Does the Tokyo guidelines predict the extent of gallbladder inflammation in patients with acute cholecystitis? A single center retrospective analysis

Role of intraoperative indocyanine green roadmap as a safety measure in emergent laparoscopic cholecystectomy

Acute cholecystitis is a growing pathology, with high surgical risk due to the related patients' comorbidity. The gold standard treatment is laparoscopic cholecystectomy, which, despite its high volume, still presents elevated rates of biliary tract injury. Standardization of the procedure and accurate identification of the anatomical structures of the biliary tree are the key in avoiding severe complications associated with this injury. Innovation in minimally invasive technologies, such as infrared indocyanine green as a radiotracer to delimit the biliary anatomy, could reduce the rate of biliary tract lesions. A single-center case-control study was conducted, including patients undergoing emergency surgery between November 2023 and November 2024 for acute cholecystitis (Tokyo Guidelines 2018 criteria). Eighty-seven patients were allocated into two groups: emergency laparoscopic cholecystectomy with or without intraoperative indocyanine green cholangiography. The primary aim was to evaluate ICG's impact on reducing bile duct injury. Secondary outcomes included operative time, hospital stay, and conversion rates. The mean operative time (93 min vs. 104.6 min, p = 0.087), ASA scale (p = 0.302) and Charlson comorbidity index (2.55 vs. 2.84; p = 0.58) were not significantly different when comparing both groups. The control group showed duplicated preoperative CRP values as compared to the ICG group (138.24 mg/l vs. 71.02 mg/l; p = 0.06), and a higher median hospital stay (5 days ± 3 vs. 3 days ± 1.75; p = 0.001). The control group showed a greater need for conversion to open surgery (14.3% vs. 0%; p = 0.015). Trends towards fewer bile duct injuries (0% vs. 4.1%; p = 0.208) and fewer complications (15.87% vs. 18.4%; p = 0.752) in the ICG group were not statistically significant. The use of ICG may reduce the need for conversion to open surgery and median hospital stay. However, its use has not been proven to reduce bile duct injury, postoperative complications, or operative time.

The role of serum and urıne neopterın levels on the determınatıon of acute cholecystıtıs severıty

OBJECTIVE

Acute cholecystitis (AC) is one of the most common causes of hospital admissions due to abdominal pain. Early diagnosis and prompt initiation of treatment positively impact morbidity and mortality in AC. The aim of our study was to determine serum and urine concentrations of additional biomarkers at different stages of the disease, beyond those currently used in acute cholecystitis severity staging, and to evaluate their potential inclusion as new staging parameters.

METHODS

This study prospectively analyzed data from 63 patients diagnosed with acute cholecystitis and treated by the same surgical team in 2020. In patients with AC, WBC, CRP, and PCT values, as outlined in the TG18 guidelines, showed an increasing trend. These values are commonly used to determine disease stage.

RESULTS

A correlated increase in these infectious parameters was observed as disease severity progressed. The mean S-NEO value in Stage 1-2 patients was 20.082 ± 9.517 nmol/L, while the mean U-NEO value was 3.46 ± 2.95 µmol/L. In Stage 3 patients, the mean S-NEO value was 40.92 ± 7.878 nmol/L, and the mean U-NEO value was 4.4 ± 2.42 µmol/L. The Mann-Whitney U test revealed a significant difference in S-NEO values between Stage 1-2 and Stage 3 groups (p < 0.001). However, no significant difference was observed between these groups in terms of U-NEO values (p = 0.18).

CONCLUSION

In patients with acute cholecystitis, S-NEO and U-NEO levels can serve as complementary biomarkers alongside existing diagnostic and staging parameters. Particularly in staging severity, S-NEO levels may play a crucial role in early diagnosis and timely initiation of treatment, given their high specificity and sensitivity at defined cut-off values.

Combining preoperative C-reactive protein values with the Tokyo Guidelines 2018 grading criteria can enhance the prediction of surgical difficulty in early laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Early laparoscopic cholecystectomy (ELC) is the standard treatment for acute cholecystitis (AC). However, predicting the difficulty of this procedure remains challenging. The present study aimed to develop an improved prediction model for surgical difficulty during ELC, surpassing the current Tokyo Guidelines 2018 (TG18) grading system.

METHODS

We analyzed data from 201 consecutive patients who underwent ELC for AC between 2019 and 2021. Surgical difficulty was defined as the failure to achieve the critical view of safety (non-CVS). We developed a scoring system by conducting multivariate analysis on demographics, symptoms, laboratory data, and radiographic findings. The predictive accuracy of our scoring system was compared to that of the TG18 grading system (Grade I vs. Grade II/III).

