Colecistitis aguda severa (Tokio III) en pacientes de alto riesgo: ¿Se debe preferir la colecistectomía al drenaje percutáneo?

Abstract

Gallstones are the most common cause of acute cholecystitis (AC) [1], nevertheless 80% of the patients with gallstones could be asymptomatic and 1-3% of patients with symptomatic disease develop AC [1,2]. According to Shaffer et al almost 10-15% of the American population have or will have AC [3]. Following the 2018 Tokyo guidelines AC severity is classified based on the clinical status of the patient [4]. Patients with mild illness do not develop any organ failure and should undergo early laparoscopic cholecystectomy (LC) combined with antibiotic regimen; those with moderate disease require urgent/early or delayed/elective LC depending on the success of the general supportive treatment, and in patients with severe disease (with any organ failure) and limited performance status biliary drainage is required [4]. However in patients with improved functional status, surgery it’s a feasible treatment choice [4]. For that reason In young, healthy patients with no comorbidities, laparoscopic cholecystectomy (LC) it’s the gold standard treatment for gallstone related acute cholecystitis [5]. However, it’s still a matter of concern the surgical management of patients with severe disease, high risk such as elderly, with increased operative risk due to comorbidities [6], also in patients with negative predictive factors such as jaundice, respiratory or neurological dysfunction, as well limited functional reserves could impact in clinical postoperative outcomes, and increase morbidity and mortality risk and laparoscopic cholecystectomy should be delayed [4,6,7]. For that reason, minimally invasive techniques such as percutaneous drainage of the gallbladder are described in the management of these patients, avoiding surgical risk, offering a temporary solution, being the preferred management based on some international guidelines [4,8]. Nonetheless, percutaneous cholecystostomy isn’t a definitive treatment, and could lead to re-admissions, recurrent cholecystitis, and increased risk of biliary complications [9-12]. Nowadays, a recent randomized clinical trial support the possibility to perform surgical approach in high risk patients in selected population [6], with clinical impact and in financial burden, however, some studies report an increased morbidity of 41% and 5% rate or mortality in emergency LC in high risk patients [13,14]. These data show that the management of AC with severe disease and in high risk patients remains to be a matter of debate. This study aims to describe the population of patients that enter the emergency room with AC, and shows the clinical outcomes of patients with Tokyo III grade of cholecystitis who underwent cholecystectomy or cholecystostomy according to international guidelines.