Ostre zapalenie pęcherzyka żółciowego – Rokowania, prognozy i postęp choroby

Ostre zapalenie pęcherzyka żółciowego
Rokowania, prognozy i postęp choroby

Ostre zapalenie pęcherza żółciowego (OZP) jest najczęstszym powikłaniem kamicy żółciowej i wymaga szybkiej interwencji chirurgicznej, zwłaszcza w przypadkach martwicy, ropnia czy rozedmy pęcherza. Rokowanie jest generalnie lepsze niż w ostrym zapaleniu dróg żółciowych, jednak nieleczone OZP może prowadzić do powikłań takich jak perforacja, sepsa i zapalenie otrzewnej, z śmiertelnością sięgającą 65%. Całkowita śmiertelność wynosi około 3,6%, a wyższe ryzyko obserwuje się u pacjentów w wieku ≥80 lat oraz z chorobami współistniejącymi. Laparoskopowa cholecystektomia, główna metoda leczenia, wiąże się z 6-9% ryzykiem poważnych powikłań i 0,1-1% ryzykiem śmiertelności. Wskaźnik ACME (obejmujący POChP, demencję, wiek ≥80 lat i konieczność stosowania amin wazoaktywnych) pozwala przewidzieć śmiertelność z dokładnością 92%, przewyższając klasyfikację według Wytycznych Tokijskich.

Prognoza ostrego zapalenia pęcherza żółciowego

Przebieg naturalny choroby
Wskaźniki śmiertelności
Czynniki ryzyka śmiertelności
Wpływ metody leczenia na rokowanie

Ocena ciężkości i modele predykcyjne

Klasyfikacja według Wytycznych Tokijskich
Inne modele predykcyjne

Wnioski i zalecenia

Kolejne rozdziały

Prognoza ostrego zapalenia pęcherza żółciowego

Ostre zapalenie pęcherza żółciowego (OZP) jest najczęstszym powikłaniem kamicy żółciowej i drugą najczęstszą przyczyną interwencji chirurgicznych w oddziałach ratunkowych. ¹² Pomimo że rokowanie w OZP jest generalnie lepsze niż w ostrym zapaleniu dróg żółciowych, stan ten wymaga szybkiej interwencji, zwłaszcza w przypadkach skrętu pęcherza żółciowego oraz jego odmian martwiczych, ropnych lub z rozedmą. ³

Przebieg naturalny choroby

W około 85% przypadków, ostre zapalenie pęcherza żółciowego zaczyna ustępować po 2-3 dniach i całkowicie ustępuje w ciągu tygodnia, nawet bez leczenia. ⁴ Jednakże u około 10% nieleczonych pacjentów rozwijają się powikłania miejscowe, takie jak perforacja ograniczona lub wolna, prowadząca do zapalenia otrzewnej. ⁵ Nieleczone OZP może szybko postępować do martwicy i perforacji pęcherza żółciowego, prowadząc do sepsy, wstrząsu i zapalenia otrzewnej, gdzie śmiertelność może sięgać nawet 65%. ⁶

Wskaźniki śmiertelności

Całkowita śmiertelność w przebiegu ostrego zapalenia pęcherza żółciowego wynosi około 3,6%, przy czym wyższa śmiertelność jest związana z podeszłym wiekiem (mediana 83 lata) oraz wyższym wskaźnikiem chorób współistniejących Charlsona. ⁷ W niedawnym badaniu S.P.Ri.M.A.C.C. odnotowano 30-dniową śmiertelność na poziomie 1,1% oraz 30-dniową chorobowość (poważne powikłania) na poziomie 6,6%. ⁸ Laparoskopowa cholecystektomia, która jest głównym sposobem leczenia OZP, wiąże się z 6-9% ryzykiem poważnych powikłań oraz 0,1-1% ryzykiem śmiertelności. ⁹

Czynniki ryzyka śmiertelności

Model regresji logistycznej wykazał cztery główne czynniki ryzyka śmiertelności w OZP, tworzące tak zwany wskaźnik ACME (Acute Cholecystitis Mortality Estimation):

