Review for 10.1186/s12876-015-0365-4 (2015)

Reviewer's report
Title:Does the Tokyo Guidelines predict the extent of gallbladder inflammation in
patients with acute cholecystitis? A single center retrospective analysis.
Version:2Date:28 June 2015
Reviewer: Fabio Campanile
Reviewer's report:
The manuscript is an interesting report on a very relevant topic. The validation of
the Tokyo guidelines is certainly not complete and the guidelines have several
controversial aspects (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). A retrospective analysis can be important in this contest.
There are several issues that need to be addressed:
Major compulsory revisions:
1. The Tokyo guidelines propose a severity grading system as the basis to build
the therapeutic algorithm. The series reported performs a retrospective staging in
a series that in NOT being treated according to the Tokyo algorithm. In particular
the Tokyo guidelines established that all patients in the III stage should not
receive an early cholecystectomy (and should be drained, instead) and the same
applies for the II stage if not in an “experienced center”. A different therapeutic
protocol was used. This aspect should be extensively discussed in the paper.
2. Furthermore, the definitions of the staging system implies that the stage II
should predict difficulty in performing a proper dissection (and therefore local
complications) , and the stage III should predict general complications too. For
this reason a separate analysis for stage I, II, and III, would add a great deal of
value to the study, because it could allow a direct comparison between local and
general complications (and conversion rate) between stages. All Grade V and IV
complications (and most of the Grade III) belong to the II/III severity stage: how
many are in the II and how many in the III?
3. The acute renal failure listed among the grade III complications in the table are
postoperative occurrence of acute renal failure in stage II patients? Or are they
included in the 9 cases of renal insufficiency that placed the patients in Grade III
in the first place?
4. From the methods section is not clear if the pathology has been reviewed by a
new microscopic exam of the specimens or the classification has been made
according to the paper reports from the charts. It should be specified.
5. Further comments: Lines 154-165: the pathological classification adopted it is
not clear. Does not correspond to the classification adopted by the Tokyo
guidelines and does not include a “suppurative” stage. Actually the definition of
gangrenous cholecystitis “loss of mucosal lining and vascular architecture with
profuse inflammation secondary to focal gallbladder ischemia” appears very
similar to the “suppurative” stage of the common classification (Kimura et al,
Journal of Hepato-Biliary-Pancreatic Surgery200714:1152 DOI:
10.1007/s00534-006-1152-y, or
http://bestpractice.bmj.com/best-practice/monograph/78/basics/classification.html),
whereas for “gangrenous cholecystitis” is commonly meant a progression of the
disease with transmural full thickness necrosis of the gallbladder wall.
This part should either be re-written adopting the usual classification (edematous,
necrotizing, suppurative...) or the classification adopted should be mentioned and
the choice to adopt a different classification should be explained.
Of course, the re-classification can have an impact on the data of the study,
because “gangrenous” full thickness necrosis or emphysematous or perforated
are “complicated” cholecystitis (“severe” acute cholecystitis as in but “necrotizing”
(necrosis present but NOT transmural) is an intermediate stage of the acute
cholecystitis.
Lines 184-187: why were 37 cases excluded from the analysis? It should be
specified here.
Lines 189-193 and discussion: the fact that WBC is lower in the I severity grade
is self evident because it is included in the definition of the grade (in other words
patients with WBC > 18,000 cannot belong to stage I)
Lines 287-296: this part could be better clarified: “the preoperative severity of
acute cholecystitis correlated significantly with the extent...” but “the TG13
guideline might undestimate the extent...”
The relevant data from this series show that in stage I there is a significant
number of advanced cholecystitis and “severe” cholecystitis. This is the
unexpected finding that should be better focused .
Suppl 3: it cannot be read
Discretionary revisions
The authors do not comment on the fact that the Tokyo severity grading system
is the basis, in those guidelines, to define the therapeutic strategy (laparoscopic
cholecystectomy in grade I, laparoscopic surgery only in selected centers and
percutaneous drainage in all the remaining centers for stage II, percutaneous
drainage in every III stage). In particular the definition of grade II is “the degree of
acute infl ammation is likely to be associated with increased operative difficulty to
perform a cholecystectomy”. Because the authors examine a series in which all
the patients were operated, could they comment on the predicting value of stage
II about difficult dissection? Apparently if there are several severe cholecystitis
among stage I it is possible that the stage II does not accurately predict the
“difficult dissection” and cannot be used to discriminate indications for surgery.
What about morbidity and mortality among the stage III only? Are they that much
higher that warrant the delayed approach suggested in the Tokyo guidelines?
I believe that addressing these issue could add a great value to the work.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests