Operative Treatment of Acute Cholecystitis

Symposium on Surgery of the Biliary Tree

Operative Treatment of Acute Cholecystitis Leonard Rosoff, M.D.,* and F. Gary Robbins, M.D.**

The patient is much safer in the hands of a surgeon than when left to Nature, with the feeble assistance of drugs and mineral waters. WILLIAM OSLER, 1898

The controversy of early versus delayed operative treatment of acute cholecystitis continues, despite significant reports in the literature favoring the former. 1 • 6 • 7 The relative frequency of spontaneous subsidence of acute biliary colic, as well as acute obstructive cholecystitis as a result of stone disimpaction, is well known. The complete relief of clinical findings in such instances influences many physicians and surgeons to treat all cases of acute obstructive cholecystitis nonoperatively during the acute phase, until there is evidence of unrelenting obstruction and progression of the pathologic process, requiring surgical intervention as an emergency, "off-scheduled" procedure.

METHOD OF MANAGEMENT At the Los Angeles County-University of Southern California Medical Center, an extremely busy public hospital, patients suspected of having acute cholecystitis are initially admitted to the medical service for diagnosis and nonoperative treatment. On admission to the medical ward, a history is obtained, physical examination is done, and an electrocardiogram and routine laboratory studies are obtained. The latter includes a urinalysis and determinations of hematocrit and hemoblogin, white blood count and differential, serum amylase and urine diastase, serum urea nitrogen and electrolytes, and, when indicated, serum bilirubin, alkaline phosphatase, glutamic oxylacetic transaminase, and glutamic pyruvic transaminase. ''Professor and Chairman, Department of Surgery, University of Southern California School of Medicine; Director of Surgery, Los Angeles County-University of Southern California Medical Center, Los Angeles, California '"'Resident Physician, General Surgery, Los Angeles County-University of Southern California Medical Center, Los Angeles, California Surgical Clinics of North America- Vol. 53, No.5, October 1973

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LEONARD ROSOFF AND

F.

GARY ROBBINS

In the great majority of patients, the diagnosis of acute cholecystitis may be accurately established by history and physical examination alone, especially in the presence of a tender mass in the right subcostal region. Radiographic studies include an anteroposterior abdominal film with the patient supine, a lateral decubitus abdominal film with the patient lying on his left side, and an upright posteroanterior chest film, including the upper abdomen. Intravenous cholangiography may be extremely helpful in establishing a diagnosis of acute cholecystitis. Visualization of the gallbladder is not consonant with the diagnosis of acute cholecystitis. If neither the gallbladder nor the common duct is visualized on the initial study, a film taken 24 hours later may reveal opacity of the common bile duct without visualization of the gallbladder, indicating obstruction of the cystic duct. In some instances, in the absence of nausea and vomiting, a double dose oral cholecystogram may be obtained by giving the patient the tablets of Telepaque or Orografin granules the night before and procuring radiographic studies the following morning. A leaking perforated peptic ulcer can be ruled out by obtaining an emergency upper gastrointestinal roentgenologic study utilizing a solution of Hypaque inserted through the nasogastric tube.4 Patients with sclerosing hyaline necrosis of the liver (acute alcoholic hepatitis) frequently present with symptoms and findings consistent with acute cholecystitis. In patients with such symptoms and abdominal findings, and a history of excessive use of alcohol, it is important to rule out this entity because of the extremely high mortality associated with it, especially after celiotomy.3 With a high index of suspicion of sclerosing hyaline necrosis, a percutaneous needle biopsy of the liver is obtained and the diagnosis may be established by microscopic examination of the specimen. Radionuclide scans of the liver are helpful in establishing the presence of an amebic liver abscess, which not infrequently produces symptoms and signs of acute cholecystitis. Although in the vast majority of patients it is possible with these procedures to establish the diagnosis of acute cholecystitis and have the patient optimally prepared for operation within 24 hours after admission to the hospital, nonoperative management has been the general policy, and when a clinical diagnosis of acute cholecystitis is made, supportive measures are instituted. These consist of nasogastric suction, administration of parenteral fluids, and antibiotic therapy. Ampicillin is the most frequently used antibiotic and is given either alone or in conjunction with some other agent. In the majority of patients the acute process eventually subsides. 'these patients are discharged from the hospital with an appointment to the Surgical Outpatient Clinic for subsequent evaluation and admission to the hospital for operation on one of the regular "elective" schedules. However, a significant number of such patients fail to keep their clinic appointments, only to be subsequently readmitted with another attack of acute cholecystitis, or to have such an attack while awaiting the date of their clinic appointment or scheduled hospital admission. Patients who do not improve with nonoperative treatment or who have a sudden and significant increase in symptoms and findings are seen by the surgical staff, and in the absence of contraindications, an

