Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis

Abstract

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at:

Acute calculus cholecystitis: commentary on Tokyo Guidelines 2018

“…Finally, we agree with Okamoto et al in suggesting the best expertise/hospital capability in facing difficult cases of acute cholecystitis. However, we like to support the notion that the acute surgical model, moreso than the extremely specialized one, offers the best answer for acute cholecystitis .…”

“…Similarly, we elaborated some concerns in reading the study of Endo et al , which supports the “Tokyo Guidelines 2018 Flowchart” : the treatment ranged from primary cholecystectomy, gallbladder drainage and cholecystectomy, gallbladder drainage alone, and antibiotic therapy alone. In particular, in Table 1, Endo et al compared survivors and non‐survivors on Grade III according to the treatment options.…”

Long‐term outcome and recurrence factors after percutaneous cholecystostomy as a definitive treatment for acute cholecystitis

“…The Society for American Gastrointestinal and Endoscopic Surgeons guidelines state that radiographically guided PC is an effective temporizing measure in critically ill patients with AC . The Tokyo guidelines recommend consideration of PC in moderate AC if the gallbladder is markedly inflamed . Moderate AC is defined as one or more of the following characteristics: leukocytosis more than 18 000; painful, palpable right upper quadrant mass; symptoms lasting longer than 72 h; and marked local inflammation as defined by 8‐mm wall thickness .…”

“…Acute cholecystitis (AC) is a common disease encountered in various clinical settings. According to updated Tokyo guideline 2018 (TG18), treatment strategy of AC is subdivided by risk factors, predictive factors, Charlson comorbidity index score, and the American Society of Anesthesiologists physical status classification score . In the case of grade I patients, early laparoscopic cholecystectomy is the first‐line treatment.…”

“…On the other hand, medical treatment with antibiotics and general supportive care are initially necessary for patients with surgical risk. In the case of AC in critically ill patients with other comorbidities (grades II and III), urgent or early laparoscopic cholecystectomy should be conducted at advanced centers with appropriate patients' conditions because of its high mortality, morbidity rate, increased complication rates, and longer hospital stays . Percutaneous cholecystostomy (PC) has been used as a useful alternative treatment for these AC patients unfit for surgery.…”