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Partial Cholecystectomy As a Safe and Viable Option in the Emergency Treatment of Complex Acute Cholecystitis: A Case Series and Review of the Literature

July 1, 2007

By Soleimani, Mehrdad Mehrabi, Arianeb; Mood, Zhoobin A; Fonouni, Hamidreza; Et al

Partial cholecystectomy (PC) is an alternative choice to standard cholecystectomy in situations with increased risk of Calot’s components injury. We reported our experience with the patients treated with PC and reviewed the literature. Fifty-four patients with complex acute cholecystitis underwent PC, including conventional partial cholecystectomy (CPC; n = 48) and laparoscopic partial cholecystectomy (LPC; n = 6). The clinical diagnosis was verified by ultrasonography. In addition, we reviewed 1190 published cases (1972-2005) who underwent a “nonconventional” surgery for severe cholecystitis, including cholecystostomy, CPC, or LPC. Review of the literature, including our cases, showed a male:female ratio of 1.3:1. The major operative indication was severe acute cholecystitis. Procedures included cholecystostomy (65.8%) and PC (34.2%). In the follow-up (n = 1190), biliary leak (4.8%), retained stones (4.6%), recurrent symptoms (2.3%), wound infections (1.9%), persistent biliary fistula (0.9%), and prolonged biliary drainage (0.2%) were found, with an overall mortality rate of 9.4 per cent. In 133 patients, because of postoperative complications (e.g., recurrent symptoms, remaining common bile duct stones, or persistence of bile fistula), reoperation was necessary, including 121 cases (90.1%) of cholecystectomy, whereas the other 11 patients underwent other procedures such as common bile duct exploration or closure of the fistula. The surgical trend for complex acute cholecystitis treatment has been changed from only cholecystostomy to a spectrum of cholecystostomy, CPC, and LPC with the progressive increase of PC. The proportion of the LPC compared with CPC has also increased during recent years. It seems that PC is a safe procedure for treating complicated acute cholecystitis. Whether the indication and need for alternative techniques to standard cholecystectomy is changing should be evaluated in future studies. THE DIAGNOSIS OF ACUTE cholecystitis as a common cause of the acute abdomen was distinctly improved with the development of ultrasonography and hepatobiliary scanning.1 An estimated 10 per cent of people have gallstones, and as many as one-third of them develop acute cholecystitis. Cholecystectomy for recurrent biliary colic or acute cholecystitis is one of the most common major surgical procedures performed by general surgeons, resulting in approximately 500,000 operations annually in the United States. More than 90 per cent of patients with acute cholecystitis have a complete remission within 1 to 4 days.2 However, many patients require surgery or develop some complications. Patients with acalculous cholecystitis may have a mortality rate ranging from 1 per cent to 46 per cent, which far exceeds the expected mortality rate observed in patients with calculous cholecystitis.3-5 To prevent life-threatening complications, prompt diagnosis and surgical treatment are essential. The attitude of surgeons has changed from past (medical treatment for a few weeks before operation) to now (cholecystectomy as soon as possible) in the management of cholecystitis.6-8 In performing a cholecystectomy in severe inflammation and fibrosis, portal hypertension, and Mirizzi’s syndrome, the main danger is damaging the main bile ducts or aberrant hepatic arteries during dissection of Calot’s triangle. These situations make identification of anatomical structures difficult. Many kinds of salvation have been found, such as medical treatment and operation after several weeks, cholecystostomy, conventional partial cholecystectomy (CPC), and recently, laparoscopic partial cholecystectomy (LPC). Cholecystostomy may be advisable for the acutely inflamed gallbladder that has become a phlegmonous mass. It might be warranted in the very ill patient with empyema of the gallbladder, severe concomitant disease, or sepsis (patients in ASA IV status).9, 10 However, a second definitive procedure may be necessary later.11 The PC technique has simplified removal of the difficult gallbladder, and the procedure avoids dissection in Calot’s triangle and it minimizes the risk of injury to bile duct and hepatic artery. It makes control of bleeding easier11-13 and avoids a second operation with a long recovery period.12,14,15 In addition, it can be performed in any small hospital with low cost, and surgeons do not need to use specific modern instruments. Laparoscopic cholecystectomy is one of the most common elective surgical procedures. Increasing laparoscopic experience has made LPC a feasible option16 in patients with complicated acute or chronic cholecystitis in modern equipped hospitals.

