Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too

• Published in: Surgical endoscopy Vol. 31; no. 7; pp. 2892 - 2900
• Main Authors: Amirthalingam, Vinoban, Low, Jee Keem, Woon, Winston, Shelat, Vishalkumar
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.07.2017; Springer Nature B.V
• Subjects: Abdominal Surgery; Adult; Aged; Aged, 80 and over; Bile; Cholecystectomy; Cholecystectomy, Laparoscopic - standards; Cholecystitis, Acute - diagnosis; Cholecystitis, Acute - surgery; Clinical Decision-Making; Emergencies; Female; Follow-Up Studies; Gallbladder diseases; Gastroenterology; Gynecology; Hepatology; Humans; Length of Stay; Male; Medicine; Medicine & Public Health; Middle Aged; Patients; Practice Guidelines as Topic; Proctology; Retrospective Studies; Severity of Illness Index; Surgery; Time Factors; Body mass index; Delayed cholecystectomy; Acute cholecystitis; Subtotal cholecystectomy; Tokyo Guidelines; Early laparoscopic cholecystectomy; Gallbladder drainage; Percutaneous cholecystostomy
• ISSN: 0930-2794; 1432-2218
• DOI: 10.1007/s00464-016-5300-4

Objective The aim of this study was to determine whether early laparoscopic cholecystectomy (LC) is safe and feasible for patients diagnosed with moderate (grade 2) and severe (grade 3) acute cholecystitis (AC) according to the Tokyo Guidelines 2013 (TG13). Background Early cholecystectomy is the current accepted standard of care for patients with mild (grade 1) and selected grade 2 AC based on TG13. For selected grade 2 and grade 3 AC, early percutaneous cholecystostomy (PC) followed by delayed cholecystectomy is recommended. Methods Patients diagnosed with AC over a 14-month period were identified and divided into three grades of AC based upon chart review using the grading and severity indicators according to TG13. Results A total of 149 patients underwent emergency LC. Eighty-two (55 %) patients were male. Eighty-four (56.4 %) patients were classified as grade 1 AC, 49 (32.9 %) as grade 2, and 16 (10.7 %) as grade 3. Eighty-three (98.8 %) patients with grade 1 AC underwent emergency LC, and 1 patient (1.2 %) underwent PC followed by emergency LC. The median length of hospital stay for grade 1 AC patients was 2 (1–11) days. There were 2 (2.4 %) readmissions with fever and no additional complications. Among the 65 patients identified with grade 2 or 3 AC, 6 (9.2 %) underwent PC followed by emergency LC. Fifty-nine (90.8 %) patients underwent emergency cholecystectomy: 58 (98.3 %) LC and one (1.7 %) open cholecystectomy. Among the 58 patients with LC, 3 (5.2 %) patients had open conversion and 10 (17.2 %) patients required subtotal cholecystectomy. One patient was converted to open due to bile duct injury and had hepaticojejunostomy repair. Two other patients were converted due to dense adhesions and inability to safely dissect Calot’s triangle. The median length of hospital stay was 4 (1–28) days. There was one readmission for ileus. Conclusion Severity grading of AC is not the sole determinant of early LC. Patient comorbidity also impacts clinical decision. Confirmation in a larger cohort is warranted.