Training vs practice: A tale of opposition in acute cholecystitis

Abstract

Acute cholecystitis is one of the most common surgical diagnoses encountered by general surgeons. Despite its high incidence there remains a range of treatment of approaches. Current practices in biliary surgery vary as to timing, intraoperative utilization of biliary imaging, and management of bile duct stones despite growing evidence in the literature defining best practice. Management of patients with acute cholecystitis with early laparoscopic cholecystectomy (LC) results in better patient outcomes when compared with delayed surgical management techniques including antibiotic therapy or percutaneous cholecystostomy. Regardless of this data, many surgeons still prefer to utilize antibiotic therapy and complete an interval LC to manage acute cholecystitis. The use of intraoperative biliary imaging by cholangiogram or laparoscopic ultrasound has been demonstrated to facilitate the safe completion of cholecystectomy, minimizing the risk for inadvertent injury to surrounding structures, and lowering conversion rates, however it is rarely utilized. Choledocholithiasis used to be a diagnosis managed exclusively by surgeons but current practice favors referral to gastroenterologists for performance of preoperative endoscopic removal. Yet, there is evidence that intraoperative laparoscopic stone extraction is safe, feasible and may have added advantages. This review aims to highlight the differences between existing management of acute cholecystitis and evidence supported in the literature regarding best practice with the goal to change surgical practice to adopt these current recommendations.

Keywords: Cholangiography; Acute cholecystitis; Ultrasound; Laparoscopy; Cholecystectomy; Evidence based

Core tip: General surgeons commonly perform laparoscopic cholecystectomy for acute cholecystitis; however, current practices in biliary surgery often vary regarding timing, intraoperative biliary imaging, and management of bile duct stones. In spite of growing evidence in the literature defining best practice and societal guidelines supporting early cholecystectomy, intraoperative cholangiogram and ultrasound, and laparoscopic bile duct exploration utilizing laparoscopic ultrasound and performing common bile duct exploration, an overwhelming number of surgeons still perform delayed operations, rarely perform intraoperative imaging and defer treatment of common bile duct stones. Efforts should be made to adopt the evidence-based data supported in the literature.