{"id":7399,"date":"2026-06-20T02:49:20","date_gmt":"2026-06-20T02:49:20","guid":{"rendered":"https:\/\/gothi.gov.eg\/?page_id=7399"},"modified":"2026-06-20T03:00:37","modified_gmt":"2026-06-20T03:00:37","slug":"%d8%ac%d8%b1%d8%a7%d8%ad%d9%87-%d8%b9%d8%a7%d9%85%d9%87","status":"publish","type":"page","link":"https:\/\/gothi.gov.eg\/?page_id=7399","title":{"rendered":"\u062c\u0631\u0627\u062d\u0647 \u0639\u0627\u0645\u0647"},"content":{"rendered":"\t\t
\n\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t\t\t\t\t\n
    \n
  1. <\/li>\n<\/ol>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t
    \n\t\t\t\t\t
    \n\t\t\t\t
    \n\t\t\t\t
    \n\t\t\t\t\t

    \u062c\u0631\u0627\u062d\u0647 \u0639\u0627\u0645\u0647\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
    \n\t\t\t\t
    \n\t\t\t\t\t
    \n\n
    \n\n
    \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Management of Anal Fissures <\/span>\n\n <\/h5>\n\n
    \n
    \n
    \n
    \n
    “last update: 12 May 2025\u00a0\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0Download Guideline<\/u><\/a><\/b><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
    \n

    – Executive Summary<\/h3>\n
    \n

    \u00a0<\/p>\n

    This guideline offers evidence-based recommendations on the targeted levels of Clinical practice guidelines and provide healthcare professionals with practical guidance on the diagnosis and treatment of anal fissure.<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Non-operative treatment of acute anal fissures continues to be safe, has few side effects, and should typically be recommended as the first-line treatment, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Treatment of anal fissures with topical nitrates is recommended, although side effects may limit their efficacy, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0The use of calcium channel blockers for chronic anal fissures has a similar efficacy to topical nitrates, with a superior side effect profile, and can be recommended as first-line treatment, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend Botulinum toxin as second-line therapy\u00a0<\/u>following treatment with topical therapies in treatment of chronic anal fissure, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend internal sphincterotomy, (IS) in the treatment of chronic anal fissures as first line of treatment or as a second line of treatment after failure of medical treatment, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Laser therapy is not routinely recommended for the treatment of anal fissures due to limited evidence supporting its efficacy in this context, (Good practice statement).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend to repeat IS or botulinum toxin injection for recurrent anal fissure, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In recurrent anal fissure the use of an ano-cutaneous flap may be recommended to decreases postoperative pain and allows for primary wound healing, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In the presence of multiple anal fissures or abnormal sites of fissure or recurrent fissure, we recommend excluding other causes of anal fissure: such as Crohn\u2019s disease or sexually transmitted diseases, (conditional recommendation).<\/p>\n

    \u00a0<\/u><\/b><\/p>\n
    \n

    \u00a0<\/p>\n<\/div>\n<\/div>\n

    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n
    \n\n
    \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Acute Appendicitis <\/span>\n\n <\/h5>\n\n
    \n
    \n
    \n
    \n
    “last update: 12 May 2025\u00a0\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<\/span>Download Guideline<\/u><\/a><\/b><\/h5>\n
    \u00a0<\/h5>\n<\/div>\n<\/div>\n<\/div>\n
    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
    \n

    – Executive Summary<\/h3>\n
    \n

    \u00a0<\/p>\n

    \u00a0 This guideline offers evidence-based recommendations on the targeted levels of Clinical practice guidelines and provide healthcare professionals with practical guidance on the diagnosis and treatment of acute appendicitis, (AA).<\/p>\n

    \u00b7\u00a0 \u00a0We recommend to adopt a tailored individualized diagnostic approach for stratifying the risk and disease probability and planning an appropriate stepwise diagnostic pathway in patients with suspected acute appendicitis, depending on age, sex, and clinical signs and symptoms of the patient, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend the use of clinical scores,\u00a0<\/b>(Alvarado score and the new Adult Appendicitis Score) to exclude acute appendicitis and identify intermediate-risk patients needing of imaging diagnostics, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend the use of\u00a0biochemical markers as a diagnostic tool for the identification of both negative cases and complicated acute appendicitis in adults, (good practice statement).<\/p>\n

