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

Abstract

Early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) poses multiple challenges. The Tokyo Guidelines 2018 (TG18) eliminated the time limit (< 72h) 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. From 2019 to 2021, we managed all AC patients with a TG18 flowchart and prospectively enrolled those who underwent ELC within 7days of symptom onset. The primary outcome was overall morbidity, with a comparison between mild (Grade I) and moderate/severe (Grade II/III) AC. 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 ± 15.2years and time to surgery from symptom onset was 0 (12.9%), 1-3 (66.7%), and 4-7days (20.4%). Mean operative time and blood loss were 118.9 ± 42.7min and 57.8 ± 99.4mL, 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. 127.3min, p = 0.014), blood loss was higher (40.3 vs. 80.1mL, 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. 4-7days). 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.