Bellal Joseph1, Faisal Jehan2, Michael Dacey3, Narong Kulvatunyou2, Muhammad Khan2, Muhammad Zeeshan2, Lynn Gries2, Terence O'Keeffe2, Taylor S Riall3. 1. Division of Trauma, Critical Care, Emergency Surgery, and Burns, College of Medicine, University of Arizona, Tucson, AZ. Electronic address: bjoseph@surgery.arizona.edu. 2. Division of Trauma, Critical Care, Emergency Surgery, and Burns, College of Medicine, University of Arizona, Tucson, AZ. 3. Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
Abstract
BACKGROUND: The 2013 Tokyo Guidelines (TG13) are used to diagnose, grade severity, and guide management of acute cholecystitis (AC). The aim of our study was to verify the diagnostic criteria, severity assessment, and management protocols based on the TG13. STUDY DESIGN: Our prospectively maintained emergency general surgery registry was used to review patients who had a surgical consultation for right upper quadrant pain (from 2013 to 2015). Diagnosis and severity were graded based on TG13 and compared with pathology reports. Our institutional management protocols were compared with TG13. RESULTS: Nine hundred and fifty-two patients were analyzed, of which 857 had biliary diseases. Mean age was 42 ± 18 years and 67% were female. Seven hundred and seventy-nine had a cholecystectomy, 15 underwent cholecystostomy tube placement, and 63 patients were managed conservatively. Only 4% were febrile on presentation and 51% of patients had leukocytosis. Fifty-nine percent of patients did not have any signs of AC on ultrasonography. The TG13 criteria had a sensitivity of 53% for diagnosing AC (definitive 27%, suspected 26%, and undiagnosed 47%) when compared with the final pathology report; 92.5% of patients with grade I, 93% with grade II, and even 64% with grade III, underwent cholecystectomy safely at our institute. There were no differences in complication rates (3.7% vs 4.7%; p = 0.81), return to operating room rates (0.6% vs 0.7%; p = 0.95), or mortality rates (0.3% vs 0%; p = 0.96) between grade I and grade II patients who underwent early cholecystectomy. CONCLUSIONS: The TG13 diagnostic criteria lack sensitivity and missed more than half of the patients with AC, as many patients lack clinical signs (fever and leukocytosis). The TG13 recommendations for conservative management and delayed cholecystectomy in grade II and grade III disease are not warranted.
BACKGROUND: The 2013 Tokyo Guidelines (TG13) are used to diagnose, grade severity, and guide management of acute cholecystitis (AC). The aim of our study was to verify the diagnostic criteria, severity assessment, and management protocols based on the TG13. STUDY DESIGN: Our prospectively maintained emergency general surgery registry was used to review patients who had a surgical consultation for right upper quadrant pain (from 2013 to 2015). Diagnosis and severity were graded based on TG13 and compared with pathology reports. Our institutional management protocols were compared with TG13. RESULTS: Nine hundred and fifty-two patients were analyzed, of which 857 had biliary diseases. Mean age was 42 ± 18 years and 67% were female. Seven hundred and seventy-nine had a cholecystectomy, 15 underwent cholecystostomy tube placement, and 63 patients were managed conservatively. Only 4% were febrile on presentation and 51% of patients had leukocytosis. Fifty-nine percent of patients did not have any signs of AC on ultrasonography. The TG13 criteria had a sensitivity of 53% for diagnosing AC (definitive 27%, suspected 26%, and undiagnosed 47%) when compared with the final pathology report; 92.5% of patients with grade I, 93% with grade II, and even 64% with grade III, underwent cholecystectomy safely at our institute. There were no differences in complication rates (3.7% vs 4.7%; p = 0.81), return to operating room rates (0.6% vs 0.7%; p = 0.95), or mortality rates (0.3% vs 0%; p = 0.96) between grade I and grade II patients who underwent early cholecystectomy. CONCLUSIONS: The TG13 diagnostic criteria lack sensitivity and missed more than half of the patients with AC, as many patients lack clinical signs (fever and leukocytosis). The TG13 recommendations for conservative management and delayed cholecystectomy in grade II and grade III disease are not warranted.
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Authors: Michele Pisano; Niccolò Allievi; Kurinchi Gurusamy; Giuseppe Borzellino; Stefania Cimbanassi; Djamila Boerna; Federico Coccolini; Andrea Tufo; Marcello Di Martino; Jeffrey Leung; Massimo Sartelli; Marco Ceresoli; Ronald V Maier; Elia Poiasina; Nicola De Angelis; Stefano Magnone; Paola Fugazzola; Ciro Paolillo; Raul Coimbra; Salomone Di Saverio; Belinda De Simone; Dieter G Weber; Boris E Sakakushev; Alessandro Lucianetti; Andrew W Kirkpatrick; Gustavo P Fraga; Imitaz Wani; Walter L Biffl; Osvaldo Chiara; Fikri Abu-Zidan; Ernest E Moore; Ari Leppäniemi; Yoram Kluger; Fausto Catena; Luca Ansaloni Journal: World J Emerg Surg Date: 2020-11-05 Impact factor: 5.469