Przewlekła obturacyjna choroba płuc (POChP) – (OR 4,66; 95% CI 1,7-12,8; P=0,001)
Demencja – (OR 4,12; 95% CI 1,34-12,7; P=0,001)
Wiek ≥80 lat – (OR 1,12; 95% CI 1,02-1,21; P=0,001)
Konieczność stosowania amin wazoaktywnych przed operacją – (OR 9,9; 95% CI 3,5-28,3; P=0,001)

¹⁰

Wskaźnik ACME pozwolił dokładnie przewidzieć śmiertelność w 92% przypadków, co jest lepszym wynikiem niż klasyfikacja według Wytycznych Tokijskich. ¹¹

Wpływ metody leczenia na rokowanie

Wybór metody leczenia ma istotny wpływ na rokowanie. Śmiertelność u pacjentów poddanych początkowo leczeniu nieoperacyjnemu była sześciokrotnie wyższa niż u tych, którzy otrzymali leczenie chirurgiczne. ¹² Cholecystektomia metodą otwartą wiązała się z 20-krotnie wyższą śmiertelnością w porównaniu do podejścia laparoskopowego (20% vs 1%; P=0,001). ¹³ Cholecystektomia całkowicie leczy ostre zapalenie pęcherza żółciowego i uśmierza ból żółciowy. ¹⁴

W przypadkach, gdy zabieg operacyjny musi być opóźniony z powodu ciężkich chorób współistniejących (np. choroby sercowo-płucnej lub ciężkiej choroby wątroby), które zwiększają ryzyko operacyjne, istnieje możliwość przeprowadzenia cholecystektomii po 6 tygodniach od ustąpienia ostrego zapalenia. Należy jednak pamiętać, że opóźniona operacja niesie ze sobą ryzyko nawracających powikłań żółciowych. ¹⁵

Ocena ciężkości i modele predykcyjne

Klasyfikacja według Wytycznych Tokijskich

Wytyczne Tokijskie (Tokyo Guidelines, TG) klasyfikują ciężkość ostrego zapalenia pęcherza żółciowego na trzy stopnie:

Ciężkie (stopień III): ostre zapalenie pęcherza żółciowego związane z dysfunkcją narządów
Umiarkowane (stopień II): ostre zapalenie pęcherza żółciowego związane z trudnościami w wykonaniu cholecystektomii z powodu miejscowego stanu zapalnego
Łagodne (stopień I): ostre zapalenie pęcherza żółciowego niespełniające kryteriów dla ciężkiego lub umiarkowanego zapalenia

¹⁶

Progresja ostrego zapalenia pęcherza żółciowego z formy łagodnej/umiarkowanej do ciężkiej oznacza rozwój zespołu niewydolności wielonarządowej (MODS). ¹⁷ Do oceny dysfunkcji narządów u krytycznie chorych pacjentów stosuje się czasami skale dysfunkcji narządów, takie jak skala niewydolności wielonarządowej Marshalla (MOD) i skala sekwencyjnej oceny niewydolności narządów (SOFA). ¹⁸

Śmiertelność pacjentów z ciężkim zapaleniem pęcherza żółciowego (stopień III według TG18) była dziewięciokrotnie wyższa niż u pacjentów z łagodnym zapaleniem. ¹⁹ Na podstawie badań o wysokim ryzyku błędu systematycznego, TG13 stopień 3 ciężkości może być związany z większą śmiertelnością niż stopień 1. ²⁰

Inne modele predykcyjne

W badaniu S.P.Ri.M.A.C.C. zwalidowano zewnętrznie model Chole-risk, jednak stwierdzono, że CHOLE-POSSUM jest dokładniejszym modelem predykcyjnym. ²¹ CHOLE-POSSUM okazał się niezawodnym narzędziem do stratyfikacji pacjentów z OZP na grupę niskiego ryzyka, która może być bezpiecznym kandydatem do wczesnej cholecystektomii, oraz grupę wysokiego ryzyka, gdzie nowe minimalnie inwazyjne techniki endoskopowe mogą znaleźć najużyteczniejsze zastosowanie. ²²

