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3 ScienceDirect 67
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7 journal homepage: www.JournalofSurgicalResearch.com 72
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A proposal for a preoperative clinical scoring 76
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13 system for acute cholecystitis 78
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16 Q7 Q6 Peter C. Ambe, MD,* Marios Papadakis, MD, and Hubert Zirngibl 81
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Department of Surgery II, Helios Klinikum Wuppertal, Witten/Herdecke University, Wuppertal, Germany
18 Q1 83
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20 85
21 article info abstract 86
22 87
23 Article history: Background: Acute cholecystitis is a common diagnosis for which surgery is usually indi- 88
24 Received 7 July 2015 cated. However, the heterogeneity of clinical presentation makes it difficult to standard 89
25 Received in revised form management. The variation in clinical presentation is influenced by both patient- 90
26 30 August 2015 dependent and disease-specific factors. A preoperative clinical scoring system designed 91
27 Accepted 3 September 2015 to included patient-dependent and clinical factors might be a useful tool in the clinical 92
28 Available online xxx decision making. 93
29 Methods: The data of patients undergoing laparoscopic cholecystectomy for acute chole-
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30 95
Keywords: cystitis in a university hospital were retrospectively reviewed. Patient-dependent factors
31 96
Acute cholecystitis (age, sex, body mass index, and American Society of Anesthesiologists score) and disease-
32 97
33 Preoperative clinical score specific factors (history of biliary colics, white blood count, C-reactive protein, and gall- 98
34 Gallbladder wall thickness, bladder wall thickness) were used to compute a clinical score between zero and nine for 99
35 elevated CRP each patient. Cholecystitis was classified as mild (score
3), moderate (4
score
6), or 100
36 High white blood count severe (score  7). 101
37 Laparoscopic cholecystectomy Results: Cholecystitis was mild in 45 cases, moderate in 105 cases, and severe in 27 cases. 102
38 Among patient-dependent factors, the male gender, age >65 y, and American Society of 103
39 Anesthesiologists score >2 correlated significantly with high scores, P ¼ 0.001. Equally, high 104
40 white blood count, elevated C-reactive protein, and gallbladder wall thickness >4 mm 105
41 106
correlated significantly with high scores P ¼ 0.001. These findings were confirmed on
42 107
multivariate analyses. High scores correlated significantly with the duration of surgery
43 108
(P ¼ 0.007), the need of intensive care unit management (P ¼ 0.001) and the length of stay
44 109
45 (P ¼ 0.001). However, there was no significant association between the preoperative score 110
46 and the rate of conversion (P ¼ 0.103) or the rate of complication (P ¼ 0.209). 111
47 Conclusions: This preoperative clinical scoring system has a potential to select patients with 112
48 severe cholecystitis and therefore might be a useful tool in the clinical decision making. 113
49 ª 2015 Elsevier Inc. All rights reserved. 114
50 115
51 116
52 117
53 1. Introduction difficult. Being able to determine the preoperative extent of 118
54 gallbladder inflammation might facilitate the clinical decision 119
55 Acute cholecystitis (AC) is a frequent reason for a visit to the making. 120
56 emergency department. Although surgery is generally The clinical presentation, disease course and outcome of 121
57 122
accepted as the main stay of treatment, the divergence in the AC might be influenced by both patient-dependent and clin-
58 123
clinical presentation renders the standardization of treatment ical factors. Advanced age at the time of surgery, male gender,
59 124
60 125
