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Cefmetazole (CMZ), an antibiotic with limited international distribution, is recommended by the Tokyo Guidelines 2018 (TG18) for non-severe cases of acute cholangitis (AC). However, the risk factors for CMZ-non-susceptible (CMZ-NS) bacteremia in AC remain unclear. Here, we aimed to investigate the risk factors for CMZ-NS bacteremia and evaluate mortality in patients with AC. This single-center, retrospective, observational study included all patients diagnosed with definite bacteremic AC, based on TG18, from April 2019 to March 2023. Risk factors for CMZ-NS bacteremia were analyzed by univariate, and age- and sex-adjusted, logistic regression analyses. Mortality was compared by cause of obstruction, CMZ-susceptible/CMZ-NS bacteremia, and initial treatment. In total, 165 patients were enrolled. CMZ-NS bacteremia was diagnosed in 46 (27.9 %) patients. Histories of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy were identified as significant factors associated with the risk of CMZ-NS bacteremia. Thirteen patients died within 30 days of hospital admission. The mortality of patients with AC and malignant biliary obstruction was statistically higher than that of patients with bile duct stones. No patients with AC and bile duct stones died in the group with CMZ-NS bacteremia and inappropriate initial antibiotics. In AC, a history of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy are associated with an increased risk of CMZ-NS bacteremia. Therefore, the choice of empiric therapy for AC should be based on the etiology and patient background, rather than on the severity. [ABSTRACT FROM AUTHOR]

Purpose: To analyze if, after implementation of an evidence-based local multidisciplinary protocol for acute cholecystitis (AC), an intermediate surgical audit could improve early cholecystectomy (EC) rate and other therapeutic indicators. Methods: Longitudinal cohort study at a tertiary center. The local protocol, promoted, created, and periodically revised by the Acute Care Surgery Unit (ACSu) was updated and approved on March 2019. A specific registry was prospectively fulfilled with demographics, comorbidity, type of presentation, diagnostic items, therapeutic decision, and clinical course, considering both non-operative management (NOM) or cholecystectomy, early and delayed (EC and DC). Phase 1: April 2019–April 2021. A critical analysis and a surgical audit with the participation of all the involved Departments were then performed, especially focusing on improving global EC rate, considered primary outcome. Phase 2: May 2021–May 2023. Software SPSS 23.0 was used to compare data between phases. Results: Initial EC rate was significantly higher on Phase 2 (39.3%vs52.5%, p < 0.004), as a significantly inferior rate of patients were initially bailed out from EC to NOM because of comorbidity (14.4%vs8%, p < 0.02) and grade II with severe inflammatory signs (7%vs3%, p < 0.04). A higher percentage of patients was recovered for EC after an initial decision of NOM on Phase 2, but without reaching statistical significance (21.8%vs29.2%, n.s.). Global EC rate significantly increased between phases (52.5%vs66.3%, p < 0.002) without increasing morbidity and mortality. A significant minor percentage of elective cholecystectomies after AC episodes had to be performed on Phase 2 (14%vs6.7%, p < 0.009). Complex EC and those indicated after readmission or NOM failure were usually performed by the ACSu staff. Conclusion: To adequately follow up the implementation of a local protocol for AC healthcare, registering and periodically analyzing data allow to perform intermediate surgical audits, useful to improve therapeutic indicators, especially EC rate. AC constitutes an ideal model to work with an ACSu. [ABSTRACT FROM AUTHOR]

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788–54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815–0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837–0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak. [ABSTRACT FROM AUTHOR]

Context: Acute cholecystitis (AC) is one of the most common afflictions of the gastrointestinal system presenting to hospitals whose delayed diagnosis can lead to severe complications. Neutrophil-to-lymphocyte ratio (NLR) is a new and inexpensive predictor of severe AC that can be used as prognostic biomarker for the stratification of patients for appropriate management. Aims: The aims of the study are to determine the usefulness of the NLR as a prognostic marker and to find range that distinguishes between grades of AC and to compare NLR use with white blood cell, high sensitivity C-reactive protein, and radiological modalities in the diagnosis of severe AC. Settings and Design: This is a 1-year prospective observational study in tertiary care center. Subjects and Methods: Demographic data, investigations, and management of 110 patients diagnosed with AC were collected. Categorization in mild, moderate, or severe AC group was based on Tokyo guidelines and NLR was calculated as absolute neutrophil count/absolute lymphocyte count. Statistical Analysis Used: One-way analysis of variance. Results: Sixty-four were male and 46 were female. 23.64% had severe AC, 30.91% had moderate, and 45.45% had mild AC. Mean hospital stay and intensive care unit stay were more in severe cholecystitis group. Diabetes mellitus was commonly associated comorbidity in severe cholecystitis (35.48%). As per the study, NLR ranges 10 in severe AC (sensitivity of 97% and specificity of 88%). The cardiovascular system was most commonly affected in severe AC, followed by renal derangement. Conclusions: NLR has proved to be a prognostic marker to determine disease severity in patients with AC which will help in appropriate management and better patient outcome.

