Emergency General Surgery

The Vicious Rolling Stones – Part 2

Good timing is invisible. Bad timing sticks out a mile.

Tony Corinda

Hello everyone.

In the previous post on acute cholecystitis, we have explained the pathogenesis of this disease, how to make the diagnosis and to determine the severity grading, and which antibiotic to use… This time we are going to explore in detail the treatment options according to the severity grading and the patient’s performance status.

Let’s start with a couple of examples…

Case 1:
Man, 38 yo. No previous medical history.
He complains about pain in the right upper quadrant (onset about 24 earlier), fever (37.8°C), nausea, no vomiting. Murphy sign is present.
Lab tests: WCC 18700/mm3, CRP 179 mg/L;
Abdominal Ultrasound: features of acute cholecystitis.

Case 2:
Woman, 76 yo. Previous history of hypertension, type 2 diabetes, chronic heart failure.
She complains about pain in the right upper quadrant that started a couple of hours earlier, fever (38.1°C). Murphy sign is present.
Lab tests: WCC 16400/mm3, CRP 63 mg/L, Creatinine 2.3 mg/dL;
Abdominal Ultrasound: features of acute cholecystitis.

Is there any difference between these two case scenarios?

Specific Management According to Grading
A: Charlson Comorbidity Index ≤ 5 and/or ASA Score ≤ 2 (low risk);
B: Charlson Comorbidity Index ≥ 6 and/or ASA Score ≥ 3 (high risk). In Grade III, CCI ≥ 4 and ASA Score ≥ 3 are high-risk features;
#: Antibiotics & Supportive Care successful;
*: Antibiotics & Supportive Care fail to control inflammation;
α: No Negative Predictive Factors (i.e. total bilirubin ≥2, neurological dysfunction, respiratory dysfunction) and Favorable organ system failure (i.e. cardiovascular or renal, which are rapidly reversible after admission and before surgery);
β: Negative predictive factors and/or No favorable organ system failure;
1: In Grade II & III, it is recommended to perform blood culture before the initiation of administration of antibiotics;
2: In Grade II & III, laparoscopic cholecystectomy is recommended only in Advanced Centers;
3: A bile culture should be performed during gallbladder drainage.

Let’s now focus on each grade specifically…

Grade I (Mild) Acute Cholecystitis

Grade I management is quite straight-forward.

If your patient has a good performance status (i.e. ASA Score ≤2 and/or CCI ≤5), he/she can easily undergo a laparoscopic cholecystectomy. The surgical operation should be performed within 7 days from the onset of symptoms (i.e. early). However, anticipating it during the first 72 hours (i.e. urgent) would be better.

On the other hand, if the patient has a poor performance status (i.e. ASA Score ≥3 and/or CCI ≥6), antibiotics and supportive care are the preferable treatment. In case of failure of conservative management, a laparoscopic cholecystectomy is still an option. Even in this scenario, the timing of the surgical procedure should adhere strictly to the one stated before.

The success or failure of conservative management can be noted within the first 48 hours.

The reason behind the strict timing for surgery reported above can be explained by the evolution of this pathology. In fact, during the first few days, the inflamed gallbladder causes edema in the surrounding tissues, thus making it easier to remove. When this first phase passes by, fibrous tissue replaces the edema and, after a few more days, it makes the surrounding tissue to retract. When this happens, the dissection of the main structures of the gallbladder (i.e. the cystic artery and the cystic duct) is far more difficult. Furthermore, this process may retract the main bile duct and make it stick to the cystic duct, thus increasing significantly the risk of damaging it during the dissecting maneuvers.

For this reason, many authors recommend performing laparoscopic cholecystectomy within the first 3-5 days from the onset of symptoms.

Grade II (Moderate) Acute Cholecystitis

The initial approach to a patient with a grade II acute cholecystitis must include supportive measures and the initiation of antibiotics. Blood cultures may be of some help and should be performed before the first administration of antibiotics.

Once the initial care has been started, you need to assess two conditions: the patient’s general status using the ASA Score and/or the Charlson Comorbidity Index, and the inflammatory response to the initial treatment.

