Acute cholecystitis: WSES position statement
World Journal of Emergency Surgery
Acute cholecystitis: WSES position statement
Fabio Cesare Campanile 0
Michele Pisano 2
Federico Coccolini 2
Fausto Catena 1
Ferdinando Agresta 3
Luca Ansaloni 2
0 Division of Surgery, Ospedale San Giovanni Decollato - Andosilla , Civita Castellana, VT , Italy
1 Department of Emergency Surgery, Maggiore Parma Hospital , Parma , Italy
2 General Surgery Department, Papa Giovanni XXIII hospital , Bergamo , Italy
3 Department of General Surgery, ULSS19 del Veneto , Adria, RO , Italy
Background: The management of acute calculous cholecystitis still offers room for debate in terms of diagnosis, severity scores, treatment options and timing for surgery. Material and methods: A systematic review about the treatment of acute cholecystitis has been completed. The recommendations of recent guidelines have also been examined taking into account the results of the review. Results: The evidence available in the literature supports the recommendation about laparoscopic cholecystectomy as treatment of choice for acute cholecystitis. Surgery should be performed as soon as possible after the diagnosis because early treatment reduces total hospital stay and does not increase complication or conversion rates. The antibiotics can play different roles and attention should be posed to the risk of emerging resistance. A surgical or percutaneous drainage of the gallbladder is advocated by some authors in the advanced forms of inflammation or patients with severe co-morbidities; however, the available evidence does not support it, and further studies are necessary to clarify its role.
The literature about the treatment of acute calculous
cholecystitis has been recently examined in more than one
Consensus Conference [1-3]. The disease could present
with a picture ranging from mild, self-limiting, to a
potentially life-threatening illness, and the severity of
inflammation and its life-threatening potential is also strongly
determined by the general condition of the patient. The
degree of inflammation of the gallbladder and the
conditions of patients with their co-morbidities contribute to
indicate the best therapeutic option for every single
patient. However, such heterogeneity makes very difficult
to standardize a therapeutic protocol for this condition.
The optimal surgical treatment for acute cholecystitis
should be examined according to its severity; however,
no uniform grading system is yet available, and the need
for practical patient-related operative guidelines has
been stressed elsewhere .
Even the evidences about the outcome of the
therapeutic procedures adopted are difficult to evaluate in this
heterogeneous context; studies available have not generally
examined the optimal treatment for acute cholecystitis
according to its severity. A systematic review of the
literature must take into consideration this aspect.
The literature review has been presented to the 2nd
World Society for Emergency Surgery held in Bergamo
in July 2013. This position paper follows the indication
emerged in that meeting.
Review of literature
The results of the systematic literature review performed
for the EAES Consensus Conference about the
laparoscopic approach to the acute abdomen, published in 2012
were entirely considered for this analysis; the literature
search strategy adopted has been detailed in that paper .
An additional literature search was done from 2010
through February 2013 with the following limits and
filters: adult, clinical trial, review and english language.
The PICO (population, intervention, comparison,
outcome) system was applied for the MeSH (Medical
Subject Headings) search whenever possible. Analogous
search has covered the Cochrane Collaboration database
and the Google Scholar in order to gather all the
remaining evidence, synopses and guidelines on the topic.
The following search string was used:
(cholecystitis, acute[MeSH Terms] OR (cholecystitis
[All Fields] AND acute[All Fields]) OR acute cholecystitis
[All Fields] OR (acute[All Fields] AND cholecystitis[All
Fields]))) AND ((Clinical Trial [ptyp] OR Review [ptyp])
AND (2010/01/01[PDAT]: 2013/12/31[PDAT]) AND
humans[MeSH Terms] AND English [lang]).
A total of 79 citations was identified.
A search without the limits clinical trial and review
was then carried out, obtaining 392 additional papers
whose abstracts were examined for relevance. Two
authors (FCC and MP) collected data independently.
After exclusion of duplicates, publications with no
abstract and of low interest in the specific topics and key
questions, 77 publications were taken into consideration:
The papers have been classified for evidence strength
following the Oxford CEBM 2011 scheme. In the rest of
this paper, the level of evidence obtained has been
specified after every relevant reference citation as evidence
level (EL) 15.