    \u00b7\u00a0\u00a0We recommend POCUS (point of care ultrasound)\u00a0 as the most appropriate first-line diagnostic tool in both adults and children, if an imaging investigation is indicated based on clinical assessment, (Strong recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0We recommend the routine use of a combination of clinical parameters and US to improve diagnostic sensitivity and specificity and reduce the need for CT scan in the diagnosis of acute appendicitis, (Strong recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0We recommend CT before surgery for patients with normal investigations but non-resolving right iliac fossa pain, (Strong recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0After negative imaging, initial non-operative treatment may be recommended, (conditional recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0Explorative laparoscopy is recommended to establish\/exclude the diagnosis of acute appendicitis or alternative diagnoses, in patients with progressive or persistent pain,\u00a0 (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We suggest graded compression trans-abdominal ultrasound as the preferred initial imaging method for suspected acute appendicitis during pregnancy, (conditional recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0We suggest MRI in pregnant patients with suspected appendicitis, if this resource is available, after inconclusive US, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0We recommend discussing NOM with antibiotics as a safe alternative to surgery in selected patients with uncomplicated acute appendicitis and absence of appendicolith, advising of the possibility of failure and misdiagnosing complicated appendicitis, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We suggest against treating acute appendicitis non-operatively during pregnancy until further high-level evidence is available, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0In the case of NOM, we recommend initial intravenous antibiotics with a subsequent switch to oral antibiotics based on patient’s clinical conditions, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend planning open or laparoscopic appendectomy for the next available operating list within 24\u2009h in case of uncomplicated acute appendicitis, minimizing the delay wherever possible, (Strong recommendation).<\/p>\n

    \u00b7\u00a0We recommend against delaying appendectomy for acute appendicitis needing surgery beyond 24\u2009h from the admission, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend laparoscopic appendectomy as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, where laparoscopic equipment and expertise are available, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend laparoscopic appendectomy\u00a0<\/b>in obese patients, older patients, and patients with high peri- and postoperative risk factors, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We suggest laparoscopic appendectomy in pregnant patients in\u00a0<\/b>the first and second trimesters\u00a0<\/b>instead of opens appendectomy\u00a0<\/b>when surgery is indicated (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend protection of the edges of the wound by ring protectors in open appendectomy to decrease the risk of SSI, (Strong recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0We recommend primary skin closure with a unique absorbable intradermal suture for open appendectomy wounds, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend performing suction alone\u00a0<\/b>in complicated appendicitis patients with intra-abdominal collections undergoing laparoscopic appendectomy, (Strong recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0We suggest appendix removal if the appendix appears \u201cnormal\u201d during surgery and no other disease is found in symptomatic patients, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We suggest the open or laparoscopic approach as treatment of choice for patients with complicated appendicitis with phlegmon or abscess, (conditional recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0We recommend routine histopathology after appendectomy, (conditional recommendation).<\/p>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n

    \n\n
    \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Management of Groin Hernia <\/span>\n\n <\/h5>\n\n
    \n
    \n
    \n
    \n
    “last update: 12 May 2025\u00a0\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Download Guideline<\/u><\/a><\/b><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
    \n

