Evaluating the Relevance of the 2013 Tokyo Guidelines for the Diagnosis and Management of Cholecystitis

Bellal Joseph, Faisal Jehan, Michael Dacey, Narong Kulvatunyou, Muhammad Khan, Muhammad Zeeshan, Lynn Gries, Terence OKeeffe, Taylor S. Riall

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Background: The 2013 Tokyo Guidelines (TG13) are used to diagnose, grade severity, and guide management of acute cholecystitis (AC). The aim of our study was to verify the diagnostic criteria, severity assessment, and management protocols based on the TG13. Study Design: Our prospectively maintained emergency general surgery registry was used to review patients who had a surgical consultation for right upper quadrant pain (from 2013 to 2015). Diagnosis and severity were graded based on TG13 and compared with pathology reports. Our institutional management protocols were compared with TG13. Results: Nine hundred and fifty-two patients were analyzed, of which 857 had biliary diseases. Mean age was 42 ± 18 years and 67% were female. Seven hundred and seventy-nine had a cholecystectomy, 15 underwent cholecystostomy tube placement, and 63 patients were managed conservatively. Only 4% were febrile on presentation and 51% of patients had leukocytosis. Fifty-nine percent of patients did not have any signs of AC on ultrasonography. The TG13 criteria had a sensitivity of 53% for diagnosing AC (definitive 27%, suspected 26%, and undiagnosed 47%) when compared with the final pathology report; 92.5% of patients with grade I, 93% with grade II, and even 64% with grade III, underwent cholecystectomy safely at our institute. There were no differences in complication rates (3.7% vs 4.7%; p = 0.81), return to operating room rates (0.6% vs 0.7%; p = 0.95), or mortality rates (0.3% vs 0%; p = 0.96) between grade I and grade II patients who underwent early cholecystectomy. Conclusions: The TG13 diagnostic criteria lack sensitivity and missed more than half of the patients with AC, as many patients lack clinical signs (fever and leukocytosis). The TG13 recommendations for conservative management and delayed cholecystectomy in grade II and grade III disease are not warranted.

Original languageEnglish (US)
Pages (from-to)38-43.e1
JournalJournal of the American College of Surgeons
Volume227
Issue number1
DOIs
StatePublished - Jul 1 2018

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Cholecystitis
Tokyo
Guidelines
Acute Cholecystitis
Cholecystectomy
Leukocytosis
Fever
Cholecystostomy
Pathology
Operating Rooms
Registries
Ultrasonography
Emergencies
Referral and Consultation
Pain
Mortality

ASJC Scopus subject areas

  • Surgery

Cite this

Evaluating the Relevance of the 2013 Tokyo Guidelines for the Diagnosis and Management of Cholecystitis. / Joseph, Bellal; Jehan, Faisal; Dacey, Michael; Kulvatunyou, Narong; Khan, Muhammad; Zeeshan, Muhammad; Gries, Lynn; OKeeffe, Terence; Riall, Taylor S.

In: Journal of the American College of Surgeons, Vol. 227, No. 1, 01.07.2018, p. 38-43.e1.

Research output: Contribution to journalArticle

Joseph, Bellal ; Jehan, Faisal ; Dacey, Michael ; Kulvatunyou, Narong ; Khan, Muhammad ; Zeeshan, Muhammad ; Gries, Lynn ; OKeeffe, Terence ; Riall, Taylor S. / Evaluating the Relevance of the 2013 Tokyo Guidelines for the Diagnosis and Management of Cholecystitis. In: Journal of the American College of Surgeons. 2018 ; Vol. 227, No. 1. pp. 38-43.e1.
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abstract = "Background: The 2013 Tokyo Guidelines (TG13) are used to diagnose, grade severity, and guide management of acute cholecystitis (AC). The aim of our study was to verify the diagnostic criteria, severity assessment, and management protocols based on the TG13. Study Design: Our prospectively maintained emergency general surgery registry was used to review patients who had a surgical consultation for right upper quadrant pain (from 2013 to 2015). Diagnosis and severity were graded based on TG13 and compared with pathology reports. Our institutional management protocols were compared with TG13. Results: Nine hundred and fifty-two patients were analyzed, of which 857 had biliary diseases. Mean age was 42 ± 18 years and 67{\%} were female. Seven hundred and seventy-nine had a cholecystectomy, 15 underwent cholecystostomy tube placement, and 63 patients were managed conservatively. Only 4{\%} were febrile on presentation and 51{\%} of patients had leukocytosis. Fifty-nine percent of patients did not have any signs of AC on ultrasonography. The TG13 criteria had a sensitivity of 53{\%} for diagnosing AC (definitive 27{\%}, suspected 26{\%}, and undiagnosed 47{\%}) when compared with the final pathology report; 92.5{\%} of patients with grade I, 93{\%} with grade II, and even 64{\%} with grade III, underwent cholecystectomy safely at our institute. There were no differences in complication rates (3.7{\%} vs 4.7{\%}; p = 0.81), return to operating room rates (0.6{\%} vs 0.7{\%}; p = 0.95), or mortality rates (0.3{\%} vs 0{\%}; p = 0.96) between grade I and grade II patients who underwent early cholecystectomy. Conclusions: The TG13 diagnostic criteria lack sensitivity and missed more than half of the patients with AC, as many patients lack clinical signs (fever and leukocytosis). The TG13 recommendations for conservative management and delayed cholecystectomy in grade II and grade III disease are not warranted.",
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AU - Jehan, Faisal

AU - Dacey, Michael

AU - Kulvatunyou, Narong

AU - Khan, Muhammad

AU - Zeeshan, Muhammad

AU - Gries, Lynn

AU - OKeeffe, Terence

AU - Riall, Taylor S.

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