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The optimal treatment of patients with mild and moderate acute cholecystitis: time for a revision of the Tokyo Guidelines

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Abstract

Introduction

According to the Tokyo Guidelines, severity of acute cholecystitis is divided into three grades based on the degree of inflammation and the presence of organ dysfunction. These guidelines recommend grade I (mild) acute cholecystitis to be treated with early laparoscopic cholecystectomy and grade II (moderate) acute cholecystitis with delayed cholecystectomy. Yet, several studies have shown that, for acute cholecystitis in general, early cholecystectomy is superior to delayed cholecystectomy in terms of complication rate, duration of hospital stay and costs. The aim of this study was to determine the clinical outcomes of emergency cholecystectomy in patients with grade II acute cholecystitis. Based on our findings, we propose a revision of the Tokyo Guidelines.

Methods

We performed a retrospective observational cohort study of 589 consecutive patients undergoing emergency cholecystectomy for acute calculous cholecystitis in a large teaching hospital between January 2002 and January 2015. Patients were classified according to the severity assessment criteria of the Tokyo Guidelines. Patients with grade I and grade II acute cholecystitis were compared for perioperative outcomes.

Results

Emergency cholecystectomy was performed in 270 patients with grade I acute cholecystitis and 187 patients with grade II acute cholecystitis. There was no difference in conversion rate (6 vs. 6%, p = 0.985) and operating time (60 min [25–255] vs. 70 min [30–255], p = 0.421). Also the perioperative complication rate (7 vs. 9%, p = 0.517), 30-day mortality (1 vs. 1%, p = 0.648) and length of hospital stay (4 days [1–42] vs. 4 days [1–62], p = 0.327) were similar between grade I and grade II acute cholecystitis.

Conclusion

The clinical outcomes of emergency cholecystectomy did not differ between patients with grade I and grade II acute cholecystitis. The findings support a revision of the Tokyo Guidelines with respect to the recommendation of performing emergency cholecystectomy in both grade I and grade II acute cholecystitis.

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References

  1. Everhart JE, Khare M, Hill M, Maurer KR (1999) Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 117:632–639

    Article  CAS  PubMed  Google Scholar 

  2. Bethesda, MD: American Gastroenterological Association, 2001. (2001) The burden of gastrointestinal diseases

  3. Strasberg SM (2008) Clinical practice. Acute calculous cholecystitis. N Engl J Med 358:2804–2811. doi:10.1056/NEJMcp0800929

    Article  CAS  PubMed  Google Scholar 

  4. Takada T, Kawarada Y, Nimura Y, Yoshida M, Mayumi T, Sekimoto M, Miura F, Wada K, Hirota M, Yamashita Y, Nagino M, Tsuyuguchi T, Tanaka A, Kimura Y, Yasuda H, Hirata K, Pitt HA, Strasberg SM, Gadacz TR, Bornman PC, Gouma DJ, Belli G, Liau KH (2007) Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg 14:1–10. doi:10.1007/s00534-006-1150-0

    Article  PubMed  PubMed Central  Google Scholar 

  5. Mayumi T, Takada T, Kawarada Y, Nimura Y, Yoshida M, Sekimoto M, Miura F, Wada K, Hirota M, Yamashita Y, Nagino M, Tsuyuguchi T, Tanaka A, Gomi H, Pitt HA (2007) Results of the Tokyo consensus meeting Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14:114–121. doi:10.1007/s00534-006-1163-8

    Article  PubMed  PubMed Central  Google Scholar 

  6. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG, Committee Tokyo Guidelines Revision (2013) TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 20:35–46. doi:10.1007/s00534-012-0568-9

    Article  PubMed  Google Scholar 

  7. Miura F, Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gouma DJ, Garden OJ, Buchler MW, Yoshida M, Mayumi T, Okamoto K, Gomi H, Kusachi S, Kiriyama S, Yokoe M, Kimura Y, Higuchi R, Yamashita Y, Windsor JA, Tsuyuguchi T, Gabata T, Itoi T, Hata J, Liau KH, Tokyo Guidelines Revision Committee (2013) TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20:47–54. doi:10.1007/s00534-012-0563-1

