Minireviews
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 18, 2015; 7(23): 2470-2473
Published online Oct 18, 2015. doi: 10.4254/wjh.v7.i23.2470
Training vs practice: A tale of opposition in acute cholecystitis
Purvi P Patel, Shaun C Daly, Jose M Velasco
Purvi P Patel, Shaun C Daly, Jose M Velasco, Department of General Surgery, Rush University Medical Center, Chicago, IL 60612, United States
Author contributions: Patel PP, Daly SC and Velasco JM contributed equally to this work.
Conflict-of-interest statement: The authors disclose no conflict of interests.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jose M Velasco, MD, FACS, FCCM, Department of General Surgery, Rush University Medical Center, 1735 West Harrison Street, Suite 810, Chicago, IL 60612, United States. jose_velasco@rush.edu
Telephone: +1-312-9425000 Fax: +1-312-5632080
Received: April 27, 2015
Peer-review started: May 1, 2015
First decision: July 6, 2015
Revised: September 1, 2015
Accepted: September 7, 2015
Article in press: September 8, 2015
Published online: October 18, 2015
Processing time: 175 Days and 5.7 Hours
Abstract

Acute cholecystitis is one of the most common surgical diagnoses encountered by general surgeons. Despite its high incidence there remains a range of treatment of approaches. Current practices in biliary surgery vary as to timing, intraoperative utilization of biliary imaging, and management of bile duct stones despite growing evidence in the literature defining best practice. Management of patients with acute cholecystitis with early laparoscopic cholecystectomy (LC) results in better patient outcomes when compared with delayed surgical management techniques including antibiotic therapy or percutaneous cholecystostomy. Regardless of this data, many surgeons still prefer to utilize antibiotic therapy and complete an interval LC to manage acute cholecystitis. The use of intraoperative biliary imaging by cholangiogram or laparoscopic ultrasound has been demonstrated to facilitate the safe completion of cholecystectomy, minimizing the risk for inadvertent injury to surrounding structures, and lowering conversion rates, however it is rarely utilized. Choledocholithiasis used to be a diagnosis managed exclusively by surgeons but current practice favors referral to gastroenterologists for performance of preoperative endoscopic removal. Yet, there is evidence that intraoperative laparoscopic stone extraction is safe, feasible and may have added advantages. This review aims to highlight the differences between existing management of acute cholecystitis and evidence supported in the literature regarding best practice with the goal to change surgical practice to adopt these current recommendations.

Keywords: Cholangiography; Acute cholecystitis; Ultrasound; Laparoscopy; Cholecystectomy; Evidence based

Core tip: General surgeons commonly perform laparoscopic cholecystectomy for acute cholecystitis; however, current practices in biliary surgery often vary regarding timing, intraoperative biliary imaging, and management of bile duct stones. In spite of growing evidence in the literature defining best practice and societal guidelines supporting early cholecystectomy, intraoperative cholangiogram and ultrasound, and laparoscopic bile duct exploration utilizing laparoscopic ultrasound and performing common bile duct exploration, an overwhelming number of surgeons still perform delayed operations, rarely perform intraoperative imaging and defer treatment of common bile duct stones. Efforts should be made to adopt the evidence-based data supported in the literature.