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Aggressive Laparoscopic Cholecystectomy in Accordance with the Tokyo Guideline 2018
Naoto Takahashi1, Akira Umemura2, Takayuki Suto1
1Department of Surgery, Morioka Municipal Hospital, Morioka, Iwate, Japan.
Insights
Early laparoscopic cholecystectomy is safe for acute cholecystitis patients, regardless of disease severity or patient comorbidity. This approach is acceptable, demonstrating that neither severity nor Charlson comorbidity index disqualifies patients from early surgery.
Area of Science:
- Gastroenterology and Hepatobiliary Surgery
- Surgical Outcomes Research
Background:
- The Tokyo Guidelines 2018 are widely adopted for acute cholecystitis management.
- Previous outcome reports often overlook disease severity and patient comorbidities.
- The Charlson Comorbidity Index (CCI) is a key measure of patient general condition.
Purpose of the Study:
- To evaluate the relationship between acute cholecystitis severity, CCI, and clinical outcomes after laparoscopic cholecystectomy.
- To determine if severity or CCI impacts the success of early laparoscopic cholecystectomy.
Main Methods:
- Retrospective analysis of 370 Japanese patients undergoing early laparoscopic cholecystectomy (within 72 hours of onset).
- Comparison of postoperative factors based on Tokyo Guidelines severity (Grade I vs. Grade II/III).
- Comparison of postoperative factors based on CCI (low < 4 vs. high ≥ 4).
Main Results:
- Blood loss was significantly higher in severe acute cholecystitis (Grade II/III) compared to Grade I (60.1 mL vs. 20.9 mL, P=0.0164).
- Operating time was significantly longer in patients with a high CCI (≥ 4) compared to those with a low CCI (67.8 min vs. 53.4 min, P=0.0153).
- No mortalities were observed; mean operating time was 62.3 min, mean blood loss 24.4 mL, and mean hospital stay 3.6 days.
Conclusions:
- Early laparoscopic cholecystectomy is an acceptable and safe strategy for acute cholecystitis across all severity grades.
- Disease severity and Charlson Comorbidity Index do not disqualify patients from undergoing early laparoscopic cholecystectomy.
- The findings support an aggressive surgical approach for acute cholecystitis.
Objectives:
The Tokyo Guidelines 2018 have been widely adopted since their publication. However, the few reports on clinical outcomes following laparoscopic cholecystectomy have not taken into account the severity of the acute cholecystitis and the patient's general condition, as estimated by the Charlson comorbidity index. This study aimed to assess the relationships between severity, Charlson comorbidity index, and clinical outcomes subsequent to laparoscopic cholecystectomy.
Methods:
We extracted the retrospective data for 370 Japanese patients who underwent emergency or scheduled early laparoscopic cholecystectomy within 72 hours from onset between February 2015 and August 2018. We compared postoperative factors in relationship to severity (grade I versus grade II/III). Then, we made a similar comparison between those with low (< 4) and high Charlson comorbidity index (≥ 4).
Results:
According to the Tokyo guideline 2018 levels of severity, there were 282 (76.2%), 61 (16.5%), and 27 (7.3%) patients in grades I, II, and III, respectively. With regards to surgical outcomes, the mean operating time was 62.3 minutes and the mean blood loss was 24.4 mL. The mean hospital stay was 3.6 days, with no mortalities. Blood loss was the only factor affected by severity (20.9 mL versus 60.1 mL, P = 0.0164), and operating time was the only factor affected by high Charlson comorbidity index (53.4 versus 67.8 minutes, P = 0.0153).
Conclusion:
Our aggressive strategy is acceptable, and severity and Charlson comorbidity index are not critical factors suggesting the disqualification of early laparoscopic cholecystectomy in patients with any grade acute cholecystitis.
