The Tokyo Guidelines (TG) introduced diagnostic criteria, severity ratings, and management pathways for acute cholecystitis. We sought to assess penetrance of guideline adherence at our academic centre and the impact on patient outcomes.

We retrospectively reviewed 150 patients with a diagnosis of acute cholecystitis who underwent cholecystectomy during admission. Preoperative data were examined for a severity designation, otherwise assigning one retrospectively. Moderate and severe cases were pooled for analysis. Operative and postoperative data were recorded. TG definitions were used for antibiotic and time to operating room (TTOR) compliance. Primary outcome was guideline compliance; secondary outcomes were complications and length of stay (LOS). Parametric and nonparametric analysis was used to compare groups, with logistic regression to determine predictors of complications.

Severity was not recorded for any patient. 104 cases were graded as mild, 45 as moderate, and 1 as severe. Compliance with antibiotic recommendations was poor overall (41.3%) and worse for moderate/severe than for mild cholecystitis (13.0 vs. 53.8%, p<0.01). TTOR compliance was 86.0% and equivalent between groups (p=0.63). Operative length was increased for moderate/severe cases (98 vs. 78 minutes, p=0.01); rate of conversion to laparotomy was comparable (p=0.46). Overall postoperative complication rate was similar (mild 20.2%, moderate/severe 28.3%; p=0.38). After adjustment, comorbidities (Odds Ratio [OR] 1.5, p<0.01) and conversion to laparotomy (OR 13.1, p=0.01) were found to be predictive of postoperative complications, while severity (OR 1.0, p=0.99), antibiotic compliance (OR 0.9, p=0.90), and time to OR (1.0, p=0.72) had no effect. LOS was 3 days for mild and 4 days for moderate/severe cases (p=0.04). Readmission rates were similar (mild 7.3%, moderate/severe 4.3%; p=0.39).

Compliance with severity grading and antibiotic administration was poor, while TTOR was acceptable. Severity and guideline compliance had no impact on complication rate. Quality improvement measures could improve antibiotic stewardship in this context.

Diagnosis and Management of Acute Cholecystitis: An Audit of Guideline Adherence and Patient Outcomes