Early Versus Delayed Cholecystectomy for Acute Cholecystitis: Comments on the ACDC Study

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To the Editor:
In the September 2013 issue of Annals of Surgery, the results of the multicenter randomized ACDC study were presented by Gutt et al.1 The article was read with great interest because of the shortage of published, well-conducted analyses on the matter. The interest regarding the issue addressed is highlighted by the fact that the article resulted in a wide and valuable debate.2–5 Some of our perplexities regarding the article have already been raised by other authors; however, several aspects require further consideration.
The authors considered 4 clinical findings to enroll patients: upper right abdominal pain, Murphy sign, leukocytosis, and rectal temperature. When at least 3 of the aforementioned conditions were present in association with cholecystolithiasis (gallstones and/or sludge) or ultrasound signs of cholecystitis, patients were considered eligible to be enrolled in the trial.
Some concerns arise. The clinical conditions evaluated by the protocol are commonly recognized as nonspecific6,7 and may also be present in a number of patients without acute cholecystitis suffering from different abdominal conditions. Particularly, this may be the case of patients with cholecystolithiasis experiencing biliary colics.
On ultrasound examination, the study protocol considered as eligibility criteria not only signs of cholecystitis but also cholecystolithiasis per se. This means that a number of symptomatic patients received a diagnosis of acute cholecystitis despite a radiological assessment revealing none of the major ultrasonographic diagnostic criteria.8,9 In this regard, it is not clear why, once an ultrasound assessment was obtained for each patient, the diagnosis of acute disease was not made accordingly, given that ultrasonography has excellent sensitivity and specificity, far higher than clinical features.6,7 Indeed, according to the literature, in the absence of characteristic imaging findings, only a diagnosis suggestive of acute cholecystitis can be made.6,10
In conclusion, it would be extremely interesting to know how many included patients had ultrasound evidence of acute cholecystitis and how many did not. Second, it would be interesting to know in what percentage of patients the diagnosis of acute cholecystitis was confirmed at surgery by direct intraoperative assessment.
We congratulate Dr Gutt et al on their elegant and timely study, although we recommend particular caution in interpreting their data. The selection criteria used to enroll patients may impair the power of the analysis and the possibility of drawing definitive conclusions from their outcomes.
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