as days oass if not operate on the beggining of the onset of acute cholecistitis, a flegmon and fibrosis will appear that will transform in a difficult surgery. Is that correct? Should it interfere in the guideline? Antibiotics must be offered to the patients imediately after the diagnosis?
Congratulations
Emilio
In New Zealand, we start iv antibiotics (Cefuroxime, Metronidazole) in emergency department in patients with suspected acute cholecystitis. After the diagnosis is confirmed by upper abdominal US or abdominal CT scan patients are booked for acute or emergency cholecystectomy. Priority for operation theatre depends on patients' clinical presentation, inflammatory markers and results of US and CT scan. Patients with dramatic improvement in their conditions following antibiotic therapy, iv fluids and analgesia are discharged from hospitals and referred to elective cholecystectomy in 5-6 weeks. Non-responders and patients with severe cholecystitis (gangrenous, perforated acute cholecystitis, etc) are operated during the index hospital admission. Patients with recurrent episodes of acute cholecystitis (who have acute on chronic cholecystitis on histological examination of excised gallbladders) are at increased risk of conversion of laparoscopic cholecystectomy to open surgery when compared to patients with histologic chronic cholecystitis. However, their risk of conversion to open surgery is less then in those with histologic moderate-severe acute cholecystitis. In our paper "Histologic classification of severity of acute cholecystitis that has been submitted for publication we proposed to include histologic acute on chronic cholecystitis into clinical classification of acute cholecystitis severity. In addition, we have found that inflammatory markers such as CRP, neutrophil-to-lymphocyte ratio, neutrophil and lymphocyte counts have good discriminative powers in predicting histologic severity of acute cholecystitis. Unfortunately, WCC has relatively poor discriminative power in predicting severity of gallbladder inflammation.
According to guidelines and in my opionio, antibiotics should be started promptly and everything should be done in order to perform cholecystectomy during the index admission (within 10 days from the admission), avoiding a late cholecystectomy 5-6 weeks later.
I think the best way to management a cholecystitis is in "Cold period", but if it is resistant from conservative treatment and re-acutisation form is often, is correct to operate as soon as possible
Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.
I totally agree with your comments. It is better to operate early rather than later or repeatedly treat acute cholecystitis with antibiotics. TG13 for acute cholecystitis do not recognize acute on chronic cholecystitis as a histologic variant of acute cholecystitis that is associated with an increased risk of conversion of laparoscopic cholecystectomy to open surgery.
Dear colleagues.
It is pretty clarified, when and how to operate pts with acute cholecystitis (WSES guidelines 2016, TG07, TG 13 and ets.). Tactics always depends on: severity of physiologic condition of the patient, and severity of the inflamation (TG07). Timing and type of procedure (WSES 2016, statement 5,1 and 5,2). We also should keep in mind "difficult LCE" (WSES 2016, statements 6,1-5). Operative grading system had been stated in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4394404/pdf/13017_2015_Article_5.pdf
Sincerely.
For a long time, the concept that the recommended timing for acute cholecystitis treatment is surgery within 48 to 72 hours of the onset of the disease. Generally, however, the patient comes to hospital almost always after a few days from the onset of the symptoms, so in these cases an antibiotic and infusion therapy is recommended. Only if there is no response to the therapy you can think of performing a surgical procedure.
In our opinion, acute calculous cholecystitis should be operated as early as possible from the onset of the disease. With the late treatment of the patient, the optimal period of the operation is the first four days. Every subsequent day increases the risk of conversion, although it was possible to perform laparoscopic cholecystectomy and on the tenth day from the onset of the disease.
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