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Background: Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. Methods: All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien–Dindo classification. Results: We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1 week (53.1%), 2–5 weeks (28.3%), and ≥ 6 weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien–Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention. Conclusion: The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC. [ABSTRACT FROM AUTHOR]

Objective: To compare outcomes following percutaneous cholecystostomy drain placement based on presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis. Methods: Chart review was performed to identify the presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis in 146 patients who underwent percutaneous cholecystostomy between 2012 and 2015. Those who met criteria were compared to those who did not in terms of demographics, laboratory values, drain indwelling time, treatment response, eventual surgical management, and 30-day mortality. Results: 94 patients (64%) met Tokyo Guidelines diagnostic criteria, while 52 did not (36%). Patients within criteria had a shorter mean length of stay (13.5 days vs 18.9 days), were more likely to have a positive gallbladder fluid culture (64.5% vs 28.6%), demonstrated greater response to treatment (87.2% vs 32.7%), and had lower 30-day mortality (6.4% vs 37.8%). There was no significant difference in terms of ICU requirement (38.3% vs 38.9%), mean drain indwelling time (58.8 days vs 65.3 days), eventual laparoscopic cholecystectomy (40.4% vs 25.0%), or open cholecystectomy performed (9.5% vs 9.6%). Conclusion: Patients outside of Tokyo Guidelines diagnostic criteria for acute cholecystitis were less likely to respond to treatment with percutaneous cholecystostomy and had worse outcomes. Further research may be indicated to better define the indications for percutaneous cholecystostomy placement in this group. [ABSTRACT FROM AUTHOR]

Early laparoscopic cholecystectomy (LC) after gallbladder drainage is recommended in cases with acute cholecystitis (AC); however, the safety of LC after gallbladder drainage is still controversial, and it is not clear whether the drainage contributes to prevent bile leakage during operative procedure. A single institutional retrospective cohort study was performed to assess the safety of LC after gallbladder drainage as well as the frequency of bile leakage during LC. Twenty-four patients that had gallbladder drainage (Drainage group) and 67 patients that had early LC (Early LC group) were treated for AC. Charlson comorbidity index was significantly higher in the Drainage group (P = 0.015). Early LC group had a shorter operative time than Drainage group (P = 0.020) and tend to have less bile leakage rate than Drainage group. In cases when the initial treatment was started within a day after the onset of symptom, no bile leakage was observed in either group. LC after gallbladder drainage can be performed safely; however, it does not reduce the bile leakage rate. Early laparoscopic cholecystectomy with immediate admission as possible might help to prevent the postoperative bile leakage. [ABSTRACT FROM AUTHOR]

Introduction: The revised Tokyo Guidelines include criteria for determining the severity of acute cholecystitis with treatment algorithms based on severity. The aim of this study was to investigate the relationship of the revised Tokyo Guidelines severity grade to clinical outcomes of cholecystectomy for acute cholecystitis.Methods: We identified 66 patients with acute cholecystitis from a prior study of difficult cholecystectomy cases. We examined the relationship between severity grade and multiple variables related to perioperative and postoperative outcomes.Results: A more severe revised Tokyo Guidelines grade was associated with a higher number of complications (p = 0.03) and a higher severity of complications (p = 0.01). Severity grade did not predict operative time, estimated blood loss, intensive care unit admission or length of stay. Compared to planned open cholecystectomy, intended laparoscopic cholecystectomy was associated with significantly fewer total and Clavien-Dindo grade 3 complications, fewer intensive care unit admissions, and shorter length of stay (p values range from 0.03 to < 0.0001).Conclusion: In technically difficult operations for acute cholecystitis, the revised Tokyo guidelines severity grade correlates with the number and severity of complications. However, intended performance of laparoscopic cholecystectomy rather than open cholecystectomy in difficult operations predicts broader beneficial outcomes than severity grade. [ABSTRACT FROM AUTHOR]

Background: We assess the performance of ultrasound (US) and hepatobiliary scintigraphy (HIDA) as confirmatory studies in acute cholecystitis (AC) and demonstrate our current imaging protocol's impact on outcomes. Study Design: Between January 2013 to July 2014, 117 patients were admitted through the emergency room with a preliminary diagnosis of AC. Overall, 106/117 (91%) of the patients received US preadmission and 34/117 (29%) received a HIDA post admission. Primary end points included: 1) diagnostic test reliability for AC, and 2) outcome and quality measures (time to surgery, LOS, costs, etc.). Results: Laparoscopic cholecystectomy was performed in 96/117 (82%) and open cholecystectomy in 21/117 (18%) of the patients. Overall, histopathologic features consistent with AC was present in 46/117 (39%). AC alone was present in 23/117 (20%), and AC superimposed on chronic cholecystitis was present in 23/117 (20%). For AC, US had a sensitivity and specificity of 26% and 80%, respectively. HIDA scan had a sensitivity and specificity of 87% and 79%, respectively. Time to surgery (TTS) was 4 vs 2.3 days in patients who received HIDA vs US alone (p = 0.001), and length of stay (LOS) was 6.7 vs 4.3 days, respectively (p = 0.001). Age >50 years, glucose >140 (mg/dl), and WBC count >10 (×109 /L) were statistically significant independent variables associated with AC. Conclusion: HIDA scan is superior to US as a diagnostic study in the setting of AC. Our current protocol of delayed HIDA (post-admission) was associated with increased TTS, LOS, and overall costs. Early confirmation with HIDA in high risk patients may hasten treatment allocation and improve outcomes in the setting of AC. [ABSTRACT FROM AUTHOR]

