Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines

The aim of this article is to propose new criteria for the diagnosis and severity assessment of acute cholecystitis, based on a systematic review of the literature and a consensus of experts. A working group reviewed articles with regard to the diagnosis and treatment of acute cholecystitis and extracted the best current available evidence. In addition to the evidence and face-to-face discussions, domestic consensus meetings were held by the experts in order to assess the results. A provisional outcome statement regarding the diagnostic criteria and criteria for severity assessment was discussed and finalized during an International Consensus Meeting held in Tokyo 2006. Patients exhibiting one of the local signs of inflammation, such as Murphy's sign, or a mass, pain or tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. Patients in whom suspected clinical findings are confirmed by diagnostic imaging are also diagnosed with acute cholecystitis. The severity of acute cholecystitis is classified into three grades, mild (grade I), moderate (grade II), and severe (grade III). Grade I (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure. Grade II (moderate acute cholecystitis) is associated with no organ dysfunction but there is extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy. Grade II disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 h; and imaging studies indicating significant inflammatory changes in the gallbladder. Grade III (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.     

Double pathology in acute cholecystitis.

Three cases are described in which there was concurrent development of acute cholecystitis and a second acute abdominal illness. Acute cholecystitis occurred in patients with acute appendicitis, small bowell obstruction, and acute colonic diverticulitis. Experience with three such cases over the course of eight years by a single surgeon suggests a possible aetiological link between the two diseases. It is suggested that, under some circumstances, exploration of an acute abdomen may need to be more than cursory.     

Laparoscopic cholecystectomy in acute cholecystitis.

The experience of laparoscopic cholecystectomy in 79 patients with acute cholecystitis is described. This group is subdivided into acute and severe acute cholecystitis. These categories are defined. Six percent of our patients with acute disease and 30% of our patients with severe acute disease were converted to open cholecystectomy. Those patients who were converted to open cholecystectomy are discussed. The four port technique and decompression of the gallbladder is described. We conclude that acute cholecystitis should not be a contra-indication to the well-trained laparoscopic surgeon.     

Bile peritonitis in acute cholecystitis.

In a series of 20 patients with bile peritonitis seen during a 15-year period, 15 were men and 5 women, with an average of 72 years. They represented 1.8% of 1123 patients with acute cholecystitis admitted during the same period. Three patients were not operated upon and all died, while 5 of 17 operated patients died. The high mortality rate is due to a delay in diagnosis and treatment. Early operative treatment of acute cholecystitis should be resorted to whenever possible.     

Diagnostic ultrasonography in acute cholecystitis.

In a 12-month period 100 patients with clinical evidence of acute disease of the gallbladder were studied in hospital by grey-scale ultrasonography. During the same hospital admission it was possible to correlate results of ultrasonography with operative findings in 66 patients. In 52 patients the ultrasonographic diagnosis of gallstones was proved to be correct. There were no false-positive results. In seven patients the ultrasonographic report of a normal gallbladder without stones was also confirmed. In two patients, the report of a normal gallbladder without stones was erroneous. In two more patients the scan was indeterminate and stones were found at operation. In the remaining three patients echogenic material was reported and at operation minute stones and "sludge" were found. No complications resulted from the ultrasonography. The study showed that grey-scale ultrasonography is a reliable, rapid and safe technique for detecting gallstones in patients with a clinical diagnosis of acute cholecystitis.     

A study on the mechanism of the postoperative fall in serum iron concentration

The purpose of this study was to investigate the mechanism of the postoperative fall in serum iron concentration. Simultaneous measurements of iron uptake from, and release to, the plasma were made using two iron radioisotopes. Eight rabbits were submitted to laparotomy and eight were used as controls. Six hours after laparotomy, when the plasma iron concentration was decreasing, the clearance half-time from the plasma was decreased from 82.0 +/- 3.0 min in controls to 25.0 +/- 4.0 min (P less than 0.001) but the amount of iron uptake was increased from 0.289 +/- 0.013 to 0.574 +/- 0.092 mumole/liter blood/day (P less than 0.001). Twenty-four hours after laparotomy, when the plasma iron concentration was increasing, the half-time remained shortened in the operative group but the amount of iron uptake was decreased from 0.39 +/- 0.28 to 0.25 +/- 0.1 mumole/liter blood/day although this difference is not significantly different. At both times studied there was no difference in the amount of iron released to the plasma. These results suggest that the fall in iron concentration after surgery is due to increased uptake from the plasma.     

Laparoscopic treatment of acute cholecystitis.

Retrospective review of the first 210 patients treated by laparoscopic cholecystectomy revealed 55 patients (26%) with acute cholecystitis diagnosed preoperatively or intraoperatively. Average age was 52 years amongst 38 women and 17 men. Cardiac history was present in 4%, pulmonary disease was noted in 9%, and other significant medical history was found in 10%. Abnormal preoperative laboratory values (white blood cell count, liver function) were seen in 80%. Operations averaged 104 minutes. Dissection was performed with the potassium titanyl phosphate (KTP) laser in 9%, neodymium-doped yttrium aluminum garnet (Nd Yag) laser in 20%, and electrocautery alone in 71%. Average body habitus was 5 ft 9 in, 178 lb for men and 5 ft 5 in, 155 lb for women. Average length of stay was 2.6 days. Thirty-eight patients (69%) left the hospital in < 2 days. Postoperative complications included one case each of urinary retention, pneumonia, myocardial infarction, and three cases of postoperative fever. Drains were placed in 10 patients (18%). There was no mortality. Suggestions are made for technical considerations that make laparoscopic cholecystectomy a safe and efficient approach to acute cholecystitis.     