RESULTS

Through multivariate logistic regression analysis, a novel scoring system was formulated. This system incorporated preoperative C-reactive protein (CRP) values (≥5: 1 pt, ≥10: 2 pts, ≥15: 3 pts) and TG18 grading score (duration >72 h: 1 pt, image criteria for Grade II AC: 1 pt). Our model, a cutoff score of ≥3, exhibited a significantly elevated area under the curve (AUC) of 0.721 compared to the TG18 grading system alone (AUC 0.609) (p = 0.001).

CONCLUSION

Combining preoperative CRP values with TG18 grading criteria can enhance the accuracy of predicting intraoperative difficulty in ELC for AC.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I

INTRODUCTION

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

AIM

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

MATERIAL AND METHODS

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

RESULTS AND CONCLUSIONS

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis

BACKGROUND

Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances.

METHODS

We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed.

RESULTS

2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114 min vs 79 min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independent risk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC.

CONCLUSIONS

Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.

Intraoperative holography navigation using a mixed-reality wearable computer during laparoscopic cholecystectomy

BACKGROUND

Mixed-reality technology, a new digital holographic image technology, is used to present 3-dimensional (3D) images in the surgical space using a wearable mixed-reality device. This study aimed to assess the safety and efficacy of laparoscopic cholecystectomy using a holography-guided navigation system as an intraoperative support image.In this prospective observational study, 27 patients with cholelithiasis or mild cholecystitis underwent laparoscopic cholecystectomy between April 2020 and November 2020. Nine patients underwent laparoscopic cholecystectomy with 3D models generated by a wearable mixed-reality device (laparoscopic cholecystectomy with 3D models) and 18 underwent laparoscopic cholecystectomy with conventional two-dimensional images (laparoscopic cholecystectomy with 2D images) as surgical support images. Surgical outcomes such as operative time, blood loss, and perioperative complication rate were measured, and a four-item questionnaire was used for subjective assessment. All surgeries were performed by a mid-career and an experienced surgeon.

RESULTS

Median operative times of laparoscopic cholecystectomy with 3-dimensional models and 2-dimensional images were 74.0 and 58.0 minutes, respectively. No intraoperative blood loss or perioperative complications occurred. Although the midcareer surgeon indicated that laparoscopic cholecystectomy with 3-dimensional models was "normal" or "easy" compared with 2-dimensional images in all cases, the experienced surgeon rated 3-dimensional models as more difficult in 3 (33%) of 9 cases.

CONCLUSION

This study provides evidence that laparoscopic cholecystectomy with 3-dimensional models is feasible. However, the efficacy of laparoscopic cholecystectomy with 3-dimensional models may depend on the surgeon's experience, as indicated by the different ratings provided by the surgeons.

Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis

Previous studies have shown that signal intensity variations in the gallbladder wall on magnetic resonance imaging (MRI) are associated with necrosis and fibrosis in the gallbladder of acute cholecystitis (AC). However, the association between MRI findings and operative outcomes remains unclear. We retrospectively identified 321 patients who underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and early laparoscopic cholecystectomy (LC) for AC. Based on the gallbladder wall signal intensity on MRI, these patients were divided into high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI) groups. Comparisons of bailout procedure rates (open conversion and laparoscopic subtotal cholecystectomy) and operating times were performed. The recorded bailout procedure rates were 6.8% (7/103 cases), 26.7% (31/116 cases), and 40.2% (41/102 cases), and the median operating times were 95, 110, and 138 minutes in the HSI, ISI, and LSI groups, respectively (both p < 0.001). During the multivariate analysis, the LSI of the gallbladder wall was an independent predictor of both the bailout procedure (odds ratio [OR] 5.30; 95% CI 2.11–13.30; p < 0.001) and prolonged surgery (≥144 min) (OR 6.10, 95% CI 2.74–13.60, p < 0.001). Preoperative MRCP/MRI assessment could be a novel method for predicting surgical difficulty during LC for AC.

Risk Factors of Postoperative Complications in Laparoscopic Cholecystectomy for Acute Cholecystitis

Introduction:

There are often cases with postoperative complications after laparoscopic cholecystectomy (LC), resulting in severe consequences. This study aimed to identify potential risk factors of postoperative complications in cases of LC for acute cholecystitis.