TABLE 1. Data on Clinical Manifestation, Indication of Operation, Type of Surgical Treatment, and Additional Surgical Interventions in Patients Who Underwent a “Nonconventional” Surgical Treatment of Complex Acute Cholecystitis (Review of the Lirterature from 1972- 2005)

TABLE 1. Data on Clinical Manifestation, Indication of Operation, Type of Surgical Treatment, and Additional Surgical Interventions in Patients Who Underwent a “Nonconventional” Surgical Treatment of Complex Acute Cholecystitis (Review of the Lirterature from 1972- 2005)

TABLE 1. Data on Clinical Manifestation, Indication of Operation, Type of Surgical Treatment, and Additional Surgical Interventions in Patients Who Underwent a “Nonconventional” Surgical Treatment of Complex Acute Cholecystitis (Review of the Lirterature from 1972- 2005)

The aim of this article is to present our experiences in the treatment of cases of acute severe cholecystitis that were treated by PC, and to review the literature for the “nonconventional” surgical treatments (cholecystostomy, CPC, and LPC) of cholecystitis, when a classic cholecystectomy is technically difficult or even dangerous. This review should provide surgeons with an easy decision in choosing the optimal surgical strategy in severely ill patients with cholecystitis in the presence of portal hypertension or when severe inflammation and fibrosis or Mirizzi’s syndrome exist.

Patients and Methods

Our Experience

At the Department of Surgery, Tehran University of Medical Sciences, from 1993 to 2003, 54 patients with acute severe cholecystitis underwent only PC. For all patients, the demographic data, clinical symptoms, type of operative procedures, postoperative surgical or medical complications, and mortality rate were prospectively recorded and evaluated. The diagnosis of acute cholecystitis was clinical and verified by ultrasonography. Endoscopic retrograde cholangiopancreatography (ERCP) was not performed before operation. In all patients, gallstones were present. If necessary, we used ERCP after operation. In these patients, the indication for PC was severe inflammation in the region of Calot’s triangle. All operations were performed under general anesthesia and antibiotic therapy. In our patients, we used the PC technique reported by Bornman and Terblanche.12 At first, a right transverse incision was made and dissection was kept to a minimum to prevent tissue injuries. No attempt was made to dissect Calot’s triangle or to identify cystic duct, cystic artery, and the common bile duct (CBD). The gallbladder was aspirated and infected bile was sent for bacteriological examination. The gallbladder was then excised using diathermy. Re section of gallbladder was started at the fundus with cautery, and the contents (including infected bile and impacted stones) were evacuated. After completing the partial resection of the gallbladder, the posterior wall was left attached to the liver bed and its rim was oversewn with a running suture (2-0 Vicryl) immediately to control bleeding. The cystic duct orifice was identified from inside the gallbladder using a probe, and any residual stones were gently removed. Puncture of the CBD was avoided. If necessary, retained stones in the CBD were removed by performing a postoperative ERCP with sphincterotomy. For preventing biliary leakage or fistula formation, the cystic duct was always oversewn from within the gallbladder. Curettage of the remaining mucosa was performed with a fine curette or diathermy. We did not perform intraoperative cholangiography. At the end, if possible, we “packed” the remaining portion of the gallbladder with an omentum patch to prevent bowel adhesion and subsequent intestinal obstruction. Drainage of the gallbladder bed was routinely used.

Review of the Literature

At the Department of Surgery, University of Heidelberg, the literature from 1972 to 2005 for the “nonconventional” surgical management of severe inflammation of the gallbladder, including cholecystostomy, CPC, and LPC, was reviewed using the Medline database. The focus of our analysis was on demographic data, clinical manifestations, type of surgical treatment, clinical outcome, need for postoperative surgical or nonsurgical intervention, and morbidity and mortality rate.

