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which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Acute cholecystitis – early laparoskopic surgery versus antibiotic therapy and delayed elective cholecystectomy: ACDC-study
Kilian Weigand1, Jörg Köninger2, Jens Encke1, Markus W. Büchler2, Wolfgang Stremmel1,Carsten N. Gutt2,*
1 Department of Gastroenterology and Hepatology, University of Heidelberg, Germany
2 Department of General Surgery, University of Heidelberg, Germany
Carsten Gutt, M.D. Professor of SurgeryDepartment of General SurgeryUniversity of Heidelberg, Medical SchoolIm Neuenheimer Feld 110D-69120 HeidelbergGermanyemail: [email protected]Abstract Background: Acute cholecystitis occurs frequent in the elderly and in patients with gall
stones. Most cases of severe or recurrent cholecystitis eventually require surgery, usually
laparoscopic cholecystectomy in the Western World. It is unclear whether an initial,
conservative approach with antibiotic and symptomatic therapy followed by delayed elective
surgery results in better morbidity and outcome than immediate surgery. At present, treatment
is generally determined by whether the patient first sees a surgeon or a gastroenterologist. We
wish to investigate whether both approaches are equivalent. The primary endpoint is the
morbidity until day 75 after inclusion into the study. Design: A multicenter, prospective, randomized non-blinded study to compare treatment
outcome, complications and 75-day morbidity in patients with acute cholecystitis randomized
to laparoscopic cholecystectomy within 24 hours of symptom onset or antibiotic treatment
with moxifloxacin and subsequent elective cholecystectomy. For consistency in both arms
moxifloxacin, a fluorquinolone with broad spectrum of activity and high bile concentration is
used as antibiotic. Duration: October 2006 – November 2008
Organisation/Responsibility: The trial was planned and is being conducted and analysed by
the Departments of Gastroenterology and General Surgery at the University Hospital of
Heidelberg according to the ethical, regulatory and scientific principles governing clinical
research as set out in the Declaration of Helsinki (1989) and the Good Clinical Practice
Trial Registration: ClinicalTrials.gov NCT00447304 Background Medical problem:
Acute cholecystitis is one of the most significant acute diseases in the Western World, and
may be associated with only mild pain and nausea or become a severe, life-threatening illness
due to complications. Acute cholecystitis is mainly caused by gall stones, whilst cholestasis is
mainly associated with superinfection with bacteria, in general species of enterobacteria,
enterococci, bacteroides and anaerobic streptococci .
The principal complication is recurrent biliary colic and cholestasis. The latter may lead to
ascending cholangitis, and whilst this can be managed with antibiotics, other complications
can not be cured conservatively, such as gangrenous changes, gall bladder perforation and
biliary leakage, and acute necrotic gallstone pancreatitis [2-5]. Liver abscesses and underlying
incidental carcinoma have also been reported in some cases [2, 6].
The risk of developing second and subsequent episodes of acute cholecystitis is higher than
the risk of suffering an initial episode [7, 8]. Laparoscopic cholecystectomy is therefore
usually recommended, but whether this should be performed immediately or after first giving
antibiotic treatment to allow the acute condition to subside is controversial [9-12]. Immediate surgery versus conservative procedure with subsequent elective surgery:
The approach taken is often decided by whether the patient first sees a gastroenterologist, who
favors conservative initial antibiotic therapy with later elective surgery, or a surgeon, who
It is still unclear which approach is better in medical and health economic terms. The
infection may not respond to conservative treatment on one hand, on the other hand surgical
intervention while the disease is acute may increase complications, and conversion to open
surgery may be necessary. It is unclear whether it is better to conduct early cholecystectomy,
thereby avoiding the risk of recurrent cholecystitis or pancreatitis.
A meta-analysis by Papi et al. (2003) including 12 prospective randomized trials showed no
significant difference for morbidity and mortality between immediate surgical intervention
(laparoscopic or open) and elective surgery after the acute inflammation had subsided .