    – Executive Summary<\/h3>\n
    \n

    \u00a0<\/p>\n

    Clinical practice guidelines on the management of groin hernia are discussed., laboratory, and imaging studies are discussed. The different types of treatment of groin hernia, whether open or laparoscopic are evaluated.
    \u00b7\u00a0\u00a0There is good evidence that surgery effectively reduces symptoms and prevents complications of groin hernia. We recommend it, (Strong recommendation).
    \u00b7\u00a0We recommend preventive measures to reduce intra-abdominal pressure to lower the risk of hernia. (Strong recommendation).
    \u00b7\u00a0 \u00a0We recommend appropriate surgical technique and special post-operative management to reduce the risk of recurrence of hernia, (conditional recommendation).
    \u00b7\u00a0\u00a0We recommend physical examination as the primary diagnostic tool for groin hernias, (Strong recommendation).
    \u00b7\u00a0\u00a0We recommend US, CT or MRI in certain cases based on clinical circumstances, such as the patient’s history or the need for surgical planning, (Conditional recommendation).
    \u00b7\u00a0\u00a0We recommend proper clinical differentiation between inguinal and femoral hernias, which is vital for accurate diagnosis and appropriate management, (Strong recommendation).
    \u00b7\u00a0\u00a0We recommend thorough distinction between abscesses and groin hernias through clinical examination and imaging for guiding appropriate treatment, (Conditional recommendation).
    \u00b7\u00a0 \u00a0We recommend thorough distinction between inguinal lymph node or other soft tissue tumors and groin hernias by clinical examination and imaging for guiding appropriate treatment, (Conditional recommendation).
    \u00b7\u00a0\u00a0We recommend the use of classification systems in groin hernia to standardize the management, (Conditional recommendation).
    \u00b7\u00a0\u00a0We recommend the approach of tailoring the surgical technique to the individual patient\u2019s needs and hernia characteristics, (Conditional recommendation).
    \u00b7\u00a0\u00a0We recommend\u00a0 the idea that hernia repair can be successfully performed in low-resource settings with basic tools and techniques,\u00a0 including the use of non-mesh techniques when necessary, and emphasizes the value of training local surgeons to ensure sustainable healthcare improvements, (Conditional recommendation).
    \u00b7\u00a0 \u00a0We recommend the use of mesh in hernia repairs due to its superior outcomes in preventing recurrence. (Strong recommendation).
    \u00b7\u00a0\u00a0We recommend the use of open mesh repairs, such as Lichtenstein and TIPP, as effective and reliable methods with low recurrence rates, (Strong recommendation).
    \u00b7\u00a0\u00a0We recommend laparoscopic repair techniques as an option in hernias, (Conditional recommendation).
    \u00b7\u00a0We recommend drain after inguinal hernia repair in special circumstances, (Conditional recommendation).
    \u00b7\u00a0\u00a0<\/strong>We recommend early mobilization as it is beneficial for reducing the risk of postoperative complications and speeding up recovery, (Conditional recommendation).
    \u00b7\u00a0\u00a0In cases of intestinal incarceration without strangulation or need for bowel resection, we recommend the use of mesh-based repair, (Strong recommendation).
    \u00b7\u00a0\u00a0Mesh-based repair is generally not recommended for patients with intestinal strangulation or concurrent bowel resection (clean-contaminated surgical field) or in presence of high risk of infection, (Strong recommendation).
    \u00b7\u00a0Biological mesh could be considered and recommended in very specific cases, but it is not a routine approach, (Conditional recommendation).
    \u00b7\u00a0We recommend the urgent management of femoral hernias due to the high risk of complications such as strangulation, (Strong recommendation).
    \u00b7\u00a0We recommend the use of mesh in femoral hernia repair to reduce recurrence, (Strong recommendation).
    \u00b7\u00a0\u00a0We recommend the open anterior approach, (Lockwood)\u00a0<\/b>for femoral hernia repair, particularly in emergency settings or for incarcerated hernias, (Strong recommendation).
    \u00b7\u00a0\u00a0Open Low, (Lotheissen-McVay) approach, is recommended in resource-limited settings, (conditional recommendation).
    \u00b7\u00a0\u00a0The plug or patch technique is recommended as it is a simple and effective method for femoral hernia repair, particularly in elective cases, (conditional recommendation).
    \u00b7\u00a0 \u00a0Open tissue repair without mesh is recommended in specific cases, (conditional recommendation).
    \u00b7\u00a0 \u00a0The laparoscopic TAPP approach is recommended as an option for elective femoral hernia repair, especially in patients with bilateral hernias or those requiring concurrent inguinal hernia repairs, (conditional recommendation).
    \u00b7\u00a0\u00a0We recommend the TEP approach for femoral hernia repair in patients without prior lower abdominal surgery, (conditional recommendation).
    \u00b7\u00a0\u00a0In women with groin hernia, we recommend surgical repair techniques, including open and laparoscopic approaches, as those used in men, (Conditional recommendation).
    \u00b7\u00a0\u00a0We recommend\u00a0<\/strong>the use of advanced diagnostic tools to detect occult hernias and the preference for simultaneous repair of bilateral hernias, (Conditional recommendation).
    \u00a0
    \u00a0<\/h5>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n
    \n\n
    \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Management of Gall Stone Disease <\/span>\n\n <\/h5>\n\n
    \n
    \n
    \n
    \n
    “last update: 13 May 2025\u00a0\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0Download Guideline<\/u><\/a><\/b><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
    \n