The literature obtained has also been used to update
the results of the above cited Consensus Conference.
This update has been presented at the 32nd Congresso
Nazionale ACOI held in Florence (Italy) in May 2013.
For the purpose of publication, the search was extended
to April 2014.
Timing of surgery
The issue of early versus delayed laparoscopic
cholecystectomy for acute cholecystitis is examined in seven
randomized controlled trials [5-11] and 5 meta-analyses
(EL1) [12-17]. The studies show that an early treatment
reduces total hospital stay and does not increase
complication or conversion rates. In particular, the rate of bile
duct injury has been shown to be higher in the delayed
treated patients, but the difference was not statistically
significant due to the small numbers analyzed in the
The optimal delay for surgery after the onset of
symptoms it is not completely clarified in the above
mentioned studies and deserves a more precise definition.
One of the systematic reviews examined above [10,12]
performed a subgroup analysis and could not
demonstrate a statistically significant difference between the
patients treated less than four days from the onset of
symptoms and those of the studies also including
patients with a longer delay. One large population-based
studies, mentioned above, examined the risk-adjusted
association between outcomes and preoperative length of
hospital stay (used as a proxy for the onset of symptoms).
There was no significant association between preoperative
length of stay and 30-day postoperative mortality or
overall morbidity. However, patients hospitalized for two or
more days preoperatively sustained longer operative times
and were significantly more likely to require open
cholecystectomy compared with patients who received
operation on the day of admission . The above mentioned
evidence supported the EAES Consensus Conference to
recommend early cholecystectomy for acute cholecystitis,
and to state that surgery should be performed as soon as
possible after the onset of symptoms.
On the contrary, the authors of the Tokyo guidelines
maintain that, despite the demonstration that early
cholecystectomy is indicated for acute cholecystitis in an
unselected population, still it could be possible to
improve the overall outcome of this condition tailoring the
treatment according to the severity of the condition and
to the patient status. They suggest a staging system based
upon severity assessment criteria such as degree of local
inflammation and patient conditions. According to their
classification acute cholecystitis is defined as severe
(grade III) if associated with organ dysfunction,
moderate (grade II) if the completion of a cholecystectomy is
likely to be difficult due to local inflammation (criteria
predicting when conditions might be unfavorable for
cholecystectomy in the acute phase), and mild (grade I)
if it does not meet the criteria for grade II or III [19-21].
Based on that scheme, the Tokyo guidelines suggest
early laparoscopic cholecystectomy only in the mild
forms of the disease (grade I), in which a laparoscopic
cholecystectomy is likely to be easy. In the moderate
cases, medical therapy with or without early gallbladder
drainage (surgical or percutaneous) followed by delayed
cholecystectomy is indicated, except in experienced
centers. The severe grade (with organ dysfunction) is
trusted to cholecystostomy.
However, several reports show that early
cholecystectomy is safe even in the severe forms of the disease
[22-24] or in the elderly population [25-27]. In
particular, a recent review of prospective and retrospective
series (EL3)  did not show an increase in local
postoperative complications in severe cholecystitis and
confirmed that laparoscopic cholecystectomy is to be
considered an acceptable indication for it, despite a
demonstrated threefold conversion rate.
Laparoscopic vs open cholecystectomy
There are two randomized trials (EL2) [29,30], a
populationbased outcome research (EL3)  and numerous
comparative studies demonstrating that laparoscopic
cholecystectomy is associated with faster recovery and shorter
hospital stay than open cholecystectomy; the
populationbased outcome research showed also lower morbidity
and mortality . This evidence supported the EAES
Consensus Conference recommendation that
laparoscopic cholecystectomy be the treatment of choice for
The preference for laparoscopic cholecystectomy is
also expressed in the Tokyo guidelines ; however, the
severity tailored approach suggested in those
guidelines limits the indication for surgery only to the mildest
forms of acute cholecystitis and takes in consideration
the above evidence only in part (EL5). One of the trials
mentioned above, specifically included gangrenous
cholecystitis (to be classified in the moderate form according
to the Tokyo guidelines)  and a recent meta-analysis
shows that straight laparoscopic cholecystectomy is
indicated in severe (gangrenous, empyematous) cholecystitis
Advanced age also does not preclude the indication
for laparoscopic cholecystectomy (EL3) [32-35].
