Thursday, June 12, 2008

Well duh

Sometimes it's necessary to dress up the obvious as science in order to remind people (surgeons) of certain fundamental truths. The Archives of Surgery this month published an article entitled "Early Laparoscopic Cholecystectomy is the Preferred Management of Acute Cholecystitis". Whoa! Stop the presses! Alert the Nobel committee in Stockholm!

Seriously though, it has to be done every so often. We've seen this nefarious idea of "cooling down hot gallbags" creep into general surgery culture over the past several years. Admit the patient, put them on broad spectrum IV antibiotics (Zosyn) and if they feel better the next day, bring the patient back in several weeks or months for an elective cholecystectomy. Although this article isn't particualrly strong (retrospective, non-randomized), there is a wealth of recent surgical literature supporting earlier surgical intervention for acutely inflamed gallbladders. Hospitalizations are shorter. Accrued costs to the patient and hospitals are less. Fewer complications are seen. It's a no brainer.

So why are we cooling off gallbladders instead of whacking them out? Several reasons. In the early days of laparoscopy, it was felt that acute cholecystitis was a contraindication to lap chole. We now know that not to be true; in fact the operation often proceeds much more easily because the edema facillitates dissection of the tissue planes. But that initial thinking has carried over for some older surgeons who learned lap chole on the fly as attendings. Another reason, I'm embarassed to admit, is one of convenience. Sometimes it's hard to get a lap chole on the schedule at the end of a long day. Or maybe you just don't feel like waiting around until 8 at night to get it done. As opposed to appendicitis, there is a perception that hot gallbladders can be delayed and put off as long as the patient is feeling better with antibiotics. Finally, it's a resource issue. Especially at county or charity hospitals, OR time is limited and it's hard enough to get your appendix and perforated bowel cases on in a timely fashion. My skin starts crawling even now just thinking about the hassle and frustration involved in trying to start an emergency case at Cook County Hospital in Chicago.

Conservative management of acute cholecystitis may initially be successful but it's more expensive and leads to multiple and prolonged hospitalizations. Moreover, when the acute inflammation subsides, the gallbladder and porta hepatis heal by forming scar tissue which can distort normal anatomy and make the surgery much more dangerous. Most surgeons will tell you that some of the most difficult cholecystectomies they have seen are the ones done for patients with a long history of multiple gallbladder attacks.

Acute cholecystitis is one of the more common causes of "acute abdomen". The ideal treatment is surgical. Sometimes it's good to be reminded of that, no matter how obvious it seems.....


Sid Schwab said...

Surgeons in the group other than mine in town always scheduled acute choles in the evening and it always ended up delaying me when I had a more urgent case. It has to be done right away, they'd invariably say. Used to bug me: at that time --lots of years ago -- we had to call in a crew to do after hours surgery, and it was the rare gallbladder that I though justified that. I'd do them next morning, etc., if I could. But then came lap chole and suddenly there were no more unavoidably urgent gallbladders. Moral of the story? No idea.

Anonymous said...

Thanks for the educational post. I read the article, quoted it to my chief, got in an argument with him (he prefers the "wait six weeks" approach), found the attending agreeing with me (at night, on the weekend, to the chief's intense annoyance), and am now going to list your post as one of my sources for the presentation the chief assigned as a form of penance cum revenge (no, maybe I won't). I think the net result is good, but I wanted you to know that your post has had a significant impact at my hospital (although I hope you'll excuse my not mentioning your name).