    – Executive Summary<\/h3>\n
    \n

    \u00a0<\/p>\n

    This guidelines describes the management of gall stone disease including diagnosis of chronic and acute calculus cholecystitis, (clinically, laboratory, and with image studies) as well as the treatment of gall stone disease with stress on common bile duct (CBD) stones and accidental CBD injury.<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend diagnosing gallbladder stones by the characteristic symptoms of episodic attacks of severe pain in the right upper abdominal quadrant or epigastrium for at least 15-30 minutes with radiation to the right back or shoulder and a positive reaction\u00a0<\/span>to analgesics, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In a patient with a recent history of biliary pain, abdominal ultrasound should be performed, (Strong recommendation). \u00a0<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In case of strong clinical suspicion of gallbladder stones and negative abdominal ultrasound, endoscopic ultrasound or magnetic resonance imaging may be performed (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0As no feature has sufficient diagnostic power to establish or exclude the diagnosis of ACC, it is recommended not to rely on a single clinical or laboratory finding, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0For the diagnosis of ACC, we suggest using a combination of detailed history, complete clinical examination, laboratory tests and imaging investigations, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend the use of abdominal ultrasound (US) as the preferred initial imaging technique, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We suggest the use CT & MRI for the diagnosis of ACC, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Common bile duct stones should be searched for in patients with jaundice, acute cholangitis or acute pancreatitis, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against the use of elevated LFTs or bilirubin as the only method to identify CBDS in patients with CCh, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Abdominal ultrasound should be the first imaging method when CBD stones are suspected, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend that patients with moderate risk for CBDS undergo one of the following: preoperative magnetic resonance cholangiopancreatography (MRCP), ERCP, intraoperative cholangiography (IOC), or laparoscopic ultrasound (LUS), depending on local expertise and availability,\u00a0(<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Suspect Cholangitis is in patients with fever and a history of chills, together with abdominal pain and jaundice.\u00a0 White blood cells, C-reactive protein and liver biochemical tests should be determined and abdominal ultrasound should be performed as the initial investigations, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Suspect acute biliary pancreatitis in the presence of upper abdominal pain and altered pancreatic and liver biochemical tests in patients with gallbladder and\/ or common bile duct stones,\u00a0(<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0The exclusion of bile duct stones by endoscopic ultrasound (or magnetic resonance cholangiopancreatography) may prevent the potential risks of endoscopic retrograde Cholangiopancreatograph (ERCP) in patients with acute biliary pancreatitis and suspected bile duct stones, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend against using bile acids alone or in combination with extracorporeal shock wave lithotripsy for dissolving gallbladder stones, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We suggest considering NOM, (i.e medical therapy with antibiotics and observation), for patients refusing surgery or those who are not suitable for surgery, (Conditional recommendation).<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend cholecystectomy as the preferred option for treatment of symptomatic gallbladder stones, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Routine treatment is not recommended for patients with asymptomatic gallbladder stones, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Asymptomatic patients with porcelain gallbladder may undergo cholecystectomy, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cholecystectomy is not recommended in patients with gallbladder polyps \u22645 mm,\u00a0(<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cholecystectomy should be performed in patients with gallbladder polyps \u22651 cm without or with gallstones regardless of their symptoms,\u00a0(<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cholecystectomy is considered in patients with asymptomatic gallbladder stones and gallbladder polyps 6-10 mm and in case of growing polyps, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cholecystectomy may be recommended for asymptomatic patients with primary sclerosing cholangitis and gallbladder polyps irrespective of size, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend laparoscopic cholecystectomy as the first-line treatment for patients with ACC, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend avoiding laparoscopic cholecystectomy in case of septic shock or absolute anesthesiology contraindications, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend laparoscopic cholecystectomy as the first-choice treatment in high risk patients with ACC. Immediate laparoscopic cholecystectomy is superior to percutaneous trans-hepatic gallbladder drainage (PTGBD) in this group of patients, (Strong recommendation).