Different antibiotic regimens can be employed in acute
cholecystitis; the choice must be based on the most
common pathogens, community acquired or health care
associated infections, pharmacodynamics and
pharmacokinetics of the antibiotic and evolution of sepsis.
Moreover, the antibiotics can be administered with different
intent: as an ancillary role for early surgery or
cholecystostomy or as the unique treatment for acute episode in
the non-operative setting and delayed surgery.
The most accredited guidelines arise from TG 2013
and the WSES: the last one is the most updated and take
into consideration also new drugs such a Tigecycline
(see Table 1) [36,37].
Percutaneous cholecystostomy (PC)
Percutaneous tube cholecystostomy (followed or not by
surgery) is reported in the literature as an alternative for
the emergency treatment in septic high-risk patients. In
particular, as mentioned above, the Tokyo guidelines
consider the percutaneous (or surgical) drainage as
mandatory in the severe grade of acute cholecystitis and
also suggest its use in the moderate grade, in order to
overcoming the technical difficulties of an inflamed
gallbladder. However, gallbladder drainage has never been
proven to be an effective alternative to early surgery; the
evidence on its role is still poor. The panel of the Tokyo
Guidelines states that it is known to be an effective
option in critically ill patients, especially in elderly patients
and patients with complications; however, no evidence is
provided to support the statement, and it is recognized
that there have been no randomized controlled trials on
As a matter of fact, a Cochrane systematic review
included two trials, and none of them addressed the
No Severe Sepsis ESBL
No Severe Sepsis ESBL +
Severe Sepsis ESBL +
Pipera-Tazo + Tigecycline + Fluconazole
comparison of early cholecystectomy vs. percutaneous
A recent review performed a particularly detailed
examination of 53 papers about cholecystostomy as an option
in acute cholecystitis (EL3). It found no evidence to
support the recommendation of percutaneous drainage rather
than straight early emergency cholecystectomy even in
critically ill patients. Actually, it suggested that
cholecystectomy seems to be a better option for treating acute
cholecystitis in the elderly and/or critically ill population
. Even if the results obtained from the studies reviewed
are non-homogeneous, the mortality rate after PC (15.4%)
is significantly higher than reported after early
cholecystectomy (4.5%) in published series of similar patients. Of
course, the reports analyzed in the PC group take into
account also patients who could not have tolerated any
surgery, and this limitation has to be considered.
After their review, about 27 further observational
studies have been published, confirming that the groups
considered in the studies, their inclusion criteria, the results
and even the conclusions reached by different authors
are largely non-homogeneous. With these limitations in
mind, the reported in-hospital mortality for
cholecystostomy varies between 4 and 50% (vs. 4.5% reported for
cholecystectomy) and its morbidity ranges between 8.2
The role of percutaneous drainage of the gallbladder is
difficult to investigate also because different definitions
are used to identify high-risk patients.
At the present time, percutaneous cholecystostomy
cannot be recommended as part of a routine protocol
for treatment of acute cholecystitis, but only considered
as a possible alternative to reduce anesthesiology risk in
a small subset of patients unfit for emergency surgery
due to their severe co-morbidities. A randomized
controlled trial (CHOCOLATE Trial) has been planned to
attempt to clarify the largely conflicting evidence .
We recommend that laparoscopic cholecystectomy be
considered the treatment of choice for acute
cholecystitis and that surgery be performed as soon as possible
after the diagnosis.
The role of antibiotics is relevant both in conservative
therapy of the inflammation or as support to invasive
Pipera-Tazo + Tigecicline + Echinocandin or
Carbap Antibiotics + Teicoplanin + Echinocandin
Table 1 Recommendation for antibiotic strategy in acute cholecystitis (modified from WSES 2013)
procedures. A frequent assessment of the therapeutic
protocol is necessary to deal with bacterial resistance.
We recommend the use of the 2013 WSES guidelines
because they take into account several new drugs
compared to TG13.
