1. A new preoperative Severity Scoring System For Acute Cholecystitis
Peter C Ambe
HELIOS Universitätsklinkum Wuppertal Department of Surgery Universität Witten / Herdecke
Wuppertal, Germany
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery
17th European Congress of Trauma & Emergency Surgery

2. Need for a new severity scoring system for acute cholecystitis
Factors affecting the outcomes of laparoscopic cholecystectomy. Ambe & Zirngibl, 2016
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery
17th European Congress of Trauma & Emergency Surgery

3. Patient – dependent factors
Sex: male gender
Ambe et al.: Is laparoscopic cholecystectomy more challenging in male patients?
Surg Endosc 2011, 25(7):
Rosen M, et al.: Predictive factors for conversion of laparoscopic cholecystectomy. American journal of surgery 2002, 184(3):
Age: advanced age ( >65 yrs)
Bingener et al : Laparoscopic cholecystectomy for elderly patients: gold standard for golden years?
Archives of surgery 2003, 138(5): ;
Ambe et al: Primary cholecystectomy is feasible in elderly patients with acute cholecystitis.
Aging Clin Exp Res 2015, 27(6):
Obesity: BMI > 30 kg/m2
Angrisani et al.: Laparoscopic cholecystectomy in obese patients compared withnonobese patients.
Surgical laparoscopy & endoscopy 1995, 5(3):
Ammori et al.: Laparoscopic cholecystectomy in morbidly obese patients.
Surgical endoscopy 2001, 15(11):
Concomitant medical conditions : ASA Scores
Laurila et al.: Acute acalculous cholecystitis in critically ill patients.
Acta anaesthesiologica Scandinavica 2004, 48(8):
Papadakis et al.: Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation. World J Emerg Surg 2015, 10:59.
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

4. Disease - specific factors
History of gallbladder disease
Halldestam et al.: Development of symptoms and complications in individuals with asymptomatic gallstones.
The British journal of surgery 2004, 91(6):
Duration of symptoms of acute cholecystitis
Gutt et al: Acute cholecystitis: Early versus delayed cholecystectomy, a multicenter randomized trial (ACDC Study).
Annals of Surgery 2013, 258(3):
Ambe et al.: Cholecystectomy for acute cholecystitis. How time-critical are the so called "golden 72 hours"?
Or better "golden 24 hours" and "silver hour"? A case control study. WJES 2014, 9(1):60.
Elevated c- reactive protein and high white blood count
Wevers et al. "Laparoscopic cholecystectomy in acute cholecystitis: C-reactive protein level combined with age predicts conversion."
Surgical Laparoscopy Endoscopy & Percutaneous Techniques 23.2 (2013):
Gallbladder wall thickness on abdominal ultrasound
Raman et al.: The degree of gallbladder wall thickness and its impact on outcomes after laparoscopic cholecystectomy.
Surgical endoscopy 2012, 26(11):
Teefey et al.: Acute cholecystitis: do sonographic findings and WBC count predict gangrenous changes?
AJR Am J Roentgenol 2013, 200(2):
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery
17th European Congress of Trauma & Emergency Surgery

5. Clinical severity score for acute cholecystitis
Table 11 e Parameters used for the development of this clinical severity score.
Parameters Score
Patient-dependent parameters Sex
Female 0
Male 1
Age (y)
:::65 0
>65 1
BMI
:::30 kg/m 0 2
>30 kg/m2 1
ASA score
1e2 0
3 1
>3 2
Clinical parameters Recurrent colics
Yes 1
No 0
Gallbladder wall thickness
:::4 mm 0
>4 mm 1
WBC
:::
>
CRP
:::5 0
>5 1
Severity grade
0 – 3 : Mild cholecystitis
4 - 6: moderate cholecystitis
7 - 9 : Severe cholecystitis
Ambe PC, Papadakis M, Zirngibl H: A proposal for a preoperative clinical scoring system for acute cholecystitis.
J Surg Res 2016, 200(2):
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

6. Distribution of scores in the study population
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

7. Distribution of the study population
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

8. Demographic characteristics
Features
mild
moderate
severe
p-value
Sex
Female
10(22.2%)
49 (46.7%)
19 (70.4%)
0.001
Male
35 (77.8%)
59 (56.3%)
8 (29.6% )
Age
Mean
51.2±14.7
65.5±17.3
75±13.9
Range
20 – 83
19 – 97
36 – 96
BMI
Kg/m2
mean
26.9±3.4
30.3±19.6
31.7±10.2
0.369
range
17.8 – 37.7
18.9 – 40.1
20.2 – 63.9
ASA 1
24 (53.3%)
23 (21.9%)
1 (3.72%) 2
20 (44.4%)
50 (47.6%)
5 (18.5%) 3
1 (2.3%)
28 (26.9%) 4
4 (3.8%)
2 (7.4%)
Summary of the baseline characteristics of the study population. BMI : Body Mass Index
ASA: American Society of Anesthesiologists.
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

9. Preoperative findings
Features
Mild
Moderate
Severe P P1 P2 P3
History of colics
Yes
27 (60%)
62 (59%)
7 (25.9%)
0.350 - No
18 (40%)
43 (41%)
20 (74.1%)
WBC / µl
Mean
10.4±3.9
12.1±5.1
18.8±9.9
0.001
0.154
Range
4±19.8
3.1 – 53.8
CRP
(mg/dl)
3.2±5.7
10.5±11.1
22.4±11.9
0.1 – 30
0.1 – 58.8
5 – 40.6
Gallbladder wall thickness
(mm)
4.1±1.7
6.1±2.9
7.1±1.9
0.184
2 – 9
2 – 15
4 - 10
WBC; White blood cell count, CRP: C- reactive protein. MM: millimeters
P1-P3 : Bonferroni corrected p-values between the three severity groups
P1: between mild and moderate, P2 : between moderate and severe and P3: between mild and severe
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

10. Postoperative Outcomes
Parameter
Mild
Moderate
Severe
p-value
Duration of Surgery in min
Mean
83.2±34.2
109.4±53.1
97.5±30.9
0.007*
Range
35 – 202
39 – 290
45 – 149
Conversion rate
0 %
10/105 (9.5%)
2/27 (7.4%)
0.103
Complication rate
1 /45 (2.2%)
0.291
ICU management
19/105 (18.1%)
7/20 (25.9%)
0.003
Mortality rate
2/105 (1.9%)
1/27 (3.7%)
0.483
Length of stay / d
3.4±1.6
6.4±7.7
7.6±3.5
0.006
2 – 8
2 - 12
3 - 18
ICU: Intensive care unit. Min : minutes, d : days
*Posthoc analysis with Bonferroni corrected p-values confirmed a significant
difference in the duration of surgery between the group with mild and moderate cholecystitis.
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

11. Key points Individualization of the severity of AC Easy to compute
Clinical decision – making with regard to prioritization of cholecystectomy
Indicator for the need of post surgical management in the ICU
Enables comparison of surgical expertise with regards to cholecystectomy
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

12. Validation ? Limitation Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery

13. THANK YOU
Peter C. Ambe
17th European Congress of Trauma & Emergency Surgery