Introductıon: This study was undertaken to investigate the importance of the CRP/albumin ratio (CAR) as an early prognostic marker for determining disease severity in acute cholangitis. Methods: A total of 366 patients aged >18 years diagnosed with acute cholangitis were included in the study. Acute cholangitis severity was determined according to the 2018 Tokyo criteria. Results: The study population consisted of 49.2% patients with mild, 24.6% moderate, and 26.2% severe acute cholangitis. The cut-off CAR value for predicting moderate risk compared to the mild risk group was found to be >1 with 73.3% sensitivity and 76.7% specificity (AUC±SE: 0.785±0.03; +PV: 61.1%, -PV: 85.2%; p<0.001). The CAR cut-off value for predicting severe risk compared to the moderate risk group was found to be >2.9 with 71.9% sensitivity and 71.1% specificity (AUC±SE: 0.788±0.03; +PV: 72.6%, -PV: 70.3%; p<0.001). The CAR cut-off value for predicting admission to the intensive care unit (ICU) was >2.5 with 77.4% sensitivity and 74.6% specificity (AUC±SE: 0.803±0.03; +PV: 43.1%, -PV: 90.1%; p<0.001). The CAR cut-off value for predicting mortality was >2.8 with 100% sensitivity and 74.9% specificity (AUC±SE: 0.890±0.03; +PV: 19.5%, -PV: 100%; p<0.001). Compared to its components, the CAR was found to exhibit superior diagnostic performance in predicting moderate or severe risk, ICU admission, and mortality. Conclusion: We found that the CAR is a good prognostic marker in determining the severity of acute cholangitis in the early period. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to clarify the incidence, therapeutic modality, and prognosis of acute acalculous cholecystitis and to reveal its optimal treatment strategy. Methods: As a project study of the Japanese Society for Abdominal Emergency Medicine, we performed a questionnaire survey of demographic data and perioperative outcomes of acute acalculous cholecystitis treated between January 2018 and December 2020 from 42 institutions. Results: In this study, 432 patients of acute acalculous cholecystitis, which accounts for 7.04% of acute cholecystitis, were collected. According to the Tokyo guidelines severity grade, 167 (38.6%), 202 (46.8%), and 63 (14.6%) cases were classified as Grade I, II, and III, respectively. A total of 11 (2.5%) patients died and myocardial infarction/congestive heart failure was the only independent risk factor for in‐hospital death. Cholecystectomy, especially the laparoscopic approach, had more preferable outcomes compared to their counterparts. The Tokyo guidelines flow charts were useful for Grade I and II severity, but in the cases with Grade III, upfront cholecystectomy could be suitable in some patients. Conclusions: The proportions of severity grade and mortality of acute acalculous cholecystitis were found to be similar to those of acute cholecystitis, and laparoscopic cholecystectomy is recommended as an effective treatment option. (UMIN000047631). [ABSTRACT FROM AUTHOR]

Aim: To find the factors contributing to postcholecystectomy symptoms after laparoscopic cholecystectomy. Methodology: A retrospective observational study with 50 symptomatic patients visiting the outpatient department (OPD) of the Department of Surgery and Department of Casualty following laparoscopic cholecystectomy whose perioperative clinical factors were evaluated to predict the development of postcholecystectomy syndromes using a Chi-square test. Conclusion: • Pain was the predominant symptom seen in all (100%) of the patients. • Female sex (70%) and body mass index (BMI; 30%) were a strong significant predictor. • Previous history of hospitalization (p < 0.0008) for acute cholecystitis (32%), acute pancreatitis (4%), obstructive jaundice (18%), cirrhosis (14%) were significant predictors of pelvic congestion syndrome (PCS). • Ultrasonography (USG) findings (p < 0.0471) of thickened gallbladder (GB) wall (40%) and pericholecystic collection (16%) were strong predictors of difficult surgery and contributed to PCS. • The most common type of early PCS was bile leak (16%). • Age and previous abdominal surgeries were not significant predictors. [ABSTRACT FROM AUTHOR]

Context: Acute cholecystitis (AC) is one of the most common afflictions of the gastrointestinal system presenting to hospitals whose delayed diagnosis can lead to severe complications. Neutrophil-to-lymphocyte ratio (NLR) is a new and inexpensive predictor of severe AC that can be used as prognostic biomarker for the stratification of patients for appropriate management. Aims: The aims of the study are to determine the usefulness of the NLR as a prognostic marker and to find range that distinguishes between grades of AC and to compare NLR use with white blood cell, high sensitivity C-reactive protein, and radiological modalities in the diagnosis of severe AC. Settings and Design: This is a 1-year prospective observational study in tertiary care center. Subjects and Methods: Demographic data, investigations, and management of 110 patients diagnosed with AC were collected. Categorization in mild, moderate, or severe AC group was based on Tokyo guidelines and NLR was calculated as absolute neutrophil count/absolute lymphocyte count. Statistical Analysis Used: One-way analysis of variance. Results: Sixty-four were male and 46 were female. 23.64% had severe AC, 30.91% had moderate, and 45.45% had mild AC. Mean hospital stay and intensive care unit stay were more in severe cholecystitis group. Diabetes mellitus was commonly associated comorbidity in severe cholecystitis (35.48%). As per the study, NLR ranges <6.5 in mild, 6.5–10 in moderate, and >10 in severe AC (sensitivity of 97% and specificity of 88%). The cardiovascular system was most commonly affected in severe AC, followed by renal derangement. Conclusions: NLR has proved to be a prognostic marker to determine disease severity in patients with AC which will help in appropriate management and better patient outcome. [ABSTRACT FROM AUTHOR]

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788–54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815–0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837–0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak.

Abstract Background The aim of this study was to determine the recurrence rate of patients who did not have interval cholecystectomy after treatment with percutaneous cholecystostomy and to investigate the factors that may affect the recurrence. Methods Patients who did not undergo interval cholecystectomy after percutaneous cholecystostomy treatment between 2015 and 2021 were retrospectively screened for recurrence. Results 36.3% of the patients had recurrence. Recurrence was found more frequently in patients with fever symptoms at the time of admission to the emergency department (p = 0.003). Recurrence was found to be more frequent in those who had a previous cholecystitis attack (p = 0.016). It was determined that patients with high lipase and procalcitonin levels had statistically more frequent attacks (p = 0.043, p = 0.003). It was observed that the duration of catheter insertion was longer in patients who had relapses (p = 0.019). The cut-off value for lipase was calculated as 15.5, and the cut-off value for procalcitonin as 0.955, in order to identify patients at high risk for recurrence. In the multivariate analysis for the development of recurrence, presence of fever, a history of previous cholecystitis attack, lipase value higher than 15.5 and procalcitonin value higher than 0.955 were found to be risk factors. Conclusions Percutaneous cholecystostomy is an effective treatment method in acute cholecystitis. Insertion of the catheter within the first 24 h may reduce the recurrence rate. Recurrence is more common in the first 3 months following removal of the cholecystostomy catheter. Having a previous history of cholecystitis attack, fever symptom at the time of admission, elevated lipase and procalcitonin are risk factors for recurrence.

