1. WSES GUIDELINES on ACUTE CALCULOUS CHOLECYSTITIS
Dr. Luca Ansaloni
Head, General and Emergency Surgery ,
M. Bufalini Hospital, Cesena
AUSL Romagna, Italy
, Mozyr, Belarus

2. WSES GL on ACC
2016

3. WSES GL on ACC EPIDEMIOLOGY: very common disease
Gallstones: prevalence of 15-20% in western population
1-4%/year symptomatic
20% of them develop ACC
95% of ACUTE CHOLECYTITIS are related to gallstones
Duncan, J Gastrointest Surg 2012
Strasberg, N Engl J Med 2008
Friedman, J Clin Epidemiol 1989

4. Tokyo Guidelines 2007, 2013 and 2018 Why a CC on ACC?
But first guidelines on ACC…
Tokyo Guidelines 2007, 2013 and 2018

5. Why a CC on ACC? TG: Controversial issues…
It is a current matter of discussion
Maybe Tokyo Guidelines 2007
improved the interest ?
TG: Controversial issues…
Severity of ACC or Severity of patient condition?
No clear support to early Laparoscopic cholecystectomy
No assessment of suspected CBD stones

6. Why a CC on ACC?
Tokyo Guidelines’s proposal, despite evidences, show the great uncertainty of the surgeons ?

7. 2014: preparation july 2015: CC in Jerusalem 2016: publication
Timeline…
2014: preparation
july 2015: CC in Jerusalem
2016: publication

8. Key questions for CC on ACC
Key questions and key words used to develop the Consensus Conference on Acute Calculous Cholecystitis (ACC)
Key Questions
Key words
1) DIAGNOSIS OF ACC: INVESTIGATIONS.
Acute calculous cholecystitis Diagnosis, Ultrasound, Gallstones disease diagnosis.
2) TREATMENT OF ACC: BEST OPTIONS.
Gallstones Dissolution, No-surgery gallstones, Extra- corporeal shock wave lithotripsy, Acute calculous cholecystitis, Gallstone disease, Management Gallstones, Endoscopy, Gallstone removal, Observation gallstones.
3) ANTIBIOTIC THERAPY FOR ACC.
Antibiotics ,Acute calculous cholecystitis, Gallstone disease, Management Gallstones.
4) PATIENT SELECTION FOR SURGERY: RISK STRATIFICATION I.E. DEFINITION OF HIGH RISK PATIENTS
Acute calculous cholecystitis, Gallstone disease, Surgical risk score, High risk patient, old patient, PPossum score, Apache score
5) TIMING FOR SURGERY FOR ACC
Acute calculous cholecystitis, acute cholecystitis
6) TYPE OF SURGERY FOR ACC
Acute calculous cholecystitis, Surgery, Laparoscopy, Laparotomy, Cholecystectomy, Partial cholecystectomy, Subtotal cholecystectomy, Cirrhosis, Pregnancy
7) ASSOCIATED COMMON BILE DUCT STONE: SUSPICION AND DIAGNOSIS AT THE PRESENTATION
common bile duct stone; choledocholthiasis; endoscopic ultrasound, MRCP, ERCP,
8) ALTERNATIVE TREATMENTS FOR HIGH RISK PATIENTS
Acute calculous cholecystitis, Surgery, Gallbladder Drainage, Percutaneous gallbladder drainage, Cholecystostomy, High Risk Patient