61 * Corresponding author. Department of Surgery II, Helios Klinikum Wuppertal, Witten/Herdecke University, Heusner Str. 40, Wuppertal 126
62 42283, Germany. Tel.: þ49 2028961544; fax: þ49 2028963725. 127
63 E-mail address: peter.ambe@helios-kliniken.de (P.C. Ambe). 128
64 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. 129
65 http://dx.doi.org/10.1016/j.jss.2015.09.010 130

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concomitant conditions, body mass index (BMI), gallbladder Demographic data including age, sex, BMI and comorbid-
131 196
132 wall thickness, recurrent biliary colics, C-reactive protein ities as defined by the American Society of Anesthesiologists 197
133 (CRP), white blood count (WBC), and the extent of gallbladder (ASA) at the time of surgery were retrieved for each patient. 198
134 inflammation have been confirmed as risk factors for com- History of gallbladder complaint, for example, upper abdom- 199
135 plications in patients undergoing laparoscopic cholecystec- inal colics was recorded. Preoperative data including WBC, 200
136 tomy (LC) [1e9]. CRP, and sonographic gallbladder wall thickness were recor- 201
137 The Tokyo Guidelines of 2007 and the updated version of ded for each patient. Postoperative data including the 202
138 2013 (TG13) provide recommendations for the diagnosis and duration of surgery, rate of conversion, complications, man- 203
139 severity grading of acute cholangitis and cholecystitis. The agement in the intensive care unit, mortality, and the length 204
140 205
TG13 uses clinical data, findings from blood chemistry, and of stay (LOS) were recorded for each case. The final histopa-
141 206
abdominal ultrasound sonography to classify AC into three thology records were consulted for the extent of gallbladder
142 207
severity grades [10e12]. Our experience with patients pre- inflammation. Gallbladder inflammation was classified as
143 208
144 senting with AC suggests that the clinical decision making “uncomplicated” or “complicated”. Uncomplicated cholecys- 209
145 should be individualized, owing to the heterogeneity of pre- titis was defined as gallbladder edema with acute inflamma- 210
146 sentation. Therefore, a preoperative clinical severity grading tion and the presence of neutrophilic granulocytes. 211
147 system for AC should be designed to include both individual Complicated cholecystitis included empyematous cholecys- 212
148 and clinical parameters. titis (AC with gallbladder empyema), necrotizing cholecystitis 213
149 The aim of this study was to design a preoperative clinical (total necrosis of all layers of gallbladder wall), or gangrenous 214
150 scoring system for acute cholecystitis. This preoperative cholecystitis (loss of mucosal lining and vascular architecture 215
151 clinical scoring system was designed by computing patient- with profound inflammation). 216
152 217
dependent and clinical risk factors for complications after We used known risk factors for complications after LC for
153 218
LC for AC and might be helpful in the clinical decision making AC to design this clinical scoring system, Table 1. Using this
154 219
155 and comparison of therapeutic outcomes. system, a clinical score in the range from 0e9 was calculated 220
156 for each patient included. 221
157 The Statistical Package for Social Science, IBM, version 22, 222
158 was used to analyze the collected data. Continuous variables 223
159 2. Methods were described using absolute case numbers and percentages. 224
160 As the data were not normally distributed, central tendencies 225
161 This study was approved by the ethics committee of the were described using mean values with the corresponding 226
162 WitteneHerdecke University. A retrospective review of our 227
163 228
departmental database for patients undergoing LC for AC
164 229
within a 3-y period from January 2012 until December 2014
165 230
was performed. Patients were consecutively recorded after Q4
166 Table 1 e Parameters used for the development of this 231
