Predictors of failure of conservative management of cholecystitis: a systematic review of the literature.

Objectives: While emergency cholecystectomy is the preferred treatment for acute cholecystitis, conservative management can be used as a bridge to definitive surgical management in situations where emergency surgical services are limited. The objective of this systematic review is to identify factors associated with conservative management failure as defined as either failed resolution of symptoms on initial presentation, or the recurrence of symptoms whilst awaiting an elective cholecystectomy. This study aims to allow clinicians to make evidence-based recommendations for conservative versus operative management.

Methods: A systematic review of the Medline database was conducted in May 2022 to identify studies analysing the success of non-operative management of acute cholecystitis. Two independent reviewers selected studies based on predefined criteria, and the risk of bias was evaluated. Out of the initial 1344 studies retrieved, 12 studies met the inclusion criteria.

Results: Factors significantly associated with persistence of symptoms in at least one study on multivariable analysis included diabetes mellitus, age >70, tachycardia, elevated temperature, elevated white cell count >15 000/uL and a distended gallbladder >5 cm. Factors significantly associated with recurrence of symptoms included Age <40 or >80, male sex, acute cholecystitis grade 2 or 3, elevated creatinine, serum albumin <4 g/dL, thickened gallbladder wall >5 mm.

Conclusion: Several factors have been identified which may facilitate future evidence-based recommendations for tailored management strategies for patients with acute cholecystitis.