Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (37 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Biliary colic
The initial treatment for biliary colic consists of adequate analgesia and antiemetics. Although opiate analgesia is widely prescribed, non-steroidal anti-inflammatory drugs (NSAIDs) are also effective in relieving pain. Moreover, studies have suggested that NSAIDs can reduce the number of patients progressing from biliary colic to acute cholecystitis. Early laparoscopic cholecystectomy should be offered.
Initial therapy in acute cholecystitis includes intravenous fluid resuscitation, analgesia, a nil-by-mouth regimen and administration of intravenous antibiotics. Although the initial inflammation is sterile, secondary infection with aerobic Gram-negative organisms, enterococci and anaerobes occurs.
Clostridium perfringens
infection of the necrotic gallbladder may be a particular complication in the diabetic patient. Few data exist to support the optimum antibiotic regimen and local microbiology recommendations should be followed, although a second- or third-generation cephalosporin combined with metronidazole is frequently prescribed.
Urgent surgical intervention is indicated in those patients with generalised peritonitis arising from a gallbladder perforation or in those with emphysematous cholecystitis (
Fig. 8.7
). Outwith these circumstances, the therapeutic options are to remove the gallbladder, either during the index admission or, electively, at a later admission. Early operation has the advantage of prompt definitive therapy but surgical intervention may be technically more difficult. The rationale for deferred surgery is to allow for resolution of inflammation, but the patient remains at risk of exacerbations during the ‘waiting’ period, leading to readmission and increased healthcare-associated costs. In addition, as many surgeons can attest, subsequent ‘delayed’ surgery may still be technically very demanding. Several randomised trials over the last 15 years comparing early versus late laparoscopic cholecystectomy for acute cholecystitis have now confirmed that early laparoscopic cholecystectomy is both safe and has significant benefits for patients. Conversion rate, hospital stay and complications are all significantly lower in the early surgery group.
6
–
8
A meta-analysis of five randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis has demonstrated that there is no difference in conversion rate or incidence of bile duct injury and the total hospital stay is shorter.
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Figure 8.7
CT image of emphysematous cholecystitis demonstrating gas in the gallbladder wall with extension into the hepatoduodenal ligament.
The benefits of early laparoscopic cholecystectomy over early open cholecystectomy have also been assessed.
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A total of 63 patients with acute cholecystitis were randomised to either early laparoscopic cholecystectomy (
n
= 32) or early open cholecystectomy (
n
= 31). Conversion to the open procedure was required in five patients randomised to laparoscopic cholecystectomy. Although there were no deaths or bile duct injuries in either group, the postoperative complication rate was significantly higher in the open group (
P
= 0.0048): seven patients (23%) had major and six (19%) had minor complications after open cholecystectomy, whereas only one (3%) minor complication occurred after the laparoscopic procedure. Both the postoperative hospital stay (median 4 days vs. 6 days;
P
= 0.0063) and duration of sick leave (mean 13.9 days vs. 30.1 days;
P
< 0.0001) were significantly shorter in the laparoscopic group.
Early laparoscopic cholecystectomy should be attempted in all patients with acute cholecystitis who are fit for surgery, recognising that there will be some in whom the acute inflammation prevents adequate visualisation of the anatomy and conversion will be required.
6
–
10
It therefore follows that patients admitted to hospital as an emergency with acute biliary colic should also be offered early laparosocpic cholecystectomy.
Antibiotic cover for urgent cholecystectomy:
Antibiotic therapy following successful early cholecystectomy for acute non-gangrenous cholecystitis does not need to be continued beyond 12 hours.
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Non-surgical options for decompressing the gallbladder in acute cholecystitis:
Although early laparoscopic cholecystectomy is optimal management for acute cholecystitis, surgery may not be feasible in some patients because of comorbid conditions. In these patients US-guided percutaneous cholecystostomy is a useful alternative (
Fig. 8.8
). If the diagnosis is in doubt, such as might be the case in the critically ill patient on the intensive care unit, percutaneous cholecystostomy can also be diagnostic,
12
with successful drainage of the gallbladder possible in up to 90% of patients.
13
Although cannulation of the gallbladder may be achieved through a transperitoneal approach, a transhepatic approach is to be preferred because of the lower risk of biliary peritonitis and the earlier maturation of the cholecystostomy tract. Following insertion of the drainage tube into the gallbladder, free drainage is established. On occasions, simple aspiration of the gallbladder may be effective; however, a recent randomised trial concluded that placement of a percutaneous cholecystostomy drain was associated with a superior clinical response rate.
14
With effective intervention, clinical improvement usually occurs within 24–48 hours; therefore, in those in whom rapid improvement does not occur, a complication, either of the original acute cholecystitis (gallbladder necrosis and/or perforation) or of the cholecystostomy tube placement (bile leak, visceral perforation, bleeding, etc.), should be suspected and surgical intervention should be reconsidered. The cholecystostomy tube should be maintained until a mature fistula tract is achieved, which usually forms within 3 weeks. Contrast radiology in the form of a ‘tubogram’ may be undertaken in order to confirm drain position, cystic and common bile duct patency, as well as the presence and site of any calculi.
Figure 8.8
Ultrasound of a patient with acute cholecystitis.
(a)
Before treatment; note the microabscesses within the thickened gallbladder wall.
(b)
After successful percutaneous transhepatic drainage.
With thanks to Dr Paul Allan, Consultant Radiologist, Royal Infirmary of Edinburgh, UK.
A randomised clinical trial assessing the role of percutaneous cholecystostomy in patients with acute cholecystitis who are high-risk surgical candidates included 123 patients with acute cholecystitis and an Acute Physiological and Chronic Health Evaluation (APACHE) II score of 12 or greater.
15
Patients were randomised to either percutaneous cholecystostomy (PC;
n
= 60) or to conservative therapy (C;
n
= 63). Percutaneous cholecystostomy was associated with a number of major complications in the initial stages of the trial, although this appeared to be due to the use of non-locking drains inserted under CT guidance. A change in technique to US transhepatic placement of locking drains helped to lower procedure-related complications. Nevertheless, in this trial rates of clinical resolution (PC 86% vs. C 87%) and mortality (PC 17.5% vs. C 13%) were similar between the two groups.
Percutaneous cholecystostomy should only be used in those patients not fit for surgery whose symptoms do not improve rapidly on standard non-operative therapy.
15
The results of the current multicentre randomised controlled (CHOCOLATE) trial, comparing percutaneous cholecystostomy with laparoscopic cholecystectomy, are awaited.
16
In patients who have not been offered early cholecystectomy for their acute cholecystitis, including those who have undergone cholecystostomy, following disease resolution, definitive therapy directed towards the gallbladder needs to be considered. Recurrent symptoms will occur in approximately one-third of patients who have previously had acute calculous cholecystitis and have not undergone definitive treatment.
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Therefore, interval cholecystectomy following optimisation of any comorbid disease should be considered. In those patients in whom surgical intervention is absolutely contraindicated, the cholecystostomy tube may be left in situ for a more prolonged period. Cholelithiasis may then be treated by percutaneous extraction of the gallstones or, less commonly, by direct dissolution with a solvent such as methyl-
tert
-butyl ether. However, recurrence of gallstones following these therapies is common, with studies suggesting that 10–20% of all patients treated by these methods develop further symptoms.
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–
20
As a result of these limitations, such approaches are not widely employed.