The numbers of patients and rates of complications were too low to enable any conclusions to
be drawn. Also, their definition of “immediate” was between 1 and 7 days after disease onset,
while the modern standard favors laparoscopic surgery within 24 hours of onset [14, 15].
All studies in the meta-analysis had been performed between 1970 and 2000, and Papi
concluded that new studies in an adequate number of patients to show statistical significance
should be performed . Two subsequent prospective randomized trials concerning the
appropriate timing for surgery also failed to lead to conclusive results, except for a slightly
shorter hospital stay in patients treated with immediate surgery [16, 17].
In many centers early cholecystectomy is well established although the evidence is not yet
conclusive. To our knowledge there has never been a study in which both specialties -
gastroenterology and surgery - are equally involved. Choice of antibiotic:
Moxifloxacin (Avalox) covers the spectrum of gram-positive, gram-negative and anaerobic
bacteria usually responsible for intra-abdominal infections [18-20]. It can be applied orally or
intravenously in a single dose of 400 mg/day, resulting in bile concentrations significantly
above the minimum inhibitory concentration , and 3–4 times higher than plasma
A controlled double-blinded study in 379 patients in the USA showed moxifloxacin to be at
least as effective as standard treatment by with piperacillin + tazobactam i.v. followed by oral
amoxicillin + clavulanate in complicated intra-abdominal infections [23, 24]. A European
prospective randomized and controlled open-label study showed equivalent efficacy for
moxifloxacin and ceftriaxone plus metronidazole (AIDA study) . Moxifloxacin was
effective and well-tolerated in both studies, with gastrointestinal disorders like nausea and
diarrhea being the most frequent adverse events [26, 27]. Study Design Aim of the study:
The objective of this trial is to compare the 75-day morbidity of two different approaches to
the treatment of acute cholecystitis: (i) laparoscopic cholecystectomy within 24 hours of
hospital admission; and (ii) initial antibiotic treatment with moxifloxacin followed by
cholecystectomy in the infection-free interval (Day 7 to 45). Organization of the study:
The trial is a GCP-compliant, multicenter, prospective, randomized non-blinded study.
Patients with acute cholecystitis meeting the inclusion criteria are randomized to one of the
treatment arms. The study is being audited by members of a contract research organization
(CRO) and may be subject to government inspection. The trial was approved by the German
Number of patients needed:
The primary aim of the study is to compare morbidity in the two groups 75 days after
enrolment. A difference in morbidity of less than 10% is defined as equivalent. The null-
/ρM1 - ρM2 / > 0.1, where ρMi is the morbidity rate of treatment group i.
Complications are expected in 16% of patients in each group; each group therefore needs to
enroll 273 patients to permit verification of the null-hypothesis with an α-error of 0.05 and a
β-error at 0.15, yielding a power of 90%. Assuming a validity rate of 85%, 322 patients are
required per group, resulting in a total patient sample of 644. Eligibility criteria Inclusion criteria:
• Patients with acute cholecystitis with three of the following symptoms or signs
abdominal pain in the upper right quadrant
rectal temperature > 38 °C or < 36.5 °C
cholecystolithiasis (stones/sludge) or sonographic signs of cholecystitis
(thickening and triple layer formation of the gall bladder wall)
• Immediate antibiotic therapy (400 mg Moxifloxacin i.v. once a day)
• Laparoscopic cholecystectomy possible within 24 hours after presentation of the
• Perforation or abscess of the gall bladder
• No possibility of laparoscopic surgery
• Additional antibiotics needed for secondary disease
• Intolerance to moxifloxacin or other quinolones
• Pregnancy (also suspected), breast feeding
• End-stage liver disease (Child-Pugh C)
• Psychiatric or severe neurologic disease
• Relevant bradycardia or other symptomatic arrhythmias
• Hypocalcaemia or other electrolyte disorders
Ethics, Study Registration and Consent
The final protocol was approved by the independent ethics committee of the University of
Heidelberg. The study was registered at ClinicalTrials.gov (NCT00447304). Patients who are