Materials and Methods:

A total of 423 patients with cholecystitis underwent LC. We divided the patients into two groups: group without postoperative complications (Group A) and group with postoperative complications (Group B). Pre-operative findings, surgical findings, and the methods for evaluating the risk of peri-operative complications were compared between the two groups with a univariate analysis. Independent risk factors of postoperative complications were then evaluated in a multivariate analysis with the factors shown to be statistically significant in the univariate analysis.

Results:

A Physiological and Operative severity Score for enUmeration of Mortality and morbidity (POSSUM) of ≥ 48.3 and moderate or severe cholecystitis were independent risk factors of postoperative complications in LC.

Conclusions:

This study indicated that POSSUM morbidity and moderate or severe cholecystitis were potential risk factors of postoperative complications. The pre-operative management of the general condition and cholecystitis using antibiotics, infusion, percutaneous transhepatic gallbladder drainage, and other approaches may be significant for the prevention of postoperative complications. Once the POSSUM morbidity reaches the threshold after LC, postoperative management becomes difficult, so strict control of the general condition should be performed.

Validity of the Glasgow prognostic score and modified systemic inflamma-tion score in predicting complicated cholecystitis

BACKGROUND

Complicated cholecystitis (CC) is the severe form of acute cholecystitis (AC). Clinical, radiological, inflammatory, or biochemical parameters are used to predict presence of CC. We aimed to evaluate the Glasgow prognostic (GPS) and modified systemic inflammation scores (mSIS) that are used to predict presence of CC.

METHODS

We retrospectively analyzed data from patients who underwent AC surgery from January 2014 to August 2019. Collected information included age, gender, length of stay (LOS), pathology [as CC or uncomplicated (UCC)], albumin, C-reactive protein (CRP), white blood cells (WBC), and neutrophils (NEU) results. The lymphocyte-to-monocyte ratio (LMR) was calculated. The GPS was calculated using CRP and albumin levels, and mSIS was calculated using LMR and albumin levels, and it was scored from 0 to 2.

RESULTS

Among the 593 hospitalized patients, 217 patients underwent AC surgery and were included in the study. Among them, 40.1 % of the patients had CC, 53.4 % were male, and the mean age was 51.76 ± 13.8 years. LOS was significantly longer for CC compared to UCC (p =0.018). Four patients died from CC (1.8 %). The mean CRP, WBC, and NEU levels were not different CC compared to UCC (p =0.821, p =0.84, and p =0.196, respectively). The cut-off values for CC were 103.54 mg/L, 15.18 ×10⁶/μL, and 11.79 ×10³/μL, respectively. GPS and mSIS were significantly higher in CC compared to UCC (p =0.008, p =0.022, respectively).

CONCLUSION

CRP, WBC, and NEU could be used to predict presence of CC. The combination of CRP or LMR with albumin could be a positive but weak predictor of CC, and it is quick, easy to use, and reliable. HIPPOKRATIA 2020, 24(1): 15-20.

Operative complications and economic outcomes of cholecystectomy for acute cholecystitis

BACKGROUND

Recent management of acute cholecystitis favors same admission (SA) or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings. We adopted the practice of SA cholecystectomy for the treatment of acute cholecystitis at our tertiary care center and wanted to evaluate the economic benefit of this practice. We hypothesized that the existence of complications, particularly among patients with a higher degree of disease severity, during SA cholecystectomy could negate the cost savings.

AIM

To compare complication rates and hospital costs between SA vs delayed cholecystectomy among patients admitted emergently for acute cholecystitis.

METHODS

Under an IRB-approved protocol, complications and charges for were obtained for SA, later after conservative management (Delayed), or elective cholecystectomies over an 8.5-year period. Patients were identified using the acute care surgery registry and billing database. Data was retrieved via EMR, operative logs, and Revenue Cycle Operations. The severity of acute cholecystitis was graded according to the Tokyo Guidelines. TG18 categorizes acute cholecystitis by Grades 1, 2, and 3 representing mild, moderate, and severe, respectively. Comparisons were analyzed with χ², Fisher’s exact test, ANOVA, t-tests, and logistic regression; significance was set at P < 0.05.