Przeanalizowane skale wydają się przewidywać śmiertelność z wysoką dokładnością, podczas gdy ich skuteczność w przewidywaniu poważnej chorobowości jest ogólnie niższa. ²³ Badanie określiło POSSUM PS jako najlepszy istniejący model predykcji ryzyka powikłanego przebiegu po wczesnej cholecystektomii u pacjentów z OZP, z najlepszą wartością graniczną dla wyboru pacjentów wysokiego ryzyka wynoszącą 25. ²⁴

Wnioski i zalecenia

Wczesna diagnoza ostrego zapalenia pęcherza żółciowego umożliwia szybkie leczenie i zmniejsza zarówno śmiertelność, jak i chorobowość. ²⁵ W przypadku pacjentów z ciężkim OZP (stopień III według TG) należy rozważyć wczesne skierowanie do specjalistycznych ośrodków o dużej przepustowości. ²⁶

Istnieje znaczna niepewność co do zdolności czynników prognostycznych i modeli przewidywania ryzyka w prognozowaniu wyników u osób z ostrym kamiczym zapaleniem pęcherza żółciowego. ²⁷ Konieczne są dalsze dobrze zaprojektowane badania prospektywne, aby lepiej określić czynniki ryzyka i opracować bardziej precyzyjne modele przewidywania rokowania w OZP. ²⁸

Skuteczne zarządzanie ryzykiem w ostrym zapaleniu pęcherza żółciowego, identyfikacja pacjentów wysokiego ryzyka i odpowiednie dobieranie metod leczenia mają kluczowe znaczenie dla poprawy rokowania i zmniejszenia śmiertelności w tej powszechnej chorobie chirurgicznej.