Background: It is not well understood whether the severity of acute cholecystitis (AC) correlates with the extent of gallbladder (GB) inflammation or laboratory findings. This study aimed to assess whether the severity of AC, in accordance with the Tokyo Guidelines (TGs), is consistent with the extent of GB inflammation on histopathological and laboratory findings, including microbiological isolation in blood and bile. Methods: The medical records of patients who underwent cholecystectomy for AC between January 2017 and May 2020 were reviewed. Demographic data, laboratory findings, the microbiologic culture of blood and bile, the extent of GB inflammation, and stone composition were compared in accordance with the TGs. Results: A total of 217 patients were divided into three groups of increasing severity—Grade I (n = 146), Grade II (n = 51), and Grade III (n = 20)—in accordance with the TGs. The Grade III group contained significantly older patients compared with the Grade I or Grade II groups (Grade I, 56.9 ± 13.9; Grade II, 64.3 ± 15.4; Grade III, 69.9 ± 9.9; p-value < 0.001). Patients in the Grade III group showed significantly higher levels of CRP, WBC, creatinine, and bilirubin and lower levels of platelets and albumin compared with the Grade I or Grade II group. As the grade of severity increased, the rate of microbiological isolation in blood (Grade I, 0% [0/146]; Grade II, 2.0% [1/51]; Grade III, 20% [4/20]; p-value < 0.001) and bile (Grade I, 19.9% [29/146]; Grade II, 33.3% [17/51]; Grade III, 70% [14/20]; p-value < 0.001) also increased significantly. However, there were no significant differences in the extent of GB inflammation between grades. Conclusions: AC severity, as stated by the TGs, does not correlate with the extent of GB inflammation on histopathological and laboratory findings. However, microbiological isolation in blood and bile was increased proportionally to the grade of the TGs. [ABSTRACT FROM AUTHOR]

Purpose: Although mortality and morbidity of severe acute calculous cholecystitis (ACC) are still a matter of concern, the impact of inadequate empirical antibiotic therapy has been poorly studied as a risk factor. The objective was to assess the impact of the adequacy of empirical antibiotic therapy on complication and mortality rates in ACC. Methods: This observational retrospective cohort chart-based single-center study was conducted between 2012 and 2016. A total of 963 consecutive patients were included, and pure ACC was selected. General, clinical, postoperative, and microbiological variables were collected, and risk factors and consequences of inadequate treatment were analyzed. Results: Bile, blood, and/or exudate cultures were obtained in 76.3% of patients, more often in old, male, and severely ill patients (P < 0.001). Patients who were cultured had a higher overall rate of postoperative complications (47.4% vs. 29.7%; P < 0.001), as well as of severe complications (11.6% vs. 4.7%; P = 0.008). Patients with positive cultures had more overall complications (54.8% vs. 39.6%; P = 0.001), more severe complications (16.3% vs. 6.7%; P = 0.001), and higher mortality rates (6% vs. 1.9%; P = 0.012). Patients who received inadequate empirical antibiotic therapy had a fourfold higher mortality rate than those receiving adequate therapy (n = 283; 12.8% vs. 3.4%; P = 0.003). This association was especially marked in severe ACC TG–III patients (n = 132; 18.2 vs. 5.1%; P = 0.018) and remained a predictor of mortality in a binary logistic regression (OR 4.4; 95% CI 1.3–15.3). Conclusion: Patients with positive cultures developed more complications and faced higher mortality. Adequate empirical antibiotic therapy appears to be of paramount importance in ACC, particularly in severely ill patients. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine the recurrence rate of patients who did not have interval cholecystectomy after treatment with percutaneous cholecystostomy and to investigate the factors that may affect the recurrence. Methods: Patients who did not undergo interval cholecystectomy after percutaneous cholecystostomy treatment between 2015 and 2021 were retrospectively screened for recurrence. Results: 36.3% of the patients had recurrence. Recurrence was found more frequently in patients with fever symptoms at the time of admission to the emergency department (p = 0.003). Recurrence was found to be more frequent in those who had a previous cholecystitis attack (p = 0.016). It was determined that patients with high lipase and procalcitonin levels had statistically more frequent attacks (p = 0.043, p = 0.003). It was observed that the duration of catheter insertion was longer in patients who had relapses (p = 0.019). The cut-off value for lipase was calculated as 15.5, and the cut-off value for procalcitonin as 0.955, in order to identify patients at high risk for recurrence. In the multivariate analysis for the development of recurrence, presence of fever, a history of previous cholecystitis attack, lipase value higher than 15.5 and procalcitonin value higher than 0.955 were found to be risk factors. Conclusions: Percutaneous cholecystostomy is an effective treatment method in acute cholecystitis. Insertion of the catheter within the first 24 h may reduce the recurrence rate. Recurrence is more common in the first 3 months following removal of the cholecystostomy catheter. Having a previous history of cholecystitis attack, fever symptom at the time of admission, elevated lipase and procalcitonin are risk factors for recurrence. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: It is not well understood whether the severity of acute cholecystitis (AC) correlates with the extent of gallbladder (GB) inflammation or laboratory findings. This study aimed to assess whether the severity of AC, in accordance with the Tokyo Guidelines (TGs), is consistent with the extent of GB inflammation on histopathological and laboratory findings, including microbiological isolation in blood and bile. Methods: The medical records of patients who underwent cholecystectomy for AC between January 2017 and May 2020 were reviewed. Demographic data, laboratory findings, the microbiologic culture of blood and bile, the extent of GB inflammation, and stone composition were compared in accordance with the TGs. Results: A total of 217 patients were divided into three groups of increasing severity—Grade I (n = 146), Grade II (n = 51), and Grade III (n = 20)—in accordance with the TGs. The Grade III group contained significantly older patients compared with the Grade I or Grade II groups (Grade I, 56.9 ± 13.9; Grade II, 64.3 ± 15.4; Grade III, 69.9 ± 9.9; p-value < 0.001). Patients in the Grade III group showed significantly higher levels of CRP, WBC, creatinine, and bilirubin and lower levels of platelets and albumin compared with the Grade I or Grade II group. As the grade of severity increased, the rate of microbiological isolation in blood (Grade I, 0% [0/146]; Grade II, 2.0% [1/51]; Grade III, 20% [4/20]; p-value < 0.001) and bile (Grade I, 19.9% [29/146]; Grade II, 33.3% [17/51]; Grade III, 70% [14/20]; p-value < 0.001) also increased significantly. However, there were no significant differences in the extent of GB inflammation between grades. Conclusions: AC severity, as stated by the TGs, does not correlate with the extent of GB inflammation on histopathological and laboratory findings. However, microbiological isolation in blood and bile was increased proportionally to the grade of the TGs.