9. Oxford 2011 LoE Level Therapy / Prevention, Aetiology / Harm Prognosis
Diagnosis
Differential diagnosis / symptom prevalence study
Economic and decision analyses 1a
SR (with homogeneity*) of RCTs
SR (with homogeneity*) of inception cohort studies; CDR”  validated in different populations
SR (with homogeneity*) of Level 1 diagnostic studies; CDR”  with 1b studies from different clinical centres
SR (with homogeneity*) of prospective cohort studies
SR (with homogeneity*) of Level 1 economic studies 1b
Individual RCT (with narrow Confidence Interval”¡)
Individual inception cohort study with > 80% follow-up; CDR”  validated in a single population
Validating** cohort study with good” ” ”  reference standards; or CDR”  tested within one clinical centre
Prospective cohort study with good follow-up****
Analysis based on clinically sensible costs or alternatives; systematic review(s) of the evidence; and including multi-way sensitivity analyses 1c
All or none§
All or none case-series
Absolute SpPins and SnNouts” “
Absolute better-value or worse-value analyses ” ” ” “ 2a
SR (with homogeneity*) of cohort studies
SR (with homogeneity*) of either retrospective cohort studies or untreated control groups in RCTs
SR (with homogeneity*) of Level >2 diagnostic studies
SR (with homogeneity*) of 2b and better studies
SR (with homogeneity*) of Level >2 economic studies 2b
Individual cohort study (including low quality RCT; e.g., <80% follow-up)
Retrospective cohort study or follow-up of untreated control patients in an RCT; Derivation of CDR”  or validated on split-sample§§§ only
Exploratory** cohort study with good” ” ”  reference standards; CDR”  after derivation, or validated only on split-sample§§§ or databases
Retrospective cohort study, or poor follow-up
Analysis based on clinically sensible costs or alternatives; limited review(s) of the evidence, or single studies; and including multi-way sensitivity analyses 2c
“Outcomes” Research; Ecological studies
“Outcomes” Research
Ecological studies
Audit or outcomes research 3a
SR (with homogeneity*) of case-control studies
SR (with homogeneity*) of 3b and better studies 3b
Individual Case-Control Study
Non-consecutive study; or without consistently applied reference standards
Non-consecutive cohort study, or very limited population
Analysis based on limited alternatives or costs, poor quality estimates of data, but including sensitivity analyses incorporating clinically sensible variations. 4
Case-series (and poor quality cohort and case-control studies§§)
Case-series (and poor quality prognostic cohort studies***)
Case-control study, poor or non-independent reference standard
Case-series or superseded reference standards
Analysis with no sensitivity analysis 5
Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles”
Expert opinion without explicit critical appraisal, or based on economic theory or “first principles”

10. Oxford 2011 GoR A consistent level 1 studies B
consistent level 2 or 3 studies or extrapolations from level 1 studies C
level 4 studies or extrapolations from level 2 or 3 studies D
level 5 evidence or troublingly inconsistent or inconclusive studies of any level

11. 1. Diagnosis topic # LoE GoR Diagnosis 1.1 4 C
Diagnosis
1.1 4 C
There is no single clinical or laboratory finding with sufficient diagnostic accuracy to establish or exclude acute cholecystitis. Combination of detailed history, complete clinical examination, and laboratory tests may strongly support the diagnosis of ACC
1.2 2 B
Abdominal ultrasound (AUS) is the preferred initial imaging technique for patients who are clinically suspected to have ACC because of its lower cost, better availability, lack of invasiveness, and high accuracy for gallbladder stones.
1.3 3
AUS exploration is a fairly reliable investigation method but its sensitivity and specificity for diagnosing ACC is relatively low according to the adopted AUS criteria.
1.4
Evidence on the diagnostic accuracy of computed tomogram (CT) is scarce. While diagnostic accuracy of magnetic resonance imaging (MRI) might be comparable to that of AUS, insufficient data are available to support this. Hepatobiliary iminodiacetic acid scan (HIDA scan) has the highest sensitivity and specificity for AC, although its scarce availability, long time required to perform the test, and exposure to ionizing radiation limit its use.
1.5
Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known.

