From the Guidelines
Laparoscopic cholecystectomy is the first-choice treatment for acute calculus cholecystitis (ACC) in high-risk patients, as it has been shown to be superior to percutaneous transhepatic gallbladder drainage (PTGBD) in terms of reducing mortality, length of hospital stay, and number of readmissions for gallstone-related diseases. The 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of ACC support this recommendation, citing high-quality evidence 1.
Key Points
- The Tokyo Guidelines classify cholecystitis into three severity grades: Grade I (mild), Grade II (moderate), and Grade III (severe) 1.
- Initial management includes NPO status, IV fluids, antibiotics, and pain control, with antibiotic recommendations varying based on disease severity 1.
- Early laparoscopic cholecystectomy (within 72 hours) is preferred for Grade I and II, while Grade III may require initial gallbladder drainage followed by delayed cholecystectomy 1.
- A systematic review and the CHOCOLATE trial have demonstrated the superiority of laparoscopic cholecystectomy over PTGBD in high-risk patients with ACC, with reduced major complications and healthcare resource utilization 1.
Treatment Recommendations
- Laparoscopic cholecystectomy is the recommended first-choice treatment for ACC in high-risk patients, as supported by the 2020 World Society of Emergency Surgery guidelines and high-quality evidence 1.
- Percutaneous transhepatic gallbladder drainage (PTGBD) may be considered for patients who are not candidates for laparoscopic cholecystectomy, but it is not the preferred treatment due to higher rates of complications and readmissions 1.
From the Research
Tokyo Guidelines for Cholecystitis
The Tokyo Guidelines provide a comprehensive framework for the diagnosis, severity assessment, and management of acute cholecystitis. The guidelines have undergone several revisions, with the most recent updates being published in 2013 2 and 2018 3.
Diagnostic Criteria
The diagnostic criteria for acute cholecystitis, as proposed in the Tokyo Guidelines, include the presence of local signs of inflammation, such as Murphy's sign, or a mass, pain, or tenderness in the right upper quadrant, as well as systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level 4. The guidelines also recommend the use of diagnostic imaging to confirm the diagnosis.
Severity Assessment
The severity of acute cholecystitis is classified into three grades:
- Grade I (mild): no organ dysfunction and limited disease in the gallbladder
- Grade II (moderate): no organ dysfunction but extensive disease in the gallbladder
- Grade III (severe): acute cholecystitis with organ dysfunction 4
Management
The management of acute cholecystitis depends on the severity of the disease. The Tokyo Guidelines 2018 propose a flowchart for the management of acute cholecystitis, which includes 3:
- Early laparoscopic cholecystectomy (Lap-C) for Grade I patients with Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2
- Early Lap-C for Grade II patients with CCI ≤5 and ASA-PS ≤2, or medical treatment and/or gallbladder drainage followed by delayed Lap-C
- Lap-C for Grade III patients with strict criteria, including favorable organ system failure, negative predictive factors, CCI ≤3, and ASA-PS ≤2, and who are being treated at an advanced center
Key Points
- The Tokyo Guidelines provide a comprehensive framework for the diagnosis, severity assessment, and management of acute cholecystitis [(2,4,3)]
- The diagnostic criteria include local and systemic signs of inflammation, as well as diagnostic imaging 4
- The severity of acute cholecystitis is classified into three grades 4
- The management of acute cholecystitis depends on the severity of the disease and includes early Lap-C, medical treatment, and/or gallbladder drainage 3