167 presentation in the emergency department. Findings from clinical severity score. 232
168 clinical examination, abdominal ultrasound sonography, and 233
Parameters Score
169 blood chemistry were used to diagnose AC as outlined in the 234
170 Tokyo Guidelines [10e12]. Patient-dependent parameters 235
171 Sex 236
As part of our institutional standards, all patients with AC
Female 0
172 were put on intravenous antibiotics usually Tazobactam. A 237
Male 1
173 same “admission cholecystectomy policy” is maintained in 238
Age (y)
174 our department. Thus, surgery was scheduled as soon as 239

65 0
175 240
possible depending on the presence or absence of comorbid- >65 1
176 241
ities with the need for special consultations. Patients classi- BMI
177
30 kg/m2 0
242
178 fied as “unfit for surgery” were conservatively managed with 243
>30 kg/m2 1
179 antibiotics, pain medication, and bowel resting. In such cases, 244
ASA score
180 elective cholecystectomy was offered about 6 wk after “cool- 245
1e2 0
181 ing off” the acute episode. 3 1 246
182 Laparoscopic cholecystectomy is a standard procedure in >3 2 247
183 our department. In all cases, LC was performed using four Clinical parameters 248
184 trocars. Surgery began with the placement of a 12-mm trocar Recurrent colics 249
185 after a supra-umbilical incision. Surgery proceeded with the Yes 1 250
186 No 0 251
placement of an 11-mm trocar in the epigastrium slightly to
187 Gallbladder wall thickness 252
the left of middle line and two 5-mm trocars in the right upper
4 mm
188 0 253
abdomen under visual control. The leading surgeon was an >4 mm
189 1 254
190 attending surgeon with expertise in laparoscopy. Single shot WBC 255
191 antibiotic was administered before incision depending on the
12.000 0 256
>12.000 1
192 time interval between the last antibiotic application and begin 257
CRP
193 of surgery. The gallbladder was removed via the supra- 258

5 0
194 umbilical incision using an endobag. Histopathology was 259
>5 1
195 performed in all cases. 260

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standard deviations and a 95% confidence interval. Statistical

261 326
262 significances were calculated using the chi square test with 327
263 the level of significance placed at P < 0.05. Furthermore, 328
264 multivariate analyses were performed to further characterize 329
265 the influence of each factor on the outcomes. Variations be- 330
266 tween variables would be reported using Bonferroni corrected 331
267 P values. 332
268 The study population was divided into three groups based 333
269 on the clinical scores. Group I (mild cholecystitis) was made 334
270 335
up of patients with clinical score
3, group II (moderate
271 336
cholecystitis) included patients with clinical scores  4 to
6,
272 337
whereas group III (severe cholecystitis) composed of patients
273 338
274 with clinical score  7. The effect of each parameter as an 339
275 independent risk factor was analyzed using multivariate 340
276 analysis. 341
277 The clinical value of this scoring system was tested by 342
278 comparing the postoperative outcomes among the three pre- 343
279 operative severity groups. The postoperative outcomes 344
280 included the duration of surgery, the rate of conversion, the 345
281 rate of postoperative complications, the need of intensive care 346
282 Fig. 1 e Distribution of the study population. Cholecystitis 347
unit (ICU) management, rate of mortality, the LOS, and the
283 was scored as mild in 45 cases, moderate in 105, and 348
extent of gallbladder inflammation on histopathology
284 349
(complicated versus Uncomplicated). severe in 27 cases.
285 350
286 351
287 3.2. Clinical parameters 352
288 3. Results 353
289 Table 3 presents the perioperative findings in this study. There 354
290 Within the period of investigation, 1024 cholecystectomies 355
was no statistically significant difference among all three
291 were performed in our department. The indication for surgery 356
groups with respect to history of biliary colics, P ¼ 0.350.