Results

Presenting Our Experience

From 1993 to 2003, 54 patients underwent PC, including six LPCs. The age of patients ranged between 25 and 65 years (mean, 49.1). There were 12 men (22.2%) and 42 women (77.8%). None of our patients had preoperative invasive imaging such as percutaneous transhepatic cholangiography or ERCP. In all patients cholecystitis, gallstones, and inflammation of the Calot’s triangle were present. In five (9.3%) cases, the gallbladder had a gangrenous fundus without frank perforation. Empyema was present in eight (14.8%) and hydrops was present in 10 (18.5%) patients. We did not perform intraoperative cholangiography in any patient. Closure of the cystic duct was difficult in seven (13%) patients and could not be performed in three (5.6%) patients. In these three cases, we left the cystic duct open with a drain. All of these 10 cases developed a self-limiting postoperative bile leak 3 to 5 days postoperatively, which improved spontaneously after 2 weeks without any symptoms of peritonitis. ERCP was applied in 11 (20.4%) patients after the operation, and we found CBD stones in six of them during postoperative ERCP. A postoperative exploration of the bile duct was only necessary in three (5.6%) patients in the case of ERCP failure. Five (9.3%) patients had Mirizzi’s syndrome (Type I), and common bile duct stricture and inflammation was confirmed by ERCP. In two of the patients, the syndrome was not resolved 60 days after operation and a choledochojejunostomy (Roux-en-Y anastomosis) was performed for treatment. All patients were followed-up for a mean of 24 months (range, 7-18). Three (5.6%) patients had cholangitis that resolved about 3 to 4 weeks after the operation by antibiotic therapy without any further intervention. During operation, gallbladder carcinoma with liver and local lymph nodes metastasis was found in three (5.6%) patients, confirmed by pathological sampling. No further interventions were performed, and they were referred to a chemotherapist. All of them died from progression of advanced gallbladder carcinoma 3 to 9 months postoperatively. In our series, there was no mortality directly related to the PC procedure. Review of the Literature

The available data of 1280 patients in 28 case series or case reports (including our cases) were analyzed for the review. One thousand two hundred forty-four cases underwent cholecystostomy or PC, whereas in 36 patients, the operation converted to cholecystectomy or other surgical techniques because of different causes. The most cases were reported in 1972 (n = 154) and 1981 (n = 374) by Welch17 and Glenn,18 respectively. They mainly gathered data of patients who underwent only a cholecystostomy. An overview of reviewed and analyzed publications is summarized in Table 1.

Demographic Data, Clinical Manifestations, and Indication of Operation

Among the cases were 374 (56.2%) women, 292 (43.8%) men (female:male ratio of 1.28:1), and 614 cases without declaration of the gender. The reported cases ranged from 17 to 95 years old, with mean of 61.09 years in 590 cases with accessible data. Most of the patients who underwent a “nonconventional” surgical therapy of cholecystitis or cholelithiasis were in the sixth or seventh decade of their lives. The most common presenting signs and symptoms of the patients were the same as an acute cholecystitis (available data in 1012 patients, 79.1%; Table 1). Apart from ultrasonography, which was the routine type of evaluation, different diagnostic imaging modalities (n = 452) were mentioned for evaluation of the CBD perioperatively, including perioperative and/or intravenous cholangiography (n = 265, 58.6%), ERCP (n = 120, 26.5%), oral cholecystography (n = 36, 8%), percutaneous transhepatic cholangiography (n = 8, 1.8%), cholecintigraphy (hydroxy iminodiacetic acid scan; n = 3, 0.7%), and CT/magnetic resonance imaging scan (n = 20, 4.4%). After reviewing the articles, it could be assumed that the major indication of operations in the total of 1200 patients (excluding 80 patients who had incidental gallbladder operation during another operation) was severe inflammation with/ without fibrosis (n = 1099, 91.6%), Mirizzi’s syndrome in 79 (6.6%) patients, and portal hypertension in 15 (1.2%) patients. In seven (0.6%) patients, anatomical variations were the main cause (Fig. 1; Table 1).

FIG. 1. Indication for operation in patients undergoing a “nonconventional” surgical treatment of complex acute cholecystitis (literature reviewed from 1972-2005).

Types of Operations, Procedures, and Postoperative Complications

Overall, the most common operation was cholecystostomy, with 818 (65.8%) cases, whereas CPC and LPC were performed on 272 (21.9%) and 154 (12.4%) patients, respectively (Table 1; Fig. 2). Major additional operations, which were occasionally applied in combination or instead of cholecystostomy, CPC, or LPC for more complicated situations such as Mirizzi’s syndrome or choledochal stones, were exploration of the CBD in 74 (5.8%) cases and choledochostomy and other bypass operations in 47 (3.7%) cases. As an intraoperative finding, empyema was found in 74 (5.8%) patients, gangrenous and/or perforated gallbladder were found in 65 (5.1%) patients, carcinoma was found in 6 (0.5%) patients, and cirrhosis was found in 5 (0.4%) patients.

