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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

GANGRENOUS CHOLECYSTITIS: A COMPLICATION OF DELAYED MANAGEMENT OF ACUTE CHOLECYSTITIS


R Ceulemans, MD, É Totté, MD, R van Hee, MD, Academic Surgical Center Stuivenberg, Antwerp, Belgium

1. Introduction


Two-stage or delayed management of acute cholecystitis is still applied in many centers. The failure and complication rate, however, is substantial, thus lending to the argument for early laparoscopic cholecystectomy, preferably within the first 3-4 days. This case with its clinical progression is an example of a serious complication of the initial non-operative management of an uncomplicated acute cholecystitis in an elderly patient. This case outlines the potential difficulties in decision-making.

2. Summary


Acute cholecystitis, with a two-day history of symptoms, was treated conservatively with antibiotics on a general medicine ward. The clinical progression led to gangrenous cholecystitis associated with a large perisplenic, subdiaphragmatic collection. Simple puncture of this collection was not advisable since a subcapsular splenic hematoma or abscess was difficult to exclude. The patient was subsequently treated by laparoscopic cholecystectomy and drainage of the abscess. Although the patient’s outcome was uneventful the timing of this operation was poor, making the cholecystectomy challenging and potentially dangerous.

3. Keywords


Acute cholecystitis, gangrene, complication, timing

4. Patient


80-year-old male, Caucasian

5. Past medical history


Cardiovascular (right bundle branch block), pulmonary (bilateral pneumonia), glaucoma, cataracts, penicillin allergy, TURP (Trans-Urethral Resection of the Prostate), chronic renal failure, dyspepsia, small abdominal aortic aneurysm (4 cm), 2 days of symptoms prior to admission caused by acute cholecystitis.

6. History of present illness


An 80-year-old patient was admitted with a 2-day history of constant right upper quadrant pain without radiation, starting a few hours after a large meal and associated with nausea and vomiting. Clinical examination revealed no temperature, normal pulse and blood pressure. The abdomen was soft without peritoneal signs. Palpation noted clear right upper quadrant tenderness but no mass.
Lab results: WBC of 18 500/cc, CRP of 20 mg/dL. Liver function tests were normal. A Chest X-ray and plain abdominal film showed no abnormalities. An ultrasound confirmed the presence of cholecystitis with a distended gallbladder and wall-thickening. The patient was treated conservatively with antibiotics. The clinical progression was poor with very mild subjective improvement but significant rise of CRP. Ultrasound control revealed a large distended gallbladder (11 cm) with sludge and an edematous wall. The first CT scan, one week after admission, confirmed the diagnosis but showed no complications. Further conservative therapy was decided on. Eight days after admission clinical symptoms improved. CRP improvement was noted a few days later. An ultrasound 2 weeks after admission, prior to possible discharge, showed a large perisplenic subdiaphragmatic collection. A repeat CT scan confirmed these findings. Moderate ascitis was noted. A subcapsular splenic collection, hematoma or abscess, could not be excluded. On referral to our surgical department the patient still complained of a dull ache and a bloated feeling in the upper abdomen. The decision was made to perform a laparoscopic cholecystectomy and drainage.

7. Examinations


7.1. Examination 1

CT scan 1 week after admission showing cholecystitis with a large distended thick-walled gallbladder, pericholecystitis and a small amount of ascitis.
Figure
Figure 7.1.a
Figure
Figure 7.1.b

7.2. Examination 2

CT scan 2 weeks after admission showing significant regression of the cholecystitis. However, a large perisplenic or subcapsular collection or abscess and moderate ascitis is noted.
Figure
Figure 7.2.a
Figure
Figure 7.2.b
Figure
Figure 7.2.c
Figure
Figure 7.2.d
Figure
Figure 7.2.e

7.3. Examination 3

CT scan 2 weeks after surgery and almost complete resolution of the collection.
Figure
Figure 7.3.a
Figure
Figure 7.3.b

8. Treatment


A laparoscopic cholecystectomy was performed using 4 trocars: umbilical, epigastric, left upper quadrant and left flank (modified Reddick-Olsen position). A seropurulent collection was drained simultaneously using a 14 French closed suction drain and an multilamellar drain to facilitate rinsing and draining postoperatively. The cholecystectomy, performed using hook cautery, was difficult because of the poor timing and lasted for 150 minutes. Dense adhesions and fibrosis was encountered. No intraoperative complications were seen.

9. Postoperative period


The patient’s postoperative hospital stay was uneventful. He tolerated clear liquids the first postoperative day and a normal diet the third postoperative day. The use of analgesia was limited to acetaminophen, 1000 mg TID, on the third postoperative day and no analgesia was required on day 6. The suction and multilamellar drains were removed on day 3 and 5 respectively. The patient was discharged 2 weeks after surgery due to social circumstances although he was ready for discharge after 6 days. A CT scan 2 weeks postoperatively showed almost complete resolution of the collection.

10. Discussion


This case is a true example of a complication of delayed surgical treatment of acute cholecystitis. The management of these complications is difficult, especially in the elderly where associated morbidity may evolve into poor postoperative outcome and higher mortality. Although this patient had an uneventful postoperative course, the timing of the operation in this case is the issue. Gallstone disease is the most common indication for surgery in the elderly. Acute cholecystitis in this population is associated with higher morbidity and mortality due to the presence of co-morbidity. More frequently, delayed treatment of acute cholecystitis in the elderly will evolve into complications such as gangrene, abscess and empyema formation, fistulization and perforation. The literature shows a significantly lower conversion rate, a lower incidence of intraoperative complications and a lower total cost and hospital stay in early cholecystectomy. The exact timing of surgery for acute cholecystitis remains controversial. Many authors, however, present significantly higher conversion and complication rates more than 96 hours after the onset of symptoms. We recommend early laparoscopic cholecystectomy in case of acute cholecystitis, preferably within the first 3-4 days after the onset of symptoms. Laparoscopic cholecystectomy in case of acute cholecystitis in elderly patients should not be delayed. In this elderly patient antibiotics were adequately administered on the day of admission. However, early cholecystectomy would have prevented the complications described earlier and would have decreased the operation time and level of difficulty, total hospital stay and cost.

11. References


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