scheduled for laparoscopic cholecystectomy (immediate or elective) due to acute cholecystitis
are informed about the trial (laparoscopic surgery, possibility of conversion to open surgery,
other risks, benefits and confidential handling of documented findings) and are given the
opportunity to participate at the screening visit. Informed consent is required. Patients may
withdraw from the study at any time without giving reasons and without jeopardizing their
further treatment. The investigator may also withdraw patients if this is in their best interests. Randomisation and procedures for minimizing bias
This study is randomized to minimize bias. Sealed randomization envelopes are provided in
packs of four by the CRO and are held centrally at each investigational site. An envelope is
opened when a patient agrees to take part and patients are informed whether they are to be
treated with immediate surgery or initial conservative antibiotic therapy. Study treatment
Day 1 is defined as the day the patient presents to the hospital. He undergoes a physical
examination, vital signs are documented, and an abdominal ultrasound investigation is
performed to confirm the diagnosis of acute cholecystitis. A blood sample is also taken for
standard laboratory diagnosis (including Na, K, INR, Hb, platelets, leukocytes, bilirubin,
ALT, AST, gamma-GT, AP, amylase, lipase, urea, creatinin and CRP). All relevant
concomitant diseases (e.g. coronary heart disease, diabetes mellitus) indicative for morbidity
The patient is informed about the trial and is given the opportunity to participate. After the
patient has given his informed consent, he is randomized, and all baseline findings, date of
birth, age, sex, medical history, height and weight are documented in the CRF.
All patients are examined daily while in the hospital. The laboratory investigations are
repeated on Day 3. Samples are taken for microbiological cultures, if necessary. At Day 75
(test-of-cure visit), all diagnostic procedures and treatments between Day 1 and Day 75 are
documented. The laboratory determinations and physical examination are repeated, and vital
signs are measured. Morbidity is documented according to Table 2. Procedure for patients receiving immediate surgery:
• Laparoscopic cholecystectomy in the 24 hours after hospital admission
• Antibiotic therapy with moxifloxacin 400 mg i.v. once per day for 48 hours followed
by oral Moxifloxacin 400 mg daily or discontinuation of antibiotic treatment if
• Discharge of the patient as soon as possible after Day 2, if the body temperature, CRP
Procedure for patients receiving primarily conservative therapy with elective surgery:
• Therapy with i.v. moxifloxacin 400 mg once daily for 48 hours followed by oral
moxifloxacin 400 mg per day. Discontinuation of moxifloxacin after Day 7, provided
body temperature, CRP and leukocytes are normal
• Discharge of the patient as soon as possible after Day 4 on oral moxifloxacin
• Elective cholecystectomy between Days 7 and 45 after admission to study using
single-shot moxifloxacin i.v. for prophylaxis
Primary and secondary endpoints Primary endpoints:
Primary endpoint is morbidity at the test-of-cure (TOC) visit (75 days after trial inclusion) in
the tested population valid for efficacy. Secondary endpoints:
1. Morbidity over 75 days using the scoring system showed in Table 2
2. Morbidity 3 days after cholecystectomy (immediate and elective)
3. Rate of conversion from laparoscopic to open surgery
4. Change of antibiotic due to non-response or non-toleration of moxifloxacin
9. Duration of hospital stay after cholecystectomy (days)
Adverse events and serious adverse events
Adverse events and serious adverse events and deaths occurring up to Day 75 were recorded.
An adverse event (AE) is every medical event that worsens or impairs the well-being of the
patient not being part of the natural course of the disease but may be due to treatment or drug
application. The term AE can cover any sign, symptom or reaction, including not normal
laboratory findings, independent if caused by the tested procedure and medication or not.
Adverse event intensity (mild, moderate or severe) and relationship to the treatment or the
study drug moxifloxacin (probable, possible, unlikely or none) were categorized. Serious
adverse events (SAEs) included those events that were fatal, life-threatening, required
hospitalization, resulted in disability or otherwise endangered the patient.