During follow-up of reported cases (n = 1190), wound infections were found in 26 (2.1%) cases. A persistent biliary fistula was noticeable in 12 (0.9%) patients after cholecystostomy, and a prolonged biliary drainage was found in 3 (0.2%) patients who underwent LPC. Fifty-seven (4.6%) patients showed CBD or gallbladder stones, and 60 (4.8%) patients showed a biliary leak. Thirty (2.3%) patients had recurrent symptoms. In 133 patients, because of postoperative complications (e.g., recurrent symptoms, remaining CBD stones, or persistence of bile fistula), reoperation was necessary, including 121 (90.1%) of cholecystectomy, whereas the rest ( 11 patients) underwent other procedures such as CBD exploration or closure of fistula. The overall mortality rate was 9.4 per cent (n = 117).

Discussion

In acute cholecystitis, different therapeutic approaches according to the individual situation are required. It may be treated by removal of the inflamed gallbladder during the acute phase of the disease or by conservative treatment followed later by cholecystectomy. Medical therapies do not eliminate the need for cholecystectomy despite the need for resuscitation of ill patients, whereas a second attack is not uncommon. On the other hand, urgent cholecystectomy is necessary in patients with acute life- threatening complications such as empyema and suspected or confirmed perforation. Early cholecystectomy prevents the complications of delayed operation and reduces the mortality rate and the hospital stay, as well as the treatment costs.19-22 In recent years, surgeons prefer cholecystectomy as soon as possible in the management of cholecystitis. However, in severe cholecystitis with involvement of Calot’ s triangle, it is sometimes difficult to perform a classic cholecystectomy. In this case, cholecystostomy, CPC, or LPC might be a proper solution.

FIG. 2. Different surgical techniques for the treatment of complex acute cholecystitis in patients from 1972 to 2005 (reviewed literature).

Cholecystostomy, as an initial life-saving procedure, might be a safe approach and served as a definitive procedure in elderly patients without the risk of gallstone recurrence.10,18,23-26 It may eliminate the need for potentially dangerous dissection of distorted biliary tract anatomy and it can be performed rapidly through a small incision under local anesthesia.17 As shown in Fig. 2, this technique outnumbered other techniques and alone, it comprises 66 per cent of all procedures. It seems that cholecystostomy, as an alternative safe procedure to cholecystectomy, has the disadvantage of a high rate of retained stones (up to 50%), which then requires a subsequent cholecystectomy.15,17,27-30 Recently, interventional gallbladder drainage as a primary procedure seems to be an alternative to urgent surgery.31 PC is not a new operation, many years ago, destroying the mucosa of the gallbladder with diathermy was suggested32-34 by identification and ligation of the Calot’ s triangle structures. Some authors described resection of the peritoneal wall of the gallbladder down to the opening of the cystic duct, which is left unsutured and drained in the early postoperative phase.35 Bornman and Terblanche12 termed their modification “subtotal cholecystectomy,” leaving the posterior wall of the gallbladder attached to the liver and securing the cystic duct at its origin as we used in our patients. Partial (subtotal) cholecystectomy combines the advantages of cholecystostomy and cholecystectomy.12,27 Like cholecystostomy, PC is a safe, easy, and definitive operation. It avoids difficult dissection in the inflamed Calot’s triangle and prevents bile duct injury, which minimizes the conversion rate.36,37 Therefore, PC should be considered as a surgical option in inflamed, gangrenous, perforated, deeply placed, or fibrotic gallbladder, and also in the presence of high-grade cirrhosis with the increased risk of bleeding or in severely ill patients with coagulopathy.”

