Acute calculus cholecystitis: commentary on Tokyo Guidelines 2018
Fabio Cesare Campanile
© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery
We read with interest the papers by Yokoe et al.  and
Okamoto et al. .
In the ﬁrst paper, the preservation of the original TG
severity score, as the basis for TG18, is supported by the
study of Yokoe et al. ; however, in our opinion, the
scientiﬁc power is insufﬁcient to draw a robust conclusion
because the authors did not report therapeutic and out-
come information for the 25% (169 out of 680) of Grade
III patients; at the opposite end, the mortality rate was
available for the 75% (511 out of 680) who received pri-
mary surgery, omitting the fact that in Grade III, TG13
suggests gallbladder drainage.
Similarly, we elaborated some concerns in reading the
study of Endo et al. , which supports the “Tokyo
Guidelines 2018 Flowchart” : the treatment ranged
from primary cholecystectomy, gallbladder drainage and
cholecystectomy, gallbladder drainage alone, and antibi-
otic therapy alone. In particular, in Table 1, Endo et al.
compared survivors and non-survivors on Grade III
according to the treatment options. In Grade III, the gall-
bladder drainage alone outcome is signiﬁcantly worse than
surgery (P = 0.0007; 156/21 vs. 387/16), worse than gall-
bladder drainage plus surgery (P < 0.0001; 156/21 vs.
253/2), and to antibiotic treatment alone, although without
reaching statistical signiﬁcance (P = 0.0765; 156/21 vs.
135/8). Despite these ﬁndings, surgery for Grade III, even
in the TG18, has a narrow place. Moreover, the wide
range of time for “primary cholecystectomy” (from 0 up
to 31 days) could inﬂuence the outcome comparisons
between primary surgery and gallbladder plus surgery (P
= 0.0137; 387/16 vs. 253/2).
As we pointed out in the past  we agree with Endo
et al. that “in daily practice, treatment strategies are
determined not only based on disease severity, but also on
the patients’ condition, including age, comorbidities and
performance status”. Then the multivariate analysis of
Endo et al. offered the opportunity to incorporate body
mass index, Charlson comorbidity index (CCI), age and
jaundice in the TG18 treatment ﬂowchart, for each TG13
However, we underline that the heart, renal, pul-
monary, and neurological dysfunctions, in this way, are
included twice: in the CCI and in the TG13 severity
score; furthermore, the jaundice seems a weak clinical
parameter, as expression of hepatic dysfunction, also
because of the risk of concomitant bile duct stones in
acute calculus cholecystitis.
The last methodological concern, for the validating stud-
ies of TG18 [3, 4], is that the starting population is the same
in the Japan-Taiwan multicenter cohort study, but the analy-
sis cohorts are different (4,360 vs. 5,329) with different
exclusion numbers but the same exclusion criteria.
Finally, we agree with Okamoto et al.  in suggesting
the best expertise/hospital capability in facing difﬁcult
cases of acute cholecystitis. However, we like to support
the notion that the acute surgical model, moreso than the
extremely specialized one, offers the best answer for acute
As a consequence of different perspectives, it is time,
as co-authors of the World Society of Emergency Surgery
guidelines on acute calculus cholecystitis , to promote
a joined meeting with the Tokyo Guidelines task force.
1. Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wak-
abayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria
and severity grading of acute cholecystitis (with videos). J
Hepatobiliary Pancreat Sci. 2018;25:41–54.
2. Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo
I, et al. Tokyo Guidelines 2018: ﬂowchart for the management of
acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:55–72.
3. Yokoe M, Takada T, Hwang T-L, Endo I, Akazawa K, Miura
F, et al. Validation of TG13 severity grading in acute
M. Pisano (
Surgical Unit, Department of Emergency, Papa Giovanni XXIII
Hospital, Piazza OMS 1, 24127 Bergamo, Italy
F. C. Campanile
Department of Surgery, Ospedale San Giovanni Decollato Andosilla,
Civita Castellana, Italy
J Hepatobiliary Pancreat Sci (2018) 25:E1–E2
LETTER TO THE EDITOR