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Tokyo guidelines (TG13/18) are used for the severity assessment of acute cholangitis (AC). Lactate is a clinical marker of tissue hypoxia and disease severity, independent from blood pressure. Aim: The aim of this study is to investigate the relationship between blood lactate level and TG13/18 criteria in patients diagnosed with AC. Methods: One hundred fifteen patients with AC were included in this retrospective study. Demographic characteristics of the patients and laboratory data were scanned from their hospital medical records. According to TG13/18 guidelines, the patients were divided into 3 groups as mild (grade 1), moderate (grade 2), and severe (grade 3) AC. Results: Sixty three (54.7%) of the patients were grade 1, 37 (32.1%) were grade 2, and 15 (13.0%) were grade 3. It was found that blood lactate level increased significantly from grade 1 to grade 3 (p < 0.001). In logistic regression analysis, white blood cell (WBC) count, total bilirubin and blood lactate levels independently determined the patients to be grade 2 or 3 AC. When the blood lactate cut-off value was taken as 16.5 mg/dL, we diagnosed grade 2 or 3 AC with a sensitivity of 78.8% and a specificity of 75.7%. From among lactate, WBC, and C reactive protein, lactate showed the highest value regarding the area under the curve, which is an index for predicting grade III upon ROC analysis. Conclusion: The blood lactate level is associated with the severity of AC. In addition to TG13/18 guidelines, blood lactate level can be a useful biomarker in the severity grading of AC. [ABSTRACT FROM AUTHOR]

Background: Socratic method, which is an educational method to promote critical thinking through a dialogue, has never been practiced in a large number of people at the academic societies. Methods: Modified Socratic method was performed for the first time as an educational seminar using an example case of moderate acute cholecystitis based on the evidence described in Tokyo Guidelines 2018. We adopted a method that Takada had been modifying for many years: the instructor first knows the degree of recognition of the audience, then the instructor gives a lecture in an easy‐to‐understand manner and receives questions from the audience, followed by repeated questions and answers toward a common recognition. Results: Using slides, video, and an answer pad, 281 participants including the audience, instructors and moderators came together to repeatedly ask and answer questions in the five sessions related to the case scenario. The recognition rate of the topic of Critical View of Safety increased significantly before vs after this method (53.0% vs 90.3%). The seminar had been successfully performed by receiving a lot of praise from the participants. Conclusion: This educational method is considered to be adopted by many academic societies in the future as an effective educational method. [ABSTRACT FROM AUTHOR]

Background: Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. Method: This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. Results: For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. Conclusion: The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness. [ABSTRACT FROM AUTHOR]

• The Tokyo Guideline components associate with HIDA results in the treatment of acute cholecystitis. • A prediction model using the Tokyo Guideline components is able to predict HIDA results. • Predicting HIDA results can avoid unnecessary studies. Hepatobiliary Scintigraphy (HIDA) aids the diagnosis of acute cholecystitis (AC) but has limitations. We sought to design a model based on the Tokyo Guidelines 2018 (TG18) to predict HIDA results. A retrospective review of patients who underwent a HIDA scan during the evaluation of AC was performed. Using logistic regression techniques incorporating the TG18 criterion and additional readily available patient characteristics, a prediction model was created to identify patients likely to test negative for acute cholecystitis by HIDA scan. In 235 patients with suspected AC, a HIDA scan was performed. Variables associated with positive HIDA results were male gender (RR 2.0 (CI 1.33-2.99), age (OR 1.02 (CI 1.01-1.04), right upper quadrant tenderness (RR 1.7 (CI 1.1-2.8)), clinical Murphy's sign (RR 2.2 (CI 1.5-3.4)), ultrasound findings suggestive of AC by any of its components (RR 3.2 (CI 1.6-6.5)), gallbladder wall thickening (RR 2.0 (CI 1.3-3.1)), and gallbladder distention (RR 1.9 (CI 1.3-2.9)). These variables allowed for creation of a model to predict HIDA results. The model predicted HIDA results in 36.9% of patients with an area under the curve of 0.81. In the era of TG18, HIDA is probably over utilized. We developed an accurate, simple model based on TG18 that identifies a group of patients for whom a HIDA scan is unnecessary to establish the diagnosis of AC. [ABSTRACT FROM AUTHOR]

Introduction: Early laparoscopic cholecystectomy (ELC) has shown to reduce length of stay and improve patients' satisfaction as compared to delayed laparoscopic cholecystectomy (DLC). However, logistics and manpower limitations often preclude ELC. Methods: A retrospective study was conducted in a single institute to compare outcomes of AC before (August 2013–2014) and after (August 2017–2018) establishment of emergency surgery and trauma (ESAT). Results: There were 82 patients in pre-ESAT period and 172 patients in ESAT period. Mean age was 52.3 ± 11.6 and 55.7 ± 13.8 years, respectively, p = 0.369. There were more patients with moderate–severe grading of cholecystitis based on Tokyo Guidelines (TG 18) in ESAT 143/172 (83.1%) as compared to pre-ESAT 65/82 (79.3%), p = 0.042. Index cholecystectomy was performed in 145/172 (84.3%) of patients in the ESAT vs 34/82 (41.5%) of patients in the pre-ESAT period (p = 0.001). Time interval between booking to surgery was 180 ± 56 min in ESAT vs 197 ± 98 min in pre-ESAT, p = 0.014. Operative duration was shorter in ESAT 121 ± 38.5 min vs 139 ± 53.4, in pre-ESAT period, p = 0.030. Conversion rates were lower in ESAT (4/172, 2.3%) vs (9/72, 11%) in pre-ESAT, p = 0.003. Length of stay was shorter in ESAT (DLC 1.89 ± 1.6 and ELC ± 2.9 days) as compared to pre-ESAT (DLC 4.55 ± 2.2 and ELC 5.03 ± 2.6 days), p = 0.001. 30-day readmissions were lower in ESAT (3/172, 1.7%) vs pre-ESAT (8/72, 9.8%). Conclusion: The ESAT model provided more early laparoscopic cholecystectomies with improved efficiency and clinical outcomes. [ABSTRACT FROM AUTHOR]

Acute cholangitis (AC) is a biliary tract emergency which causes significant morbidity and mortality. The direct cause of death in AC is sepsis that leads to irreversible shock and multiple organ failure. The most common predisposition are bile duct stones and previous invasive manipulation of the biliary tree. Biliary infection and biliary obstruction are the two main factors in pathophysiology of AC. Gram-negative bacteria are isolated frequently from bile and blood culture in cholangitis. The most common cause of biliary obstruction is gallstone. The Charcot’s triad which commonly has been used to diagnose AC is severely limited and the clinical presentation of the disease has wide spectrum ranging from mild symptoms to severe life-threatening disease. Thus, the use of the most updated Tokyo Guidelines (TG18) is imperative to diagnose the disease and to assess the severity. The TG18 diagnostic criteria is based on the presence of systemic inflammmation, cholestasis, and evidence on imaging studies of biliary tract. The prompt treatment is tailored according to severity assessed by TG18. Initial treatment includes sufficient fluid replacement, hemodynamic control, electrolyte compensation, intravenous antibiotic administration, and intravenous analgesic administration. The definitive treatment which related to the pathophysiology of the disease are biliary drainage and antibiotic administration.