12. 2. Treatment
Treatment
2.1 2 B
There is no role for gallstones dissolution, drugs or extra-corporeal shock wave lithotripsy (ESWL) or a combination in the setting of ACC.
2.2 4 C
Since there are no reports on surgical gallstone removal in the setting of ACC, surgery in the form of cholecystectomy remains the main option
2.3 3
Surgery is superior to observation of ACC in the clinical outcome and shows some cost-effectiveness advantages due to the gallstone-related complications and to the high rate of readmission and surgery in the observation group
2.4
Antibiotics should be suggested as supportive care; they are effective in treating the first episode of ACC but a high rate of relapse can be expected. Surgery is more effective than antibiotics alone in the treatment of ACC.
2.5
Cholecystectomy is the gold standard for treatment of ACC.
2.6 5 D
If surgery is not available, medications such as antibiotics and analgesic should be prescribed and the patients should be referred to a surgical center (depending upon the general condition) due to the high rate of gallstone-related events.

13. 3. Antibiotics Antibiotics 3.1 1 B
Patients with uncomplicated cholecystitis can be treated without post-operative antibiotics when the focus of infection is controlled by cholecystectomy
3.2 3
In complicated cholecystitis, the antimicrobial regimens depend on presumed pathogens involved and risk factors for major resistance patterns
3.3 C
The results of microbiological analysis are helpful in designing targeted therapeutic strategies for individual patients to customize antibiotic treatment and ensure adequate antimicrobial coverage in patients with complicated cholecystitis and at high risk for antimicrobial resistance.

14. 3. Antibiotics
Antibiotics commonly used to treat biliary tract infections and their biliary penetration ability
Good penetration efficiency
(ABSCR >=1)
Low penetration efficiency
(ABSCR <1)
Piperacillin/tazobactam(4.8)
Tigecycline (> 10)
Amoxicillin/clavulanate (1.1)
Ciprofloxacin (> 5)
Ampicillin/Sulbactam (2.4)
Cefepime (2.04)
Levofloxacin (1.6)
Penicillin “G” (>5)
Imipenem (1.01)
Ceftriaxone(0.75)
Cefotaxime (0.23)
Meropenem (0.38)
Ceftazidime (0.18)
Vancomycin (0.41)
Amikacin (0.54)
Gentamicin (0.30)
ABSCR = Antibiotics Bile/Serum Concentration Ratio

15. 3. Antibiotics
Antimicrobial regimens suggested for acute calculous cholecystitis
Community acquired
Health-care associated
1) Beta-lactam/beta-lactamase inhibitor combinations based regimens
AMOXICILLIN/CLAVULANATE (in stable patients)
TICARCILLIN/CLAVULANATE (in stable patients)
PIPERACILLIN/TAZOBACTAM (in unstable patients)
2) Cephalosporins based regimens
CEFTRIAZONE + METRANIDAZOLE (in stable patients)
CEFEPIME + METRANIDAZOLE (in stable patients)
CEFTAZIDIME + METRANIDAZOLE (in stable patients)
CEFOZOPRAM + METRANIDAZOLE (in stable patients)
3) Carbapenem based regimens
ERTAPENEM (in stable patients)
IMIPENEM/CILASTATIN (only in unstable patients)
MEROPENEM (only in unstable patients)
DORIPENEM (only in unstable patients)
4) Fluoroquinolone based regimens (In case of allergy to beta-lactams)
CIPROFLOXACIN + METRONIDAZOLE (only in stable patients)
LEVOFLOXACIN + METRONIDAZOLE (only in stable patients)
MOXIFLOXACIN (only in stable patients)
5) Glycylcycline based regimen
TIGECYCLINE (in stable patients if risk factors for ESBLs)
TIGECYCLINE + PIPERACILLIN/TAZOBACTAM (in stable patients)
IMIPENEM/CILASTATIN +/- TEICOPLANIN (only in unstable patients)
MEROPENEM +/- TEICOPLANIN (only in unstable patients)
DORIPENEM +/- TEICOPLANIN (only in unstable patients)

16. 4. High risk patients high risk patients 4.1 3 B
Patient’s age above 80 in ACC is a risk factor for worse clinical behaviour, morbidity and mortality.
4.2 C
The co-existence of diabetes mellitus does not contraindicate urgent surgery but must be re-considered as a part of the overall patient comorbidity.
4.3 4
Currently, there is no evidence of any scores in identifying patient’s risk in surgery for ACC. ASA, POSSUM and APACHE II are correlated to surgical risk in patients with gallbladder perforation, higher accuracy being for APACHE II. However, APACHE II is built to predict morbidity and mortality in the patients admitted to ICU: its use as a preoperative score should be considered as an extension usage from the original concept. Therefore, prospective and multicentre studies to compare different risk factors and scores are necessary