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Materiały źródłowe

#1 Acute Cholecystitis – Hepatic and Biliary Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
Acute cholecystitis is the most common complication of cholelithiasis. […] Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients, even without treatment. […] Without treatment, patients can develop localized or free perforation and peritonitis. […] Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%. […] Although acute cholecystitis resolves spontaneously in 85% of patients, localized perforation or another complication develops in 10%. […] Cholecystectomy cures acute cholecystitis and relieves biliary pain. […] Surgery may be delayed when patients have an underlying severe chronic disorder (eg, cardiopulmonary disease or severe liver disease) that increases the surgical risks. […] If cholecystitis resolves, cholecystectomy may be done 6 weeks later. Delayed surgery carries the risk of recurrent biliary complications.
#2 Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-021-00368-x
Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. The overall mortality was 3.6%. Mortality was associated with older age (68 +IQR 27 vs. 83 +IQR 5.5; P= 0.001) and higher Charlson Comorbidity Index (3.5 +5.3 vs. 0 +2; P= 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.712.8 P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7, P= 0.001), age 80 years (OR 1.12: 95% CI 1.021.21, P= 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.528.3, P = 0.001) which predicted the mortality in a 92% of the patients. Mortality was higher in ACC patients treated with non-surgical treatment. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. The mortality rate of patients with severe cholecystitis (grade III of the TG18) was nine times greater than that of patients with mild cholecystitis. Patients with an initial NST experienced a mortality six times higher than those with initial ST. The open cholecystectomy approach was followed by a 20-fold higher mortality than the laparoscopic cholecystectomy approach (20% vs. 1%; P= 0.001). A multivariate model predicting mortality, the acute cholecystitis mortality estimation (ACME), retained a set of four variables: COPD (OR 4.66; 95% CI 1.712.8; P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7; P= 0.001), age 80 years (OR 1.12; 95% CI 1.021.21; P= 0.001), and preoperative vasoactive amines (OR 9.9; 95% CI 3.528.3; P = 0.001), which accurately predicted mortality in 92% of cases. The model retained a set of four variables which accurately predicted mortality better than the TG classification. The mortality risk score ACME could promptly identify the high-risk patient with ACC in our population.
#3 Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines
https://pmc.ncbi.nlm.nih.gov/articles/PMC2784516/
Early diagnosis of acute cholecystitis allows prompt treatment and reduces both mortality and morbidity. […] Acute cholecystitis has a better prognosis than acute cholangitis, but may require immediate management, especially in patients with torsion of the gallbladder and emphysematous, gangrenous, or suppurative cholecystitis. […] Acute cholecystitis has a better outcome/prognosis than acute cholangitis but requires prompt treatment if gangrenous cholecystitis, emphysematous cholecystitis, or torsion of the gallbladder are present. […] The progression of acute cholecystitis from the mild/moderate to the severe form means the development of the multiple organ dysfunction syndrome (MODS). […] Organ dysfunction scores, such as Marshalls multiple organ dysfunction (MOD) score, and the sequential organ failure assessment (SOFA) score, are sometimes used to evaluate organ dysfunction in critically ill patients.
#4 Acute Cholecystitis – Hepatic and Biliary Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
Acute cholecystitis is the most common complication of cholelithiasis. […] Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients, even without treatment. […] Without treatment, patients can develop localized or free perforation and peritonitis. […] Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%. […] Although acute cholecystitis resolves spontaneously in 85% of patients, localized perforation or another complication develops in 10%. […] Cholecystectomy cures acute cholecystitis and relieves biliary pain. […] Surgery may be delayed when patients have an underlying severe chronic disorder (eg, cardiopulmonary disease or severe liver disease) that increases the surgical risks. […] If cholecystitis resolves, cholecystectomy may be done 6 weeks later. Delayed surgery carries the risk of recurrent biliary complications.
#5 Acute Cholecystitis – Hepatic and Biliary Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
Acute cholecystitis is the most common complication of cholelithiasis. […] Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients, even without treatment. […] Without treatment, patients can develop localized or free perforation and peritonitis. […] Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%. […] Although acute cholecystitis resolves spontaneously in 85% of patients, localized perforation or another complication develops in 10%. […] Cholecystectomy cures acute cholecystitis and relieves biliary pain. […] Surgery may be delayed when patients have an underlying severe chronic disorder (eg, cardiopulmonary disease or severe liver disease) that increases the surgical risks. […] If cholecystitis resolves, cholecystectomy may be done 6 weeks later. Delayed surgery carries the risk of recurrent biliary complications.
#6 Acute Cholecystitis – Hepatic and Biliary Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