292 was AC in 405 cases. After excluding cases with negative pa- 357
Generally, the mean WBC increased significantly with
293 358
thology and incomplete files, 177 cases of AC including 78 increasing clinical score, P ¼ 0.001. However, a Bonferroni
294 359
female and 99 male patients were included for analysis. correction did not identify any significant difference in the
295 360
Using the above-mentioned scoring system, mild chole- mean WBC among patients in groups I and II, P ¼ 0.154. The
296 361
297 cystitis was present in 45 patients (25.4%), group I. Cholecys- mean CRP increased significantly with increasing clinical 362
298 titis was classified as moderate in 105 patients (59.3%), group score, P ¼ 0.001. A Bonferroni correction confirmed this trend 363
299 II, whereas severe cholecystitis was present in 27 patients between all three groups, P ¼ 0.001. The thickness of the 364
300 (15.3%), group III, Figure 1. Figure 2 shows the distribution of gallbladder wall increased significantly with increasing score, 365
301 the clinical scores in the study population, whereas the P ¼ 0.001. However, there was no significant difference be- 366
302 baseline features are summarized in Table 2. 367
tween patients in groups II and III with regard to gallbladder
303 368
304 3.1. Patient-dependent risk factors 369
305 370
306 371
With the exception of group III, the male gender constituted a
307 372
308 significant majority of the study population (P ¼ 0.001). 373
309 Concomitant medical conditions (ASA > 2) correlated signifi- 374
310 cantly with increasing clinical score (P ¼ 0.001). Cardiovascu- 375
311 lar disorders including high blood pressure, ischemic heart 376
312 disease, hypertensive heart disease, atrial fibrillation, and 377
313 peripheral artery disease constituted the leading concomitant 378
314 disorders in the study and were recorded in 50 cases (75%). 379
315 Type 2 diabetes was present in 31 cases (46%). Chronic 380
316 381
obstructive pulmonary disease was present in 19 cases (28%),
317 382
whereas chronic kidney disease was seen in 16 cases (24%).
318 383
The mean age at the time of surgery increased significantly
319 384
320 (P ¼ 0.001) with increasing clinical score. There was no sig- 385
321 nificant difference (P ¼ 0.369) among the three groups with 386
322 regard to BMI, Table 2. The male gender, age >65 y, and ASA 387
323 score >2 were shown on multivariate analysis to independent 388
324 risk factors for high clinical scores (Pillai’s Trace ¼ 0. 282, F (4, Fig. 2 e Clinical scores. Distribution of the preoperative 389
325 177) ¼ 17.405, P ¼ 0.001, partial h2 ¼ 0.282). clinical scores across the study population. 390

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complications (9.5%) were seen in group II: three cases of bile

391 Table 2 e Summary of the baseline characteristics of the 456
392 study population. duct injury, two cases of liver abscess and wound dehiscence 457
393 as well as one case of subphrenic abscess, pneumonia, and 458
Features Mild Moderate Severe P value
394 pulmonary embolism. Two complications (7.4%) including 459
395 Sex one case of postoperative hemorrhage and respiratory failure 460
396 Female 10(22.2%) 49 (46.7%) 19 (70.4%) 0.001 were recorded in group III. 461
397 Male 35 (77.8%) 59 (56.3%) 8 (29.6%) 462
However, 11.1% (6 of 54) of these complications were
398 Age 463
registered in patients with ASA > 2 compared to 5.6% (7 of 123)
Mean 51.2  14.7 65.5  17.3 75  13.9 0.001
399 in patients with ASA
2. Therefore, the morbidity rate was 464
Range 20e83 19e97 36e96
400 465
BMI, kg/m2 significantly higher in patients with ASA >2, P ¼ 0.046.
401 466
mean 26.9  3.4 30.3  19.6 31.7  10.2 0.369 Twenty-six patients (14.7%) were managed in the ICU after
402 467
range 17.8e37.7 18.9e40.1 20.2e63.9 surgery. The need for postoperative ICU management
403 468
ASA increased significantly with increasing score, P ¼ 0.001. The
404 1 24 (53.3%) 23 (21.9%) 1 (3.72%) 0.001
469
405 need for ICU management was significantly higher in patients 470
2 20 (44.4%) 50 (47.6%) 5 (18.5%)
406 with ASA >2 compared to those with ASA
2, that is 18 of 54 471
3 1 (2.3%) 28 (26.9%) 19 (70.4%)
407 4 0 4 (3.8%) 2 (7.4%) (33.3%) versus 8 of 123 (6.5%) respectively, P ¼ 0.001. 472
408 Three deaths (1.7%) were recorded in this study. Although 473
409 no mortality was recorded in group I, two cases of mortality 474
410 were recorded in group II (1.9%) after heart attack and pul- 475
411 wall thickness after Bonferroni correction, P ¼ 0.184. Gall- 476
monary embolism. The last case of mortality was recorded in
412 bladder wall thickness, WBC, and CRP were confirmed on 477
group III (3.7%) secondary to respiratory insufficiency. There
413 multivariate analysis as independent risk factors for high 478
was no significant relationship between clinical severity score
414 clinical scores (Pillai trace ¼ 0.293, F (4, 175) ¼ 18.157, P ¼ 0.001, 479
415 and the rate of mortality, P ¼ 0.483. 480
partial h2 ¼ 0.293).
