Diagnosis and treatment of acute calculus cholecystitis: WSES 2020 Guideline

• Laparoscopic cholecystectomy is recommended as the first-line treatment for patients with ACC.
• Avoiding laparoscopic cholecystectomy is recommended in case of septic shock or absolute anaesthesiology contraindications.
• Laparoscopic cholecystectomy should be performed for ACC patients with Child’s A and B cirrhosis, patients with advanced age (including more than 80 years old) and patients who are pregnant.
• Laparoscopic or open subtotal cholecystectomy is recommended in situations in which anatomic identification is difficult and in which the risk of iatrogenic injuries is high.
• Conversion from laparoscopic to open cholecystectomy is recommended in case of severe local inflammation, adhesions, bleeding from the Calot’s triangle or suspected bile duct injury.

Timing of Cholecystectomy in People with ACC

• In the presence of adequate surgical expertise, ELC should be performed as soon as possible, within 7 days from hospital admission and within 10 days from the onset of symptoms.
• DLC should be performed beyond 6 weeks from the first clinical presentation, in case ELC cannot be performed (within 7 days of hospital admission and within 10 days of onset of symptoms).

Risk Prediction in ACC

• The use of any prognostic model in patients with ACC cannot be suggested.

Alternative Treatment for Patients with ACC who are not Suitable for Surgery

• The use of NOM is recommended, i.e. best medical therapy with antibiotics and observation, for patients refusing surgery or those who are not suitable for surgery.
• Alternative treatment options should be considered for patients who fail NOM and who still refuse surgery or patients who are not suitable for surgery.
• Immediate laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) in high risk patients with ACC. Laparoscopic cholecystectomy is recommended as the first-choice treatment in this group of patients.
• Gallbladder drainage should be performed in patients with ACC who are not suitable for surgery, as it converts a septic patient with ACC into a non-septic patient.
• Delayed laparoscopic cholecystectomy is suggested after reduction of perioperative risks to decrease readmission for ACC relapse or gallstone-related disease.
• In patients with ACC who are not suitable for surgery, endoscopic transpapillary gallbladder drainage (ETGBD) or ultrasound-guided transmural gallbladder drainage (EUS-GBD) should be considered safe and effective alternatives to PTGBD, if performed in high-volume centers by skilled endoscopists.
• If endoscopic transpapillary gallbladder drainage is performed, both endoscopic nasogatric endoscopic gallbladder drainage (ENGBD) and endoscopic gallbladder stenting (EGBS) should be considered suitable options, based on patient characteristics and on the endoscopist’s decision.
• EUS-GBD with lumen-apposing self-expandable metal stents (LAMSs) should be preferred to ETGBD, if performed by skilled endoscopists.
• If a EUG-GBD is performed using metal stents, we recommend their removal within 4 weeks, in order to avoid food impaction with subsequent high risk of recurrence of ACC.