A recent review (Baron TD, et al. NEJM 2015; 373: 357-65) provides a useful review of surgical and interventional approaches to gallbladder disease.
One recommendation in particular caught my attention:
“Recent data favor early laparoscopic cholecystectomy over medical management with delayed cholecystectomy. In one randomized trial involving patients with uncomplicated acute cholecystitis, laparoscopic cholecystectomy, when performed within 24 hours after the onset of cholecystitis, significantly reduced morbidity, length of hospital stay, and costs without increasing the need for conversion to open surgery.” (References: JAMA Surg 2015; 150: 129-36, Ann Surg 2013; 258: 385-93)
The authors’ Table 1 provides diagnostic guidelines and disease severity guidelines.
- Grade 1 (mild): acute cholecystitis in otherwise healthy patient with mild local inflammatory changes and without organ dysfunction
- Grade 2 (moderate) any of the following: leukocytosis >18K, palpable tender mass in RUQ, symptom duration >72 hr, marked local inflammation (gangrenous or emphysematous cholecystitis, pericholecystic or hepatic abscess, biliary peritonitis)
- Grade 3 (severe) any of the following: hypotension requiring dopamine or norepinephrine, decreased consciousness, hypoxia, oliguria or creatinine >2.0 mg/dL, INR >1.5, or platelet count <100K
The review highlights the NOTES procedure, percutaneous cholecystotomy, and peroral endoscopic drainage (transpapillary vs. transmural).
Related blog post: Early Surgery For Acute Cholecystitis