The combination of the results of these two assessments determines three possible pathways:

  1. Successful initial treatment + low-risk patient (i.e. ASA Score ≤2 and/or CCI ≤5): urgent/early laparoscopic cholecystectomy is recommended, mainly if you’re skilled enough;
  2. Successful initial treatment + high-risk patient (i.e. ASA Score ≥3 and/or CCI ≥6): delayed/elective laparoscopic cholecystectomy should be preferred to improve the patient’s conditions before the surgical intervention;
  3. Failure of the initial treatment: urgent/early gallbladder drainage (i.e. cholecystostomy). During this procedure, a sample of bile should be collected to perform a bile culture. Afterward, once the inflammatory status has subsided, a delayed/elective laparoscopic cholecystectomy should be considered.

In our opinion, if the patient is fit for surgery (according to the ASA Score and/or the Charlson Comorbidity Index) and you have an OR immediately available, there is no need to wait for an assessment of the success of the initial treatment. In fact, you may proceed with the laparoscopic cholecystectomy straight forward.

Grade III (Severe) Acute Cholecystitis

The management of patients with grade III acute cholecystitis is more challenging.

The first step, as per grade II patients, consists of antibiotics and supportive care. Obviously, according to the grade III definition, supportive care may be more aggressive than in grade II.

The presence of negative predictive factors and favorable organ system failure will define the subsequent decision.

To be clear… The negative predictive factors are:

  • Jaundice (total bilirubin ≥2 mg/dL);
  • Neurological dysfunction;
  • Respiratory dysfunction.

Where the favorable organ system failure includes:

  • Cardiovascular failure;
  • Renal failure.

These two are considered “favorable” because they are rapidly reversible after admission and before surgery.

The same as per grade I and II patients, the performance status must be taken into account. Remember that in the case of grade III acute cholecystitis patients are considered at high risk with ASA Score ≥3 and/or CCI ≥4.

Patients with no negative predictive factors, favorable organ system failure but poor performance status should undergo an urgent/early gallbladder drainage. On the other hand, patients with good performance status may be subjected to an early laparoscopic cholecystectomy. No need to say that these patients should be treated surgically only in advanced centers, where intensive care and advanced laparoscopic techniques are available.

On the other hand, patients with negative predictive factors and/or no favorable organ system failure should be treated with an urgent/early cholecystostomy. Afterward, depending on their performance status, they may be eligible for delayed/elective laparoscopic cholecystectomy if at low risk, or they may be just observed if at high risk.

Let’s go back to our two patients…

Case 1:
He had a grade II acute cholecystitis (WCC >18000/mm3).
He had a good performance status (CCI=0).
He started supportive care and antibiotics. Since the OR was available, he underwent an urgent laparoscopic cholecystectomy.

Case 2:
She had a grade III acute cholecystitis (Creatinine >2 mg/dL).
She had a Charlson Comorbidity Index of 5. In a grade III acute cholecystitis, this means she was at high risk.
She started supportive care and antibiotics at first.
Renal failure is indeed included in the favorable organ system failure group, but she had a CCI=5. Therefore, the correct next step to take is an urgent/early gallbladder drainage.

These two cases explain why the choice of which is the best treatment in patients with acute cholecystitis is far from being easy and straightforward. There are a lot of conditions you need to consider.

Final Considerations

As you have seen, the management of patients with acute cholecystitis is far from being straight forward, and laparoscopic cholecystectomy is not the only option you have nor the best, because there is no best treatment at all.

Insisting on operating all patients with acute cholecystitis no matter what will only increase your morbidity and mortality rate.

Remember that performing a laparoscopic cholecystectomy may be a walk-through hell if the timing is wrong, and it may lead to catastrophic complications (e.g. main bile duct transection…).

One last thing… Think about the cut-off points established to define a patient as having a poor performance status (i.e. being at high risk). In a world where more and more patients are elderly, finding one with CCI ≥6 and/or ASA Score ≥3 is as easy as finding a fish in the ocean.

Don’t be eager to operate on anyone…

Don’t be ready to deny the usefulness of the conservative treatment after one failure…

Don’t be a surgeon…

References
  1. Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018;25:41-54.
  2. Mayumi T, et al. Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:96-100.
  3. Okamoto K, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2018;25:55-72.
How to Cite This Post

Bellio G, Marrano E. The Vicious Rolling Stones – Part 2. Surgical Pizza. Published on January 9, 2021. Accessed on May 5, 2021. Available at [https://surgicalpizza.org/emergency-surgery/the-vicious-rolling-stones-part-2/].

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