17. 5. Timing
timing
5.1 1 A
ELC is preferable to DLC in patients with ACC as long as it is completed within 10 days of onset of symptoms.
5.2 2 B
ELC should not be offered for patients beyond 10 days from the onset of symptoms unless symptoms suggestive of worsening peritonitis or sepsis warrant an emergency surgical intervention. In people with more than 10 days of symptoms, delaying cholecystectomy for 45 days is better than immediate surgery.
5.3
ELC should be performed as soon as possible but can be performed up to 10 days of onset of symptoms. However, it should be noted that earlier surgery is associated with shorter hospital stay and fewer complications.

18. 6. Type of surgery type of surgery 6.1 2 B
In ACC, a laparoscopic approach should initially be attempted except in case of absolute anaesthesiology contraindications or septic shock.
6.2 1 A
LC for ACC is safe, feasible, with a low complication rate and associated with shortened hospital stay.
6.3 3 C
Among high-risk patients, in those with Child A and B cirrhosis, advanced age >80, or pregnant women, laparoscopic cholecystectomy for ACC is feasible and safe.
6.4
Laparoscopic or open subtotal cholecystectomy is a valid option for advanced inflammation, gangrenous gallbladder, or any setting of the “difficult gallbladder” where anatomy is difficult to recognize and main bile duct injuries are more likely.
6.5
In case of local severe inflammation, adhesions, bleeding in Calot’s triangle or suspected bile duct injury, conversion to open surgery should be strongly considered.

19. associated common bile duct stones
7. Associated CBD stones
associated common bile duct stones
7.1 2 B
Elevation of liver biochemical enzymes and/or bilirubin levels are not sufficient to identify ACC patients with choledocholithiasis and further diagnostic tests are needed.
7.2 1 A
At AUS, the visualization of CBDS is a very strong predictor of choledocholithiasis. Indirect signs of stone presence such as increased diameter of CBD are not sufficient to identify ACC patients with choledocholithiasis and further diagnostic tests are needed.
7.3
Liver biochemical tests, including ALT, AST bilirubin, ALP, gamma glutamyl transferase (GGT), AUS should be performed in all patients with ACC to assess the risk for CBDS.
7.4 5 D
CBD stone risk should be stratified according to the proposed classification, modified from the American Society of Gastrointestinal Endoscopy and the Society American of Gastrointestinal Endoscopic Surgeon Guidelines.
7.5
Patients with moderate risk for choledocholithiasis should undergo preoperative MRCP, EUS, intraoperative cholangiography (IOC), or LUS depending on the local expertise and availability.
7.6
with high risk for choledocholithiasis should undergo preoperative ERCP, IOC, LUS, depending on the local expertise and the availability of the technique.
7.7
CBDS could be removed preoperatively, intraoperatively, or postoperatively according to the local expertise and the availability of the technique.

20. SAGES 7. Associated CBD stones
Predictive Factor for choledocholitiasis
Evidence of CBD stone at abdominal US
VERY STRONG
Ascending cholangitis
Total Serum Bilirubin > 4 mg/dL
STRONG
Common Bile duct diameter > 6mm (with gallbladder in situ)
Bilirubin level 1,8-4 mg/dL
Abnormal liver biochemical test other than bilirubin
MODERATE
Age older than 55 y
Clinical gallstone pancreatitis
SAGES
Risk class for choledocolithiasis
HIGH
Presence of any VERY STRONG or
Presence of both STRONG predictors
LOW
No predictors present
INTERMEDIATE
All other patients

21. 7. Associated CBD stones
SAGES

22. 8. Alternative treatments alternative treatments
8.1 4 B 
Gallbladder drainage, together with antibiotics, converts a septic cholecystitis into a non-septic condition; however the level of evidence is poor.
8.2 C
Among standardized gallbladder drainage techniques percutaneous transhepatic gallbladder drainage (PTGBD) is generally recognized as the preferred technique due to the ease and the reduced costs.
8.3 2 B
PC could be considered as a possible alternative to surgery after the failure of conservative treatment in a small subset of patients unfit for emergency surgery due to their severe co-morbidities.
8.4 5 D
DLC could be offered to patients after reduction of operative and anesthesiology- related risks to reduce further hospitalization.

