Tokyo Guidelines 2018 flowchart for the management of acute cholecystitis

We propose a new flowchart for the treatment of acute cholecystitis (AC) in TG18. Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson Comorbidity Index (CCI)≤5 and American Society of Anesthesiologist physical status classification (ASA-PS)≤2. For Grade II AC, if patients meet the criteria of CCI≤5 and ASA-PS≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/ or gall bladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure (FOSF), and negative predictive factors, who meet the criteria of CCI≤3 and ASA-PS≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. This article is protected by copyright. All rights reserved.