SURGERY FOR ACUTE CHOLECYSTITIS

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operation is performed as an emergency any time of the day or night. As at other large and very busy public hospitals, all emergency operations are scheduled for the available operating rooms with the priority based primarily on the life-threatening nature of the disease process for which the operation is being done.

OPERATION In operations for acute cholecystitis, an upper abdominal midline, linea alba incision permits ready access to the peritoneal cavity and provides adequate exposure in the majority of instances. When necessary, additional exposure may be readily obtained by extending the incision by means of a horizontal incision to the right, starting at the lower end of the midline incision. This modified Czerny "flap" incision provides excellent exposure, an essential requisite in surgery of the biliary tract. The technique of the operation is essentially similar to that used for elective cholecystectomy provided in the excellent and detailed description by Glenn2 and others. Cholecystectomy is done by removing the gallbladder from the fundus to the ductal region after preliminary temporary ligation of the cystic duct and the cystic artery, if the latter is unequivocally identified. If not, the cystic artery and its branches are subsequently ligated and divided as the dissection of the gallbladder from its capsule proceeds from the fundus to the ductal region. After temporary ligation of the cystic duct, it may be utilized for intraoperative cholangiography, if conditions permit. Just as in elective cholecystectomy, this is usually done before removal of the gallbladder, unless the gallbladder is gangrenous or has perforated previously, in which case this can be done after removal of the gallbladder. Smears, cultures, and antibiotic sensitivity tests of the gallbladder contents should be obtained. The indications for choledochostomy during acute phase operations for acute cholecystitis are the same as the indications during interval surgery for chronic cholecystitis, unless contraindicated by the general condition of the patient. Whenever the general condition of the patient is nonpermissive, or when the local findings at operation are such that the anatomic relationships are obscured because of inflammatory reactions, a cholecystostomy is preferable to cholecystectomy. On occasion, cholecystectomy may become feasible after decompression of a markedly distended and acutely inflamed gallbladder. In performing a cholecystostomy, every attempt should be made to remove all stones and, most importantly, the obstructing calculus. Drainage of the gallbladder is achieved with a malecot or large Robinson catheter which is inserted through the fundus and secured by a pursestring suture. The fundus of the gallbladder is not sutured to the parietal peritoneum. Whenever possible, the cholecystostomy tube, as it leaves the gallbladder, is drawn through omentum and brought out of the abdomen through a separate small incision in the right flank. The small portion of the fundus removed for the cholecystostomy is routinely submit-

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ted to the pathologist for subsequent microscopic examination. On rare occasions, an unrecognized carcinoma of the gallbladder has been detected on such examinations.