23. ACC treatment comprehensive algorithm
ACC: acute calculous cholecystitis;
CBD: common bile duct;
DLC: delayed laparoscopic cholecystectomy;
ELC: early laparoscopic cholecystectomy;
ERCP endoscopic retrograde cholangiopancreateography; EUS: endoscopic ultrasound; IOC: intraoperative cholangiography;
LUS: laparoscopic ultrasound; MRCP magnetic resonance cholangiopancreatography.

24. THM Take home messages Diagnosis: AUS + lab test Treatment: surgery
Antibiotic: the right for the right pt (resistence!!!)
High risk patients: select the right pt for surgery
Timing: early ASAP (10 days from symptoms’ onset)
CBD stone: assesment and removal
Alternative: percutaneus cholecystostomy

25. thank you for the attention!
             

26. thank you for the attention!
             

27. EVIDENCES AND GUIDELINES
ACUTE CHOLECYSTITIS -
EVIDENCES AND GUIDELINES
Luca Ansaloni
Papa Giovanni XXIII Hospital – Bergamo, Italy
World Society of Emergency Surgery

28. EPIDEMIOLOGY Gallstones: prevalence of 15-20% in western population
1-4%/year symptomatic
20% of them develop Acute cholecystitis
95% of ACUTE CHOLECYTITIS are related to Gallstones
Duncan, J Gastrointest Surg 2012
Strasberg, N Engl J Med 2008
Friedman, J Clin Epidemiol 1989

29. ? What is acute cholecystitis But… From TG13:
“Acute inflammatory disease of the gallbladder, often attributable to gallstones, but many factors, such as ischemia, motility disorders, direct chemical injury, infections by microorganism, protozoon and parasites, collagen disease, and allergic reaction are also involved.”

30. DIAGNOSIS TOKYO GUDELINES 2013 – diagnostic criteria
No shared diagnostic criteria until 2007
Great variability and difficulty to standardize patients
TOKYO GUDELINES 2013 – diagnostic criteria
Local signs of inflammation (murphy’s sign, RUQ pain)
Sistemic Signs of inflammations (WBC, CRP, fever)
Imaging
Suspected diagnosis: A+B
Definite diagnosis: A+B+C
Sn 91.2 % Sp96.9%

31. IMAGING
Which technique?
Imaging findings: enlarged gallbladder, thickening of the wall >5mm, stones, debris echo; US Murphys’s sign
Sn 88% Sp 80%
Shea, Arch Intern Med 1994
Yokoe, J hepatobiliary pancreat sci 2013

32. CLASSIFICATION No classification until 2007
Proposal By TG are three degree of severity
Grade III SEVERE
Grade II MODERATE
Grade I MILD

33. CLASSIFICATION Grade III - SEVERE acute cholecystitis
Associated with dysfunction of any one of the following organs/systems:
1. Cardiovascular dysfunction: Hypotension with dopamine >5 µg/kg per min, or norepinephrine
2. Neurological dysfunction: Decreased level of consciousness
3. Respiratory dysfunction: PaO2/FiO2 ratio<300
4. Renal dysfunction: Oliguria, creatinine>2.0 mg/dl
5. Hepatic dysfunction: PT-INR>1.5
6. Hematological dysfunction: Platelet count<100,000/mm3

34. CLASSIFICATION Grade II - MODERATE acute cholecystitis
Associated with any one of the following conditions:
1. Elevated white blood cell count (>18,000/mm3)
2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints>72 h
4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous
cholecystitis)