Similar to cholecystectomy, PC prevents recurrent gallstone formation, as no residual diseased gallbladder mucosa is left in continuity with the biliary system. ’2 However, recurrence of stones remains a possibility, particularly if a blind pouch is formed by approximation of Hartmann’s pouch.38 Gorrini et al.39 applied PC with choledochoplasty and exploration of the distal part of CBD by a transduodenal sphincteroplasty to prevent recurrent gallstone formation. We found CBD stones in six patients postoperatively, even though the risk of residual stones in the gallbladder remnant after PC is bound to be less than after cholecystostomy.38 In addition, PC deals adequately with the necrotic portions of the gallbladder; we had five cases with a gangrenous fundus of the gallbladder, a common finding in acalculous cholecystitis.40 On the other hand, the possible disadvantages of PC are an increased incidence of infection by the opened gallbladder, although some authors stated that the infection rate is no greater than a cholecystostomy,41 the so- called cystic stump syndrome (continuous mucus discharge from the retained gallbladder mucosa), and subphrenic collection or persistent discharge from the drain site.12,38 Closure of the cystic duct may lead to a self-limiting postoperative bile leak. In our study, closure of the cystic duct was difficult in seven (13%) patients and could not be performed in three patients. These 10 cases developed a self-limiting bile leak 3 to 5 days postoperatively, which improved spontaneously after 2 weeks without any symptoms of peritonitis. Sometimes it is possible to ligate the cystic duct with the help of a probe inside. However, we did not use this technique to prevent unwanted trauma to branches of the hepatic artery. Gholson et al.42 quoted that the insertion of a 10 F endoprothesis resulted in a complete closure of the persistent fistula within 6 weeks. Surgeons encountered a difficult situation during the handling of severe cholecystitis such as Mirizzi’s syndrome. Some authors have suggested that PC is the treatment of choice for Mirizzi’s syndrome Type I (five cases in our study)14,27,43,44 with complete recovery.45,46 As described by Baer et al.,47 in cholecystobiliary fistula, PC with choledochoplasty using a gallbladder flap is the treatment of choice. Baer treated Mirizzi’s syndrome Type II by performing a combination of PC and cholecysto-choledochoduodenostomy. By introducing laparoscopic surgery, another choice is available in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is technically feasible in the majority of patients with acute cholecystitis. The essential surgical steps remain similar to those of open cholecystectomy. However, in complex acute cholecystitis, the conversion rate to open surgery is higher and the operative time is longer,48,49 with an increased risk of bile duct injury.50 LPC has been reported during the past years.51,52 Increasing laparoscopic experience has made LPC a feasible option in patients with complicated acute or chronic cholecystitis. LPC is a safe, relatively simple, and definitive procedure that allows the management of complex acute cholecystitis and reduces the need for conversion or cholecystostomy in a majority of patients.36-53 Mirizzi’s syndrome is generally considered a contraindication for laparoscopic cholecystectomy, which can easily result in CBD injury.54-57 However, laparoscopic treatment of Mirizzi’s Type I syndrome by an experienced laparoscopic surgeon is technically feasible and safe.51,58

FIG. 3. Change in the management of complex acute cholecystitis in different time periods (literature reviewed from 1972-2005).

The surgical trend for the treatment of the complex acute cholecystitis has been changed from performing only cholecystostomy (100%) in the period between 1972 and 1982 to a spectrum of operations, including cholecystostomy, CPC, and LPC after that time. The proportion of PC in the operation of difficult cholecystitis cases has increased progressively from O per cent between 1972 and 1982 to 58 per cent of operations in the period of 1983 to 1994 and to 81 per cent between 1995 and 2005. In this way, because of the increase of experiences in minimally invasive surgery, the part of LPC in the PC procedure for complex acute cholecystitis has increased from 2.4 per cent of operations between 1983 and 1994 to 43 per cent of operations in the period of 1995 to 2005 (Fig. 3). In conclusion, PC is a safe and definitive procedure for the treatment of complex acute cholecystitis. The procedure avoids dissection in Calot’s triangle and reduces the risk of bile duct injury. In addition, it makes the control of bleeding easier and avoids the need for a second look with a better postoperative recovery in high- risk patients. Whether the indication and need for alternative techniques to standard cholecystectomy is changing should be evaluated in future studies.

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MEHRDAD SOLEIMANI, M.D.,*,[dagger] ARIANEB MEHRABI, M.D.,[dagger] ZHOOBIN A. MOOD, M.D.,[dagger]

HAMIDREZA FONOUNI, M.D.,[dagger] ARASH KASHFI, M.D.,[dagger] MARKUS W. BUCHLER, M.D.,[dagger] JAN SCHMIDT, M.D.[dagger]

From the * Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran and the

[dagger] Department of General, Visceral, and Transplantation Surgery, University of Heidelberg,

Heidelberg, Germany

Address correspondence and reprint requests to Dr. A. Mehrabi, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.

Copyright Southeastern Surgical Congress May 2007

(c) 2007 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.




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