RESULTS

Four hundred eighty-six (87.7%) underwent a SA while 68 patients (12.3%) received Delayed cholecystectomy. Complication rates were increased after SA compared to Delayed cholecystectomy (18.5% vs 4.4%, P = 0.004). The complication rates of patients undergoing delayed cholecystectomy was similar to the rate for elective cholecystectomy (7.4%, P = 0.35). Mortality rates were 0.6% vs 0% for SA vs Delayed. Patients with moderate disease (Tokyo 2) suffered more complications among SA while none who were delayed experienced a complication (16.1% vs 0.0%, P < 0.001). Total hospital charges for SA cholecystectomy were increased compared to a Delayed approach ($44500 ± $59000 vs $35300 ± $16700, P = 0.019). The relative risk of developing a complication was 4.2x [95% confidence interval (CI): 1.4-12.9] in the SA vs Delayed groups. Among eight patients (95%CI: 5.0-12.3) with acute cholecystitis undergoing SA cholecystectomy, one patient will suffer a complication.

CONCLUSION

Patients with Tokyo Grade 2 acute cholecystitis had more complications and increased hospital charges when undergoing SA cholecystectomy. This data supports a selective approach to SA cholecystectomy for acute cholecystitis.

Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters

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.

The delta neutrophil index is an early predictive marker of severe acute cholecystitis

BACKGROUND

Predicting severe acute cholecystitis (SAC) is important because the mortality rate is higher for patients with SAC than for non-SAC (NSAC) patients. We evaluated the predictive value of the delta neutrophil index (DNI), which is greater in patients with infectious and inflammatory conditions, for SAC among patients in the emergency department (ED).

METHODS

This retrospective observational study included 379 consecutive adult patients with AC admitted to the ED from January 2015 to December 2016. The included patients were classified into 2 groups (NSAC and SAC) according to the Tokyo Guidelines 2018. White blood cell (WBC) count, C-reactive protein (CRP) levels, and DNI values were assessed at ED admission.

RESULTS

The SAC group contained 28 patients (7.4%). DNI was among the early predictors of SAC and was an inflammatory marker with a significantly higher predictive value than WBC count or CRP level for detecting SAC. The predictive power of DNI was significantly higher than that of CRP when used in conjunction with WBC count, abdominal computed tomography, and clinical variables.

CONCLUSIONS

DNI measured at ED admission may serve as an early predictor of SAC.

Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations

BACKGROUND

Early laparoscopic cholecystectomy (LC) is advocated in patients with an acute biliary presentation but may require some precaution. We aimed to assess the intra-operative difficulty of cholecystectomy in patients who underwent early intervention, and to establish a prediction model for a 'complicated' LC.

METHODS

Retrospective analysis of prospectively collected data from patients presenting to the emergency department with acute biliary symptoms, and who subsequently underwent early LC between 2015 and 2018. Operative difficulty was assessed by standardized grading of intra-operative findings (grades 1-4). Pre-operative predictors for a 'complicated' LC (grades 3/4) were assessed using univariable and multivariable logistic regression analysis. A prediction model was created using variable regression coefficients. Cut-off and accuracy of the model were assessed using a receiver operating characteristic curve.

RESULTS

A total of 185 patients were included and 59% presented with acute cholecystitis. In this cohort 113 (61%) patients underwent a 'complicated' LC. A prediction model for a 'complicated' LC (0-4.5 points) included: clinical diagnosis of acute cholecystitis (2 points), C-reactive protein >10.5 mg/L (1.5 points) and pericholecystic fluid on pre-operative imaging (1 point). A score ≥2.5 had a sensitivity of 77.7%, specificity of 81.7% and positive and negative predictive values of 87.0% and 69.9%, respectively.

CONCLUSION

Early LC may be 'complicated' in up to 60% of cases. The presented prediction model uses readily available information in the emergency department and is a simple but accurate way to predict a likely 'complicated' LC in patients with acute biliary presentations.

An Acute General Surgical Unit (AGSU) Negates the Impact of the Tokyo Guidelines 2018 (TG18) Diagnostic Criteria for the Treatment of Acute Cholecystitis

PURPOSE

The Tokyo Guidelines 2018 (TG18) were developed to aid diagnosis and treatment for acute cholecystitis. The benefits of being treated in an acute general surgical unit (AGSU) include earlier diagnosis and treatment. This study aims to define the usefulness of TG18 before and after the introduction of AGSU.

METHODOLOGY

Patients who underwent cholecystectomy at Northern Health were audited retrospectively and assessed for TG18 diagnostic criteria and outcomes between 1 February 2012 and 1 February 2014 (one-year pre- and post-AGSU).

