Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as
empyema,
gangrene, perforation of the gallbladder, and
sepsis. The gold standard treatment for AC is
laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of
laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these
critically ill patients, percutaneous
cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to
cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c)
Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous
cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e)
Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo
cholecystectomy, the
catheter may be maintained for a prolonged period or even definitively; f) If the
cholecystostomy catheter is maintained for a long period of time several complications may occur, such as
bleeding, bile leakage, obstruction,
pain at the insertion site, accidental removal of the
catheter, and recurrent AC; g) The ideal waiting time between
cholecystostomy and
cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between
cholecystostomy and
cholecystectomy may be associated with new episodes of
acute cholecystitis, multiple
hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.