title: The optimal treatment of patients with mild and moderate acute cholecystitis: time for a revision of the Tokyo Guidelines.
abstract: According to the Tokyo Guidelines, severity of acute cholecystitis is divided into three grades based on the degree of inflammation and the presence of organ dysfunction. These guidelines recommend grade I (mild) acute cholecystitis to be treated with early laparoscopic cholecystectomy and grade II (moderate) acute cholecystitis with delayed cholecystectomy. Yet, several studies have shown that, for acute cholecystitis in general, early cholecystectomy is superior to delayed cholecystectomy in terms of complication rate, duration of hospital stay and costs. The aim of this study was to determine the clinical outcomes of emergency cholecystectomy in patients with grade II acute cholecystitis. Based on our findings, we propose a revision of the Tokyo Guidelines.
  
  
  
  We performed a retrospective observational cohort study of 589 consecutive patients undergoing emergency cholecystectomy for acute calculous cholecystitis in a large teaching hospital between January 2002 and January 2015. Patients were classified according to the severity assessment criteria of the Tokyo Guidelines. Patients with grade I and grade II acute cholecystitis were compared for perioperative outcomes.
  
  
  
  Emergency cholecystectomy was performed in 270 patients with grade I acute cholecystitis and 187 patients with grade II acute cholecystitis. There was no difference in conversion rate (6 vs. 6%, p = 0.985) and operating time (60 min [25-255] vs. 70 min [30-255], p = 0.421). Also the perioperative complication rate (7 vs. 9%, p = 0.517), 30-day mortality (1 vs. 1%, p = 0.648) and length of hospital stay (4 days [1-42] vs. 4 days [1-62], p = 0.327) were similar between grade I and grade II acute cholecystitis.
  
  
  
  The clinical outcomes of emergency cholecystectomy did not differ between patients with grade I and grade II acute cholecystitis. The findings support a revision of the Tokyo Guidelines with respect to the recommendation of performing emergency cholecystectomy in both grade I and grade II acute cholecystitis.
authors.affiliation: Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3430 EM, Nieuwegein, The Netherlands. c.loozen@antoniusziekenhuis.nl.
authors.forename: Charlotte S
authors.initials: CS
authors.lastname: Loozen
authors.affiliation: Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3430 EM, Nieuwegein, The Netherlands.
authors.forename: Maaike M
authors.initials: MM
authors.lastname: Blessing
authors.affiliation: Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3430 EM, Nieuwegein, The Netherlands.
authors.forename: Bert
authors.initials: B
authors.lastname: van Ramshorst
authors.affiliation: Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3430 EM, Nieuwegein, The Netherlands.
authors.forename: Hjalmar C
authors.initials: HC
authors.lastname: van Santvoort
authors.affiliation: Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3430 EM, Nieuwegein, The Netherlands.
authors.forename: Djamila
authors.initials: D
authors.lastname: Boerma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002763:Cholecystectomy / Q000009:adverse effects / Q000379:methods*; D041881:Cholecystitis, Acute / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D061887:Conversion to Open Surgery / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000009:adverse effects / Q000379:methods; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome
keywords: Acute cholecystitis; Emergency cholecystectomy