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Emergency Cholecystectomy in Patients Classified as High Risk According to the Tokyo Guidelines 2018: A Real-World
Satoshi Mii1, So Yamaki1, Daisuke Hashimoto1
1Department of Pancreatobiliary Surgery Kansai Medical University Hirakata Japan.
Annals of Gastroenterological Surgery
|July 3, 2026
Summary
Emergency cholecystectomy for high-risk acute cholecystitis may be safe for carefully selected patients. Physiological instability, not age or comorbidities, predicts complications, suggesting individualized surgical decisions.
Area of Science:
- Gastroenterology and Hepatobiliary Surgery
- Surgical Risk Assessment
- Clinical Decision-Making
Background:
- Emergency cholecystectomy for acute cholecystitis is controversial in high-risk patients per Tokyo Guidelines 2018 (TG18).
- The perioperative risk for TG18 non-recommended patients is not well-defined.
- Real-world emergency settings often necessitate surgery despite TG18 contraindications.
Purpose of the Study:
- To evaluate perioperative outcomes in patients undergoing emergency cholecystectomy against TG18 recommendations.
- To identify clinical factors associated with actual operative risk in this population.
- To explore the feasibility of emergency cholecystectomy in TG18 non-recommended patients.
Main Methods:
- Retrospective cohort study of 252 patients undergoing emergency cholecystectomy for acute cholecystitis (2018-2025).
- Patients stratified into TG18 recommended and non-recommended groups.
- Comparison of perioperative outcomes and evaluation of risk factors for major postoperative complications (Clavien-Dindo grade ≥III).
Main Results:
- Major postoperative complications occurred in 11.9% of patients, significantly higher in the TG18 non-recommended group (18.0% vs. 2.9%, p<0.001).
- American Society of Anesthesiologists physical status classification ≥3 and preoperative shock were independent predictors of major complications.
- Age and Charlson Comorbidity Index were not significant predictors; TG18 non-recommended patients without physiological instability had low complication rates.
Conclusions:
- Emergency cholecystectomy can be feasible in select TG18 non-recommended patients.
- Perioperative risk is primarily linked to physiological instability, not age or comorbidity.
- An individualized approach to surgical decision-making is supported for these patients.
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