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Tokyo Guidelines 2018

Acute Cholecystitis Severity Grading — TG18
Evidence-based severity grading for acute cholecystitis. Guides timing and urgency of laparoscopic cholecystectomy based on local inflammation, systemic response, and end-organ dysfunction.
General Surgery Biliary Surgery Cholecystitis
Tokyo Guidelines 2018 — Cholecystitis Grade
Local Signs of Inflammation
Systemic Signs of Inflammation
Grade II Severity Markers (No organ dysfunction)
Organ Dysfunction (Grade III criteria)
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Tokyo Grade
Select relevant criteria above

Severity Grading

Grade Criteria Management
Grade I (Mild) Meets local/systemic signs; no Grade II or III criteria Early LC; can be elective same admission
Grade II (Moderate) Local/systemic signs + ≥1: WBC >18, RUQ mass, >72h, severe local imaging Early LC preferred within 72h; cholecystostomy if not safe
Grade III (Severe) Any organ dysfunction Emergency drainage, ICU, reassess for LC after stabilisation

Clinical Application

TG18 updated from TG13; the grade determines the urgency and type of intervention for acute cholecystitis.

  • Grade I: Same-admission laparoscopic cholecystectomy is safe and cost-effective; reduces risk of recurrence and avoids interval readmission.
  • Grade II: Timing matters — LC performed within 72 hours of symptom onset achieves the best outcomes. If the patient is high operative risk, percutaneous cholecystostomy tube bridges to interval LC after recovery.
  • Grade III: Biliary drainage (cholecystostomy or ERCP) first; definitive surgery only after organ recovery and physiological optimisation.
  • TG18 defines "early LC" as laparoscopic cholecystectomy performed during the same admission for acute cholecystitis, regardless of symptom duration.
  • All grade determinations must be interpreted in the context of the patient's overall operative risk (ASA, comorbidities, anaesthetic fitness).

References

  1. Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41–54.
  2. Wakabayashi G, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55–72.
  3. Mori Y, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018.

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