Limiting factors for the strict adherence to Tokyo Guidelines 2018/2013 in the treatment of acute cholecystitis

Background: The applicability of Tokyo Guidelines 2018/2013 update (TG18/TG13) for the diagnosis, grading and management of acute cholecystitis is a reliable quality indicator of health care. We aimed to assess the implementation of TG18/TG13 in our centre. The main outcome was the protocol accomplishment in terms of clinical management. Detection of limiting factors for the implementation in clinical practice was the secondary outcome. Material and Methods: This was a restrospective study. The primary endpoint was the analysis of the appropriate management according to the severity grade. Adult patients admitted for acute cholecystitis between 2014 and 2018 were included. Results: Four hundred and thirty-six patients were recruited during the study period. Of those, 244 were male, 192 female and the mean age was 69 ± 15 years. One hundred and seventy-four patients were grade I severity. In 96 grade I severity with high surgical risk patients, 50 (52%) were treated conservatively, while the others (48%) underwent surgery. In total 214 patients were grade II severity and surgery was performed in 136 (64%). Of those, 67% were considered high risk patients. Finally, 48 patients were grade III. According to the TG18/TG13 cholecystostomy should be indicated in 39 grade III severity patients, however in our serie, 23 (49%) patients were treated with antibiotics only. The percentage of patients with appropriate management according to severity grade was 65, 80 and 50%, respectively. While monitoring began in 2018, the overall percentage increased to 85%. Conclusion: Monitoring the implementation of TG18/TG13 is a reliable method to evaluate and improve quality in the management of acute cholecystitis. However, it might be argued that some limiting factors commonly play a significant role making it difficult to strictly follow the recommendations in all patients and all centres.