1. LAPAROSCOPY AND MINIMALLY INVASIVE SURGERY IN PALESTINE First International Congress FERDINANDO AGRESTA, MD DEPT OF GENERAL SURGERY ULSS19 DEL VENETO – ADRIA (RO) ITALY ACUTE CHOLECYSTITIS

2. LAPAROSCOPY AND MINIMALLY INVASIVE SURGERY IN PALESTINE First International Congress ACUTE CHOLECYSTITIS FERDINANDO AGRESTA, MD DEPT OF GENERAL SURGERY ULSS19 DEL VENETO – ADRIA (RO) ITALY

3. …The development of new instruments and the refinement of established techniques will lead to the expansion of minimally invasive surgery to new areas of interest for general surgeons. However, one must realize – and accept, that minimally invasive surgery only represents a different technique that offers an alternative to open surgery. The indication for surgery are similar for both minimally invasive surgery and open surgery…It is important for all general surgeons to keep up with this trend and become an integral part of the revolution in medicine that the advent of minimally surgery has wrought … H.S. Himal: Minimally invasive (laparoscopic) surgery. The future of general surgery. Surg Endosc 2002; 16: 1647-52

4. “…As doctor and surgeons our mission is to treat patients to the best of our knowledge and expertise. The exponential knowledge eruption and the nearly daily skill-related technology advances in minimal invasive surgery make it more than ever mandatory that we, surgeons and doctors, humbly examine, analyze and objectively audit our own practice…we have to recognise and discard our acquired biases, and base our diagnostic procedures and surgical therapy on “hard” evidence…” Fingerhut A. Do we need consensus conferences? Surg Endosc 2002; 16:1149-1450

5. …a need to discuss a share experience, using the same language...

11. ACUTE CHOLECYSTITIS Patients with acute cholecystitis should be treated by laparoscopic cholecystectomy (GoR A). Severe (gangrenous, empyematous) cholecystitis and advanced age do not preclude the indication for laparoscopic cholecystectomy (GoR B). Surgery should be performed as soon as possible after the onset of symptoms (GoR A). Early laparoscopic surgery should be offered also to elderly patients (GoR B). In patients with severe co- morbidities, conservative treatment or percutaneous cholecystostomy, followed or not by early or delayed surgery, may be alternatives in order to reduce surgical or anesthesiological risk (GoR C).

12. ACUTE CHOLECYSTITIS- OPEN VS LAP Patients with acute cholecystitis should be treated by laparoscopic cholecystectomy (GoR A). Severe (gangrenous, empyematous) cholecystitis and advanced age do not preclude the indication for laparoscopic cholecystectomy (GoR B). 1 Csikesz N, Ricciardi R, Tseng JF, Shah SA (2008) Current status of surgical management of acute cholecystitis in the United States. World J Surg 32(10):2230-6 2 Borzellino G, et al. (2008) Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results. Surg Endosc 22(1):8-15. +1 population-based outcome research study (EL2C) 1 + 1 meta-analysis of prospective and retrospective series (EL2a) on severe cholecystitis 2 + 4 comparative studies (EL2b) in elderly patients show reduced hospital stay and morbidity either unchanged or improved

13. ACUTE CHOLECYSTITIS - TIMING (EAES 2005) Surgery should be carried out as early as possible after admission (GoR A). 5 RCT (Early vs delayed) -No differences in conversion, morbidity, bile duct lesion -Shorter total hospital stay in the early group -Failure of conservative treatment in the delayed group 15,7 to 31,8% 1 Metanalysis -Papi 03 -Lo 98 -Lai 98 -Chandler 00 -Johansson 03 -Kolla04 Different timing criteria but homogeneous results: 6 Prospective* Delayed surgery is associated with increased intra-operative difficulties and conversions. *Kullman 97, Willsher 99, Eldar 99, Pesseaux 00, Suter 01, Sinha 02