RESULTS The records of 58 patients who had emergency operations at the Los Angeles County-University of Southern California Medical Center from July 1970 to July 1972 for unrelenting and advanced stages of acute cholecystitis were reviewed. There were 4 deaths, an overall mortality of 6.8 per cent, all occurring in patients with no history of previous episodes of biliary colic or acute cholecystitis. The 4 deaths occurred in patients with preoperative sepsis of a severe degree, and gram-negative bacteremic shock in 3. Emergency operations were performed for control of the overwhelming sepsis complicating the acute cholecystitis in these patients. In each instance the cause of death appeared to be directly related to the inability to control the pre-existing preoperative sepsis (Table 1). Approximately 30 per cent of the patients had had at least four previous attacks of cholecystitis (Table 2). The current episode of acute cholecystitis had been present for periods of time varying from less than 24 hours to longer than 10 days. In each instance death occurred in patients with a history of onset of the attack 3 days or longer prior to the operation (Table 3). Cholecystectomy was performed in 52 (90 per cent) of the cases (Table 4). In 14 of these a common duct exploration was also done because of jaundice or evidence of associated suppurative cholangitis. There were no deaths in this latter group of patients and no complications related to the biliary tract. In 6 patients a cholecystostomy was done because of the suboptimal condition of the patient and necrosis of the gallbladder, local abscess formation, and the loss of anatomic configuration owing to the local inflammatory reaction. Two of these patients died, one 6 days and the other 7 weeks after the operation. Of the 4 survivors, one had an elective cholecystectomy 23 days later and multiple stones were found in the gallbladder. The second had a cholecystectomy and choledochotomy 6 weeks later; multiple stones were found in the gallbladder and common duct. The third had an elective cholecystectomy 6 months later. All three had uneventful postoperative courses after cholecystectomy. One patient failed to keep his appointment for elective cholecystectomy. A cholecysto-choledochogram obtained 5 weeks after the cholecystostomy revealed no calculi. The pathologic process in the gallbladder, as encountered by the surgeon, varied from severe acute inflammatory changes, frequently with hydropic enlargement and empyema, to necrosis and perforation of the wall of the gallbladder with free spill into the peritoneal cavity or a pericholecystic abscess (Table 5). In 72 per cent of the patients, the lesion had progressed beyond the stage of a simple inflammatory reaction confined to the wall of the gallbladder.

Table 1.

Analysis of Deaths

r:Jl

l:d C'l t<:

PREVIOUS

DURATION

COEXISTING

PREOPERATIVE

AGE

SEX

ATTACKS

OF SYMPTOMS

DISEASE

BACTEREMIA

61

F

0

c::

GALLBLADDER DISORDER

OPERATION

Severe inflammation with hydrops

Cholecystostomy

REMARKS

":!

3 days

Chronic renal failure being treated with regular peritoneal dialysis

Escherichia coli; septic shock

Died 7 weeks after operation; uncontrolled sepsis

0 l:d

> (')

c::

""t
53

F

0

4 days

59

F

0

10 days

79

M

0

3 days

Convalescing from recent pulmonary embolism following internal fixation of fractured hip

Klebsiella-aerobacter; Septic shock

Recent above-knee amputation for vascular disease; infected stumpuncontrolled diabetes

?

-

Septic shock

0

Gangrenous gallbladder with perforation and bile peritonitis

Cholecystectomy

Gangrenous gallbladder

Cholecystectomy

Died 16 days after operation; uncontrolled sepsis, renal failure

I'"

t
(')

><:

[Jl

""

H

::l [Jl

Empyema of Cholecystostomy gallbladderand no stones; choledochostomy pericholecystic abscess

Patient transferred from convalescent hospital 10 days after onset of symptoms; died 13 days after operation; uncontrolled sepsis with renal failure No stones in gallbladder; common duct explored for marked jaundice and sepsis-no stones; died 6th day after operation; uncontrolled sepsis

.....

0 00 ~

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LEONARD ROSOFF AND

Table 2.

F.

GARY ROBBINS

History of Previous Attacks of Cholecystitis

First attack Second attack Third attack Fourth attack Five attacks or more

Table 3.

DEATHS

25 11

4 0 0 0 0

4 17

Duration of Symptoms PATIENTS

DEATHS

5 8 11

0 0 0 3

24 hours or less 24 to 48 hours 48 to 72 hours 72 to 96 hours over 96 hours

Table 4.

CASES

10

24

Operations Performed

OPERATION

PATIENTS

DEATHS

Cholecystectomy with choledochostomy Cholecystostomy with choledochostomy

38 14

2 0

Table 5.

5

Diagnosis at Operation AVERAGE DURATION OF SYMPTOMS PATIENTS

(DAYS)

DEATHS

Acute cholecystitis with hydrops with empyema

16 19 8

6 5 10

0 1 0

Gangrenous gallbladder-no visible perforation with perforation and free spill with localized abscess

10 3

4 3 3

0

Pericholecystic abscess

3

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SURGERY FOR ACUTE CHOLECYSTITIS