All AEs and SAEs will be documented in detail in the case report form (CRF) and will be
reported to the principal investigator at regular intervals. SAEs have to be reported within 24
hours to the principal investigator, and must be documented separately on an SAE report form
within 24 hours. According to law and guidelines, SAEs have to be reported to the ethics
committee(s) and supervisory board(s) as necessary. The period of observation for AE
All statistical tests will be performed two-sided with a level of significance of 5%. The
patients will be analyzed as treated. The principle analysis will be on evaluable patients and a
supportive intent-to-treat analysis will be performed. Patients will be stratified according to
severity of their condition (ASA ≤ 2 vs. ASA > 2); the principle analysis will be stratified, but
a non-stratified analysis will also be performed
The groups will be tested for equivalence of distribution of age, sex and body mass index. The
analysis will be conducted using analysis of variance with the factors study group and severity
of disease, stratified by the Cochran-Mantel-Haenszel test.
95% confidence intervals (CI) for the difference of morbidity rates will be calculated. If and
only if this CI lies between –10% and +10% the two procedures will be considered
equivalent. The calculation of the 95% CI will be stratified by severity (ASA ≤ 2 vs. ASA >
2). A Breslow-Day test will be performed to check for homogeneity between these two strata.
Amongst the secondary variables, the mean morbidity score in the two groups stratified by
severity of disease will be compared using the Wilcoxon rank-sum test. Where appropriate,
descriptive statistics will also be performed for all other variables. Study organization
All eligible patients are seen by a gastroenterologist or surgeon and are enrolled after giving
informed consent. The incidence of patients with acute cholecystitis ranges from 10 to >100
per year at different investigational sites. With about 30 sites, it is estimated that enrollment of
644 patients will take about 24 months. All findings are recorded in the patients medical
records and CRF provided for this study by the investigator. Data verification is performed by
the CRO, who will also perform the analysis on the locked database after plausibility testing
The authors declare that they have no competing interests. Authors contributions
K.W. participated in the design and coordination of the study and drafted the manuscript. J.E.,
C.G. and J.K. participated in the design and coordination and helped to draft the manuscript.
J.E. and C.G. conceived the study. J.E., C.G., J.K. and K.W. supervised the coordination of
the different trial centers. M.W.B. and W.S. supervised the coordination of the study. All
authors read and approved the final version of the manuscript. References
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Copeland CP, POSSUM a scaring system for surgical audit. Br J Surg, 1991. 78: p. 356-360. Table 1: ASA-Criteria ASA Physical Status (PS) Classification System from the American Society of Anesthesiologists ASA PS Category Preoperative Health Status
Patients with severe systemic disease thatis a constant threat to life
Moribund patients who are not expectedto survive without the operation
A declared brain-dead patient who organsare being removed for donor purposes
American Society of Anesthesiologists (ASA) Physical Status (PS) Classification System. Categories to classify the preoperative health status of patients. Table 2: Morbidity Score
Pain treated by morphine or derivatives > 72 h
Rectal temperature > 38.5°C at least twice
Persistently elevated CRP or leukocytosis
Any problem leading to re-opening of the wound with
Need for more than two bags of packed red cells during or after
New increase in AP, GGT (>2x ULN), bilirubin (>1x ULN) plus
leukocytosis (> 12 x 103 /µl) or increase in CRP (> 5x ULN)
New increase in bilirubin, AP and GGT (>2x ULN)
Persistent leakage shown by CT, MRI or ERCP
Shown by X-ray plus drop in arterial pO2 plus clinical signs of
pneumonia plus leukocytosis plus increased CRP
Increased PA pressure (echocardiogram), TNT/TNI, D-dimers
Increased pancreatic enzymes (> 3x ULN) plus new increase in
CRP (> 5x ULN) plus positive clinical signs
Drop in urine production below 500 mL/day plus increased
New neurological symptoms with corresponding to changes in
Changes in TNT/TNI with or without changes in the ECG
Leukocytosis (> 12 x 103 /µl) or leukopenia (< 4 x 103 /µl) plus
temperature < 36.5°C or > 38.5°C plus clinical signs
Different complications and side effects that may affect the patients during the study are listedand scored differently in increasing severity. Death as worst outcome is scored the sum of allcomplications plus 1.
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