitive management of this problem should occur at the time of the initial open operation in the form of a common duct exploration and choledocholithotomy with T-tube drainage. If the technique of common duct exploration is not within the repertoire of the operating surgeon and not available in the hospital at the time of the surgery, it is then acceptable to close the patient and obtain a postoperative ERCP. The surgeon must be aware, however, that this exposes the patient to the possibility of a failed ERCP effort and the need of other difficult and dangerous ancillary procedures.
In the unusual, but periodic, case in which the inflammatory response is so severe as to preclude complete open safe dissection of the gallbladder, a partial cholecystectomy is the next best alternative. Key elements of this technique include leaving the back wall of the gallbladder intact, cauterizing the mucosa, and attempting, if possible, to close the distal infundibulum and place closed suction drains. Finally, for patients to whom partial cholecystectomy is deemed too hazardous or in patients with sepsis who are not operable candidates, tube cholecystotomy is the appropriate and often life-saving alternative.
In recent years and in keeping with the progressive minimally invasive theme in surgery, several reduced port or alternative port procedures for biliary surgery have been proposed. Single-port access surgery with one incision predominately at the umbilicus has gained some popularity. Although the procedure at the present time appears to be as safe in selected patients as a standard multiport laparoscopic cholecystectomy, the only proven advantage so far is possibly one of cosmesis. At the extreme end of this minimally invasive effort is incisionless, or natural orifice surgery (NOTES), which involves endoscopically created portals for surgery through the vagina or stomach. The NOTES procedures are currently investigational only but certainly highlight the ongoing miracles of surgical technologic development.
Finally, the application of the robot as an adjunct to the laparoscopic technique of cholecystectomy is gaining interest and popularity. Current robotic platforms allow for single-port access cholecystectomy with the advantage of three-dimensional optics, more achievable triangulation, markedly improved ergonomics, and a proposed reduction in the technical difficulty of the operation. The advantages and the appropriateness of this technology, and cost issues, are yet to be resolved and await further study.
A litany of recognized complications can occur after laparoscopic or open cholecystectomy. It is important to note and to be aware that the conduct of these common procedures in patients with acute cholecystitis with the coincident difficulties of dissection and anatomic recognition imposed by the inherent inflammatory process creates an environment of surgical difficulty and danger. Difficulties in structure recognition can lead to the delayed diagnosis of operative injuries, often with disastrous clinical results.
Subhepatic abscess most often occurs in patients with severely inflamed, gangrenous, or perforative gallbladders. The abscess results from the spillage of infected bile with often coincident hematoma and can be catalyzed by the presence of spilled stones that are left behind. The complication is best prevented by avoidance of bile spillage, obtaining of meticulous hemostasis in the liver bed, the retrieval of all spilled stones, copious irrigation of the subhepatic space, and the placement of closed suction drains if severe contamination has occurred. Most of these situations resolve after a short period of antibiotics, but definitive treatment with the placement of CT scan–directed drains is sometimes necessary.
Excessive bleeding, either from the bed of the dissected liver or from vascular injury, can be extremely problematic and challenging, particularly in the laparoscopic case. Liver bed bleeding, although often impressive, can almost always be controlled with the aggressive use of electrocautery and liberal use of topical chemical coagulant products. Vascular injuries often create a situation where control becomes difficult because of visual limitations from the ongoing hemorrhage and vessel retraction into areas of severe inflammation. Injudicious and poorly exposed dissection, blind clamping, or indiscriminate autoclipping often leads to ductal injury and should be avoided. In the circumstance of the laparoscopic case, if after a reasonable period of time, safe exposure and dissecting techniques have not achieved hemostasis, the patient should be rapidly converted to an open procedure. It is important to note that many bile tract injuries are complex and the surgeon should avoid missing a coincident ductal injury in this situation.
Bile duct leaks are unfortunately a common complication in this set of patients. They result from either persistent drainage of the interrupted ducts of Luschka or more commonly from a cystic duct leak from a dislodged clip. Clip dislodgement seems to occur when clips are placed across severely inflamed ducts or across ducts containing calculi. In efforts to prevent this complication, both of these maneuvers should therefore be avoided. If a good clip closure cannot be achieved, then closure of the biliary system can be accomplished by placing the endoGIA across the distal infundibulum. These patients present with low-grade fever, bloating, and hyperbilirubinemia, most commonly within the first postoperative week. The diagnosis is confirmed by the presence of a subhepatic fluid collection on ultrasound scan and a ductal leak on HIDA scan. Unless the patient presents with septic peritonitis and hemodynamic instability, the treatment is nonoperative and accomplished with CT scan drainage of the subhepatic space and endoscopic biliary stent placement.
Bile duct injury is an extremely serious and potentially catastrophic complication of cholecystectomy. The worldwide reported incidence rate of this complication is 0.1% to 0.2% in open procedures and 0.4% to 0.8% in those conducted laparoscopically. The classic injury occurs when the common bile duct is mistaken for the cystic duct, most commonly resulting from excessive cephalad retraction of the gallbladder, bringing the two ductal structures into parallel alignment. The incidence of this complication is markedly increased in situations of severe inflammation, anomalous anatomy, and excessive bleeding. As stated previously, it is important to note these injuries are often complex, with concomitant hepatic artery and portal vein branch injuries in up to 12% of patients. It is also interesting to note that the use of routine cholangiography has not been shown to prevent these injuries but certainly should be attempted after intraoperative bile duct injury has been discovered. Intraoperative recognition occurs in only about 25% of patients and is noted by evidence of a bile leak, abnormal cholangiogram, or obvious anatomic disruption at the time of surgery. In most patients, ductal injury recognition is delayed, presenting in the early postoperative period with jaundice and pain with or without sepsis, or 6 months to 1 year later, often with cirrhosis or liver failure from duct disruption or stricture. The management of this complication depends on the time of the diagnosis and the extent of the injury to the duct. The goal of treatment is the prevention of cholangitis, ductal stricture, and cirrhosis. When the common bile duct injury is discovered at the time of cholecystectomy, it is important to remain calm, not panic, and attempt to accurately define the nature, extent, and location of the injury. Minor nonelectrocautery lateral ductal injuries can be managed with simple T-tube drainage of the injury site. However, significant injuries from electrocautery and those involving damage to greater than 50% of the circumference of the bile duct wall require complex Roux-en-Y choledochojejunostomy reconstruction. Although immediate reconstruction of a major ductal injury is preferable at the time of the incident, this reconstruction requires the expertise of an experienced hepatobiliary tract surgeon who is facile in the management of this complication. If this level of expertise is not available in the hospital at the time of this injury, it is imperative not to attempt the repair but to define the injury, achieve drainage, and transfer the patient to a facility with these capabilities as soon as possible. In the patient in whom the diagnosis is delayed beyond the immediate operative period, the principles of drainage and ductal imaging also apply. Bile duct anatomy and drainage is often best accomplished in these patients with percutaneous transhepatic cholangiogram (PTC). Additional anatomic definition and drainage can be provided with ERCP and CT scan–directed catheters. In these circumstances, these patients are best treated with a delayed biliary tract reconstruction in 6 to 12 weeks, allowing for the resolution of sepsis and inflammation.
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