The average duration of symptoms prior to operation was less in the patients with gangrenous gallbladders and with perforations of the gallbladder than in those patients with other lesions of the gallbladder encountered at operation. Obviously, these patients had symptoms and findings of a more fulminant and virulent septic course provocative of urgent surgical intervention. However, this also suggests that ischemic changes in the gallbladder are not late or terminal changes of acute obstructive cholecystitis, but may occur very early in the course of the disease process and be manifested by a more rapid and precipitous clinical course. Three of the 4 deaths occurred in patients with biologic perforation of the gallbladder inherent with necrosis of the wall or with gross perforation and associated bile peritonitis or localized abscess. In the absence of ischemia, the course of acute obstructive cholecystitis appears to be long and smouldering. Gallbladder stones were present in 56 of the patients. In 1 patient a calculus was found in the common duct and none in the gallbladder, and in 1 patient no stones were encountered in either the gallbladder or common duct. Stones were found and removed in 4 of the 10 patients in whom a choledochotomy was done. None of the others had "overlooked" stones that were demonstrated subsequently. Although all patients had received antibiotics, primarily ampicillin, for varying periods of time prior to the operation, organisms were grown on culture from the gallbladder contents of over 50 per cent of the patients operated upon. These were essentially Escherichia coli and Klebsiella-aerobacter (Table 6). Over half of the 43 organisms recovered were resistant to ampicillin, and all except two were sensitive to kanamycin; in only six instances were the bacteria resistant to cephalotin (Keflin). Because of this, it is our policy at present to include kanamycin in the treatment of patients with acute cholecystitis. There were strikingly few complications in the 54 patients who survived (Table 7) and the average duration of hospitalization after operation was 9 days. In no instance was there a biliary fistula or complication involving the biliary tract. There was no evidence of retained common duct stones on cholangiograms obtained through the T-tube in the patients in whom a choledochostomy was done, and no postoperative history of symptoms or difficulties attributable to the biliary tract in these patients seen in the Outpatient Clinic for periods varying from 6 weeks to over 2 years.

Table 6.

Cultures of Gallbladder Contents NUMBER OF CULTURES

Escherichia coli Klebsiella-aerobacter Streptococcus, alpha and gamma Enterobacter Paracolon species Staphylococcus aureus Proteus Serrati us Gram-negative rod (unidentified)

18 13 4 2 2

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LEONARD ROSOFF AND

Table 7.

F.

GARY ROBBINS

Non-Fatal Postoperative Complications

Wound infections Urinary tract infections Pneumonitis Acute renal insufficiency Bacteremia Pancreatitis

3 3 2 2

DISCUSSION Attempted migration of a stone in the cystic duct may produce symptoms of biliary colic which are not necessarily associated with inflammatory changes in the wall of the gallbladder. These symptoms may consist of epigastric or other upper abdominal pain, frequently intermittent and colicky in nature, and nausea and vomiting. Additionally, fever and, at times, even jaundice may be associated with stone migration without detectable morphologic changes in the gallbladder. In many instances, the symptoms and findings of biliary colic may subside completely after several hours. However, the symptoms of biliary colic may herald the occurrence of acute cholecystitis which results from impaction of a stone at the outlet of the gallbladder for a sufficient length of time to produce inflammatory changes in the wall of the viscus. This produces the characteristic symptoms and findings of acute cholecystitis which may continue for several days, despite subsequent disimpaction of the blocking stone, which may move back into the gallbladder or forward into the common bile duct and subsequently, in some instances, into the intestinal tract. However, once the inflammatory reaction has been initiated, symptoms consequent to the inflammation will continue for several days or longer, despite the relief of the causative obstructing mechanism. Such inflammation is associated with upper abdominal pain, especially in the right subcostal area, frequently radiating to the right subcapsular region, and nausea and vomiting. These symptoms are accompanied by fever, leukocytosis, rigidity, tenderness and, frequently, a palpable mass in the right subcostal area. Such patients are usually hospitalized for periods of time varying from several days to 1 or 2 weeks and operation is usually delayed until the patient has been asymptomatic 6 weeks or longer. Knowledge that in the majority of cases acute cholecystitis will subside spontaneously is of value when treating patients who have a coexisting disease of a major nature. It also provides a sufficient period of time to optimally prepare the patient for operation, consonant with the aphorism of Lord Moynihan, "We have made surgery safe for the patient- we must now make the patient safe for surgery." However, stone impaction with unrelenting obstruction of the cystic duct results in progressive pathologic changes in the wall of the gallbladder and concomitant worsening of the symptoms and physical findings. In those patients whose symptoms do not subside, the morbidity and mortality of the emergency operation will be significantly higher because of the inherent complications associated with advanced morphologic changes in the wall of the gallbladder, and frequently preventable by earlier operation. Frequently