<\/u><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We suggest performing laparoscopic cholecystectomy for CCh patients with Child\u2019s A and B cirrhosis, patients with advanced age (including more than 80 years old) and patients who are pregnant, (Conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend performing gallbladder drainage in patients with ACC who are not suitable for surgery, as it converts a septic patient with ACC into a non-septic patient, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Delayed laparoscopic cholecystectomy is suggested after reduction of perioperative risks to decrease readmission for ACC relapse or gallstone-related disease, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In patients with ACC who are not suitable for surgery, endoscopic trans-papillary 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, (Strong recommendation).<\/u><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cholecystectomy should be performed as early as possible for patients with biliary colic, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In ACC, in the presence of adequate surgical expertise, we recommend ELC be performed as soon as possible, within 7 days from hospital admission and within 10 days from the onset of symptoms,\u00a0(<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In ACC, we suggest DLC to 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), (conditional recommendation).<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Endoscopic sphincterotomy and stone extraction is a recommended treatment of bile duct stones, (Strong recommendation).<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Intraoperative endoscopic retrograde cholangiopancreatography or laparoscopic bile duct exploration in combination with cholecystectomy are recommended as alternatives when adequate expertise is available, (conditional recommendation).<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In case of failed standard stone extraction, electrohydraulic or laser lithotripsy may be performed, (conditional recommendation).<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In the case of altered anatomy (e.g. previous Roux-en-Y anastomosis, bariatric surgery) percutaneous or endoscopic (balloon endoscopy-assisted) treatment of bile duct stones can be considered, (conditional recommendation).\u00a0<\/b>\u00a0<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In the case of failed ERCP therapy, cholecystectomy combined with bile duct exploration should be performed, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In case of intraoperative detection of bile duct stones, we recommend bile duct exploration, trans-cystic stone extraction or endoscopic clearance as alternative treatment options, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Upon postoperative diagnosis of bile duct stones, endoscopic sphincterotomy and stone extraction are recommended, (strong recommendation).<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In case of surgical bile duct exploration, primary closure may be preferred over T-tube drainage in low risk cases, (conditional recommendation).<\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In patients with simultaneous gallbladder and bile duct stones, early laparoscopic cholecystectomy should be performed within 72 h after preoperative ERCP for choledocholithiasis, (<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Treatment of cholangitis should include immediate broad spectrum antibiotics and biliary drainage,\u00a0(<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Timing of biliary drainage depends on severity of the cholangitis and effects of medical therapy including antibiotics and may preferably be performed within 24 h; urgent drainage should be considered in case of severe cholangitis not responding to fluid resuscitation and intravenous antibiotics, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0For biliary pancreatitis with suspected coexistent acute cholangitis antibiotics should be initiated, and endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction should be performed, with timing depending on the severity of cholangitis but preferably within 24 hours,\u00a0(<\/b>Strong recommendation).<\/u><\/b><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0An endoscopic retrograde cholangiopancreatography is probably indicated in patients with biliary pancreatitis and obstructed bile duct, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0An early endoscopic retrograde cholangiopancreatography is probably not indicated in patients with predicted severe biliary pancreatitis in the absence of cholangitis or obstructed bile duct, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0In patients with suspected biliary pancreatitis without cholangitis, endoscopic ultrasound or magnetic resonance cholangiopancreatography may prevent potential endoscopic retrograde cholangiopancreatography and prevent its risks if no stones are detected, (conditional recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Cholecystectomy during the same hospital admission is recommended as the preferred option in patients with mild acute biliary pancreatitis,\u00a0(<\/b>Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0We recommend removing CBDS, either preoperatively, intraoperatively, or postoperatively, according to the local expertise and the availability of several techniques,\u00a0<\/b>(conditional recommendation).<\/u><\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Suspected bile duct injury after surgery warrants urgent investigation including laboratory tests (white blood count, bilirubin, liver enzymes) and imaging (abdominal ultrasound, contrast-enhanced CT, magnetic resonance cholangiopancreatography) to detect bile leak and\/or intra-abdominal fluid, (Strong recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Primary surgical repair of intraoperatively recognized bile duct lesions A, B or C (Table 3) can be carried out, if surgical expertise is available. For type D lesions intraoperative consultation of an expert center is mandatory; merely sub-hepatic drainage is advised and the patient is referred to an expert center. Late reconstruction (after 6-8 weeks) is advised, often with hepatico-jejunostomy, (conditional recommendation).<\/p>\n
    \n

