title: Could the Tokyo guidelines on the management of acute cholecystitis be adopted in developing countries? Experience of one center.
abstract: OBJECTIVE
  The Tokyo guidelines for diagnostic criteria and severity assessment of acute cholecystitis (AC), published in 2007, recommend early laparoscopic cholecystectomy (ELC) be done as soon as possible after the onset of symptoms. We conducted this study to analyze the changes in the therapeutic strategy for AC in a surgical center in Tunisia after the Tokyo guidelines were published.
  
  
  METHODS
  Between January, 2005 and January, 2013, 649 patients underwent cholecystectomy for AC at the Department of Surgery, Mohamed Tahar Maamouri Hospital in Nabeul, Tunisia. The study period was subdivided into before (n = 192) and after (n = 457) the publication of the Tokyo guidelines, that is, prior to and including 2007, and from 2008 onward, respectively. We reviewed patient records retrospectively to collect demographic data, biochemical data, radiological findings, and postoperative outcomes. All these factors were compared between the groups.
  
  
  RESULTS
  The duration of symptoms before surgery was significantly longer before 2008 (p = 0.018). ELC was significantly more frequent after 2008 (p = 0.001). Laparoscopic surgery was converted to open surgery in 16.1 % of patients before 2008 vs. 7.8 % of patients after 2008 (p = 0.02). There were no significant differences in bile duct injury or postoperative complications between the groups. The length of preoperative, postoperative, and total hospital stay was longer before 2008.
  
  
  CONCLUSIONS
  ELC is a safe and effective therapeutic strategy for AC. The Tokyo guidelines resulted in a significant increase in the number of ELCs being performed and significantly reduced preoperative and total hospital stay without increasing intra- and postoperative complications. Importantly, ELC reduced medical costs, which is crucial for a country with limited resources, such as Tunisia.
authors.affiliation: Department of Surgery, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Mrazga, 8000, Nabeul, Tunisia. bouassidamahdi@yahoo.fr.
authors.forename: Mahdi
authors.initials: M
authors.lastname: Bouassida
authors.affiliation: Department of Reanimation, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.
authors.forename: Hédi
authors.initials: H
authors.lastname: Charrada
authors.affiliation: Department of Surgery, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Mrazga, 8000, Nabeul, Tunisia.
authors.forename: Bilel
authors.initials: B
authors.lastname: Feidi
authors.affiliation: Department of Surgery, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Mrazga, 8000, Nabeul, Tunisia.
authors.forename: Mohamed Fadhel
authors.initials: MF
authors.lastname: Chtourou
authors.affiliation: Department of Surgery, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Mrazga, 8000, Nabeul, Tunisia.
authors.forename: Sélim
authors.initials: S
authors.lastname: Sassi
authors.affiliation: Department of Surgery, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Mrazga, 8000, Nabeul, Tunisia.
authors.forename: Mohamed Mongi
authors.initials: MM
authors.lastname: Mighri
authors.affiliation: Department of Surgery, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Mrazga, 8000, Nabeul, Tunisia.
authors.forename: Fethi
authors.initials: F
authors.lastname: Chebbi
authors.affiliation: Department of Surgery, Faculty of Medicine of Tunis, Mohamed Tahar Maamouri Hospital, Mrazga, 8000, Nabeul, Tunisia.
authors.forename: Hassen
authors.initials: H
authors.lastname: Touinsi
mesh_terms: D000328:Adult; D000368:Aged; D017081:Cholecystectomy, Laparoscopic / Q000191:economics; D041881:Cholecystitis, Acute / Q000175:diagnosis* / Q000191:economics / Q000601:surgery*; D017046:Cost Savings / Q000191:economics; D003906:Developing Countries; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D014041:Tokyo; D014416:Tunisia
keywords: Acute cholecystitis; Early laparoscopic cholecystectomy; Tokyo guidelines