Background: Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. Methods: All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien–Dindo classification. Results: We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1 week (53.1%), 2–5 weeks (28.3%), and ≥ 6 weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien–Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention. Conclusion: The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC. [ABSTRACT FROM AUTHOR]

Acute cholecystitis is a common reason for emergency general surgery admission. The declaration of the COVID-19 pandemic may have resulted in treatment delays and corresponding increases in severity of disease. This study compared cholecystitis admissions and disease severity pre- and postdeclaration of pandemic. Retrospective review of adult acute cholecystitis admissions (January 1,2020-May 31, 2020). Corresponding time periods in 2018 and 2019 comprised the historical control. Difference-in-differences analysis compared biweekly cholecystitis admissions pre- and postdeclaration in 2020 to the historical control. Odds of increased severity of disease presentation were assessed using multivariable logistic regression. Cholecystitis admissions decreased 48.7% from 5.2 to 2.67 cases (RR 0.51 [0.28,0.96], P = 0.04) following pandemic declaration when comparing 2020 to historical control (P = 0.02). After stratifying by severity, only Tokyo I admissions declined significantly postdeclaration (RR 0.42 [0.18,0.97]), when compared to historical control (P = 0.02). There was no change in odds of presenting with severe disease after the pandemic declaration (aOR 1.00 [95% CI 0.30, 3.38] P < 0.99) despite significantly longer lengths of symptoms reported in mild cases. Postpandemic declaration we experienced a significant decrease in cholecystitis admissions without corresponding increases in disease severity. The pandemic impacted healthcare-seeking behaviors, with fewer mild presentations. Given that the pandemic did not increase odds of presenting with increased severity of disease, our data suggests that not all mild cases of cholecystitis progress to worsening disease and some may resolve without medical or surgical intervention. [ABSTRACT FROM AUTHOR]

Objective: To compare outcomes following percutaneous cholecystostomy drain placement based on presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis. Methods: Chart review was performed to identify the presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis in 146 patients who underwent percutaneous cholecystostomy between 2012 and 2015. Those who met criteria were compared to those who did not in terms of demographics, laboratory values, drain indwelling time, treatment response, eventual surgical management, and 30-day mortality. Results: 94 patients (64%) met Tokyo Guidelines diagnostic criteria, while 52 did not (36%). Patients within criteria had a shorter mean length of stay (13.5 days vs 18.9 days), were more likely to have a positive gallbladder fluid culture (64.5% vs 28.6%), demonstrated greater response to treatment (87.2% vs 32.7%), and had lower 30-day mortality (6.4% vs 37.8%). There was no significant difference in terms of ICU requirement (38.3% vs 38.9%), mean drain indwelling time (58.8 days vs 65.3 days), eventual laparoscopic cholecystectomy (40.4% vs 25.0%), or open cholecystectomy performed (9.5% vs 9.6%). Conclusion: Patients outside of Tokyo Guidelines diagnostic criteria for acute cholecystitis were less likely to respond to treatment with percutaneous cholecystostomy and had worse outcomes. Further research may be indicated to better define the indications for percutaneous cholecystostomy placement in this group. [ABSTRACT FROM AUTHOR]

Early laparoscopic cholecystectomy (LC) after gallbladder drainage is recommended in cases with acute cholecystitis (AC); however, the safety of LC after gallbladder drainage is still controversial, and it is not clear whether the drainage contributes to prevent bile leakage during operative procedure. A single institutional retrospective cohort study was performed to assess the safety of LC after gallbladder drainage as well as the frequency of bile leakage during LC. Twenty-four patients that had gallbladder drainage (Drainage group) and 67 patients that had early LC (Early LC group) were treated for AC. Charlson comorbidity index was significantly higher in the Drainage group (P = 0.015). Early LC group had a shorter operative time than Drainage group (P = 0.020) and tend to have less bile leakage rate than Drainage group. In cases when the initial treatment was started within a day after the onset of symptom, no bile leakage was observed in either group. LC after gallbladder drainage can be performed safely; however, it does not reduce the bile leakage rate. Early laparoscopic cholecystectomy with immediate admission as possible might help to prevent the postoperative bile leakage. [ABSTRACT FROM AUTHOR]

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Purpose: This study aimed to clarify the incidence, therapeutic modality, and prognosis of acute acalculous cholecystitis and to reveal its optimal treatment strategy., Methods: As a project study of the Japanese Society for Abdominal Emergency Medicine, we performed a questionnaire survey of demographic data and perioperative outcomes of acute acalculous cholecystitis treated between January 2018 and December 2020 from 42 institutions., Results: In this study, 432 patients of acute acalculous cholecystitis, which accounts for 7.04% of acute cholecystitis, were collected. According to the Tokyo guidelines severity grade, 167 (38.6%), 202 (46.8%), and 63 (14.6%) cases were classified as Grade I, II, and III, respectively. A total of 11 (2.5%) patients died and myocardial infarction/congestive heart failure was the only independent risk factor for in-hospital death. Cholecystectomy, especially the laparoscopic approach, had more preferable outcomes compared to their counterparts. The Tokyo guidelines flow charts were useful for Grade I and II severity, but in the cases with Grade III, upfront cholecystectomy could be suitable in some patients., Conclusions: The proportions of severity grade and mortality of acute acalculous cholecystitis were found to be similar to those of acute cholecystitis, and laparoscopic cholecystectomy is recommended as an effective treatment option. (UMIN000047631)., (© 2023 The Authors. Journal of Hepato-Biliary-Pancreatic Sciences published by John Wiley & Sons Australia, Ltd on behalf of Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: Laparoscopic cholecystectomy (LC) is often performed during the index admission after emergency presentation for acute biliary pain. Many patients have acute cholecystitis (AC) that may increase operative difficulty and complications. Our primary aim was to assess the validity of Tokyo Guidelines (TG18) for diagnosing AC by comparison with the admitting team diagnosis, operative findings and histopathology. The secondary aim was to assess outcomes after same‐admission or delayed LC. Methods: Retrospective analysis of patients who underwent LC after presenting to a tertiary hospital emergency department over a 12‐month period was conducted. Results: A total of 139 patients underwent LC with no mortality or bile duct injury. A diagnosis of AC made by the admitting surgical team had sensitivity of 84% and specificity of 57%. The TG18 diagnosis had sensitivity of 84% and specificity of 53%. A diagnosis of AC by the admitting surgical team correlated well with TG18 criteria diagnosis. There was poor correlation between clinical and histopathological diagnoses. Nine percent of patients had complications and 4% required conversion to open procedure. Patients with a clinical diagnosis of AC had longer post‐operative length of stay and more complications compared with those who had non‐AC diagnosis. There was no difference in outcomes between same‐admission LC or delayed LC. Conclusion: TG18 diagnosis of AC does not improve accuracy of diagnosis or predictability of a poor outcome over the admitting surgical team diagnosis. Same‐admission LC for patients with AC is associated with similar outcomes compared to those who undergo delayed LC. [ABSTRACT FROM AUTHOR]

