The Tokyo guidelines proposed a staging system based upon the evaluation of local signs of inflammation (Murphy’s sign and RUQ mass/pain/tenderness), systemic signs (fever, elevated CRP with values of 3 mg/dl or more and abnormal WBC count) and imaging findings characteristic of acute cholecystitis. Similar diagnostic criteria are reported from other recent studies [4, 14]. As far as diagnosis and treatment of acute cholecystitis is concerned, the peculiarity of the Tokyo guidelines is the division of the disease in mild, moderate

and severe [6, 7]. No previous study examined the optimal treatment of acute cholecystitis on the basis of an organ-related severity score index. In the Tokyo consensus meeting the need for surgical treatment according to the grade of severity was suggested and discussed [7]. Subsequent studies analyzed the impact of the Tokyo guidelines on the management of patients with acute cholecystitis, stressing the attention on their impact on buy Bortezomib Silmitasertib datasheet surgical outcomes. Even if the

expert panel of that consensus made an extraordinary scientific work, no benefits have been demonstrated by applying those guidelines, except a decrease of mean length of hospital stay [8]. Acute cholecystitis could present with a picture ranging from mild, self limiting, to a potentially life threatening illness [6]. However the severity of inflammation and its life threatening potential is also strongly determined by the general condition of the patient, and the surgical treatment is often dictated more by the general conditions of the patient than by the grade of inflammation/infection of the

gallbladder. Actually no randomized controlled trials have examined the optimal surgical treatment for acute cholecystitis according to its severity grade and the panel at the Tokyo consensus meeting included patients with organ/systemic dysfunctions in the “”grade III”" of the guidelines, with the suggestion that these patients should receive delayed cholecystectomy after urgent drainage. Early gallbladder drainage is suggested also in grade II patients, with local severe inflammation, however a later systematic review of 53 papers about cholecystostomy Dolichyl-phosphate-mannose-protein mannosyltransferase as an option in acute cholecystitis found no evidence to support the recommendation of percutaneous drainage rather than straight early emergency cholecystectomy even in critically ill patients, and stated that it is not possible to make decisive recommendations about it. From their data, actually, cholecystectomy seems to be a better option than early drainage, for treating acute cholecystitis in the elderly and/or critically ill population [15]. Borzellino et al., in a recent review of prospective and retrospective series did not show an increase in local postoperative complications in laparoscopically treated severe (gangrenous and empyematous) acute cholecystitis but did not address the issue of timing of intervention in this subset of patients [16].