At present, we do not recommend that
cholecystostomy (surgical or percutaneous) be included in routine
protocols for treatment of acute cholecystitis, and we
suggest that it be considered, only in those patient
clearly unfit for emergency surgery, until better evidence
The above reported literature review clarifies the
advantages of early laparoscopic cholecystectomy in an
unselected population. It has to be stressed, however, that
acute cholecystitis is a very heterogeneous disease as far
as general and local factors are concerned. The severity
of inflammation and its life-threatening potential is
strongly determined by the general status of the patient,
and the choice of surgical treatment cannot disregard
this aspect . Also, the general principles expressed in
the literature have to be applied taking into account the
environment, the socio-economic context in which such
an emergency develops and the related logistics.
The Tokyo guidelines attempted to address such
heterogeneity with the above described classification,
that takes into account both local and general factors,
and a therapeutic protocol based on such scheme.
Such a tailored approach, however, has not been
validated by studies showing an improved outcome after its
introduction, and a retrospective series did not find any
significant benefit . It ends up in a large use of
delayed cholecystectomy, despite several meta-analysis of
RCTs establish that early laparoscopic cholecystectomy
is to be considered the gold standard. It also disregards
the examined literature about the safety of early
laparoscopic cholecystectomy in the severe forms of the disease.
Furthermore, the role of percutaneous cholecystostomy is
far from being established as discussed above: its
therapeutic potential needs to be confirmed by the literature
evidence and integrated in an evidence-based algorithm.
The risk of early surgery for acute cholecystitis should
be evaluated against a well-established risk score in
order to identifying the patients with reduced functional
reserve who should undergo a treatment alternative to
surgery. However, none of the available clinical scores
for the evaluation of surgical risk for acute conditions
[42,43] has been validated for this disease. Further
investigations could help in validating a clinical score useful
for clinical and therapeutic decision making for acute
In addition, it has to be stressed that the general
principles expressed in the evidence based recommendations
have to be adapted to the technical, environmental and
social conditions of the different areas of the world. The
indications suggested by the Tokyo Guidelines, too
limited for most of the Western countries, still have been
shown to increase the adoption of early laparoscopic
cholecystectomy in a Japanese context, as reported by
In many developing areas complex technology is not
readily available, the diffusion of laparoscopy is still
extremely sparse  and percutaneous drainage is not
available. It is still debated if the introduction of
minimally invasive surgery is proper in many developing
countries where safe performance cannot always be assured
 and economic resources could be better employed
on more essential health programs . The
interpretation of our recommendations in those environments
has to take into account that the value of early
cholecystectomy for acute cholecystitis is supported by a level
of evidence stronger than the laparoscopic approach.
Therefore, in those areas where laparoscopy is not
readily available, an early laparotomic operation may be
preferred to a long transfer to a far away facility, taking
into consideration the local situation, the logistics and
the patient conditions.
FCC collected and reviewed the literature, prepared the evidence report,
presented the results at the congress, drafted the final manuscript. MP
collected the literature and reviewed the manuscript. LA reviewed the
manuscript and drafted the antibiotic treatment paragraph. FC, FC and FA
reviewed the manuscript. All authors read and approved the final
1. Agresta F , Ansaloni L , Baiocchi GL , Bergamini C , Campanile FC , Carlucci M , Cocorullo G , Corradi A , Franzato B , Lupo M , Mandal V , Mirabella A , Pernazza G , Piccoli M , Staudacher C , Vettoretto N , Zago M , Lettieri E , Levati A , Pietrini D , Scaglione M , De Masi S , De Placido G , Francucci M , Rasi M , Fingerhut A , Urans S , Garattini S : Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Societ Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Societ Italiana di Chirurgia (SIC), Societ Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Societ Italiana di Chirurgia nell'Ospedalit Privata (SICOP), and the European Association for Endoscopic Surgery (EAES) . Surg Endosc 2012 , 26 : 2134 - 2164 .
2. Yamashita Y , Takada T , Kawarada Y , Nimura Y , Hirota M , Miura F , Mayumi T , Yoshida M , Strasberg S , Pitt HA , de Santibanes E , Belghiti J , Bchler MW , Gouma DJ , Fan ST , Hilvano SC , Lau JW , Kim SW , Belli G , Windsor JA , Liau KH , Sachakul V : Surgical treatment of patients with acute cholecystitis: Tokyo guidelines . J Hepatobiliary Pancreat Surg 2007 , 14 : 91 - 97 .