35. CLASSIFICATION Grade I - MILD acute cholecystitis
Does not meet the criteria of ‘‘Grade III’’ or ‘‘Grade II’’ acute cholecystitis.
Grade I can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative
procedure

36. CBD stones
Concomitant CBD stones??
No indications in TG. Which management?
Before, during or after surgery??
American Society Gastrointestinal Endoscopy Guidelines, 2010
Three class of risk of CBD stones

37. Predictive Factor for choledocholitiasis
Evidence of CBD stone at abdominal US
VERY STRONG
Ascending cholangitis
Total Serum Bilirubin > 4 mg/dL
STRONG
Common Bile duct diameter > 6mm (with gallbladder in situ)
Bilirubin level 1,8-4 mg/dL
Abnormal liver biochemical test other than bilirubin
MODERATE
Age older than 55 y
Clinical gallstone pancreatitis
Risk class for choledocolithiasis
HIGH
Presence of any VERY STRONG or
Presence of both STRONG predictors
LOW
No predictors present
INTERMEDIATE
All other patients

38. CBD stones

39. ANTIBIOTICS
TG does not suggest a specific antibiotic scheme but offers several combinations and opportunity
Isolated microorganisms from bile cultures
Gram-negative organisms
Escherichia coli 31–44%
Klebsiella spp. 9–20 %
Pseudomonas spp. 0.5–19 %
Enterobacter spp. 5–9 %
Acinetobacter spp. –
Citrobacter spp. –
Gram-positive organisms
Enterococcus spp. 3–34%
Streptococcus spp. 2–10%
Staphylococcus spp. 0%
Anaerobes 4–20%
Others –
Empirical therapy
WSES Guidelines abdominal infections. 2013
Stop antibiotics 24h after surgery
Sartelli, WJES 2013

40. Clinical scenario 01:25 AM at the Emergency Dept
68 years old man, BMI 27, hypertension and diabetes mellitus
8 hours of abdominal pain
Fever, 38.1°C
Murphy’s sign +++
Lab: WBC /mm3,
CRP 3.8 mg/dl
No risk of CBD stones

41. Clinical scenario What are you going to do?!
Give oral antibiotics and send him to home
Admit him in a medical ward, start antibiotics and plan for an elective cholecystectomy after 8-12 weeks
Start antibiotics and Operate him immediately that night, within few hours
Admit him in a surgical ward, start antibiotics and plan for surgery within 72 hours
Run away, tomorrow starts your holidays!

42. TREATMENT
“In conclusion I wish to express the hope that some day surgeons will be fairly unanimous in their views on the treatment of acute inflammations of the gall-bladder.”
Ann Sur. 1928

43. “TO OPERATE OR NOT TO OPERATE, during the acute phase??”
TREATMENT
“TO OPERATE OR NOT TO OPERATE, during the acute phase??”

44. TREATMENT
Untill introduction of laparoscopy the indication was to operate acute cholecystitis during the acute phase.
No differences in terms of complications, mortality or morbidity
Minor lenght of stay (9.6 ±2.5 days vs 17.8± 5.8 days; p<0.0001)
20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis
Papi, Am J gastroenterol, 2004

45. TREATMENT New technique Poor confidence, great fear
The introduction of laparocopic cholecystectomy created great confusion
New technique
Poor confidence, great fear
60-80% of surgeons prefer delayed cholecystectomy
40% of patients receives early cholecytectomy
Return of delayed approach!
Askew, 2005, campbell 2008, Badia 2014

46. TREATMENT New trials Same evidences No differences in term of:
Conversion to open cholecystectomy
Complications
Mortality
Operating time
Reduction in mean Lengh of stay (-4 days, p<.001)
Gurusamy, 2013

47. TREATMENT
Evidences show that acute choecystitis shoud be operated during the acute phase
Same conversion rate
Same mortality and morbidity
Same complications
Prevention of recurrences (20%)
Minor lenght of stay
Minor costs!!! (-2000$, QALYs) (Johner, SUrgEndosc 2013)

