Sequential Treatment Opportunities in Acute Cholecystitis, Cholangitis and Cholestatic Jaundice

Background. Obstructive jaundice associated with hepatopancreatobiliary disease is a clinically important condition that may accompany gallstone-related inflammatory complications. Management is challenging because gallstone disease, infection or inflammation, and biliary obstruction may need to be addressed simultaneously. The purpose of the study. To evaluate the outcomes of the sequential approach and describe the management strategy used in patients with gallstone disease complicated by infection and cholestatic jaundice. Methods. This retrospective descriptive study presents the sequential management of 67 adult patients with acute calculous cholecystitis and/or cholangitis associated with cholestatic jaundice, treated at the “St. Archangel Michael” Municipal Clinical Hospital, Chișinău, Republic of Moldova, from 2006 to 2017. The dataset was derived from a doctoral research project; some findings had previously been reported only partially. Treatment strategies were individualized according to the clinical presentation and severity of biliary infection. The research received approval from the hospital Ethics Committee in 2006. Results. The age range of participants was 23 to 82 years with an average age of 63.46 ± 14.22 years, and included 44 (65.7%) women and 23 (34.3%) men. In 16 patients with a simple form of acute cholecystitis and jaundice, caused by choledocholithiasis (3 cases) and stenosis of the sphincter of Oddi (13 cases), the endoscopy-laparoscopy technique was applied together with papillosphincterotomy (PST) within the first 48–72 hours followed by laparoscopic cholecystectomy within 3–4 days after biliary drainage. In acute destructive cholecystitis associated with jaundice, caused by choledocholithiasis – 13 cases, stenosis of the sphincter of Oddi – 6 cases and severe cholangitis – 12 cases, the techniques applied were: 1) Laparoscopy – endoscopy with laparoscopic cholecystectomy with Halsted drainage – 10 patients, with subsequent PST and stone removal when indicated, including during readmission after fistulography, 2) Laparotomy – endoscopy: classical cholecystectomy, choledochotomy with stone removal and Kehr drainage – 21 patients, fistulography on the 5th–7th day postoperatively followed by PST with stone removal in 17 patients. In 7 cases of residual choledocholithiasis associated with severe cholangitis and jaundice, PST with stone extraction was performed, in 3 cases associated with endoscopic nasobiliary drainage, and in 1 case – with placement of an internal biliary stent. In 13 cases of Mirizzi Syndrome, endoscopy-laparotomy techniques were applied, in the 1st stage – endoscopic retrograde cholangiopancreatography (ERCP) with PST – 10 patients, in 3 patients – endoscopic nasobiliary drainage. In the second stage, biliary tract reconstruction interventions were performed depending on the topography of the fistula, assessed during intraoperative cholangiography. Eight complications were reported in the 67-patient cohort, with no deaths. Conclusions. In the studied cohort, the timing and type of intervention were individualized according to the morphological form of the disease and the patient's clinical condition, with biliary decompression prioritized in the first stage of sequential management.