Background: Gallbladder mucocele is a potentially life‐threatening extrahepatic biliary disease in dogs. The primary aims of this study were to evaluate the prevalence of cholecystitis in dogs with gross and histopathologically confirmed gallbladder mucocele and to investigate if there is an association between cholecystitis, including its subtypes (eg, acute, acute on chronic, with necrosis, chronic), and survival. Our secondary objective was to evaluate if there is an association between cholecystitis and intraoperative bacteriological culture positivity. Key Findings: Two hundred nineteen dogs with gallbladder mucocele were included in this multi‐institutional retrospective study, of which 63 (28.8%) dogs had histopathological evidence of cholecystitis. The most common forms of cholecystitis were acute on chronic (n = 22/63, 34.9%) and with necrosis (n = 20, 31.7%). Thirty‐one (14.1%) dogs had growth of at least 1 bacterial isolate; however, 88.7% had antimicrobials administered within the 48 hours before surgery or intraoperatively. There was not an association between cholecystitis or its subtypes and survival. Furthermore, there was not an association between cholecystitis and intraoperative bacteriological culture positivity. A total of 38 (17.4%) dogs either died or were euthanized during hospitalization. Significance: Cholecystitis is a common comorbidity in dogs with gallbladder mucocele but was not associated with decreased survival. [ABSTRACT FROM AUTHOR]

Abstract Background Controversy surrounding the role of percutaneous cholecystostomy (PC) is fed by the absence of large amounts of data concerning its outcomes, and many authors have maintained that there is no evidence to support a recommendation for PC rather than cholecystectomy (CCS) in elderly or critically ill patients with acute cholecystitis (AC). Methods We conducted this study by tracking trends in the utilization and outcomes of PC and CCS using longitudinal health research data in Taiwan. Results Analyses were conducted on 236,742 patients, 11,184 of whom had undergone PC and 225,558 of whom had undergone CCS. Average annual percentage changes (AAPCs) from 2003 to 2012 increased significantly by 18.34% each year for PC and by 2.82% each year for CCS. The subset analyzes showed that the mortality rates were far higher in patients underwent PC than in patients underwent CCS in all subgroups, which increased from a minimum of 1.45-fold to a maximum of 34.22-fold. The gap of the mortality rates between PC group and CCS group narrowed as the patients aged and with the seriousness of the diseases increased. Most patients with PC or CCS who died in-hospital or within 30 days after discharge were 70 years of age or older, and a large number of them received a CCI score of at least 1. The AAPCs of the overall mortality rates from 2003 to 2012 decreased by 6.78% each year for PC and by 7.33% each year for CCS. PC was related to a higher rate of cholecystitis recurrence and readmission for complications, but a lower rate of in-hospital complications and routine discharge than CCS, and 36.41% of all patients treated with PC underwent subsequent CCS. Additionally, the patients with PC experienced longer hospital stays and generated higher costs than the patients with CCS. Conclusion Patients who underwent PC demonstrated poorer prognoses than did patients who underwent CCS. The role of PC in the Tokyo guidelines may be overstated; it is not as safe as the Tokyo guidelines have suggested in moderate-grade cholecystitis cases, and it should be limited to only the elderly and sicker patients.

Objective: To determine the frequency of elevated peak systolic proper hepatic artery velocity (HAV) in patients with acute cholangitis and to determine the diagnostic performance of this metric relative to existing criteria. Methods: Between 9/2016 and 11/2017, 107 patients clinically suspected to have cholangitis were referred for an abdominal ultrasound. Of these, 56 patients had HAV measurements and were included in the final analysis. Clinical and imaging features, including HAV, HAV resistive index (RI), portal vein velocity (PVV), biliary dilation, and presence of an obstructive etiology were extracted. The diagnostic performance of HAV was compared to the existing available clinical criteria (Charcot's triad and 2018 Tokyo Guidelines). Elevated HAV was defined as HAV > 100 cm/s. Presence of cholangitis was determined by the discharge summary following medical workup and admission or observation. Results: 32% had cholangitis while 68% did not. Average HAV for patients with cholangitis was 152 ± 54 cm/s versus 91 ± 44 cm/s for those without (p < 0.0001; t test). The HAV was elevated in 83% of patients with cholangitis. When considered in isolation, an elevated HAV had a high negative predictive value (90%), was more accurate (77%; 95% confidence interval 64–87%) than Charcot's triad (73%; 60–83%), and had similar accuracy compared to 2018 Tokyo Guidelines (79%; 66–88%). Substitution of conventional imaging criteria with elevated HAV in the 2018 Tokyo Guidelines yielded the highest overall accuracy of 84% (72–92%). Conclusion: HAV is elevated in the majority of patients with cholangitis. Substitution of an elevated HAV for conventional sonographic criteria is more accurate than existing clinical criteria in identifying patients with cholangitis. [ABSTRACT FROM AUTHOR]