416 The mean LOS was 5.8  6.3 d in this study. The LOS 481
417 increased significantly with increasing score, P ¼ 0.006. This 482
418 3.3. Postoperative outcomes trend was confirmed in all three groups after Bonferroni 483
419 correction. Table 4 lists the postoperative outcomes in this 484
420 Conversion from laparoscopic to open cholecystectomy was study. ASA score >2 was associated with a significant increase 485
421 performed in 12 cases (6.8%) in this study. Conversion was in the LOS, P ¼ 0.001. 486
422 performed because of changes in the gallbladder anatomy 487
423 488
with the inability to clearly identify the structure within the 3.4. Histopathology
424 489
triangle of calot. There was no statistically significant differ-
425 490
426 ence in the rate of conversion among the three groups, Uncomplicated cholecystitis was diagnosed in 143 cases 491
427 P ¼ 0.103. Although the mean duration of surgery increased (80.8%), whereas complicated cholecystitis in the form of 492
428 significantly (P ¼ 0.007) with increasing score, a significant gangrenous, necrotizing, and empyematous cholecystitis was 493
429 difference was only detected between patients in groups I and diagnosed in 34 cases (19.2%) after histopathology. Compli- 494
430 II after Bonferroni correction, 0.005. cated cholecystitis was diagnosed in seven patients (15.6%) 495
431 Complications were recorded in 13 cases (7.3%). There was from group I. Eighteen (17.1%) patients group II had compli- 496
432 no significant difference in the rate of complications between cated cholecystitis, whereas nine patients (33.3%) from group 497
433 the three groups, P ¼ 0.291. The rate of complication in group I III were diagnosed with complicated cholecystitis on histo- 498
434 499
was 2.2%, one case of liver abscess formation. Ten pathology. This difference, however, was not statistically
435 500
436 501
437 502
438 503
439 Q5 Table 3 e Summary of the preoperative findings in this study 504
440 Features Mild Moderate Severe P P1 P2 P3 505
441 506
History of colics
442 507
Yes 27 (60%) 62 (59%) 7 (25.9%) 0.350
443 508
d d d
No 18 (40%) 43 (41%) 20 (74.1%)
444 509
WBC/mL
445 510
Mean 10.4  3.9 12.1  5.1 18.8  9.9 0.001 0.154 0.001 0.001
446 Range 4e19.8 3.8e28 3.1e53.8
511
447 CRP (mg/dL) 512
448 Mean 3.2  5.7 10.5  11.1 22.4  11.9 0.001 0.001 0.001 0.001 513
449 Range 0.1e30 0.1e58.8 5e40.6 514
450 Gallbladder wall thickness (mm) 515
451 Mean 4.1  1.7 6.1  2.9 7.1  1.9 0.001 0.001 0.184 0.001 516
452 Range 2e9 2e15 4e10 517
453 518
P1eP3 ¼ Bonferroni corrected P values between the three severity groups. P1 ¼ between mild and moderate, P2 ¼ between moderate and severe,
454 519
and P3 ¼ between mild and severe.
