Optimal treatment of acute cholecystitis

The studies presented in this thesis focus on two main issues: treatment strategies for
acute calculous cholecystitis (Part I), and the management of acute calculous cholecystitis
in high-risk patients in particular (Part II). The last chapter focuses on the surgical
treatment of common bile duct stones (Part III).
PART I: Treatment strategies for acute calculous cholecystitis
Whether or not antibiotic prophylaxis has any additional value in preventing infectious
complications in patients with acute cholecystitis is a much debated subject in the surgical
community. Many patients undergoing emergency cholecystectomy receive postoperative
antibiotic prophylaxis intended to reduce infectious complications. The positive effect of
extending antibiotics beyond a single preoperative dose, however, has never been proven.
Chapter 2 presents the PEANUTS trial; a randomized controlled, multicenter trial to
assess the effect of extended antibiotic prophylaxis on infectious complications in patients
with mild acute cholecystitis undergoing cholecystectomy.
Also the use of preoperative antibiotic prophylaxis in patients undergoing surgery for
acute cholecystitis is disputable. Chapter 3 presents the protocol of the PEANUTS IItrial;
a randomized controlled, multicenter trial to assess the effect of preoperative
antibiotic prophylaxis in patients undergoing emergency cholecystectomy for mild and
moderate acute calculous cholecystitis.
In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. The
decision to perform surgery, however, should be well-considered since cholecystectomy
can result in serious morbidity. For some patients the surgical risk-benefit profile may
favour conservative treatment. Chapter 4 provides a literature review on the short and
long-term outcome of conservative treatment of patients with acute calculous
cholecystitis.
The severity of acute cholecystitis and its clinical manifestation vary widely among
patients. According to the international guidelines of gallstone disease, the severity is
divided in three grades based on the degree of local and systemic inflammation and the
presence of organ dysfunction. For each grade a different treatment strategy is proposed.
Percutaneous catheter drainage is advised in patients with severe acute cholecystitis.
Delayed cholecystectomy should be performed in patients with moderate acute
cholecystitis whereas early cholecystectomy should be performed in patients with mild
acute cholecystitis. In recent years, however, several randomized controlled trials
demonstrated a clear benefit in performing early rather than delayed cholecystectomy.
Chapter 5 presents a large retrospective observational cohort study on the outcome of
emergency cholecystectomy for mild and moderate acute cholecystitis. Based on the
findings an adaptation of the Tokyo guidelines is proposed.
Chapter 6 provides an overview of the recent advances in the management of acute
cholecystitis. Various aspects of the treatment are discussed, such as the optimal timing of
surgery, the indication for percutaneous drainage, the feasibility of nonoperative
management and the role of antibiotics.
PART II: Management of high-risk patients with acute calculous cholecystitis
The optimal treatment of elderly patients with acute cholecystitis remains controversial.
In view of the aging population, addressing this controversy becomes a matter of
increasing urgency. In the era of advanced surgical techniques and improved
perioperative care, the willingness to perform emergency operations in elderly patients
continues to increase. Chapter 7 presents a retrospective study on the safety and
feasibility of emergency cholecystectomy in elderly patients with acute cholecystitis.
Chapter 8 provides a comprehensive literature review on the clinical outcome of early
cholecystectomy in the elderly population.
In elderly patients with significant comorbidities or seriously ill patients, increased risk of
perioperative morbidity and mortality due to reduced physiologic reserve is of concern.
Percutaneous drainage is considered an alternative treatment option. Chapter 9 presents
the CHOCOLATE-trial: a randomized controlled, multicenter trial to determine whether
percutaneous drainage or laparoscopic cholecystectomy is best suited for high risk
patients with acute calculous cholecystitis.
PART III: Surgical treatment of common bile duct stones
Over the past century, the management of common bile duct stones has evolved
considerably, and endoscopic as well as surgical options are currently available. Chapter
10 describes the surgical techniques, and its complications, that are currently available,
focusing on the laparoscopic approach.
Chapter 11 provides a summary of the results of this thesis and a general discussion.