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WSES GUIDELINES on ACUTE CALCULOUS CHOLECYSTITIS
Dr. Luca Ansaloni Head, General and Emergency Surgery , M. Bufalini Hospital, Cesena AUSL Romagna, Italy , Mozyr, Belarus
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WSES GL on ACC 2016
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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
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Tokyo Guidelines 2007, 2013 and 2018 Why a CC on ACC?
But first guidelines on ACC… Tokyo Guidelines 2007, 2013 and 2018
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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
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Why a CC on ACC? Tokyo Guidelines’s proposal, despite evidences, show the great uncertainty of the surgeons ?
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2014: preparation july 2015: CC in Jerusalem 2016: publication
Timeline… 2014: preparation july 2015: CC in Jerusalem 2016: publication
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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
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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”
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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
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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.
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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.
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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.
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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
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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)
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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
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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.
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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.
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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.
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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
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7. Associated CBD stones SAGES
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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.
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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.
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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
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thank you for the attention!
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thank you for the attention!
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EVIDENCES AND GUIDELINES
ACUTE CHOLECYSTITIS - EVIDENCES AND GUIDELINES Luca Ansaloni Papa Giovanni XXIII Hospital – Bergamo, Italy World Society of Emergency Surgery
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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
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? 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.”
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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%
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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
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CLASSIFICATION No classification until 2007
Proposal By TG are three degree of severity Grade III SEVERE Grade II MODERATE Grade I MILD
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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
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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)
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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
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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
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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
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CBD stones
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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
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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
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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!
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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
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“TO OPERATE OR NOT TO OPERATE, during the acute phase??”
TREATMENT “TO OPERATE OR NOT TO OPERATE, during the acute phase??”
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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
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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
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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
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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)
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TREATMENT Tokyo Guidelines’s proposal, despite evidences, show the great uncertainty of the surgeons ?
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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
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CRITICALITIES No clear relationship between local inflammatory status and patients characteristics!! 2011
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CRITICALITIES Why a patient with grade III choelcystitis can not be operated? Which patient can be operated? How to calculate mortality and morbidity risk?
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CRITICALITIES Laparoscopic cholecystectomy as treatment of choice for acute cholecystitis. Surgery should be performed as soon as possible 2014
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PERSPECTIVES NEW GUIDELINES!!
WSES CONSENSUS CONFERENCE ON ACUTE CHOLECYSTITIS JERUSALEM 5-8 JULY 2015 NEW GUIDELINES!! 8 key questions for new, complete guidelines
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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 ?
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THANKS FOR YOUR ATTENTION
AND JOIN US IN JERUSALEM!! 5-8 july 2015 WORLD SOCIETY OF EMERGENCY SURGERY
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ACUTE CALCOLOUS CHOLECYSTITIS (ACC) CONSENSUS CONFERENCE:
ACUTE CALCOLOUS CHOLECYSTITIS (ACC) CONSENSUS CONFERENCE: DISCUSSION OF STETEMENTS Luca Ansaloni acc.wses.consensus 56 56 56
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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
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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
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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
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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
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More Material and Methods
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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
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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
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(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
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thank you for the attention!
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