RESULTS

Five hundred and eighty-seven patients underwent emergency cholecystectomy with 203 (34.6%) patients having a suspected diagnosis, and 234 (39.9%) patients with a definitive diagnosis of acute cholecystitis using TG18 diagnostic criteria. After the introduction of AGSU, time from imaging to operation improved from 2.5 to 1.7 days (p = 0.012). There were more operations occurring during in-hours following AGSU implementation (75.8% vs. 62.7%, p < 0.001). Maximum pre-operative CRP of >26.6 mg/L had a higher likelihood of Clavien-Dindo complication grade 3 or 4 (OR 3.86, 95%CI 1.18-12.63, p = 0.027) compared with TG18 definitive diagnosis criteria (OR 1.50, 95%CI 0.46-4.91, p = 0.501). Surprisingly, there was a trend towards higher complications and readmissions for patients operated within 24 h, although this trend was not significant.

CONCLUSION

Patients with suspected acute cholecystitis should be stratified clinically and with CRP in an AGSU with TG18 adding little value in a busy metropolitan unit.

GI Surgical Emergencies: Scope and Burden of Disease

Nearly 3 million patients are hospitalized every year for emergent gastrointestinal (GI) surgical problems and nearly one third of those will require surgery. This article reviews the scope of GI surgical emergencies within the context of emergency general surgery (EGS), costs of care, overview of several common GI surgical problems, and traditional and emerging treatment modalities. This article also argues for ongoing work in the area of risk assessment for EGS, and describes quality metrics as well as outcomes of care for these patients.

Can we predict severity of acute cholecystitis at admission?

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.

Frequency-selective non-linear blending for the computed tomography diagnosis of acute gangrenous cholecystitis: Pilot retrospective evaluation

Purpose

To compare the diagnostic performance of frequency-selective non-linear blending and conventional linear blending contrast-enhanced CT for the diagnosis of acute (AC) and gangrenous (GC) cholecystitis.

Materials and methods

Following local ethics committee approval for retrospective data analysis, a database search derived 39 patients (26 men, mean age 67.8 ± 14.6 years) with clinical signs of acute cholecystitis, contrast enhanced CT (CECT) evaluation, cholecystectomy, and pathological examination of the resected specimen. The interval between CECT and surgery was 4.7 ± 4.1 days. Pathological gross examination was used to categorize the cases into AC and GC. Subsequently, two radiologists categorized the CECT studies in a blinded and independent fashion into AC and GC, during two different reading sessions using linear blending and frequency-selective non-linear blending CECT.

Results

Histologic analysis diagnosed 31/39 (79.4%) cases of GC and 8/39 (20.6%) cases of AC. Image interpretation of linear blending CECT resulted in classification of 7/39 (17.9%) patients as GC and 32/39 (82.1%) as AC, whereas image interpretation of frequency-selective non-linear blending CECT resulted in classification of 29/39 (74.3%) patients as GC and 10/39 (25.7%) as AC. Sensitivity/specificity/PPV/NPV for detection of GC were 22.6%/100%/100%/25% with linear blending CECT and 80.6%/50%/86.2%/40% with frequency-selective non-linear blending CECT, respectively. Based on the histopathologic diagnosis frequency-selective non-linear blending had a significant improvement (p > 0.0001) in the diagnostic accuracy of gangrenous cholecystitis compared with linear blending.

Conclusion

Frequency-selective non-linear blending post-processing increases the diagnostic accuracy of gangrenous cholecystitis owing to improved visualization of absence of focal enhancement and mural ulcerations.

Acute cholecystitis: comparing clinical outcomes with TG13 severity and intended laparoscopic versus open cholecystectomy in difficult operative cases

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.

Advanced gallbladder inflammation is a risk factor for gallbladder perforation in patients with acute cholecystitis

Background

Acute perforated cholecystitis (APC) is probably the most severe benign gallbladder pathology with high rates of morbidity and mortality. The cause of APC has not been fully understood. We postulated that APC is a complication of advanced gallbladder inflammation. The aim of this study was to investigate the extent of gallbladder inflammation in patients with APC.

Methods

Patients with intraoperative and histopathologic diagnosis of APC were compared with cases with acute cholecystitis without perforation with respect to the extent of inflammation on histopathology as well as surgical outcomes.

Results

Fifty patients with APC were compared to 150 cases without perforation. Advanced age > 65 years and elevated CRP were confirmed on multivariate analysis as independent risk factors for APC. Advanced gallbladder inflammation was seen significantly more often in patients with APC (84.0 vs. 18.7%). Surgery lasted significantly longer 131.3 ± 55.2 min vs. 100.4 ± 47.9 min; the rates of conversion (22 vs. 4%), morbidity (24 vs. 7%), and mortality (8 vs. 1%) were significantly higher in patients with APC. ICU management following surgery was needed significantly more often in the APC group (56 vs. 15%), and the overall length of stay (11.2 ± 12.0 days vs. 5.8 ± 6.5 days) was significantly longer compared to the group without perforation.

