Current management and controversies in acute cholecystitis: a narrative review of surgical and nonsurgical strategies, with emphasis on suspicion or incidental detection of gallbladder carcinoma

Jorge Eduardo Maldonado Lopez; Gustavo Rodrigo Limachi Miranda; Salvador Omar Ortiz Silva; Yilber Andrés Motta Rojas; Gabriela Gomez Orozco; Joshua Matheus Vivero Barrera; Luis Cail Veliz Briones; Oziel Abner de la Cruz Román

doi:10.18203/2320-6012.ijrms20253645

Authors

Jorge Eduardo Maldonado Lopez Department of Medicine, Universidad de Cuenca, Ecuador
Gustavo Rodrigo Limachi Miranda Department of Oncology Surgery, Hospital Nacional Carlos Alberto Seguin Escobedo, Arequipa, Peru
Salvador Omar Ortiz Silva Department of Surgery, Instituto Mexicano del Seguro Social, Mexico
Yilber Andrés Motta Rojas Department of Medicine, Universidad Nacional de Colombia, Colombia
Gabriela Gomez Orozco Department of Medicine, Pontifica Universidad Javeriana de Cali, Colombia
Joshua Matheus Vivero Barrera Department of Medicine, Ministry of Public Health, Ecuador
Luis Cail Veliz Briones Department of Medicine, Universidad Naval, Mexico
Oziel Abner de la Cruz Román Department of Medicine, Universidad Naval, Mexico

DOI:

https://doi.org/10.18203/2320-6012.ijrms20253645

Keywords:

Acute cholecystitis, Laparoscopic cholecystectomy, Percutaneous cholecystostomy, Incidental gallbladder carcinoma, Re-resection, Oncological survival

Abstract

Acute cholecystitis (AC) is a frequent surgical emergency. Laparoscopic cholecystectomy (LC) remains the standard treatment, though debate continues over surgical timing, the role of percutaneous cholecystostomy (PC), and the management of incidental gallbladder carcinoma (GBC). This review analyzed data from randomized trials, meta-analyses, and large observational studies (1966–2023) on these key issues. Evidence supports early LC (within 24–72 hours) as the optimal approach, consistently reducing hospital stay by about 3–4 days (weighted mean difference: –3.07 to –4.1 days, p<0.00001) without increasing mortality or bile duct injury. Operative time is slightly longer (+9.29 minutes, NS). In high-risk patients (APACHE II ≥7), the CHOCOLATE trial demonstrated LC superiority over PC, with lower complication rates (12% versus 65%, p<0.001), fewer reinterventions, and shorter length of stay (5 vs. 9 days, p<0.001). A meta-analysis of 32 studies found PC followed by delayed LC reduced overall complications (RR 0.28, 95% CI 0.14–0.56) but increased biliary leakage when drainage was delayed. Large databases confirm PC alone yields higher mortality and longer hospitalization than LC. Incidentally detected GBC occurs in 0.25–0.89% of cholecystectomies. Registry data show re-resection significantly improves survival for pT2 (44.1 versus 12.4 months) and pT3 (23.0 versus 9.7 months) disease. Early LC is therefore preferred for most AC patients, while PC serves only as a bridge in unstable cases. For incidental GBC, timely re-resection remains essential for curative outcomes, though standardized timing and patient selection criteria require refinement.

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