Baron Todd H, Jorge Irving, Husnain Ali, Benias Petros Constantino, Reames Bradley N, Bhanushali Ashok, Docimo Salvatore, Bloom Matthew, Salem Riad, Murphy Patrick, Singh Harjit, Varadarajulu Shyam, Riaz Ahsun
Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC.
Department of Surgery, Mayo Clinic, Phoenix, AZ.
Ann Surg. 2025 Apr 21. doi: 10.1097/SLA.0000000000006741.
Review the current literature for available treatments for acute cholecystitis (AC) in non-surgical candidates and provide guidelines for the management of these patients.
Cholecystectomy is the gold standard treatment modality for AC. A considerable number of patients who are not eligible for surgery are managed by percutaneous and endoscopic techniques. There is recent data regarding endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and emerging percutaneous approaches to address cholelithiasis and remove drains.
An expert panel of surgeons, gastroenterologists, and interventional radiologists reviewed the current literature and provided recommendations for AC management in non-surgical candidates. Recommendations were based on relevant evidence, with quality and strength assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
Percutaneous cholecystostomy (PC) is advised for patients ineligible for lumen-apposing metal stent (LAMS) or with reversible conditions, aiming to bridge to cholecystectomy. The optimal timing of cholecystectomy after PC remains unclear. In cases where surgery is not feasible, potential definitive treatments such as percutaneous cholecysto-lithotripsy/lithectomy and cholecystoduodenal stenting should be considered. For calculous AC, EUS-GBD with LAMS is recommended as a therapy for never-surgical candidates if they are eligible for monitored anesthesia care or general anesthesia and there is institutional expertise and minimal intervening ascites.
The management of AC in non-surgical candidates remains a challenge, with institutional protocols varying based on physician preferences and expertise. The proposed protocol integrates percutaneous and endoscopic approaches and emphasizes the need for multidisciplinary collaboration. Further research is required to evaluate these evolving management techniques, as the current literature is limited.
回顾当前关于非手术候选患者急性胆囊炎（AC）可用治疗方法的文献，并为这些患者的管理提供指导方针。
胆囊切除术是AC的金标准治疗方式。相当一部分不符合手术条件的患者采用经皮和内镜技术进行治疗。最近有关于内镜超声引导下胆囊引流（EUS-GBD）以及处理胆石症和拔除引流管的新兴经皮方法的数据。
一个由外科医生、胃肠病学家和介入放射科医生组成的专家小组回顾了当前文献，并为非手术候选患者的AC管理提供建议。建议基于相关证据，使用推荐分级评估、制定和评价（GRADE）框架评估质量和强度。
对于不符合管腔贴附金属支架（LAMS）条件或病情可逆的患者，建议行经皮胆囊造瘘术（PC），目的是过渡到胆囊切除术。PC术后胆囊切除术的最佳时机仍不清楚。在手术不可行的情况下，应考虑潜在的确定性治疗方法，如经皮胆囊碎石术/取石术和胆囊十二指肠支架置入术。对于结石性AC，如果从未接受过手术的候选患者符合监测麻醉护理或全身麻醉条件，且有机构专业知识且腹水最少，则推荐使用LAMS进行EUS-GBD作为治疗方法。
非手术候选患者的AC管理仍然是一项挑战，机构方案因医生偏好和专业知识而异。提议的方案整合了经皮和内镜方法，并强调了多学科协作的必要性。由于当前文献有限，需要进一步研究来评估这些不断发展的管理技术。