3. Yamashita Y , Takada T , Strasberg SM , Pitt HA , Gouma DJ , Garden OJ , Bchler MW , Gomi H , Dervenis C , Windsor JA , Kim S-W , de Santibanes E , Padbury R , Chen X-P , Chan ACW , Fan S-T , Jagannath P , Mayumi T , Yoshida M , Miura F , Tsuyuguchi T , Itoi T , Supe AN : TG13 surgical management of acute cholecystitis . J Hepatobiliary Pancreat Sci 2013 , 20 : 89 - 96 .
4. Campanile FC , Catena F , Coccolini F , Lotti M , Piazzalunga D , Pisano M , Ansaloni L : The need for new patient-related guidelines for the treatment of acute cholecystitis . World J Emerg Surg 2011 , 6 : 44 .
5. Lai PB , Kwong KH , Leung KL , Kwok SP , Chan AC , Chung SC , Lau WY : Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis . Br J Surg 1998 , 85 : 764 - 767 .
6. Lo CM , Liu CL , Fan ST , Lai EC , Wong J : Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis . Ann Surg 1998 , 227 : 461 - 467 .
7. Dvila D , Manzanares C , Pich ML , Albors P , Crdenas F , Fuster E : Experience in the treatment (early vs delayed) of acute cholecystitis via laparoscopy . Cir Esp 1999 , 66 ( suppl 1 ): 233 .
8. Chandler CF , Lane JS , Ferguson P , Thompson JE , Ashley SW : Prospective evaluation of early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis . Am Surg 2000 , 66 : 896 - 900 .
9. Johansson M , Thune A , Blomqvist A , Nelvin L , Lundell L : Management of acute cholecystitis in the laparoscopic era: results of a prospective, randomized clinical trial . J Gastrointest Surg 2003 , 7 : 642 - 645 .
10. Kolla SB , Aggarwal S , Kumar A , Kumar R , Chumber S , Parshad R , Seenu V : Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial . Surg Endosc 2004 , 18 : 1323 - 1327 .
11. Yadav RP , Adhikary S , Agrawal CS , Bhattarai B , Gupta RK , Ghimire A : A comparative study of early vs. delayed laparoscopic cholecystectomy in acute cholecystitis . Kathmandu Univ Med J (KUMJ) 2009 , 7 ( 25 ): 16 . 20.
12. Papi C , Catarci M , D'Ambrosio L , Gili L , Koch M , Grassi GB , Capurso L : Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis . Am J Gastroenterol 2004 , 99 : 147 - 155 .
13. Shikata S , Noguchi Y , Fukui T : Early versus delayed cholecystectomy for acute cholecystitis: a meta-analysis of randomized controlled trials . Surg Today 2005 , 35 : 553 - 560 .
14. Lau H , Lo CY , Patil NG , Yuen WK : Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis . Surg Endosc 2006 , 20 : 82 - 87 .
15. Gurusamy KS , Davidson C , Gluud C , Davidson BR : Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis . Cochrane Database Syst Rev 2013 , 6 :CD005440. doi:10.1002/14651858.CD005440.pub3.
16. Siddiqui T , MacDonald A , Chong PS , Jenkins JT : Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials . Am J Surg 2008 , 195 : 40 - 47 .
17. Gurusamy K , Samraj K , Gluud C , Wilson E , Davidson BR : Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis . Br J Surg 2010 , 97 : 141 - 150 .
18. Banz V , Gsponer T , Candinas D , Gller U : Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy . Ann Surg 2011 , 254 : 964 - 970 .
19. Hirota M , Takada T , Kawarada Y , Nimura Y , Miura F , Hirata K , Mayumi T , Yoshida M , Strasberg S , Pitt H , Gadacz TR , Santibanes E d, Gouma DJ , Solomkin JS , Belghiti J , Neuhaus H , Bchler MW , Fan S-T , Ker C-G , Padbury RT , Liau K-H , Hilvano SC , Belli G , Windsor JA , Dervenis C : Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines . J Hepatobiliary Pancreat Surg 2007 , 14 : 78 - 82 .