Background Acute calculous cholecystitis is a common disease presentation in critically ill patients. It is associated with increased mortality and morbidity rates in case of insufficient treatment. However, the best approach to management is still debatable. Patients and methods This is a retrospective analysis of prospectively designed study for the evaluation of different management planes in critically ill patients presented with acute cholecystitis in a single university hospital from 2013-2017. The study included all patients with acute cholecystitis as the main reason for patient deterioration and hospital admission and also those patients already admitted in hospital ICU and consulted other departments for symptoms of acute cholecystitis. Preoperative data and operative outcomes were analyzed. Results A total of 225 patients (median age68 years; range=57–91 years) were included. Overall, 28.9% (65 patients) underwent percutaneous cholecystostomy drainage (PCD), 34.2% (77 patients) underwent open cholecystectomy (OC), and 36.9% (83 patients) underwent laparoscopic cholecystectomy. The patients' demographics were comparable in all groups, except for age and BMI. Laparoscopic cholecystectomy was successful in 85.5% of patients. Nine patients in PCD group needed completion OC (13.8%). Preoperative comorbidities were similar in the studied groups. The postoperative infection was high in OC group (P=0.013). The overall mortality was 4%, with the highest value in the PCD group, and no significant difference was observed among all groups (0.197). Hospital and ICU stays were increased in the OC group (P=0.001). Conclusion Open and laparoscopic approaches are safe in critically ill patients and have comparable results to PCD. The advantage of disease eradication cannot be overlooked. The laparoscopic approach is better in the view of short hospital stay and infection rate. [ABSTRACT FROM AUTHOR]

Background: Emergency index-admission cholecystectomy (EIC) is recommended for acute cholecystitis in most cases. General surgeons have less exposure in managing "difficult" cholecystectomies. This study aimed to compare the outcomes of EIC between hepatopancreatobiliary (HPB) versus non-HPB surgeons., Methods: This is a 10-year retrospective audit on patients who underwent EIC from December 2011 to March 2022. Patients who underwent open cholecystectomy, had previous cholecystitis, previous endoscopic retrograde cholangiopancreatography or cholecystostomy were excluded. A 1:1 propensity score matching (PSM) was performed to adjust for confounding variables (e.g. age ≥ 75 years, history of abdominal surgery, presence of dense adhesions)., Results: There were 1409 patients (684 HPB cases, 725 non-HPB cases) in the unmatched cohort. Majority (52.3%) of them were males with a mean age of 59.2 ± 14.9 years. Among 472 (33.5%) patients with EIC performed ≥ 72 hours after presentation, 40.1% had dense adhesion. The incidence of any morbidity, open conversion, subtotal cholecystectomy and bile duct injury were 12.4%, 5.0%, 14.6% and 0.1%, respectively. There was one mortality within 30 days from EIC. PSM resulted in 1166 patients (583 per group). Operative time was shorter when EIC was performed by HPB surgeons (115.5 min vs. 133.4 min, P < 0.001). The mean length of hospital stay was comparable. EIC performed by HPB surgeons was independently associated with lower open conversion [odds ratio (OR)=  0.24, 95% confidence interval (CI): 0.12-0.49, P < 0.001], lower fundus-first cholecystectomy (OR=  0.58, 95% CI: 0.35-0.95, P=  0.032), but higher subtotal cholecystectomy (OR=  4.19, 95% CI: 2.24-7.84, P < 0.001). Any morbidity, bile duct injury and mortality were comparable between the two groups., Conclusion: EIC performed by HPB surgeons were associated with shorter operative time and reduced risk of open conversion. However, the incidence of subtotal cholecystectomy was higher., (Copyright © 2023 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Background and Objective: Acute cholecystitis (AC) is an inflammation of the gallbladder. Tokyo Guidelines (TGs) for the diagnosis of AC classified this condition according to severity as mild, moderate and severe. Therapeutic intervention regulated according to the type of severity. This study aimed to determine laboratory parameters that predict the severity of AC at hospital admission.Methods: One-hundred and ten patients with AC were retrospectively reviewed. These patients were treated in our department of surgery within a one-year period (2015-2016). Three patient groups were formed depending on the severity of Acute cholecystitis.Results: The baseline mean values for white blood cell count (WBC), blood urea nitrogen (BUN), creatinine and international normalized ratio (INR) were higher in the severe patient group at a significant level compared to the mild patient group. The WBC level was also significantly higher in the moderate group than the mild group. However, none of the laboratory parameters differentiated the severe group from the moderate group.Conclusion: Acute cholecystitis patients with high WBC, BUN, creatinine and INR levels at admission should be referred to an advanced care center for management. [ABSTRACT FROM AUTHOR]

Introduction: The revised Tokyo Guidelines include criteria for determining the severity of acute cholecystitis with treatment algorithms based on severity. The aim of this study was to investigate the relationship of the revised Tokyo Guidelines severity grade to clinical outcomes of cholecystectomy for acute cholecystitis.Methods: We identified 66 patients with acute cholecystitis from a prior study of difficult cholecystectomy cases. We examined the relationship between severity grade and multiple variables related to perioperative and postoperative outcomes.Results: A more severe revised Tokyo Guidelines grade was associated with a higher number of complications (p = 0.03) and a higher severity of complications (p = 0.01). Severity grade did not predict operative time, estimated blood loss, intensive care unit admission or length of stay. Compared to planned open cholecystectomy, intended laparoscopic cholecystectomy was associated with significantly fewer total and Clavien-Dindo grade 3 complications, fewer intensive care unit admissions, and shorter length of stay (p values range from 0.03 to < 0.0001).Conclusion: In technically difficult operations for acute cholecystitis, the revised Tokyo guidelines severity grade correlates with the number and severity of complications. However, intended performance of laparoscopic cholecystectomy rather than open cholecystectomy in difficult operations predicts broader beneficial outcomes than severity grade. [ABSTRACT FROM AUTHOR]

Aim: Acute calculous cholecystitis is a frequent complication of gallstones that can manifest in up to 10–15 per cent of previously asymptomatic patients. Current guidelines recommend laparoscopic cholecystectomy as the gold standard treatment; however, the presence of surgery risk factors might compel physicians to opt for conservative treatment, which is often associated with longer hospital stay. Home hospitalization could be an alternative to inpatient stay for these patients. Patients and Methods: The present study was a retrospective analysis of data from a prospective patient single‐centre registry. Data from 915 patients with mild or moderate acute calculous cholecystitis, who presented in the Department of General Surgery of our hospital between 2010 and 2015, were analysed. The variables included grade of acute cholecystitis, type of treatment, use of antibiotics, inpatient stay, stay in hospital‐at‐home, complications, mortality, readmissions and relapse. Results: A total of 147 (16 per cent) patients were referred to hospital‐at‐home, while the rest completed their treatment in the hospital ward. There were no significant differences between the home hospitalization and conventional hospitalization groups in the rates of complications, mortality, readmissions, relapse and length of antibiotherapy. Home hospitalization was associated with shorter inpatient stay, but longer total hospitalization, likely due to a prolonged follow up by the home care unit. Conclusions: Home hospitalization is an effective and safe alternative to conventional hospitalization, as it provides hospital‐level care and reduces the number of admissions and length of inpatient stay. The timely referral of patients to other levels of assistance, such as primary care, is needed to ensure economic benefits of home hospitalization programmes. [ABSTRACT FROM AUTHOR]