14. ACUTE CHOLECYSTITIS - TIMING (OUR UPDATE) Surgery should be performed as soon as possible after the onset of symptoms (GoR A). Early laparoscopic surgery should be offered also to elderly patients (GoR B). 1 Sánchez Beorlegui J, et al. (2009) Treatment of acute cholecystitis in the elderly: urgent surgery versus medical therapy and surgery delay. Rev Gastroenterol Peru. 29(4):332-40 2 Riall TS et al. (2010) Failure to perform cholecystectomy for acute cholecystitis in elderly patients is associated with increased morbidity, mortality, and cost. J Am Coll Surg. 210(5):668-77, 677-9 5 + 2 RCT (Early vs delayed) 1 + 4 Metanalysis -Shikata 2005-Siddiqui 2008 - Lau 2006-Gurusamy 2006,2008 -Davila 1999 -Yadav 2009 (Early vs delayed in elderly) 1 comparative 1 1 outcome study 2 no difference38% vs 4.4% readmission rate

15. ACUTE CHOLECYSTITIS In patients with severe co-morbidities, conservative treatment or percutaneous cholecystostomy, followed or not by early or delayed surgery, may be alternatives in order to reduce surgical or anesthesiological risk (GoR C) 1 Winbladh et al. (2009) Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford). 11(3):183-93 1 systematic review (EL2a) 1 (53 papers about cholecystostomy) - low quality of the studies in the literature -no evidence to support the recommendation of percutaneous drainage in critically ill -cholecystostomy has higher mortality than early laparoscopic cholecystectomy (15,4% vs 4.5%)

16. The literature: severe cardiovascular disease Severe cardiovascular disease should non constitute an absolute contraindication to laparoscopic cholecystectomy Liu YY et al. World J Surg 2009 Popken CA et al. Am J Surg 1995

17. CLINICAL RECOMMANDATIONS the Health Technology Assessment Programme Manual (2001) “systemically developed statements to assist both the practioner and patient decisions in specific circumstances…Guidelines are viewed as useful tools for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence support…” SIGN and SNLG manuals :…clinical guidelines do not rob clinicians of their freedom, nor relieve them of their responsibility to make appropriate decisions based on their own experience and according to the particular circumstances of each patient. It is stressed that the standard of care required by Law derives from customary and accepted practice rather than from the imposition of practices through clinical guidelines…Guidelines are indended as an aid to clinical judgment not to replace it…”

18. "Science is built up of numbers, as a house is built of stones; but an accumulation of numbers is no more a science than a heap of stones is a house" [Henri Poincaré Science and Hypothesis] “EBM demands that the right patient should receive the right operation done by the right surgeon in the right clinic" [S. Sauerland Evidence-bases surgery in laparoscopic day surgery: the European perspective ]...contextualization....

20. The literature: severe cholecystitis A recent review of prospective and retrospective series (EL2a) did not show an increase in local postoperative complications and confirmed that laparoscopic cholecystectomy is to be considered an acceptable indication for severe cholecystitis despite a demonstrated threefold conversion rate. Borzellino G et al. Surg Endosc 2008

21. The panel agreed that the use of laparoscopy in an emergency setting requires surgical experience and skills, however in the literature there is no complete and objective definition of “experienced” and “skilled” and several factors limit our ability to reach such definitions. On the other hand there was a general agreement that experience gained in one specific procedure reduces the learning curve for other procedures because the judgement, ability, and the skills developed can be used in a large number of situations. A specific “learning curve” for every single situation is impossible to define, in particular, in an emergency laparoscopic setting, where the operative condition may be worsened by reduction of the surgical field (intestinal distension, adhesions), unclear anatomy due to the inflammatory status, and a wide variety of possible therapeutic findings.

22. Every surgeon has to decide the best approach according to a personal evaluation of his own experience, the particular clinical situation, his proficiency (and the experience of his team) with the various techniques and the specific organizational setting in which he is working. A low threshold for conversion carries only minor disadvantages for the patient, and such a good judgment can obviate the need for a questionable strict definition of “expert laparoscopic emergency surgeon”.

23. A semi serious history of laparoscopy by Nicola Basso Gangemi Edt, 2003

24. …These guidelines have been developed to help surgeons with their decisions in the very difficult situation of emergency surgery... …ON THE BEHALF OF ALL THE SOCIETIES AND MEMBERS OF THE CONSENSUS COMMITTEE… THANKS!