455 520

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521 Table 4 e Postoperative outcomes. 586

522 587
Parameter Mild Moderate Severe P value
523 588
524 Duration of surgery in min 589
525 Mean 83.2  34.2 109.4  53.1 97.5  30.9 0.007* 590
526 Range 35e202 39e290 45e149 591
527 Conversion rate 0% 10/105 (9.5%) 2/27 (7.4%) 0.103 592
528 Complication rate 1/45 (2.2%) 10/105 (9.5%) 2/27 (7.4%) 0.291 593
529 ICU management 0% 19/105 (18.1%) 7/20 (25.9%) 0.003 594
530 Mortality rate 0 2/105 (1.9%) 1/27 (3.7%) 0.483 595
Length of stay/d
531 596
Mean 3.4  1.6 6.4  7.7 7.6  3.5 0.006
532 597
Range 2e8 2e12 3e18
533 598
534 ICU ¼ intensive care unit. 599
535 *
Post hoc analysis with Bonferroni corrected P values confirmed a significant difference in the duration of surgery between the group with mild 600
536 and moderate cholecystitis. However, no significant difference was found between the group with moderate and severe cholecystitis. 601
537 602
538 603
539 604
540 significant, P ¼ 0.126. Complicated cholecystitis was found Similarly, the TG13 guidelines use clinical data findings 605
541 significantly more often patients with high ASA scores >2 from blood chemistry and abdominal ultrasound to classified 606
542 607
compared to those with lower ASA scores
2; 17 of 54 (31.5%) AC [11,17]. These guidelines suggest LC as the standard
543 608
versus 17 of 123 (13.8%) respectively, P ¼ 0.036. management for patients with mild cholecystitis, whereas
544 609
545 most cases with severe cholecystitis should be preferably via 610
546 percutaneous gallbladder drainage. Evidence on the benefit of 611
547 4. Discussion this recommendation, however, could not be identified in 612
548 systematic review by Winbladh et al. [18]. In a recently pub- 613
549 The aim of this study was to design a simple preoperative lished nation-wide analysis Anderson et al. [19] concluded that 614
550 clinical scoring system for AC. This scoring system was “percutaneous cholecystostomy would not benefit the sickest 615
551 designed to estimate the severity of gallbladder inflammation patient in whom cholecystectomy may never be considered”. 616
552 by computing patient-dependent risk factors and clinical pa- Therefore, although the TG 13 guidelines have been well 617
553 618
rameters. The male gender, age >65 y, obesity, and concomi- established for a while now, their validation is certainly not
554 619
tant conditions constituted patient-dependent risk factors. completed. Besides, patient’s comorbidities, BMI, and gender
555 620
Gallbladder wall thickness, CRP, WBC, and history of biliary were not considered in these guidelines. These factors directly
556 621
557 colics constituted the clinical parameters. These parameters contribute to the high degree of divergence in the clinical 622
558 were used to calculate a score between zero and nine for each presentation of patients with AC and therefore should be 623
559 patient presenting with AC. All patients were categorized in considered in any preoperative severity grading or scoring 624
560 one of three groups depending of their scores. Group I system. 625
561 composed of patients with clinical score
3, group II included Among the patient-dependent parameters analyzed in this 626
562 patients with scores 4 to
6, whereas group III was made up study, the male gender, age >65 y, and ASA score >2 corre- 627
563 of patients with clinical score >6 (7e9). Acute cholecystitis lated significantly with increasing clinical scores. Equally, the 628
564 was considered as mild in group I, moderate in group II, and clinical parameters WBC, CRP, and gallbladder wall thickness 629
565 630
severe in group III. Among the patient-dependent factors, age correlated significantly with increasing clinical scores. These
566 631
>65, male gender, and ASA score >2 correlated significantly parameters were confirmed on multivariate analysis as in-
567 632
568 with the preoperative clinical scores. Equally, gallbladder wall dependent risk factors for high preoperative clinical scores 633
569 thickness, WBC, and CRP correlated significantly with the and thus severe AC. These findings are in accordance with 634