    Article  PubMed  Google Scholar 

  8. Song G, Bian W, Zeng X, Zhou J, Luo Y, Tian X (2016) Laparoscopic cholecystectomy for acute cholecystitis: early or delayed?: Evidence from a systematic review of discordant meta-analyses. Medicine 95:e3835

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Cao AM, Eslick GD, Cox MR (2016) Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies. Surg Endosc 30:1172–1182. doi:10.1007/s00464-015-4325-4

    Article  PubMed  Google Scholar 

  10. Cao AM, Eslick GD, Cox MR (2015) Early cholecystectomy is superior to delayed cholecystectomy for acute cholecystitis: a meta-analysis. J Gastrointest Surg 19:848–857. doi:10.1007/s11605-015-2747-x

    Article  PubMed  Google Scholar 

  11. Boddy A, Bennett J, Ranka S, Rhodes M (2007) Who should perform laparoscopic cholecystectomy? A 10-year audit. Surg Endosc 21:1492–1497

    Article  CAS  PubMed  Google Scholar 

  12. Kortram K, Reinders JSK, van Ramshorst B, Wiezer MJ, Go PM, Boerma D (2010) Laparoscopic cholecystectomy for acute cholecystitis should be performed by a laparoscopic surgeon. Surg Endosc 24:2206–2209

    Article  PubMed  Google Scholar 

  13. Regimbeau JM, Fuks D, Pautrat K, Mauvais F, Haccart V, Msika S, Mathonnet M, Scotté M, Paquet JC, Vons C (2014) Effect of postoperative antibiotic administration on postoperative infection following cholecystectomy for acute calculous cholecystitis: a randomized clinical trial. JAMA 312:145–154

    Article  PubMed  Google Scholar 

  14. Cheng WC, Chiu YC, Chuang CH, Chen CY (2014) Assessing clinical outcomes of patients with acute calculous cholecystitis in addition to the Tokyo grading: a retrospective study. Kaohsiung J Med Sci 30:459–465. doi:10.1016/j.kjms.2014.05.005

    Article  PubMed  Google Scholar 

  15. Lee SW, Yang SS, Chang CS, Yeh HJ (2009) Impact of the Tokyo Guidelines on the management of patients with acute calculous cholecystitis. J Gastroenterol Hepatol 24:1857–1861. doi:10.1111/j.1440-1746.2009.05923.x

    Article  PubMed  Google Scholar 

  16. Kamalapurkar D, Pang TC, Siriwardhane M, Hollands M, Johnston E, Pleass H, Richardson A, Lam VW (2015) Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe. ANZ J Surg 85:854–859. doi:10.1111/ans.12986

    Article  PubMed  Google Scholar 

  17. Kortram K, van Ramshorst B, Bollen TL, Besselink MG, Gouma DJ, Karsten T, Kruyt PM, Nieuwenhuijzen GA, Kelder JC, Tromp E, Boerma D (2012) Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial. Trials 13:7-6215-13-7. doi:10.1186/1745-6215-13-7

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3430 EM, Nieuwegein, The Netherlands

    Charlotte S. Loozen, Maaike M. Blessing, Bert van Ramshorst, Hjalmar C. van Santvoort & Djamila Boerma

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  1. Charlotte S. Loozen
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  2. Maaike M. Blessing
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  3. Bert van Ramshorst
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  4. Hjalmar C. van Santvoort
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  5. Djamila Boerma
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Correspondence to Charlotte S. Loozen.

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Dr. Loozen, M. Blessing, Dr. Van Ramshorst, Dr. van Santvoort and Dr. Boerma have no conflict of interest or financial ties to disclose.

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Loozen, C.S., Blessing, M.M., van Ramshorst, B. et al. The optimal treatment of patients with mild and moderate acute cholecystitis: time for a revision of the Tokyo Guidelines. Surg Endosc 31, 3858–3863 (2017). https://doi.org/10.1007/s00464-016-5412-x

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  • DOI: https://doi.org/10.1007/s00464-016-5412-x

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