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patients with acute cholecystitis who are treated nonoperatively and are awaiting elective operation have another acute attack in the interim and are again hospitalized and again treated nonoperatively. Numerous patients admitted to the hospital for "elective" cholecystectomy have histories which indicate several previous hospital admissions for acute cholecystitis, with an obvious increase in morbidity and the total period of invalidism. Also important, are the economic factors associated with the increased loss of time from work, and the high costs of the increased total days of hospitalization. An operation during the ,acute phase of acute obstructive cholecystitis does not have to occur as a so-called "emergency operation" immediately upon admission to the hospital, except in rare instances, or for salvage of patients deteriorating during the course of observation. Acute phase surgery may be done during the regular scheduled operating room hours when the surgical team, operating room personnel, and facilities for intraoperative cholangiography, microscopic examination of rapid frozen tissue sections, and other regular supporting modalities are available. The diagnosis of acute cholecystitis may be established and the patient optimally prepared for operation within 24 to 48 hours after admission to the hospital. The ease of operation early in the course of the disease has been noted repeatedly. The edema can actually facilitate the dissection and separation of the tissue planes, whereas progression of the inflammatory process makes the dissection more difficult technically. However, in our cases, with an average duration of symptoms of 5 days, there were no significant difficulties in performing cholecystectomies, and even common duct explorations, and there were no technical complications of the operation. In most instances, cholecystectomy is less difficult technically in the acute phase than in some cases of "chronic" calculous cholecystitis operated upon electively in which a scirrhous, contracted gallbladder is found. Our experience with far advanced cases of cholecystitis demonstrates the feasibility of performing a definitive operation for calculous cholecystitis, including common duct exploration, with minimal complications, and at a rate comparable to those reported with delayed operations during quiescent periods. It would be reasonable to expect even better results and less difficult technical aspects in patients operated on much earlier than is presently done. The earlier in the course of the disease that this is done, the less the necessity of doing a cholecystostomy. The latter is frequently preferable to cholecystectomy in a critically ill, aged patient with uncontrolled diabetes or coexisting major respiratory or cardiovascular disease. However, far too frequently it is necessary to do a cholecystostomy because of progression of the disease process during a period of nonexistent medical treatment of acute obstructive cholecystitis.

SUMMARY Deterioration of the patient with acute cholecystitis as an indication for emergency operation is associated with a high mortality. Earlier operation in such patients may effectively reduce this mortality and the

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LEONARD ROSOFF AND

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GARY ROBBINS

complications consequent to progressive acute obstructive cholecystitis. A thorough diagnostic investigation may be completed and, concurrently, the patient can be optimally prepared for operation within 24 to 48 hours. There is considerable evidence that early operation for acute cholecystitis is not associated with greater technical difficulties or increase in mortality or morbidity. Early operation should reduce the incidence of "emergency" operations and, in addition, lessen the total period of disability and invalidism associated with the procrastinative treatment of acute cholecystitis.

REFERENCES 1. Glenn, F., and Thorbjarnarson, B.: Surgical treatment of acute cholecystitis. Surg. Gynec.

Obstet., 116:61, 1963. 2. Glenn, F.: Cholecystectomy. SuRG. CLIN. N. AMER., 46:1129, 1966. 3. Edmondson, H. A., Peters, R. L., Reynolds, T. B., et al.: Sclerosing hyaline necrosis of the liver in the chronic alcoholic. Ann. Intern. Med., 59:646, 1963. 4. Jacobson, G., Berne, C.]., Meyers, H. I., et al.: The examination of patients with suspected perforated ulcer using a water-soluble contrast medium. Amer. J. Roentgen., 86:37, 1961. 5. Osler, W.: Principles and Practice of Medicine. New York, D. Appleton and ·Co., 1898. 6. van der Linden, W., and Sunzel, H.: Early versus delayed operation for acute cholecystitis: controlled clinical trial. Amer. ]. Surg., 120:7, 1970. 7. Wall, C. A., and Weiss, R. M.: Early operation for acute cholecystitis. Arch. Surg., 77:433, 1958. Department of Surgery University of Southern California School of Medicine 1200 North State Street Los Angeles, California 90033