Universidade Federal do Paraná, Department of Surgery - Curitiba (PR), Brazil.
Hospital Federal Ipanema - Rio de Janeiro (RJ), Brazil.
Arq Bras Cir Dig. 2023 Sep 15;36:e1749. doi: 10.1590/0102-672020230031e1749. eCollection 2023.
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.
急性胆囊炎（AC）是胆囊的一种急性炎症过程，可能伴有潜在的严重并发症，如积脓、坏疽、胆囊穿孔和败血症。AC 的金标准治疗方法是腹腔镜胆囊切除术。然而，对于一小部分 AC 患者，腹腔镜胆囊切除术的风险可能非常高，主要是在伴有严重疾病的老年人中。在这些重症患者中，经皮胆囊造口术或内镜超声胆囊引流术可能是一种临时治疗选择，是胆囊切除术的桥梁。本巴西消化外科学会立场文件的目的是介绍高危手术患者中 AC 治疗的新进展，以帮助外科医生、内镜医生和内科医生为其患者选择最佳治疗方法。讨论了每种手术的有效性、安全性、优点、缺点和结果。主要结论是：a）患有高手术风险的 AC 患者最好在有外科、放射学和内镜专业知识和资源的三级医院接受治疗；b）应根据临床情况和现有专业知识对高手术风险患者的最佳治疗方式进行个体化；c）腹腔镜胆囊切除术仍然是一种极好的治疗选择，主要适用于无法进行经皮或内镜胆囊引流的医院；d）仅在设备齐全且有经验的介入放射科医生和/或内镜医生的医院进行经皮胆囊造口术和内镜胆囊引流术；e）应在 AC 缓解后取出胆囊造口术导管。然而，对于那些没有临床条件进行胆囊切除术的患者，导管可能会保留较长时间，甚至永久性保留；f）如果长时间保留胆囊造口术导管，可能会发生多种并发症，如出血、胆汁漏、阻塞、插入部位疼痛、导管意外脱落和复发性 AC；g）胆囊造口术和胆囊切除术之间的理想等待时间尚未确定，范围从临床改善后立即到几个月不等。h）胆囊造口术和胆囊切除术之间的长等待时间可能与新的急性胆囊炎发作、多次住院和增加的成本有关。最后，在选择最佳治疗方案时，还应考虑其他方面，如成本、医疗中心提供的程序以及患者的意愿。应向患者及其家属充分告知所有治疗方案，以便他们能够帮助做出最终决定。