Acute cholecystitis is the most common complication of cholelithiasis. […] Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients, even without treatment. […] Without treatment, patients can develop localized or free perforation and peritonitis. […] Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%. […] Although acute cholecystitis resolves spontaneously in 85% of patients, localized perforation or another complication develops in 10%. […] Cholecystectomy cures acute cholecystitis and relieves biliary pain. […] Surgery may be delayed when patients have an underlying severe chronic disorder (eg, cardiopulmonary disease or severe liver disease) that increases the surgical risks. […] If cholecystitis resolves, cholecystectomy may be done 6 weeks later. Delayed surgery carries the risk of recurrent biliary complications.
#7 Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-021-00368-x
Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. The overall mortality was 3.6%. Mortality was associated with older age (68 +IQR 27 vs. 83 +IQR 5.5; P= 0.001) and higher Charlson Comorbidity Index (3.5 +5.3 vs. 0 +2; P= 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.712.8 P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7, P= 0.001), age 80 years (OR 1.12: 95% CI 1.021.21, P= 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.528.3, P = 0.001) which predicted the mortality in a 92% of the patients. Mortality was higher in ACC patients treated with non-surgical treatment. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. The mortality rate of patients with severe cholecystitis (grade III of the TG18) was nine times greater than that of patients with mild cholecystitis. Patients with an initial NST experienced a mortality six times higher than those with initial ST. The open cholecystectomy approach was followed by a 20-fold higher mortality than the laparoscopic cholecystectomy approach (20% vs. 1%; P= 0.001). A multivariate model predicting mortality, the acute cholecystitis mortality estimation (ACME), retained a set of four variables: COPD (OR 4.66; 95% CI 1.712.8; P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7; P= 0.001), age 80 years (OR 1.12; 95% CI 1.021.21; P= 0.001), and preoperative vasoactive amines (OR 9.9; 95% CI 3.528.3; P = 0.001), which accurately predicted mortality in 92% of cases. The model retained a set of four variables which accurately predicted mortality better than the TG classification. The mortality risk score ACME could promptly identify the high-risk patient with ACC in our population.
#8 Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-023-00488-6
A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. […] The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. […] CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action. […] The analyzed scores seem to predict mortality with high accuracy, while they showed, in general, lower performances in predicting major morbidity. […] The CHOLE-POSSUM could be considered an excellent tool to select patients with ACC that can be safe candidates for EC without, ideally, a risk of postoperative mortality and with an acceptable risk of major complications. […] The study has defined the best existing risk prediction model for a complicated course after EC in patients with ACC as the POSSUM PS, with the best cutoff to select high-risk patients to be 25.
#9 Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis of Prognostic Factors and Predictive Models – PubMed
https://pubmed.ncbi.nlm.nih.gov/32716737/
Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%-9% risk of major complications and 0.1%-1% risk of mortality. […] We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. […] There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary.
#10 Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-021-00368-x
Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. The overall mortality was 3.6%. Mortality was associated with older age (68 +IQR 27 vs. 83 +IQR 5.5; P= 0.001) and higher Charlson Comorbidity Index (3.5 +5.3 vs. 0 +2; P= 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.712.8 P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7, P= 0.001), age 80 years (OR 1.12: 95% CI 1.021.21, P= 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.528.3, P = 0.001) which predicted the mortality in a 92% of the patients. Mortality was higher in ACC patients treated with non-surgical treatment. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. The mortality rate of patients with severe cholecystitis (grade III of the TG18) was nine times greater than that of patients with mild cholecystitis. Patients with an initial NST experienced a mortality six times higher than those with initial ST. The open cholecystectomy approach was followed by a 20-fold higher mortality than the laparoscopic cholecystectomy approach (20% vs. 1%; P= 0.001). A multivariate model predicting mortality, the acute cholecystitis mortality estimation (ACME), retained a set of four variables: COPD (OR 4.66; 95% CI 1.712.8; P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7; P= 0.001), age 80 years (OR 1.12; 95% CI 1.021.21; P= 0.001), and preoperative vasoactive amines (OR 9.9; 95% CI 3.528.3; P = 0.001), which accurately predicted mortality in 92% of cases. The model retained a set of four variables which accurately predicted mortality better than the TG classification. The mortality risk score ACME could promptly identify the high-risk patient with ACC in our population.
#11 Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-021-00368-x
Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. The overall mortality was 3.6%. Mortality was associated with older age (68 +IQR 27 vs. 83 +IQR 5.5; P= 0.001) and higher Charlson Comorbidity Index (3.5 +5.3 vs. 0 +2; P= 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.712.8 P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7, P= 0.001), age 80 years (OR 1.12: 95% CI 1.021.21, P= 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.528.3, P = 0.001) which predicted the mortality in a 92% of the patients. Mortality was higher in ACC patients treated with non-surgical treatment. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. The mortality rate of patients with severe cholecystitis (grade III of the TG18) was nine times greater than that of patients with mild cholecystitis. Patients with an initial NST experienced a mortality six times higher than those with initial ST. The open cholecystectomy approach was followed by a 20-fold higher mortality than the laparoscopic cholecystectomy approach (20% vs. 1%; P= 0.001). A multivariate model predicting mortality, the acute cholecystitis mortality estimation (ACME), retained a set of four variables: COPD (OR 4.66; 95% CI 1.712.8; P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7; P= 0.001), age 80 years (OR 1.12; 95% CI 1.021.21; P= 0.001), and preoperative vasoactive amines (OR 9.9; 95% CI 3.528.3; P = 0.001), which accurately predicted mortality in 92% of cases. The model retained a set of four variables which accurately predicted mortality better than the TG classification. The mortality risk score ACME could promptly identify the high-risk patient with ACC in our population.
#12 Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-021-00368-x
Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. The overall mortality was 3.6%. Mortality was associated with older age (68 +IQR 27 vs. 83 +IQR 5.5; P= 0.001) and higher Charlson Comorbidity Index (3.5 +5.3 vs. 0 +2; P= 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.712.8 P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7, P= 0.001), age 80 years (OR 1.12: 95% CI 1.021.21, P= 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.528.3, P = 0.001) which predicted the mortality in a 92% of the patients. Mortality was higher in ACC patients treated with non-surgical treatment. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. The mortality rate of patients with severe cholecystitis (grade III of the TG18) was nine times greater than that of patients with mild cholecystitis. Patients with an initial NST experienced a mortality six times higher than those with initial ST. The open cholecystectomy approach was followed by a 20-fold higher mortality than the laparoscopic cholecystectomy approach (20% vs. 1%; P= 0.001). A multivariate model predicting mortality, the acute cholecystitis mortality estimation (ACME), retained a set of four variables: COPD (OR 4.66; 95% CI 1.712.8; P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7; P= 0.001), age 80 years (OR 1.12; 95% CI 1.021.21; P= 0.001), and preoperative vasoactive amines (OR 9.9; 95% CI 3.528.3; P = 0.001), which accurately predicted mortality in 92% of cases. The model retained a set of four variables which accurately predicted mortality better than the TG classification. The mortality risk score ACME could promptly identify the high-risk patient with ACC in our population.
#13 Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-021-00368-x
Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. The overall mortality was 3.6%. Mortality was associated with older age (68 +IQR 27 vs. 83 +IQR 5.5; P= 0.001) and higher Charlson Comorbidity Index (3.5 +5.3 vs. 0 +2; P= 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.712.8 P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7, P= 0.001), age 80 years (OR 1.12: 95% CI 1.021.21, P= 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.528.3, P = 0.001) which predicted the mortality in a 92% of the patients. Mortality was higher in ACC patients treated with non-surgical treatment. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. The mortality rate of patients with severe cholecystitis (grade III of the TG18) was nine times greater than that of patients with mild cholecystitis. Patients with an initial NST experienced a mortality six times higher than those with initial ST. The open cholecystectomy approach was followed by a 20-fold higher mortality than the laparoscopic cholecystectomy approach (20% vs. 1%; P= 0.001). A multivariate model predicting mortality, the acute cholecystitis mortality estimation (ACME), retained a set of four variables: COPD (OR 4.66; 95% CI 1.712.8; P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7; P= 0.001), age 80 years (OR 1.12; 95% CI 1.021.21; P= 0.001), and preoperative vasoactive amines (OR 9.9; 95% CI 3.528.3; P = 0.001), which accurately predicted mortality in 92% of cases. The model retained a set of four variables which accurately predicted mortality better than the TG classification. The mortality risk score ACME could promptly identify the high-risk patient with ACC in our population.
#14 Acute Cholecystitis – Hepatic and Biliary Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
Acute cholecystitis is the most common complication of cholelithiasis. […] Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients, even without treatment. […] Without treatment, patients can develop localized or free perforation and peritonitis. […] Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%. […] Although acute cholecystitis resolves spontaneously in 85% of patients, localized perforation or another complication develops in 10%. […] Cholecystectomy cures acute cholecystitis and relieves biliary pain. […] Surgery may be delayed when patients have an underlying severe chronic disorder (eg, cardiopulmonary disease or severe liver disease) that increases the surgical risks. […] If cholecystitis resolves, cholecystectomy may be done 6 weeks later. Delayed surgery carries the risk of recurrent biliary complications.