Conclusion

Acute gallbladder perforation in patients with acute cholecystitis represents the most severe complication of cholecystitis. Acute perforated cholecystitis is a sequela of advanced gallbladder inflammation like empyematous and gangrenous cholecystitis and is associated with poor outcome compared to non-perforated cases.

The Treatment of Critically Ill Patients With Acute Cholecystitis

BACKGROUND

Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However, solid evidence on the benefit of PC in this subgroup of patients is lacking.

METHODS

In accordance with the PRISMA guidelines for systematic reviews, we systematically searched the Cochrane Library, CINAHL, MEDLINE, Embase, and Scopus for relevant studies published between 2000 and 2014. Two investigators independently screened the studies included.

RESULTS

Six studies with a total of 337 500 patients (PC 10 045, CC 327 455) were included for meta-analysis. Significant differences in favor of CC were recorded with regard to the rate of mortality (OR 4.28, [1.72 to 10.62], p = 0.0017), length of hospital stay (OR 1.41, [1.02 to 1.95], p = 0.04), and the rate of readmission for biliary complaints (OR 2.16, [1.72 to 2.73], p<0.0001). There was no statistically significant difference between both intervention arms with regard to complications (OR 0.74, [0.36 to 1.53], p = 0.42) and re-interventions (OR 7.69, [0.68 to 87.33], p = 0.10).

CONCLUSION

The benefit of percutaneous cholecystostomy (PC) over cholecystectomy (CC) in the management of critically ill patients with acute cholecystitis could not be proven in this systematic review.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines

BACKGROUND

Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes.

METHODS

Adults (≥18 years) with acute cholecystitis during 2013-2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30-day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics.

RESULTS

There were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0-6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68).

CONCLUSION

Emergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos)

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Postoperative Complications of Laparoscopic Cholecystectomy for Acute Cholecystitis: A Comparison to the ACS-NSQIP Risk Calculator and the Tokyo Guidelines

BACKGROUND

We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS.

METHODS

A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed.

RESULTS

ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes.

CONCLUSION

ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.

Descriptive review of acute cholecystitis: Japan-Taiwan collaborative epidemiological study

BACKGROUND

Since the publication of the Tokyo Guidelines (TG13) for the management of acute cholecystitis (AC), multidirectional studies have been published. However, epidemiological research about AC with big data was not projected. The aim of this study was to reveal the actual clinical conditions of AC.

METHOD

The study was designed as an international multicenter retrospective study of AC in Japan and Taiwan from 2011 to 2013. The factors investigated comprised data related to demographic, history, physical examinations, laboratory and imaging findings. Based on these data, we investigated the various values of AC, and real situation with respect to severity and treatment.

RESULTS

A total of 5,459 patients with AC were reviewed. Thirty-day mortality rate was 1.1%. Based on the diagnostic criteria, 4,088 patients had a definite diagnosis and 291 had a suspected diagnosis. According to the severity grading, 939 patients were classified as Grade III, 2,308 as Grade II, and 2,130 as Grade I. Cholecystectomy was performed in total of 4,266 patients and 2,765 patients had laparoscopic cholecystectomy. The main etiologies were gallbladder stones in 4,623 cases.

CONCLUSION

This epidemiological study with large population will undoubtedly contribute to establish the best practice for managing AC worldwide.

Validation of TG13 severity grading in acute cholecystitis: Japan-Taiwan collaborative study for acute cholecystitis

BACKGROUND

The collaborative multicenter retrospective study of acute cholecystitis (AC) was performed in Japan and Taiwan. The aim for this study was evaluation of the clinical value of TG13 severity grading for AC.

METHOD

The study was designed as an international multicenter retrospective study of AC from 2011 to 2013. Based on the data, we investigated the TG13 severity grading by analyzing the correlations between grade and prognosis, surgical procedures, histopathology, and organ dysfunction and prognosis.

RESULTS

An investigation revealed that 30-day overall mortality rate was 1.1% for Grade I, 0.8% for Grade II, 5.4% for Grade III. The mortality rate for Grade III was significantly higher than lower grades (P < 0.001). The greater the number of organ dysfunction, the higher the mortality rate (P < 0.001). However, the mortality rate varied depending on the number of organ dysfunction (3.1-25%). With respect to the surgical procedures, laparoscopic cholecystectomy was performed for Grade I patients (P < 0.001), and the higher the grade, the more likely open surgery would be selected (P < 0.001).

CONCLUSION

TG13 severity grading criteria for AC are providing great benefits in actual clinical settings. From this study, the position of each severity grade was obviously confirmed.

Evaluating the timing of laparoscopic cholecystectomy for acute cholecystitis in an experienced center based on propensity score matching

INTRODUCTION

This study evaluates the therapeutic outcomes for laparoscopic cholecystectomy for acute cholecystitis based on the time from symptom onset to surgery.

METHODS

This study enrolled 224 patients. Patients' characteristics and operative outcomes were compared between patient groups based on the timing of laparoscopic cholecystectomy from symptom onset: ≤72 h versus >72 h, and ≤7 days versus ≥8 days. Then, we performed propensity score matching of 13 relevant variables, including patient demographics, examination findings, and therapeutic factors.

RESULTS

The early surgery groups (≤72 h and ≤7 days) had significantly younger patients with fewer comorbidities and a shorter duration from symptom onset to presentation before performed propensity score matching. These groups also had shorter surgery, postoperative hospital stay, and total length of stay. Other operative outcomes, including blood loss, conversion to open surgery, bile duct injury, and postoperative complications, did not significantly differ among the groups. After propensity score matching, all therapeutic outcomes, including duration of surgery, showed no significant differences in either analysis.

CONCLUSIONS

In a center with sufficient experience, performing laparoscopic cholecystectomy at the earliest possible time after presentation was a safe therapeutic strategy for each patient with acute cholecystitis, regardless of the time from symptom onset.

The Difficult Gallbladder: A Safe Approach to a Dangerous Problem

Laparoscopic cholecystectomy is a common surgical procedure, and remains the gold standard for the management of benign gallbladder and biliary disease. While this procedure can be technically straightforward, it can also represent one of the most challenging operations facing surgeons. This dichotomy of a routine operation performed so commonly that poses such a hidden risk of severe complications, such as bile duct injury, must keep surgeons steadfast in the pursuit of safety. The "difficult gallbladder" requires strict adherence to the Culture of Safety in Cholecystectomy, which promotes safety first and assists surgeons in managing or avoiding difficult operative situations. This review will discuss the management of the difficult gallbladder and propose the use of subtotal fenestrating cholecystectomy as a definitive option during this dangerous situation.

Outcome of acute perforated cholecystitis: a register study of over 5000 cases from a quality control database in Germany

BACKGROUND

Acute perforated cholecystitis (APC) is probably the most severe complication of acute cholecystitis. However, data on the outcome of cholecystectomy for APC are limited to small series. This study investigated the outcomes of cholecystectomy for APC.

METHODS

Data from a prospectively maintained quality control database in Germany were analyzed. Cases with APC were compared to cases without gallbladder perforation with regard to demographic characteristics, clinical findings and surgical outcomes.

RESULTS

A total of 5704 patients with APC were compared to 39,661 patients without perforation. Risk factors for APC included: the male gender, advanced age (>65 years), ASA score >2, elevated white blood count (WBC), positive findings on abdominal ultrasound sonography and fever. The APC group differed significantly from the control group with regard to fever (29.8 vs. 12.2 %), elevated WBC (83.8 vs. 65.4 %) and positive findings from ultrasound sonography (84.9 vs. 78.9 %), p < 0001. Preoperative computed tomography (CT) was ordered significantly more often in the APC group compared to the control group (2.3 vs. 1.0 %, p = 0.001). Surgery lasted significantly longer in the APC group (92.3 ± 40.8 vs. 73.7 ± 34.1, p < 0.001). The rates of conversion (18.9 vs. 6.8 %), bile duct injury (1.4 vs. 0.5 %), re-intervention (6.9 vs. 2.9 %) and mortality (4.3 vs. 1.3 %) were significantly higher in the APC group (p < 0.001). Similarly, the length of stay (13.4 ± 11.4 vs. 9.0 ± 8.3, p < 0.001) was significantly longer in the APC group.

CONCLUSION

Acute perforated cholecystitis is a severe complication of acute cholecystitis. Surgical dissection could be challenging with high risks of bile duct injury and conversion. The rates of morbidity and mortality are higher compared to those of patients without perforation.

What is the fate of the cholecystostomy tube following percutaneous cholecystostomy?

INTRODUCTION

Cholecystectomy is the preferred treatment for acute cholecystitis with percutaneous cholecystostomy (PC) considered an alternative therapy in severely debilitated patients. The aim of this study was to evaluate the efficacy and outcomes of PC at a tertiary referral center.

