Although laparoscopic cholecystectomy is unusually safe and well tolerated in patients with routine symptomatic cholelithiasis, it can become a formidable procedure when used to manage biliary tract emergencies. Optimally, a reasoned and cautious approach and a low threshold for conversion can avoid major complications. One such emergency, acute cholecystitis, may be particularly hazardous because of the relatively common finding of severe inflammation with dense adhesions to adjacent viscera and gallbladder necrosis. Special modifications of technique may be required. Overall, urgent operation (within 72 hours) results in an acceptably low mortality (0.3%) but a somewhat higher conversion rate (16%) and longer hospital stay (3 days). Unnecessary delays may result in more adhesions and an increased level of operative difficulty. In patients who are at an especially high risk because of co-morbid disease, percutaneous cholecystostomy is an appropriate alternative strategy. Biliary pancreatitis may be associated with high mortality (9%) and has an unpredictable course. Accordingly, a multidisciplinary approach that may include both gastroenterologists and radiologists is generally advisable. Because common bile duct (CBD) stones are present in more than 20% of patients who present with biliary pancreatitis, endoscopic retrograde cholangiopancreatography (ERCP) can be used effectively on a selective basis during the preoperative or postoperative period; the preferred timing continues to be somewhat controversial. As an alternative approach, laparoscopic CBD exploration is gradually gaining wider acceptance. In eight reported series using a variety of techniques for stone extraction, major complications were infrequent (10%), and the conversion rate was low (5%). Acute suppurative cholangitis is a more fulminant problem that is best managed by expeditious ERCP with removal of all intraductal stones. Resuscitation should be continued until complete; laparoscopic cholecystectomy can follow at an appropriate interval.
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