Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis

Kohji Okamoto, Kenji Suzuki, Tadahiro Takada, Steven M. Strasberg, Horacio J. Asbun, Itaru Endo, Yukio Iwashita, Taizo Hibi, Henry A. Pitt, Akiko Umezawa, Koji Asai, Ho Seong Han, Tsann Long Hwang, Yasuhisa Mori, Yoo Seok Yoon, Wayne Shih Wei Huang, Giulio Belli, Christos Dervenis, Masamichi Yokoe, Seiki KiriyamaTakao Itoi, Palepu Jagannath, O. James Garden, Fumihiko Miura, Masafumi Nakamura, Akihiko Horiguchi, Go Wakabayashi, Daniel Cherqui, Eduardo de Santibañes, Satoru Shikata, Yoshinori Noguchi, Tomohiko Ukai, Ryota Higuchi, Keita Wada, Goro Honda, Avinash Nivritti Supe, Masahiro Yoshida, Toshihiko Mayumi, Dirk J. Gouma, Daniel J. Deziel, Kui Hin Liau, Miin Fu Chen, Kazunori Shibao, Keng Hao Liu, Cheng Hsi Su, Angus C.W. Chan, Dong Sup Yoon, In Seok Choi, Eduard Jonas, Xiao Ping Chen, Sheung Tat Fan, Chen Guo Ker, Mariano Eduardo Giménez, Seigo Kitano, Masafumi Inomata, Koichi Hirata, Kazuo Inui, Yoshinobu Sumiyama, Masakazu Yamamoto

Research output: Contribution to journalArticle

90 Citations (Scopus)


We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: Related clinical questions and references are also included.

Original languageEnglish
Pages (from-to)55-72
Number of pages18
JournalJournal of Hepato-Biliary-Pancreatic Sciences
Issue number1
Publication statusPublished - 01-2018

All Science Journal Classification (ASJC) codes

  • Medicine(all)

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