570 clinical score. These parameters were confirmed on multi- current literature [20e25]. 635
571 variate analyses as independent risk factors for high preop- The preoperative clinical severity scores correlated signif- 636
572 erative scores. icantly with the duration of surgery, the need of ICU man- 637
573 Many attempts have been made to predict the preopera- agement, and the LOS. Surgery lasted significantly longer in 638
574 tive outcome of LC. However, most studies dealt with the patients with high clinical scores on univariate analysis. 639
575 risk of conversion and not the preoperative clinical extent of Considering the fact that all patients were managed by 640
576 641
AC [13e15]. In 2010 Yacoub et al. [16] attempted to identify attending surgeons with experience in LC, this finding could
577 642
preoperative clinical predictors for gangrenous cholecystitis represent the surgical challenge associated with the man-
578 643
in patients presenting with AC. In their series of 245 pa- agement of severe gallbladder inflammation. Therefore,
579 644
580 tients, age >45 y, male gender, heart rate >90 beats per min, increasing clinical scores seem to correlate with the intra- 645
581 WBC >13.000 cells/mm3, and gallbladder wall thickness operative surgical challenge. The fact that between-subject 646
582 >4.5 mm were shown on multivariate analysis to be inde- analysis using the Bonferroni correction failed to identify a 647
583 pendent risk factors for gangrenous cholecystitis. Concomi- significant difference in the duration of surgery among pa- 648
584 Q2 tant conditions and BMI, however, were not considered in tients in group II and III might be due to the relatively small 649
585 this scoring system. number of cases in group III. 650

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The need for ICU management increased significantly with reason, a prospective database has been established to vali-
651 716
652 increasing score. This finding might be due to the fact that a date the trends recorded in this retrospective series. As only 717
653 vast majority of patients with high scores presented with ASA surgically managed patients were included in this study, it is 718
654 scores >2. One may argue that the concomitant conditions per hard to tell if this scoring system could be valid for non- 719
655 se and not the extent of gallbladder inflammation warranted surgically managed patients. 720
656 ICU management. 721
657 Statistically significant relationships were not observed 722
658 between clinical scores and the rate of conversion from 723
659 laparoscopic to open surgery. This was also true for the rate of Acknowledgments 724
660 725
complications. These findings may be due to the high degree
661 Authors’ contribution: P.C.A. performed the conception of the 726
of expertise in LC in our department. Although histopathology
662 study. P.C.A., M.P., and H.Z. designed the study. P.C.A. and 727
did not differ significantly among the three groups, compli-
663 M.P. performed data acquisition and analysis. P.C.A., M.P., and 728
664 cated gallbladder inflammation in the form of necrotizing, 729
gangrenous, and empyematous cholecystitis was present in H.Z. performed the interpretation of data. P.C.A. drafted the
665 730
article. P.C.A., M.P., and H.Z. critically reviewed the article.
666 over 33% of patients with high severity scores. 731
P.C.A., M.P., and H.Z. contributed to the final approval of the
667 Although AC is a very common problem, the great degree 732
668 of divergence among patients presenting with AC makes it study. 733
669 almost impossible to standardize management. This renders There was no grant or financial support for the study. 734
670 the clinical decision making extremely difficult. A simple 735
671 preoperative clinical severity score could be a helpful clinical Disclosure 736
672 737
decision-making tool. Such a scoring system must be easy to
673 738
computerize by any surgeon independent of the level of The authors declare that they have no competing interests.
