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Risk factors for complications in acute calculous cholecystitis. Deconstruction of the Tokyo Guidelines
Ana María González-Castillo1, Juan Sancho-Insenser1, Maite De Miguel-Palacio1
1Departamento de Cirugía, Universidad Autónoma de Barcelona, Barcelona, Spain; Unidad de Cirugía de Urgencias, Sección de Cirugía General, Servicio de Cirugía General y Digestiva, Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM).
Insights
Laparoscopic cholecystectomy is recommended for acute calculous cholecystitis. Only three risk factors predict severe complications, and failure-to-rescue is higher in non-surgically treated patients.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Nephrology
Background:
- Acute calculous cholecystitis (ACC) management guidelines, like the Tokyo Guidelines, identify risk factors for severe complications.
- Challenging these established risk factors is crucial for optimizing patient care and treatment strategies.
Purpose of the Study:
- To evaluate the validity of risk factors for severe complications in ACC as per the Tokyo Guidelines.
- To compare the rate of severe complications and failure-to-rescue between surgical and non-surgical initial treatments for ACC.
Main Methods:
- A retrospective single-center cohort study included 725 patients with ACC over five years.
- Analysis of 166 variables, including Tokyo Guidelines risk factors, was performed.
- Propensity Score Matching (PSM) was used to compare severe complication rates between surgical and non-surgical groups, with failure-to-rescue analyzed as a quality indicator.
Main Results:
- The study identified three independent predictors of severe complications: ASA class > II, cancer without metastases, and moderate-to-severe renal disease.
- Failure-to-rescue was significantly higher in the non-surgical treatment group (32% vs. 7%; P=0.002).
- After PSM, no significant difference in severe complications was observed between surgical and non-surgical groups (48.5% vs. 62.5%; P=0.21).
Conclusions:
- Laparoscopic cholecystectomy remains the recommended treatment for ACC.
- Only a subset of the Tokyo Guidelines' risk factors were confirmed as independent predictors of severe complications.
- Non-surgical management of ACC is associated with a higher failure-to-rescue rate.
Objective:
To challenge the risk factors described in Tokyo Guidelines in Acute Calculous Cholecystitis.
Methods:
Retrospective single center cohort study with 963 patients with Acute Cholecystitis during a period of 5 years. Some 725 patients with a "pure" Acute Calculous Cholecystitis were selected. The analysis included 166 variables encompassing all risk factors described in Tokyo Guidelines. The Propensity Score Matching method selected two subgroups of patients with equal comorbidities, to compare the severe complications rate according to the initial treatment (Surgical vs Non-Surgical). We analyzed the Failure-to-rescue as a quality indicator in the treatment of Acute Calculous Cholecystitis.
Results:
the median age was 69 years (IQR 53-80). 85.1% of the patients were ASA II or III. The grade of the Acute Calculous Cholecystitis was mild in a 21%, moderate in 39% and severe in 40% of the patients. Cholecystectomy was performed in 95% of the patients. The overall complications rate was 43% and the mortality was 3.6%. The Logistic Regression model isolated 3 risk factor for severe complication: ASA > II, cancer without metastases and moderate to severe renal disease. The Failure-to-Rescue (8%) was higher in patients with non-surgical treatment (32% vs. 7%; P = 0.002). After Propensity Score Matching, the number of severe complications was similar between Surgical and Non-Surgical treatment groups (48.5% vs 62.5%; P = 0.21).
Conclusions:
the recommended treatment for Acute Calculous Cholecystitis is the Laparoscopic Cholecystectomy. Only three risk factors from the Tokyo Guidelines list appeared as independent predictors of severe complications. The failure-to-rescue is higher in non-surgically treated patients.
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