Laparoscopic surgery in very acute cholecystitis.

The objective of this study was to demonstrate the safety and feasibility of laparoscopic cholecystectomy in empyematous or gangrenous cholecystitis. During the period from August 1998 to April 2000, we operated laparoscopically on 64 patients, without any selection, in which we established, preoperatively or intraoperatively, the diagnosis of empyematous or gangrenous cholecystitis using clinical criteria (fever, leukocytosis, persistent pain, abdominal tenderness or guarding), echographic findings and intraoperative or pathological aspects of the gallbladder. The operations were performed by experienced surgeons skillful in advanced laparoscopic procedure. We concluded successfully 59 operations. The five conversions were due to dense adhesions because of previous gastric surgery in 3 cases, to the lack of recognizing the anatomy of the biliary tree in one case and to a choledoco-duodenal fistula in the last case. No mortality and a very low morbidity with a short hospital stay, were noted in our study. We consider patients with very acute cholecystitis to be candidates for a laparoscopic approach.     

Cholescintiscan or infusion cholecystography in acute cholecystitis. A prospective study

Two methods of diagnosing acute cholecystitis--cholescintigraphy and infusion cholecystography--were compared in a prospective study of 105 patients. Sensitivity and specificity were very high (96-99% and 91%, respectively), without difference between the two methods. Infusion cholecystography gave transient rise in liver enzyme levels in more than half of the patients. Cholescintigraphy gave no side effects. Cholescintiscan could be performed at moderately elevated bilirubin levels. It also gave information concerning liver malignancy in four patients. On these grounds, cholescintigraphy is the preferable of the two methods.     

The efficacy of laparoscopy in acute cholecystitis.

OBJECTIVE: To evaluate the role of laparoscopic cholecystectomy in acute cholecystitis and establish the outcomes of this treatment modality at North Oakland Medical Centers. METHODS: This was a retrospective analysis over a three-year period (January 1, 1994 to December 31, 1996), performed at a University-affiliated urban teaching hospital, North Oakland Medical Centers, Pontiac, Michigan. Five hundred and fifty-seven patients underwent surgical treatment for gallbladder disease; 88 patients had acute cholecystitis, and 469 patients had chronic cholecystitis. Acute cholecystitis patients underwent surgery within 72 hours of the onset of symptoms; the patient's selection for laparoscopic cholecystectomy or open cholecystectomy depended on severity of disease, co-morbid factors and surgeon's preference. The parameters of age, gender, operating (OR) time, length of stay, complications, conversion rates from laparoscopic cholecystectomy to open cholecystectomy, and cost were compared in patients who underwent laparoscopic cholecystectomy and/or open cholecystectomy. RESULTS: Patients chosen to undergo laparoscopic cholecystectomy for acute cholecystitis tended to be younger females. Patients treated with laparoscopic cholecystectomy for acute cholecystitis had shorter OR times and LOS compared to patients treated with open cholecystectomy for acute cholecystitis. Conversion rates (CR) were 22% in acute cholecystitis and 5.5% in chronic cholecystitis during the study period; CR diminished considerably between the first and third year. Complications were also lower in patients who underwent laparoscopic cholecystectomy vs. open cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a reliable, safe, and cost-effective treatment modality for acute cholecystitis; however, the surgical approach should be cautionary because of the spectrum of potential technical hazards. CR is improving as surgeons gain experience.     

Laparoscopic cholecystectomy for acute cholecystitis.

Sixty-eight cases of acute cholecystitis managed by laparoscopic cholecystectomy (LC) are reviewed. Thirty-two patients were admitted up to 10 days after onset of symptoms and 31 were completed by LC. One patient was referred from intensive care with gangrenous acalculus cholecystitis and was completed by LC but required subsequent laparotomy to control a bleeding omental vessel. Five patients were admitted with recurrent attacks of pain and histology confirmed resolving acute cholecystitis. Thirty patients had LC on routine operating lists, having recently had pain within 10 days of admission. Histology confirmed acute cholecystitis or resolving acute cholecystitis in these patients. All were completed by LC. Laparoscopic cholecystectomy is a very effective treatment for acute cholecystitis if complete dissection of anatomy can be performed.     

Choledocholithiasis associated with acute cholecystitis.

A retrospective review of the records of 1,507 patients with a diagnosis of cholecystitis was conducted for the five-year period, 1972 to 1977. Of this group of patients, a histopathologic diagnosis of acute cholecystitis was established in 154 patients (10.2%). Common duct calculi were detected in 17 of these 154 patients, an incidence of 11%. Preoperative evaluation by means of serum bilirubin and alkaline phosphatase levels and intravenous cholangiography was unsatisfactory for consistent demonstration of choledocholithiasis in the presence of acute cholecystitis. Intraoperative cholangiography was found to be the most reliable method for detection of common duct calculi and was successfully employed in 14 of 17 patients with choledocholithiasis. The remaining three patients had palpable stones.