20. Mayumi T , Takada T , Kawarada Y , Nimura Y , Yoshida M , Sekimoto M , Miura F , Wada K , Hirota M , Yamashita Y , Nagino M , Tsuyuguchi T , Tanaka A , Gomi H , Pitt HA : Results of the Tokyo Consensus Meeting Tokyo Guidelines . J Hepatobiliary Pancreat Surg 2007 , 14 : 114 - 121 .
21. Yokoe M , Takada T , Strasberg SM , Solomkin JS , Mayumi T , Gomi H , Pitt HA , Gouma DJ , Garden OJ , Bchler MW , Kiriyama S , Kimura Y , Tsuyuguchi T , Itoi T , Yoshida M , Miura F , Yamashita Y , Okamoto K , Gabata T , Hata J , Higuchi R , Windsor JA , Bornman PC , Fan S-T , Singh H, de Santibanes E , Kusachi S , Murata A , Chen X-P , Jagannath P , et al: New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines . J Hepatobiliary Pancreat Sci 2012 , 19 : 578 - 585 .
22. Choi SB , Han HJ , Kim CY , Kim WB , Song T-J , Suh SO , Kim YC , Choi SY : Early laparoscopic cholecystectomy is the appropriate management for acute gangrenous cholecystitis . Am Surg 2011 , 77 : 401 - 406 .
23. Lo H-C , Wang Y-C , Su L-T , Hsieh C -H: Can early laparoscopic cholecystectomy be the optimal management of cholecystitis with gallbladder perforation? A single institute experience of 74 cases . Surg Endosc 2012 , 26 : 3301 - 3306 .
24. Nikfarjam M , Niumsawatt V , Sethu A , Fink MA , Muralidharan V , Starkey G , Jones RM , Christophi C : Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis . HPB (Oxford) 2011 , 13 : 551 - 558 .
25. Riall TS , Zhang D , Townsend CM Jr, Kuo YF , Goodwin JS : Failure to perform cholecystectomy for acute cholecystitis in elderly patients is associated with increased morbidity , mortality, and cost. J Am Coll Surg 2010 , 210 ( 5 ): 668 - 679 .
26. Snchez Beorlegui J , Lagunas Lostao E , Lamata Hernndez F , Monsalve Laguna EC : Tratamiento de la colecistitis aguda en en el anciano: ciruga urgente frente a terapia mdica y ciruga diferida . Rev Gastroenterol Peru 2009 , 29 ( 4 ): 332 - 340 .
27. Lupinacci RM , Nadal LR , Rego RE , Dias AR , Marcari RS , Lupinacci RA , Farah JFM : Surgical management of gallbladder disease in the very elderly: are we operating them at the right time ? Eur J Gastroenterol Hepatol 2013 , 25 : 380 - 384 . doi:10.1097/MEG.0b013e32835b7124.
28. Borzellino G , Sauerland S , Minicozzi AM , Verlato G , Di Pietrantonj C , de Manzoni G , Cordiano C : Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results . Surg Endosc 2008 , 22 : 8 - 15 .
29. Kiviluoto T , Siren J , Luukkonen P , Kivilaakso E : Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis . Lancet 1998 , 351 : 321 - 325 .
30. Johansson M , Thune A , Nelvin L , Stiernstam M , Westman B , Lundell L : Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis . Br J Surg 2005 , 92 : 44 - 49 .
31. Csikesz N , Ricciardi R , Tseng JF , Shah SA : Current status of surgical management of acute cholecystitis in the United States . World J Surg 2008 , 32 ( 10 ): 2230 - 2236 .
32. Pessaux P , Regenet N , Tuech JJ , Rouge C , Bergamaschi R , Arnaud JP : Laparoscopic versus open cholecystectomy: A prospective comparative study in the elderly with acute cholecystitis . Surg Laparosc Endosc Percutan Tech 2001 , 11 ( 4 ): 252 - 255 .
33. Lujan JA , Sanchez-Bueno F , Parrilla P , Robles R , Torralba JA , Gonzalez-Costea R : Laparoscopic vs. open cholecystectomy in patients aged 65 and older . Laparosc Endosc Percutan Tech 1998 , 8 ( 3 ): 208 - 210 .
34. Chau CH , Tang CN , Siu WT , Ha JP , Li MK : Laparoscopic cholecystectomy versus open cholecystectomy in elderly patients with acute cholecystitis: retrospective study . Hong Kong Med 2002 , J8 : 394 - 399 .