Background: The Tokyo guidelines provide criteria for the diagnosis and classification of acute cholecystitis in three severity grades. However, no data exists on the predictive value of these guidelines. The aim of this study was to analyze the accuracy of the Tokyo guidelines as a predicting parameter for the severity of acute cholecystitis in patients undergoing laparoscopic cholecystectomy.Methods: A retrospective analysis of the charts of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a primary care hospital within a five-year period was performed. The preoperative severity grades were compared with the histological extent of inflammation.Results: One hundred thirty-eight patients; 79 with severity grade I, 33 with grade II and 26 with grade III were analyzed. The incidence of uncomplicated cholecystitis decreased with increasing severity grade, while the incidence of complicated cholecystitis increased with increasing severity. However, complicated cholecystitis was evident in an unexpectedly high number of cases with severity grade I. There was a significant correlation (χ (2)(1) = 10. 43, p = 0.01) between the preoperative severity grade and the extent of gallbladder inflammation on histopathology. Conversion to open surgery (14 vs. 5, p = 0.002) and complications (17 vs. 7, p = 0.001) were significantly higher in patients with preoperative severity grade II/III compared to patients with severity grade I.Conclusion: Worsening clinical severity correlated significantly with worseing pathology, findings from blood test and clinical outcomes; rates of conversion and morbidity. However, the Tokyo guidelines may have a tendency to underestimate the extent of inflammation in male patients with severity grade I and over estimate the difficulty of dissection in severity grade II. [ABSTRACT FROM AUTHOR]

Introduction Early cholecystectomy within 72 hours has been shown to be superior to late or delayed cholecystectomy with regard to outcome and cost of treatment. Recently, immediate cholecystectomy within 24 hours of onset of symptom was proposed as standard procedure for the management of fit patients presenting with acute cholecystitis. We sort to find out if there are any differences in surgical outcomes between patients managed within 24 h and those managed 25-72 h following symptom begin for acute cholecystitis Patients and methods A retrospective analysis was performed. The outcomes of patients undergoing laparoscopic cholecystectomy within 24 h were compared to those of patients managed 25-72 h following symptom onset for acute cholecystitis. Results 35 patients managed 25-72 h following begin of symptoms were matched with 35 patients with similar baseline features, medical comorbidities and disease severity managed within 24 hours of symptom onset. There were no significant differences in the duration of surgery, postoperative complications, rate of conversion and length of hospital stay Conclusion Immediate laparoscopic cholecystectomy for acute cholecystitis within 24 hour of symptom onset is not superior to surgery 25-72 hour after symptoms begin. Laparoscopic cholecystectomy for acute cholecystitis therefore can be safely performed anytime within the golden 72 h. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this retrospective study was to identify the risk factors associated with the severity characteristics in the Tokyo guidelines for conversion to open surgery in patients with acute cholecystitis (AC) who underwent laparoscopic cholecystectomy. Methods: A total of 225 patients were enrolled in the study. The patients were classified into two groups: a conversion group and a no-conversion group. The preoperative characteristics and therapeutic strategy were analyzed as risk factors for conversion to open surgery. The postoperative outcomes were also analyzed. Results: Conversion to open surgery occurred in 29 patients (12.9 %), including seven patients (6.7 %) with mild AC and 22 patients (18.5 %) with moderate AC. A univariate analysis showed that the risk factors for conversion to open surgery included a duration of symptoms longer than 72 h, an elevated C-reactive protein (CRP) value and the Tokyo guidelines 2013 (TG 13) severity classification. The multivariate analysis showed that the risk factors for conversion to open surgery included a duration of symptoms longer than 72 h and a CRP value >11.5 mg/dl. Conclusions: A duration of symptoms longer than 72 h, which is included in the criterion for moderate AC severity in the TG 13, was an independent risk factor for conversion to open surgery. In addition, adoption of a high CRP value as an additional criterion for moderate AC may increase the utility of the TG 13. [ABSTRACT FROM AUTHOR]