48. TREATMENT
Tokyo Guidelines’s proposal, despite evidences, show the great uncertainty of the surgeons ?

49. CRITICALITIES !!
The treatment flow chart is not supported by any evidence!
Application of TG has not produced any benefit for patients (Lee, JGH 2009)
Percutaneous drainage is not supported by evidences, further studies are
necessary to clarify its role (Campanile, WJES 2014)
Treatment is based on classification BUT classification doesn’t consider patients characteristics but only cholecystitis

50. CRITICALITIES
No clear relationship between local inflammatory status and patients characteristics!!
2011

51. CRITICALITIES
Why a patient with grade III choelcystitis can not be operated?
Which patient can be operated?
How to calculate mortality and morbidity risk?

52. CRITICALITIES
Laparoscopic cholecystectomy as treatment of choice for acute cholecystitis.
Surgery should be performed as soon as possible
2014

53. PERSPECTIVES NEW GUIDELINES!!
WSES CONSENSUS CONFERENCE ON ACUTE CHOLECYSTITIS
JERUSALEM 5-8 JULY 2015
NEW GUIDELINES!!
8 key questions for new, complete guidelines

54. 2015 ? PERSPECTIVES Diagnosis: which instruments?
Treatment: which is the golden treatment?
Antibiotic: which schema for treatment?
Patient selection for surgery: which instruments to define high risk patients?
Timing for surgery: 72 hours or index admission?
Kind of surgery: first attempt laparoscopic approach?
Associated biliary tree stones: which instruments for suspicion and diagnosis at the presentation?
Alternative treatments for high risk patients: there is a role for percutaneous cholecystotomy? Which antibiotic schema in this subgroup of patient?
2015 ?

55. THANKS FOR YOUR ATTENTION
AND
JOIN US IN JERUSALEM!!
5-8 july 2015
WORLD SOCIETY OF
EMERGENCY SURGERY

56. ACUTE CALCOLOUS CHOLECYSTITIS (ACC) CONSENSUS CONFERENCE:
ACUTE CALCOLOUS CHOLECYSTITIS
(ACC) CONSENSUS CONFERENCE:
DISCUSSION OF STETEMENTS
Luca Ansaloni
acc.wses.consensus 56 56 56

57. Reasons for Consensus Conferences-Background
- It is a current matter of discussion
Maybe Tokyo Guidelines 2007
improved the interest ?
Controversial issues
Severity of ACC or Severity of patient condition?
No clear support to early Laparoscopic cholecystectomy
No assessment of suspected biliary tree calcolous
And something else 57 57 57

58. How we approached the ACC/cc WSES Jerusalem 2015
Founding of Scientific Secretariat (4 members) by the President: selection of 8 questions/issues
November to December 2014
December 2014 to January 2015
Founding of Scientific Committee (SC:8) and Organizational Committee (OC: 8)
Agreement on questions/issues and assignment (OC+SC+SS)
Library Secretariat: Automatic, preliminary bibliography research (no time, no language limitations) January 2015
February 2015
“Literature filtration” and manual search by OC, SC, with the aid of SS
March 2015
May-June 2015
April 2015
1 Draft by OC, SC
with the aid of SS
Statements elaboration by
OC, SC with the aid of SS
Comments by OC, SC
June 2015
Final Statements analysis by
OC, SC with the aid of SS, and by
50 Restricted WSES members
(Fabulous Fifty)
The Final Sprint 58 58

59. CONSENSUS CONFERENCE JULY 2015
Activities
Completed until
Actors
Addressees
Project plane 1st edt
20/11/2014 SS
Project plane final edt
15/12/2014
Send the project plane
OC+SC
Collection of project plane comments
15/01/2015
OC+OC
Bibliography research
16/01/2015 from
30/01/2015
HPG 23 Library Secretariat+SS
Literature evaluation
15/02/2015 from
28/02/2015
1 OC/ 1SC for each question
Collection of literature evaluation
Draft 1st edt
31/03/2015
OC+SS
Send Draft 1st edt
Collection of Draft 1st edt comments
15/04/2015
Draft 2nd edt
15/05/2015
Send Draft def edt
OC+SC + RWML
Collection of Draft 2nd edt
comments
31/05/2015
Draft final edt
15/06/2015
Send Draft final edt
OC+SC+
RWML
CONSENSUS CONFERENCE JULY 2015
SC: Scientific committee
OC: Organization Committee
SS: Scientific Secretariat 59 59