674 739
675 training at the time of presentation in the emergency 740
676 department and must include both patient-dependent and 741
677 clinical parameters. references 742
678 As high scores might suggest the presence of severe 743
679 cholecystitis with the need of urgent surgery to prevent 744
680 complications, this scoring system might influence surgical [1] Agrusa A, Romano G, Frazzetta G, et al. Role and outcomes of 745
681 scheduling and thus the clinical decision making. Besides, this laparoscopic cholecystectomy in the elderly. Int J Surg 2014; 746
682 12(Suppl 2):S37. 747
preoperative clinical scoring system might indicate the need
683 [2] Ambe PC, Weber SA, Christ H, Wassenberg D. Primary 748
for postoperative intensive care management. cholecystectomy is feasible in elderly patients with acute
684 749
A comparison of postoperative outcome after LC is an cholecystitis. Aging Clin Exp Res; 2015. Q3
685 750
issue. There is no doubt that outcomes might be influenced by [3] Leardi S, De Vita F, Pietroletti R, Simi M. Cholecystectomy for
686 751
both the disease burden and surgical expertise. As surgical gallbladder disease in elderly aged 80 years and over.
687 752
expertise varies widely, even amongst experts, and the Hepatogastroenterology 2009;56:303.
688 753
[4] Papandria D, Lardaro T, Rhee D, et al. Risk factors for
689 perception of disease burden (the extent of inflammation) 754
conversion from laparoscopic to open surgery: analysis of
690 could be very subjective, comparison of outcomes has not 755
2138 converted operations in the American College of
691 been easy. Being able to characterize the extent of gallbladder Surgeons National Surgical Quality Improvement Program. 756
692 inflammation before surgery could provide a mean of Am Surg 2013;79:914. 757
693 comparing surgical outcome and assessing surgical expertise. [5] Wevers KP, van Westreenen HL, Patijn GA. Laparoscopic 758
694 Our scoring system therefore provides a simple tool for the cholecystectomy in acute cholecystitis: C-reactive protein 759
695 level combined with age predicts conversion. Surg Laparosc 760
comparison of postoperative outcomes in patients undergoing
696 Endosc Percutan Tech 2013;23:163. 761
LC for AC and an indirect mean of assessing of surgical
697 [6] Khan ML, Abbassi MR, Jawed M, Shaikh U. Male gender and 762
698 expertise. sonographic gall bladder wall thickness: important 763
699 predictable factors for empyema and gangrene in acute 764
700 cholecystitis. J Pak Med Assoc 2014;64:159. 765
701 5. Conclusion [7] Teefey SA, Dahiya N, Middleton WD, et al. Acute 766
702 cholecystitis: do sonographic findings and WBC count 767
703 Taken together, our preoperative clinical scoring system has a predict gangrenous changes? AJR Am J Roentgenol 2013;200: 768
704 363. 769
potential to select patients with severe cholecystitis. Signifi-
705 [8] Ambe P, Esfahani BJ, Tasci I, Christ H, Köhler L. Is 770
cant results were recorded with respect to the duration of laparoscopic cholecystectomy more challenging in male
706 771
surgery, the need of ICU management, and the length of patients? Surg Endosc 2011;25:2236.
707 772
hospital stay. Therefore, the preoperative clinical scoring [9] Ambe PC, Weber SA, Wassenberg D. Is gallbladder
708 773
system might be a useful tool in the clinical decision making. inflammation more severe in male patients presenting with
709 774
acute cholecystitis? BMC Surg 2015;15:48.
710 775
[10] Takada T, Kawarada Y, Nimura Y, et al. Background: Tokyo
711 5.1. Limitations 776
Guidelines for the management of acute cholangitis and
712 cholecystitis. J Hepatobiliary Pancreat Surg 2007;14:1. 777
713 This study is mainly limited by the size of the study popula- [11] Yokoe M, Takada T, Strasberg SM, et al. TG13 diagnostic 778
714 tion and the retrospective study design. Thus, the scoring criteria and severity grading of acute cholecystitis (with 779
715 system proposed must be validated prospectively. For this videos). J Hepatobiliary Pancreat Sci 2013;20:35. 780

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 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e7 7

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[17] Takada T, Strasberg SM, Solomkin JS, et al. TG13: updated [24] Fried GM, Barkun JS, Sigman HH, et al. Factors determining
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