A Policy of Universal Cholecystectomy for Acute Cholecystitis Validating the Tokyo Guidelines 2013 -A Single Centre Experience

Vinoban Amirthalingam1, Low Jee Keem2, Sameer Padmakumar Junnakar2, Winston Woon2, Vishalkumar Shelat2. 1MINISTRY OF HEALTH HOLDINGS SINGAPORE, 2TAN TOCK SENG HOSPITAL, DIVISION OF GENERAL SURGERY – HPB

Background: Early cholecystectomy is the current accepted standard of care for surgically fit patients with grade 1 and selected grade 2 cholecystitis based on Tokyo Guidelines 2013 (TG13). For selected grade 2 and grade 3 cholecystitis it is recommended for early gallbladder drainage followed by interval cholecystectomy. Our aim of our study is that early cholecystectomy is safe and feasible in all 3 grades of cholecystitis. We propose the policy of universal cholecystectomy independent of TG13 grading.

Methods: Patients diagnosed with acute cholecystitis over a 14 month period were identified with the health records department from January 2014 to February 2015. Over that period 149 patients underwent emergency cholecystectomy  on admission for acute cholecystitis. The patients were divided into the three grades of cholecystitis: Grade 1 (n=84), Grade 2 (n=49), and Grade 3 (n=16) using the grading and severity from Tokyo Guidelines 2013. The results for this group were analysed with demographics, hospital stay, clinical symptoms, laboratory results, imaging, operative findings, length of hospital stay.

Results:  Of the 149 patients who underwent emergency cholecystectomy 82 were male (55%). 84 patients were identified with grade 1 cholecystitis. 83 patients (98.8%) underwent emergency cholecystectomy and 1 patient (1.2%) underwent percutaneous drainage followed by emergency surgery. Median length of stay was 2 days (1-11) and median operative time was 113 minutes (35-310). There were 2 readmissions (2.4%) with fever and no complications such as organ injury, CBD injury and bleeding post-surgery. 65 patients were identified with grade 2 or 3 acute cholecystitis. 6 underwent percutaneous drainage followed by emergency cholecystectomy in the same admission, 59 underwent emergency cholecystectomy. Of the 65 patients that underwent surgery: laparoscopic cholecystectomy (n=55), open cholecystectomy (n=1), laparoscopic subtotal cholecystectomy (n=5), conversion to open (n=3), and 1 hepatico-jejunostomy repair (n=1).  Average length of post-operative stay was 4 days (1-28) and average operative time was 129 minutes (90-298). There was 1 complication (CBD injury) and 1 readmission for ileus. Similar surgical outcomes were observed between the 2 groups, showing early emergency cholecystectomy should be recommended for all grades of acute cholecystitis.

Conclusion:  Universal cholecystectomy policy is safe and feasible in all severity grades of acute cholecystitis. 

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