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      2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

      1 , , 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 2 , 9 , 10 , 11 , 1 , 12 , 1 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 1 , 20 , 21 , 22 , 23 , 4 , 24 , 25 , 26 , 27 , 28 , 13
      World Journal of Emergency Surgery : WJES
      BioMed Central
      Acute cholecystitis, Early and delayed cholecystectomy, Surgery, Antibiotics, Gallbladder Drainage, High-risk patients, Guidelines

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          Acute 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 methods

          The 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.


          The 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 recommendations

          ELC 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.

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          Most cited references183

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          The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).

          Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination.
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            Complications of endoscopic biliary sphincterotomy.

            Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.
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              Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).

              The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

                Author and article information

                World J Emerg Surg
                World J Emerg Surg
                World Journal of Emergency Surgery : WJES
                BioMed Central (London )
                5 November 2020
                5 November 2020
                : 15
                : 61
                [1 ]GRID grid.460094.f, ISNI 0000 0004 1757 8431, General Surgery I, ASST Papa Giovanni XXIII Hospital, ; Bergamo, Italy
                [2 ]GRID grid.83440.3b, ISNI 0000000121901201, Division of Surgery and Interventional Science, , University College London, ; London, UK
                [3 ]GRID grid.5611.3, ISNI 0000 0004 1763 1124, Department of Surgery, , University of Verona, ; Verona, Italy
                [4 ]General Surgery Trauma Team ASST-GOM Niguarda, Milan, Italy
                [5 ]GRID grid.415960.f, ISNI 0000 0004 0622 1269, Department of Surgery, , St. Antonius Ziekenhuis, ; Nieuwegein, Netherlands
                [6 ]GRID grid.144189.1, ISNI 0000 0004 1756 8209, General Emergency and Trauma Surgery, , Pisa University Hospital, ; Pisa, Italy
                [7 ]GRID grid.426108.9, ISNI 0000 0004 0417 012X, HPB and Liver Transplant Surgery, , Royal Free Hospital, ; London, UK
                [8 ]GRID grid.411251.2, ISNI 0000 0004 1767 647X, HPB Surgeon Hospital Universitario La Princesa, ; Madrid, Spain
                [9 ]GRID grid.8042.e, ISNI 0000 0001 2188 0260, Surgical Department, , University of Macerata, ; Macerata, Italy
                [10 ]GRID grid.7563.7, ISNI 0000 0001 2174 1754, Department of General and Emergency Surgery, , University of Milano-Bicocca, ; Milan, Italy
                [11 ]GRID grid.34477.33, ISNI 0000000122986657, Department of Surgery, Harborview Medical Centre, , University of Washington, ; Seattle, USA
                [12 ]GRID grid.412116.1, ISNI 0000 0001 2292 1474, Unit of Digestive and HPB Surgery, CARE Department, , Henri Mondor Hospital and University Paris-Est, ; Creteil, France
                [13 ]GRID grid.414682.d, ISNI 0000 0004 1758 8744, General and Emergency Surgery, , Bufalini Hospital, ; Cesena, Italy
                [14 ]Emergency Room Brescia Spedali Civili General Hospital, Brescia, Italy
                [15 ]GRID grid.488519.9, ISNI 0000 0004 5946 0028, Comparative Effectiveness and Clinical Outcomes Research Center-CECORC, , Riverside University Health System Medical Center, ; Moreno Valley, CA USA
                [16 ]GRID grid.18147.3b, ISNI 0000000121724807, Department of Surgery and Medicine, , Insubria University, ; Varese, Italy
                [17 ]Department of General Surgery, Azienda USL-IRCSS di Reggio Emilia, Guastalla Hospital, Guastalla, Italy
                [18 ]GRID grid.1012.2, ISNI 0000 0004 1936 7910, Department of General Surgery Royal Perth Hospital, , The University of Western Australia, ; Perth, Australia
                [19 ]Research Institute at Medical University Plovdiv/University Hospital St George, Plovdiv, Bulgaria
                [20 ]GRID grid.414959.4, ISNI 0000 0004 0469 2139, General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, , Foothills Medical Centre, ; Calgary, AB Canada
                [21 ]GRID grid.411087.b, ISNI 0000 0001 0723 2494, Division of Trauma Surgery, School of Medical Sciences, , University of Campinas, ; Campinas, SP Brazil
                [22 ]GRID grid.414739.c, ISNI 0000 0001 0174 2901, Department of Surgery, , Sheri-Kashmir Institute of Medical Sciences, ; Srinagar, India
                [23 ]GRID grid.415402.6, ISNI 0000 0004 0449 3295, Scripps Memorial Hospital La Jolla, ; La Jolla, CA USA
                [24 ]GRID grid.43519.3a, ISNI 0000 0001 2193 6666, Department of Surgery, College of Medicine, , UAE University, ; Al Ain, UAE
                [25 ]GRID grid.239638.5, ISNI 0000 0001 0369 638X, Ernest E Moore Shock Trauma Center at Denver Health, ; Denver, CO USA
                [26 ]GRID grid.15485.3d, ISNI 0000 0000 9950 5666, Abdominal Center Helsinki University Hospital, ; Helsinki, Finland
                [27 ]Department of General Surgery, the Rambam Academic Hospital, Haifa, Israel
                [28 ]GRID grid.10383.39, ISNI 0000 0004 1758 0937, Emergency Surgery, , University Parma Hospital, ; Parma, Italy
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                : 10 July 2020
                : 17 September 2020
                Funded by: the manuscript was invited by the EiC/Editor and the EiC has agree to waive the APC ( contractual waiver)
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                acute cholecystitis,early and delayed cholecystectomy,surgery,antibiotics,gallbladder drainage,high-risk patients,guidelines


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