Acute cholecystitis managed in a rural surgical department

Abstract

Objectives This study aims to define the outcome over a prolonged period of an unselected cohort of patients presenting with acute cholecystitis (AC) to a 560 bed rural hospital in Israel. Design, setting and participants Retrospective case series analysed from a single referral centre between 2006 and 2015. Separated into Group 1 managed by emergent cholecystectomy, Group 2 treated with antibiotics and delayed cholecystectomy, Group 3 treated with percutaneous cholecystostomy (PC) and selected delayed cholecystectomy and Group 4 managed entirely conservatively with no subsequent cholecystectomy. Methods Assessment of complication rates: in-hospital and delayed cause-specific morbidity and mortality along with conversion rates and the risk of intraoperative stone spillage. Results Of 321 patients hospitalized for AC, there were 50 in Group 1, 68 in Group 2, 59 in Group 3 and 98 in Group 4. Group 3 were older with more comorbidities and when coming to surgery had more open conversions. Intraoperative stone spillage was more common in Groups 2 and 3. The length of hospital stay was greater for Groups 1 and 3. Of the Group 4 cases, 63.2 per cent remained asymptomatic over a median follow-up of 78 months. Of those with recurrent biliary symptoms, 58.3 per cent were ASA Grade III/IV with 25/36 late deaths 80 per cent of which were from non-biliary causes. Conclusion In the management of AC, early cholecystectomy is favoured with non-operative approaches like PC drainage or antibiotic treatment alone being reserved for frailer comorbid cases. The absolute need for subsequent cholecystectomy is not supported by this series and requires further investigation.