Objective: To determine the diagnostic accuracy of Tokyo guidelines (TG) 2018/2013 (TG18/TG13) and predictors of poor prognosis in acute cholangitis.Methods: Retrospective 1-year study of consecutive hospital admissions for acute cholangitis. Prognosis was defined in terms of 30 d in-hospital mortality.Results: Of the 183 patients with acute cholangitis, diagnostic accuracy based on Charcot’s triad, TG07 and TG18/TG13 was 67.8, 86.9 and 92.3% (p < .001), respectively. Regarding severity based on TG18/TG13, 30.6% of cases were severe. A poor prognosis was found in 10.9% of patients. After multivariate analysis, systolic blood pressure <90 mmHg (OR 11.010; p < .001), serum albumin <3 g/dL (OR 1.355; p = .006), active oncology disease (OR 3.818; p = .006) and malignant aetiology of obstructive jaundice (OR 2.224; p = .021) were independent predictors of poor prognosis. The discriminative ability of the model with these four variables was high (AUROC 0.842; p < .001), being superior to TG18/TG13 (AUROC 0.693; p = .005).Conclusions: TG18/TG13 showed high diagnostic accuracy in acute cholangitis. Compared with TG18/TG13, the simplified severity model ≥2 allows easy selection of patients who will benefit from admission to the intensive care unit and early biliary decompression. [ABSTRACT FROM AUTHOR]

The management of acute cholecystitis is still based on clinical expertise. This study aims to investigate whether the outcome of acute cholecystitis can be related to the severity criteria of the Tokyo guidelines and additional clinical comorbidities. A total of 103 patients with acute cholecystitis were retrospectively enrolled and their medical records were reviewed. They were all classified according to therapeutic modality, including early cholecystectomy and antibiotic treatment with or without percutaneous cholecystostomy. The impact of the Tokyo guidelines and the presence of comorbidities on clinical outcome were assessed by univariate and multivariate regression analyses. According to Tokyo severity grading, 48 patients were Grade I, 31 patients were Grade II, and 24 patients were Grade III. The Grade III patients had a longer hospital stay than Grade II and Grade I patients (15.2 days, 9.2 days, and 7.3 days, respectively, p

Objective: The aim of this study was to determine whether early laparoscopic cholecystectomy (LC) is safe and feasible for patients diagnosed with moderate (grade 2) and severe (grade 3) acute cholecystitis (AC) according to the Tokyo Guidelines 2013 (TG13). Background: Early cholecystectomy is the current accepted standard of care for patients with mild (grade 1) and selected grade 2 AC based on TG13. For selected grade 2 and grade 3 AC, early percutaneous cholecystostomy (PC) followed by delayed cholecystectomy is recommended. Methods: Patients diagnosed with AC over a 14-month period were identified and divided into three grades of AC based upon chart review using the grading and severity indicators according to TG13. Results: A total of 149 patients underwent emergency LC. Eighty-two (55 %) patients were male. Eighty-four (56.4 %) patients were classified as grade 1 AC, 49 (32.9 %) as grade 2, and 16 (10.7 %) as grade 3. Eighty-three (98.8 %) patients with grade 1 AC underwent emergency LC, and 1 patient (1.2 %) underwent PC followed by emergency LC. The median length of hospital stay for grade 1 AC patients was 2 (1-11) days. There were 2 (2.4 %) readmissions with fever and no additional complications. Among the 65 patients identified with grade 2 or 3 AC, 6 (9.2 %) underwent PC followed by emergency LC. Fifty-nine (90.8 %) patients underwent emergency cholecystectomy: 58 (98.3 %) LC and one (1.7 %) open cholecystectomy. Among the 58 patients with LC, 3 (5.2 %) patients had open conversion and 10 (17.2 %) patients required subtotal cholecystectomy. One patient was converted to open due to bile duct injury and had hepaticojejunostomy repair. Two other patients were converted due to dense adhesions and inability to safely dissect Calot's triangle. The median length of hospital stay was 4 (1-28) days. There was one readmission for ileus. Conclusion: Severity grading of AC is not the sole determinant of early LC. Patient comorbidity also impacts clinical decision. Confirmation in a larger cohort is warranted. [ABSTRACT FROM AUTHOR]

Background: We assess the performance of ultrasound (US) and hepatobiliary scintigraphy (HIDA) as confirmatory studies in acute cholecystitis (AC) and demonstrate our current imaging protocol's impact on outcomes. Study Design: Between January 2013 to July 2014, 117 patients were admitted through the emergency room with a preliminary diagnosis of AC. Overall, 106/117 (91%) of the patients received US preadmission and 34/117 (29%) received a HIDA post admission. Primary end points included: 1) diagnostic test reliability for AC, and 2) outcome and quality measures (time to surgery, LOS, costs, etc.). Results: Laparoscopic cholecystectomy was performed in 96/117 (82%) and open cholecystectomy in 21/117 (18%) of the patients. Overall, histopathologic features consistent with AC was present in 46/117 (39%). AC alone was present in 23/117 (20%), and AC superimposed on chronic cholecystitis was present in 23/117 (20%). For AC, US had a sensitivity and specificity of 26% and 80%, respectively. HIDA scan had a sensitivity and specificity of 87% and 79%, respectively. Time to surgery (TTS) was 4 vs 2.3 days in patients who received HIDA vs US alone (p = 0.001), and length of stay (LOS) was 6.7 vs 4.3 days, respectively (p = 0.001). Age >50 years, glucose >140 (mg/dl), and WBC count >10 (×109 /L) were statistically significant independent variables associated with AC. Conclusion: HIDA scan is superior to US as a diagnostic study in the setting of AC. Our current protocol of delayed HIDA (post-admission) was associated with increased TTS, LOS, and overall costs. Early confirmation with HIDA in high risk patients may hasten treatment allocation and improve outcomes in the setting of AC. [ABSTRACT FROM AUTHOR]