Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in
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and Other Interventional Techniques
Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in complex acute calculus cholecystitis: a prospective study Pinky Thapar1 · Prashant Salvi1 · Madhura Killedar1 · Philip Roji1 · Muktachand Rokade2 Received: 25 May 2020 / Accepted: 17 August 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. Methods All cases of ACC from 2008 to 2018 were graded as per Tokyo guidelines; moderate and severe ACC were termed as ‘complex ACC (CACC).’ Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien– Dindo classification. Results We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was 18,000/mm3), palpable tender mass in the right upper quadrant of the abdomen, complaints > 72 h, or signs of marked local inflammation (gangrenous or emphysematous cholecystitis, pericholecystic or hepatic abscess, biliary peritonitis); and severe (Grade 3) cholecystitis is defined by concurrent organ system dysfunction [6, 7]. We devised a protocol consisting of 7 intraoperative safety steps for ACC. Moderate and severe ACC were together considered as ‘complex ACC (CACC).’ It is well known that these patients pose special technical challenges in management due to severity of local inflammation or associated organ dysfunction [3, 8]. We designed a prospective, observational study to assess the utility and safety of a set protocol and intraoperative steps, irrespective of timing of intervention, to achieve CVS, minimize the incidence of subtotal cholecystectomy, injury to common bile duct and conversion to open surgery during LC for CACC.
Materials and methods The study enrollment period was from 2008 to 2018. Permission of the Institutional Ethics Committee was obtained prior to data collection and analysis (JH/5/15/Surg/Edu/2008). Patients were diagnosed as ACC based on clinical examination (e.g., fever accompanied by right upper quadrant tenderness, Murphy’s sign), laboratory investigations (e.g., elevated WBC count and C-reactive protein), and radiologic findings (e.g., thick-walled GB, pericholecystic fluid, overdistended GB with impacted calculus at neck, breach in the continuity of GB wall or presence of sub-diaphragmatic collection suggestive of perforation or suppurated cholec