    \u00a0<\/p>\n<\/div>\n<\/div>\n

    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div> <\/div>\n\n <\/div>\n
    \n\n
    \n\n \n\n \n <\/path><\/svg> <\/span>\n\n \n <\/path><\/svg> <\/span>\n \n <\/span>\n \n \n Management of Pilonidal Disease <\/span>\n\n <\/h5>\n\n
    \n
    \n
    \n
    \n
    “last update: 22 July \u00a02025”\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Download Guideline<\/u><\/a>
    <\/strong><\/h5>\n<\/div>\n<\/div>\n<\/div>\n
    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n<\/div>\n<\/div>\n
    \n

    – Executive Summary<\/h3>\n
    \n

    \u00a0<\/p>\n

    This guideline offers evidence-based recommendations on the targeted levels of Clinical practice guidelines and provide healthcare professionals with practical guidance on the diagnosis and treatment of pilonidal sinus.<\/p>\n

    \u00b7\u00a0 \u00a0We recommend the diagnosis of pilonidal disease clinically based on history and physical examination, with identification of midline pits, sinus tracts, and\/or abscess formation in the sacrococcygeal region, (Strong Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend a thorough patient history including risk factors such as obesity, sedentary lifestyle, family history, and recurrent infections to guide management, (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0Ultrasound or MRI may be recommended in recurrent or complex cases to assess the extent of sinus tracts and rule out other pathologies (e.g., perianal fistula, hidradenitis suppurativa), (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0 \u00a0We recommend incision and drainage (I&D) for the treatment of acute pilonidal abscesses, (Strong Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Routine postoperative antibiotics are not recommended unless there is evidence of cellulitis or systemic infection, (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0In patients with acute or chronic pilonidal disease without abscess, phenol application may be recommended as an effective treatment that may result in rapid and durable healing, (Strong Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0In patients with chronic pilonidal disease without abscess, fibrin glue may be recommended as a primary or adjunctive treatment of pilonidal disease, (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0Endoscopic pilonidal sinus treatment (EPSiT) or pit-picking (Bascom\u2019s procedure) may be recommended for selected patients with limited disease, (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0Laser surgery may be recommended to patients with PD, (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend open healing, (secondary intention), in presence of infection as it has lower recurrence rate, (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend closed techniques, (primary closure), in absence of infection as it offer faster healing, (Conditional Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0Off-midline closure techniques (e.g., Karydakis flap, Limberg flap) for Chronic\/Recurrent Disease are recommended over midline closure due to lower recurrence rates, (Strong Recommendation).<\/p>\n

    \u00b7\u00a0\u00a0We recommend proper wound hygiene and follow-up to monitor healing, (Good Practice Statement).<\/p>\n

    \u00b7\u00a0\u00a0We recommend regular hair removal (laser or shaving) in the sacrococcygeal region to reduce recurrence, (Good Practice Statement).<\/p>\n
    \n

    \u00a0<\/p>\n<\/div>\n<\/div>\n

    \n
    \n
    \n
    \u00a0<\/div>\n<\/div>\n
    \n
    \n