Table 5 WSES Guidelines statements

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

C

exploration is a fairly reliable investigation method but its sensitivity and specificity for diagnosing ACC may be relatively low according to the adopted AUS criteria.

1.4

2

B

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

4

C

Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known.

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

C

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

2

C

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

3

C

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.

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

B

In complicated cholecystitis, the antimicrobial regimens depend on presumed pathogens involved and risk factors for major resistance patterns

3.3

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.

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

3

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

C

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

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

1

A

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.

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

3

A

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 moe likely.

6.5

3

B

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.

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

2

B

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 CBS.

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

1

A

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

1

A

with high risk for choledocholithiasis should undergo preoperative ERCP, IOC, LUS, depending on the local expertise and the availability of the technique.

7.7

1

A

CBDS could be removed preoperatively, intraoperatively, or postoperatively according to the local expertise and the availability of the technique.

Alternative treatments

8.1

4

Gallbladder drainage, together with antibiotics, converts a septic cholecystitis into a non-septic condition; however the level of evidence is poor.

8.2

4

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.