60. More Material and Methods
1 President: Luca Ansaloni
4 Scientific Secretariat Members (SS)
8 Scientific Committee Members (SC)
8 Organizational Committee Members (OC)
8 Key Questions: 8 Working Groups
Key Questions?
 Members
(SC, OC, SS)
1) Diagnosis: which investigation?
Kashuk/Borzellino/
Allegri
2) Treatment: which provide the optimum outcome?
Peitzman/DiSaverio/
Pisano
3) Antibiotic: which schema for treatment?
Viale/Sartelli/
4) Patient selection for surgery: which instruments to define high risk patients?
Sakakushew/Campanile/Piazzalunga
5) Timing for surgery: at the index admission or delayed?
Gurusamy/Catena/
Piazzalunga
6) Kind of surgery: laparoscopic as preferred surgical approach?
Ivatury/Coccolini/
7) Associated biliary three stones: which instruments for suspicion and diagnosis at the presentation?
Kelly/Chiara/
Ceresoli
8) Alternative treatments for high risk patients: there is a role for percutaneous cholecystotomy?
Sugrue/Agresta/
Dedicated peoples
Dedicated mail
Few solicits
Key words: acute calcolous cholecystitis, gallbladder disease, biliary tree stones, diagnosis,
treatment, management, golden treatment, surgery, non operative treatment, colecystectomy,
laparoscopy, antibiotics, surgical risk, high risk patient, risk scores, cholecystostomy, gallbladder drainage 60

61. More Material and Methods61

62. Oxford Centre for Evidence-Based Medicine 2011
Levels of Evidence
Level 1: review and meta-analyis of RCT
Level 2: RCT or observational with dramatic effect
Level 3: observational studies
Level 4: case series
Level 5: machanism based reasoning
Grade of recommendation
Grade A: consistent level 1 studies
Grade B: consistent grade 2 or 3 studies or extrapolation from level 1
Grade C: level 4 studies or extrapolation from level 2-3
Grade D: level 5 or inconclusive studies

63. How to manage the present section
1 Working Group Presenter for question/issue
Use of a slide presentation Template
Statements presentation: Literature supporting statement (level of evidence e Grade of Evidence. 5 minutes presentation, 1 minute for vote, 6 minutes for discussion, 1 minute for Presenter resuming the discussion and modifications of the statements
Finish of present section at 9,00 a.m
Final Section at 11,00 a.m: from 9,00 to 11,00 a.m. the President
ad the Scientific Secretariat Delegate adopt the modifications.
Final presentation (based on previous slides modified) 11,00-11,30 a.m. (same room): President 63

64. (5 minutes maximum presentation)
Program of Section # 1 Consensus Conference on Acute Calcolous Cholecystitis
Jerusalem July 6, 2015.
7,30-9,00 a.m. Zion BallRoome
(5 minutes maximum presentation)
Introduction Luca Ansaloni
Diagnosis: which investigation? Borzellino
Treatment: which provide the optimum outcome? Pisano
Antibiotic: which schema for treatment? Sartelli
Patient selection for surgery: which instruments to define high risk patients?
Campanile
Timing for surgery: at the index admission or delayed? Gurusamy
Kind of surgery: laparoscopic as preferred surgical approach? Coccolini
Associated biliary three stones: which instruments for suspicion and diagnosis at the
presentation? Chiara
Alternative treatments for high risk patients: there is a role for percutaneous
cholecystotomy? Sugrue
ACC Consensus Conference 64 64

65. thank you for the attention!