#15 Acute Cholecystitis – Hepatic and Biliary Disorders – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
Acute cholecystitis is the most common complication of cholelithiasis. […] Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 week in 85% of patients, even without treatment. […] Without treatment, patients can develop localized or free perforation and peritonitis. […] Untreated, the disease can rapidly progress to gallbladder gangrene and perforation, leading to sepsis, shock, and peritonitis; mortality approaches 65%. […] Although acute cholecystitis resolves spontaneously in 85% of patients, localized perforation or another complication develops in 10%. […] Cholecystectomy cures acute cholecystitis and relieves biliary pain. […] Surgery may be delayed when patients have an underlying severe chronic disorder (eg, cardiopulmonary disease or severe liver disease) that increases the surgical risks. […] If cholecystitis resolves, cholecystectomy may be done 6 weeks later. Delayed surgery carries the risk of recurrent biliary complications.
#16 Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines
https://pmc.ncbi.nlm.nih.gov/articles/PMC2784516/
The Guidelines classify the severity of acute cholecystitis into three grades: severe (grade III): acute cholecystitis associated with organ dysfunction, moderate (grade II): acute cholecystitis associated with difficulty to perform cholecystectomy due to local inflammation, and mild (grade I): acute cholecystitis which does not meet the criteria of severe or moderate acute cholecystitis. […] Severe acute cholecystitis is associated with organ dysfunction.
#17 Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines
https://pmc.ncbi.nlm.nih.gov/articles/PMC2784516/
Early diagnosis of acute cholecystitis allows prompt treatment and reduces both mortality and morbidity. […] Acute cholecystitis has a better prognosis than acute cholangitis, but may require immediate management, especially in patients with torsion of the gallbladder and emphysematous, gangrenous, or suppurative cholecystitis. […] Acute cholecystitis has a better outcome/prognosis than acute cholangitis but requires prompt treatment if gangrenous cholecystitis, emphysematous cholecystitis, or torsion of the gallbladder are present. […] The progression of acute cholecystitis from the mild/moderate to the severe form means the development of the multiple organ dysfunction syndrome (MODS). […] Organ dysfunction scores, such as Marshalls multiple organ dysfunction (MOD) score, and the sequential organ failure assessment (SOFA) score, are sometimes used to evaluate organ dysfunction in critically ill patients.
#18 Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines
https://pmc.ncbi.nlm.nih.gov/articles/PMC2784516/
Early diagnosis of acute cholecystitis allows prompt treatment and reduces both mortality and morbidity. […] Acute cholecystitis has a better prognosis than acute cholangitis, but may require immediate management, especially in patients with torsion of the gallbladder and emphysematous, gangrenous, or suppurative cholecystitis. […] Acute cholecystitis has a better outcome/prognosis than acute cholangitis but requires prompt treatment if gangrenous cholecystitis, emphysematous cholecystitis, or torsion of the gallbladder are present. […] The progression of acute cholecystitis from the mild/moderate to the severe form means the development of the multiple organ dysfunction syndrome (MODS). […] Organ dysfunction scores, such as Marshalls multiple organ dysfunction (MOD) score, and the sequential organ failure assessment (SOFA) score, are sometimes used to evaluate organ dysfunction in critically ill patients.
#19 Mortality risk estimation in acute calculous cholecystitis: beyond the Tokyo Guidelines | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-021-00368-x
Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. The overall mortality was 3.6%. Mortality was associated with older age (68 +IQR 27 vs. 83 +IQR 5.5; P= 0.001) and higher Charlson Comorbidity Index (3.5 +5.3 vs. 0 +2; P= 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.712.8 P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7, P= 0.001), age 80 years (OR 1.12: 95% CI 1.021.21, P= 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.528.3, P = 0.001) which predicted the mortality in a 92% of the patients. Mortality was higher in ACC patients treated with non-surgical treatment. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. The mortality rate of patients with severe cholecystitis (grade III of the TG18) was nine times greater than that of patients with mild cholecystitis. Patients with an initial NST experienced a mortality six times higher than those with initial ST. The open cholecystectomy approach was followed by a 20-fold higher mortality than the laparoscopic cholecystectomy approach (20% vs. 1%; P= 0.001). A multivariate model predicting mortality, the acute cholecystitis mortality estimation (ACME), retained a set of four variables: COPD (OR 4.66; 95% CI 1.712.8; P= 0.001), dementia (OR 4.12; 95% CI 1.3412.7; P= 0.001), age 80 years (OR 1.12; 95% CI 1.021.21; P= 0.001), and preoperative vasoactive amines (OR 9.9; 95% CI 3.528.3; P = 0.001), which accurately predicted mortality in 92% of cases. The model retained a set of four variables which accurately predicted mortality better than the TG classification. The mortality risk score ACME could promptly identify the high-risk patient with ACC in our population.
#20 Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis of Prognostic Factors and Predictive Models – PubMed
https://pubmed.ncbi.nlm.nih.gov/32716737/
Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%-9% risk of major complications and 0.1%-1% risk of mortality. […] We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. […] There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary.
#21 Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-023-00488-6
A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. […] The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. […] CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action. […] The analyzed scores seem to predict mortality with high accuracy, while they showed, in general, lower performances in predicting major morbidity. […] The CHOLE-POSSUM could be considered an excellent tool to select patients with ACC that can be safe candidates for EC without, ideally, a risk of postoperative mortality and with an acceptable risk of major complications. […] The study has defined the best existing risk prediction model for a complicated course after EC in patients with ACC as the POSSUM PS, with the best cutoff to select high-risk patients to be 25.
#22 Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-023-00488-6
A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. […] The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. […] CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action. […] The analyzed scores seem to predict mortality with high accuracy, while they showed, in general, lower performances in predicting major morbidity. […] The CHOLE-POSSUM could be considered an excellent tool to select patients with ACC that can be safe candidates for EC without, ideally, a risk of postoperative mortality and with an acceptable risk of major complications. […] The study has defined the best existing risk prediction model for a complicated course after EC in patients with ACC as the POSSUM PS, with the best cutoff to select high-risk patients to be 25.
#23 Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-023-00488-6
A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. […] The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. […] CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action. […] The analyzed scores seem to predict mortality with high accuracy, while they showed, in general, lower performances in predicting major morbidity. […] The CHOLE-POSSUM could be considered an excellent tool to select patients with ACC that can be safe candidates for EC without, ideally, a risk of postoperative mortality and with an acceptable risk of major complications. […] The study has defined the best existing risk prediction model for a complicated course after EC in patients with ACC as the POSSUM PS, with the best cutoff to select high-risk patients to be 25.
#24 Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study | World Journal of Emergency Surgery | Full Text
https://wjes.biomedcentral.com/articles/10.1186/s13017-023-00488-6
A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. […] The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. […] CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action. […] The analyzed scores seem to predict mortality with high accuracy, while they showed, in general, lower performances in predicting major morbidity. […] The CHOLE-POSSUM could be considered an excellent tool to select patients with ACC that can be safe candidates for EC without, ideally, a risk of postoperative mortality and with an acceptable risk of major complications. […] The study has defined the best existing risk prediction model for a complicated course after EC in patients with ACC as the POSSUM PS, with the best cutoff to select high-risk patients to be 25.
#25 Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines
https://pmc.ncbi.nlm.nih.gov/articles/PMC2784516/
Early diagnosis of acute cholecystitis allows prompt treatment and reduces both mortality and morbidity. […] Acute cholecystitis has a better prognosis than acute cholangitis, but may require immediate management, especially in patients with torsion of the gallbladder and emphysematous, gangrenous, or suppurative cholecystitis. […] Acute cholecystitis has a better outcome/prognosis than acute cholangitis but requires prompt treatment if gangrenous cholecystitis, emphysematous cholecystitis, or torsion of the gallbladder are present. […] The progression of acute cholecystitis from the mild/moderate to the severe form means the development of the multiple organ dysfunction syndrome (MODS). […] Organ dysfunction scores, such as Marshalls multiple organ dysfunction (MOD) score, and the sequential organ failure assessment (SOFA) score, are sometimes used to evaluate organ dysfunction in critically ill patients.
#26 Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis of Prognostic Factors and Predictive Models – PubMed
https://pubmed.ncbi.nlm.nih.gov/32716737/
Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%-9% risk of major complications and 0.1%-1% risk of mortality. […] We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. […] There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary.
#27 Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis of Prognostic Factors and Predictive Models – PubMed
https://pubmed.ncbi.nlm.nih.gov/32716737/
Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%-9% risk of major complications and 0.1%-1% risk of mortality. […] We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. […] There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary.
#28 Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis of Prognostic Factors and Predictive Models – PubMed
https://pubmed.ncbi.nlm.nih.gov/32716737/
Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%-9% risk of major complications and 0.1%-1% risk of mortality. […] We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. […] There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary.