Abstract
BackgroundAcute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.Materials and methodsThe WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.ResultsThe pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.Conclusions, knowledge gaps and research recommendationsELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.
Highlights
Acute calculus cholecystitis (ACC) has a high incidence in the general population
Which is the most reliable approach for the diagnosis of ACC? Which initial imaging technique should be used in case of a suspected diagnosis of ACC? Which is the role of other imaging techniques (e.g. Hepatobiliary iminodiacetic acid—HIDA scan, abdominal computed tomography—CT scan and magnetic resonance) in the diagnosis of ACC?
Are elevated liver function tests (LFTs) or bilirubin sufficient for the diagnosis of common bile duct stones (CBDS) in patients with ACC? Which imaging features are predictive of CBDS in patients with ACC? Which tests should be performed to assess the risk of CBDS in patients with ACC? Which is the best tool to stratify the risk for CBDS in patients with ACC? Which actions are warranted in patients with ACC and at moderate for CBDS? Which actions are warranted in patients with ACC and at high risk for CBDS? Which is the appropriate treatment of CBDS in patients with ACC?
Summary
In 2018, the Scientific Board of the 6thWorld Congress of the WSES endorsed its president to organize a CC on ACC in order to update the previous WSES Guidelines. Relevant key questions regarding the diagnosis and treatment of ACC were developed and divided into seven sections, in order to analyse the topic and update the guidelines with the currently available evidence. The recommendations of the 2016 WSES guidelines were mainly based on two studies: a systematic review and meta-analysis by Trowbridge et al [12] and a prospective diagnostic study by Eskelinen et al [13] This evidence, flawed by the limitations described below, remains relevant and the associated statement remains valid. The paper by Trowbridge et al [12] included 17 studies, which reported a quantitative assessment of history, physical examination and/or laboratory tests for the diagnosis of acute cholecystitis. Accuracy of the TG13 criteria was low at 60.3%
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