Optimal treatment of acute cholecystitis

Abstract

The studies presented in this thesis focus on two main issues: treatment strategies for acute calculous cholecystitis (Part I), and the management of acute calculous cholecystitis in high-risk patients in particular (Part II). The last chapter focuses on the surgical treatment of common bile duct stones (Part III). PART I: Treatment strategies for acute calculous cholecystitis Whether or not antibiotic prophylaxis has any additional value in preventing infectious complications in patients with acute cholecystitis is a much debated subject in the surgical community. Many patients undergoing emergency cholecystectomy receive postoperative antibiotic prophylaxis intended to reduce infectious complications. The positive effect of extending antibiotics beyond a single preoperative dose, however, has never been proven. Chapter 2 presents the PEANUTS trial; a randomized controlled, multicenter trial to assess the effect of extended antibiotic prophylaxis on infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy. Also the use of preoperative antibiotic prophylaxis in patients undergoing surgery for acute cholecystitis is disputable. Chapter 3 presents the protocol of the PEANUTS IItrial; a randomized controlled, multicenter trial to assess the effect of preoperative antibiotic prophylaxis in patients undergoing emergency cholecystectomy for mild and moderate acute calculous cholecystitis. In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. The decision to perform surgery, however, should be well-considered since cholecystectomy can result in serious morbidity. For some patients the surgical risk-benefit profile may favour conservative treatment. Chapter 4 provides a literature review on the short and long-term outcome of conservative treatment of patients with acute calculous cholecystitis. The severity of acute cholecystitis and its clinical manifestation vary widely among patients. According to the international guidelines of gallstone disease, the severity is divided in three grades based on the degree of local and systemic inflammation and the presence of organ dysfunction. For each grade a different treatment strategy is proposed. Percutaneous catheter drainage is advised in patients with severe acute cholecystitis. Delayed cholecystectomy should be performed in patients with moderate acute cholecystitis whereas early cholecystectomy should be performed in patients with mild acute cholecystitis. In recent years, however, several randomized controlled trials demonstrated a clear benefit in performing early rather than delayed cholecystectomy. Chapter 5 presents a large retrospective observational cohort study on the outcome of emergency cholecystectomy for mild and moderate acute cholecystitis. Based on the findings an adaptation of the Tokyo guidelines is proposed. Chapter 6 provides an overview of the recent advances in the management of acute cholecystitis. Various aspects of the treatment are discussed, such as the optimal timing of surgery, the indication for percutaneous drainage, the feasibility of nonoperative management and the role of antibiotics. PART II: Management of high-risk patients with acute calculous cholecystitis The optimal treatment of elderly patients with acute cholecystitis remains controversial. In view of the aging population, addressing this controversy becomes a matter of increasing urgency. In the era of advanced surgical techniques and improved perioperative care, the willingness to perform emergency operations in elderly patients continues to increase. Chapter 7 presents a retrospective study on the safety and feasibility of emergency cholecystectomy in elderly patients with acute cholecystitis. Chapter 8 provides a comprehensive literature review on the clinical outcome of early cholecystectomy in the elderly population. In elderly patients with significant comorbidities or seriously ill patients, increased risk of perioperative morbidity and mortality due to reduced physiologic reserve is of concern. Percutaneous drainage is considered an alternative treatment option. Chapter 9 presents the CHOCOLATE-trial: a randomized controlled, multicenter trial to determine whether percutaneous drainage or laparoscopic cholecystectomy is best suited for high risk patients with acute calculous cholecystitis. PART III: Surgical treatment of common bile duct stones Over the past century, the management of common bile duct stones has evolved considerably, and endoscopic as well as surgical options are currently available. Chapter 10 describes the surgical techniques, and its complications, that are currently available, focusing on the laparoscopic approach. Chapter 11 provides a summary of the results of this thesis and a general discussion.