METHODS

We retrospectively reviewed all patients that had undergone PC from 2000 to 2014. Data collected included baseline demographics, comorbidities, details of PC placement and management, and post-procedure outcomes. The Charlson comorbidity index (CCI) was calculated for all patients at the time of PC.

RESULTS

Four hundred and twenty-four patients underwent PC placement from 2000 to 2014, and a total of 380 patients had long-term data available for review. Within this cohort, 223 (58.7 %) of the patients were male. The mean age at the time of PC placement was 65.3 ± 14.2 years of age, and the mean CCI was 3.2 ± 2.1 for all patients. One hundred and twenty-five (32.9 %) patients went on to have a cholecystectomy following PC placement. Comparison of patients who underwent PC followed by surgical intervention revealed that they were significantly younger (p = 0.0054) and had a lower CCI (p < 0.0001) compared to those who underwent PC alone.

CONCLUSIONS

PC placement appears to be a viable, long-term alternative to cholecystectomy for the management of biliary disease in high-risk patients. Old and frail patients benefit the most, and in this cohort PC may be the definitive treatment.

Aquaporin-1 and 8 expression in the gallbladder mucosa might not be associated with the development of gallbladder stones in humans

BACKGROUND

Cholecystolithiasis is a highly prevalent condition in the Western world. Gallbladder stone-related conditions represent the second most common gastrointestinal pathology. Cholesterol stones represent over 80% of gallstones. Cholesterol stones develop secondary to crystallization of bile cholesterol. Water resorption from gallbladder bile via aquaporin in the gallbladder mucosa might play a role in the development of cholesterol stones. This study investigated the expression of Aquaporin-1 (AQP1) and Aquaporin-8 (AQP8) in the human gallbladder mucosa and their possible association with the formation of gallbladder stones.

METHODS

The expression of AQP1 and AQP8 in the gallbladder mucosa was examined via immunohistochemical staining. The expression of both AQP1 and AQP8 in the gallbladder mucosa of stone carriers (study group) was compared to that of nonstone carriers (control group).

RESULTS

Eighty-four gallbladder specimens from 44 male (52·2%) and 40 female (47·6%) patients were analysed. The study group included 47 specimens from stone carriers, while 37 specimens from stone-free gallbladders were included in the control group. Immunostaining for both AQP1 and AQP8 was positive in 80 cases. AQP1 was expressed both over the apical and intercellular membrane, while AQP8 was expressed only over the apical membrane. A similar distribution was recorded in specimens from the cystic duct. Immunostaining with AQP1 was generally stronger in comparison with AQP8. No significant (P > 0·05) relationship was found between aquaporin expression and the presence or absence of gallbladder stones.

CONCLUSION

AQP1 and AQP8 are both expressed in the gallbladder and cystic duct mucosa. However, their role in the development of gallbladder stones is still to be proven.

Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation

Background

Acute cholecystitis is a common diagnosis and surgery is the standard of care for young and fit patients. However, due to high risk of postoperative morbidity and mortality, surgical management of critically ill patients remains a controversy. It is not clear, whether the increased risk of perioperative complications associated with the management of critically ill patients with acute cholecystitis is secondary to reduced physiologic reserve per se or to the severity of gallbladder inflammation.

Methods

A retrospective analysis of prospectively collected data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital over a three-year-period was performed. The ASA scores at the time of presentation were used to categorize patients into two groups. The study group consisted of critically ill patients with ASA 3 and 4, while the control group was made up of fit patients with ASA 1 and 2. Both groups were compared with regard to perioperative data, postoperative outcome and extent of gallbladder inflammation on histopathology.

Results

Two hundred and seventeen cases of acute cholecystitis with complete charts were available for analysis. The study group included 67 critically ill patients with ASA 3 and 4, while the control group included 150 fit patients with ASA 1 and 2. Both groups were comparable with regard to perioperative data. Histopathology confirmed severe cholecystitis in a significant number of cases in the study group compared to the control group (37 % vs. 18 %, p = 0.03). Significantly higher rates of morbidity and mortality were recorded in the study group (p < 0.05). Equally, significantly more patients from the study group were managed in the ICU (40 % vs. 8 %, p = 0.001).

Conclusion

Critically ill patients presenting with acute cholecystitis are at increased risk for extensive gallbladder inflammation. The increased risk of morbidity and mortality seen in such patients might partly be secondary to severe acute cholecystitis.