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Early laparoscopic cholecystectomy for acute cholecystitis following the Tokyo Guidelines 2018: a prospective single-center study of 201 consecutive cases

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Abstract

Background

Early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) poses multiple challenges. The Tokyo Guidelines 2018 (TG18) eliminated the time limit (< 72 h) and expanded the surgical indication to severe AC. This study aimed to evaluate the clinical outcomes of ELC for AC following the TG18 in a single high-volume center.

Methods

From 2019 to 2021, we managed all AC patients with a TG18 flowchart and prospectively enrolled those who underwent ELC within 7 days of symptom onset. The primary outcome was overall morbidity, with a comparison between mild (Grade I) and moderate/severe (Grade II/III) AC.

Results

During the study period, 201 patients underwent ELC was for Grade I (56.2%), II (40.3%), and III (3.5%) ACs. Mean age was 69 ± 15.2 years and time to surgery from symptom onset was 0 (12.9%), 1–3 (66.7%), and 4–7 days (20.4%). Mean operative time and blood loss were 118.9 ± 42.7 min and 57.8 ± 99.4 mL, respectively. The critical view of safety (CVS) was achieved in 76.1% of patients, and bailout procedures were performed in 21.4%. There were no open conversions or bile duct injuries. Major morbidities (Clavien–Dindo classification ≥ IIIa) were observed in 5.5% of cases and mortality in 0.5%. Comparing Grades II/III to Grade I, operative time was longer (112.3 vs. 127.3 min, p = 0.014), blood loss was higher (40.3 vs. 80.1 mL, p = 0.005), the CVS rate was lower (83.2 vs. 67.0%, p = 0.012), and the major morbidity rate was higher (1.8 vs. 10.2%, p = 0.012). In the subgroup analysis of Grade II/III, there were no significant differences in major morbidities (p = 0.288) between the two groups (0–3 vs. 4–7 days).

Conclusion

ELC for AC following TG18 is feasible with low morbidity rates. However, ELC for Grade II/III ACs remains challenging, and surgeons must carefully assess intraoperative difficulties and surgical risks before proceeding.

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Acknowledgements

The authors would like to thank Sarah Mitchel and Guy Temporal for their assistance in proofreading the article.

Funding

The authors declare that they have no financial ties or any other types of support to disclose.

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Author notes

  1. Kohei Mishima and Yoshiki Fujiyama have contributed equally first to this work.

Authors and Affiliations

  1. Department of Surgery, Ageo Central General Hospital, Saitama, Japan

    Kohei Mishima, Yoshiki Fujiyama, Taiga Wakabayashi, Kazuharu Igarashi, Takahiro Ozaki, Masayuki Honda, Shozo Mori, Naotake Funamizu, Atsuko Tsutsui, Nobuhiko Okamoto & Go Wakabayashi

  2. Research Institute Against Digestive Cancer (IRCAD), 1, Place de l’Hôpital, 67000, Strasbourg, France

    Kohei Mishima & Jacques Marescaux

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  1. Kohei Mishima
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Correspondence to Kohei Mishima.

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Disclosures

This research was approved by the Ethics Committee of Ageo Central General Hospital, Saitam, Japan. Kohei Mishima, Yoshiki Fujiyama, Taiga Wakabayash, Kazuharu Igarash, Takahiro Ozaki, Masayuki Honda, Shozo Mori, Naotake Funamizu, Atsuko Tsutsui, Nobuhiko Okamoto, Jacques Marescaux, and Go Wakabayashi have no conflicts of interest or financial ties to disclose.

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Mishima, K., Fujiyama, Y., Wakabayashi, T. et al. Early laparoscopic cholecystectomy for acute cholecystitis following the Tokyo Guidelines 2018: a prospective single-center study of 201 consecutive cases. Surg Endosc 37, 6051–6061 (2023). https://doi.org/10.1007/s00464-023-10094-x

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