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ACUTE CHOLECYSTITIS: CORRELATION OF TG13 SEVERITY WITH CLINICAL OUTCOMES IN DIFFICULT OPERATIVE CASES
Justin Gerard*, Daniel J. Deziel, Luu B. Minh
General Surgery, Rush University Medical Center, Chicago, IL
Introduction:
The revised Tokyo Guidelines (TG13) include criteria for determining the severity of acute cholecystitis (AC) with treatment algorithms based on severity and the anticipated difficulty of operative conditions. In North America, there is limited data on the predictive validity of TG13. The aim of this study was to investigate the relationship of TG13 severity grade to clinical outcomes of cholecystectomy for AC in cases that were operatively proven to be difficult for senior surgeons.
Methods:
We identified 66 patients with AC from a prior study of difficult cholecystectomy cases, of which, 90% were done by senior surgeons. The relationship was examined between TG13 severity grade and multiple variables including age, gender, Charlson Comorbidity Index, operative approach, OR time, EBL, ICU admission, LOS, number, type and Clavien-Dindo grade of complications. Statistical analysis included Fischer exact test, Spearman correlation coefficients, Kruskal-Wallis one way ANOVA, linear regression, logistic regression and Wilcoxon rank sum test depending upon the variable examined.
Results:
66 patients with AC (7 TG grade 1, 52 grade 2, 7 grade 3) underwent 29 intended laparoscopic (LC) and 37 planned open cholecystectomies (OC). Subtotal cholecystectomy was done in 5 patients and preop percutaneous cholecystostomy in 4. A more severe TG grade was associated with a higher number of complications (p=0.026) and higher severity of complications (p=0.013). In the TG13 grade 2 group, there was no association between the number of positive TG13 criteria (or of any specific criterion) and the frequency or severity of complications. TG13 severity did not predict OR time, EBL, ICU admission or LOS. Compared to planned OC, intended LC was associated with significantly fewer total and Clavien Dindo grade 3 complications, fewer ICU admissions and shorter LOS.
Conclusion:
In technically difficult operations for AC, TG13 severity grade correlates with the number and severity of complications. However, intended performance of LC rather than OC in difficult operations predicts broader beneficial outcomes than severity grade.
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