35. Massie MT , Massie LB , Marrangoni AG , D'Amico FJ , Sell HW : Advantages of laparoscopic cholecystectomy in the elderly and in patients with high ASA classifications . J Laparoendosc Surg 1993 , 3 : 467 - 476 .
36. Gomi H , Solomkin JS , Takada T , Strasberg SM , Pitt HA , Yoshida M , Kusachi S , Mayumi T , Miura F , Kiriyama S , Yokoe M , Kimura Y , Higuchi R , Windsor JA , Dervenis C , Liau K-H , Kim M -H: Tokyo Guideline Revision Committee: TG13 antimicrobial therapy for acute cholangitis and cholecystitis . J Hepatobiliary Pancreat Sci 2013 , 20 : 60 - 70 . doi:10.1007/s00534- 012 - 0572 -0.
37. Sartelli M , Viale P , Catena F , Ansaloni L , Moore E , Malangoni M , Moore FA , Velmahos G , Coimbra R , Ivatury R , Peitzman A , Koike K , Leppaniemi A , Biffl W , Burlew CC , Balogh ZJ , Boffard K , Bendinelli C , Gupta S , Kluger Y , Agresta F , Di Saverio S , Wani I , Escalona A , Ordonez C , Fraga GP , Junior GAP , Bala M , Cui Y , Marwah S , et al: 2013 WSES guidelines for management of intra-abdominal infections . World J Emerg Surg 2013 , 8 : 3 . doi:10.1186/ 1749 - 7922 -8- 3 .
38. Gurusamy KS , Rossi M , Davidson BR : Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis . Cochrane Database Syst Rev 2013 , 8 :CD007088. doi:10.1002/14651858.CD007088.pub2.
39. Winbladh A , Gullstrand P , Svanvik J , Sandstrm P : Systematic review of cholecystostomy as a treatment option in acute cholecystitis . HPB (Oxford) 2009 , 11 ( 3 ): 183 - 193 .
40. Kortram K , van Ramshorst B , Bollen TL , Besselink MGH , Gouma DJ , Karsten T , Kruyt PM , Nieuwenhuijzen GAP , Kelder JC , Tromp E , Boerma D : Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial . Trials 2012 , 13 : 7 .
41. Lee S-W , Yang S-S , Chang C-S , Yeh H-J: Impact of the Tokyo guidelines on the management of patients with acute calculous cholecystitis . J Gastroenterol Hepatol 2009 , 24 : 1857 - 1861 .
42. Rix TE , Bates T : Pre-operative risk scores for the prediction of outcome in elderly people who require emergency surgery . World J Emerg Surg 2007 , 2 : 16 . doi:10.1186/ 1749 - 7922 - 2 - 16 .
43. Vaid S , Bell T , Grim R , Ahuja V : Predicting risk of death in general surgery patients on the basis of preoperative variables using American College of Surgeons National Surgical Quality Improvement Program data . Perm J 2012 , 16 : 10 - 17 .
44. Asai K , Watanabe M , Kusachi S , Matsukiyo H , Saito T , Kodama H , Dotai K , Hagiwara O , Enomoto T , Nakamura Y , Okamoto Y , Saida Y , Nagao J : Changes in the therapeutic strategy for acute cholecystitis after the Tokyo guidelines were published . J Hepatobiliary Pancreat Sci 2013 , 20 : 348 - 355 . doi:10.1007/s00534- 012 - 0536 -4.
45. Afuwape OO , Akute OO : The challenges and solutions of laparoscopic surgical practice in the developing countries . Niger Postgrad Med J 2011 , 18 : 197 - 199 .
46. Manning RG , Aziz AQ : Should laparoscopic cholecystectomy be practiced in the developing world?: the experience of the first training program in Afghanistan . Ann Surg 2009 , 249 : 794 - 798 . doi:10.1097/SLA.0b013e3181 a3eaa9 .
47. Teerawattananon Y , Mugford M: : Is it worth offering a routine laparoscopic cholecystectomy in developing countries? A Thailand case study . Cost Eff Resour Alloc 2005 , 3 : 10 . doi:10.1186/ 1478 - 7547 - 3 - 10 .