-Actual_Problems_of_Emergency_Abdominal_Surgery-_ed._by_Dmitry_Victorovich_Garbuzenko

have a higher CTO rate and require a longer operation time [31]. Two-stage LC male patients

have a three times higher rate of CTO (OR = 2.8; 95% CI: 1.1–6.6, P = 0.037) than females [32].

This might be due to men’s reluctance to seek medical and surgical help, and their late hospital

presentations after several repeated attacks of AC [31].

Patients with the clinical diagnosis of AC and higher severity grades of AC carry more chances

of CTO [25, 33, 34]. Diagnostic criteria for AC are presented in Table 2 [34]. AC patients have

eight times higher risk of CTO than patients with uncomplicated gallstone disease (OR = 8.01;

95% CI: 6.1–10.5; P < 0.00005) [35]. Severity grades of AC, as defined by the 2013 Tokyo

Guidelines, are associated with an increased rate of CTO [36, 37]. The 2013 Tokyo Guidelines

for severity grades of AC are shown in Table 3 [34]. Severe AC makes LC technically more

difficult, because AC is accompanied by extensive adhesions around GB and weakness of the

GB wall, which preclude its retraction with laparoscopic forceps and cause GB perforation and

spillage of infected bile and gallstones into the peritoneal cavity [32].

Grade I (mild) acute cholecystitis

Does not meet the criteria of “grade III” or “grade II” acute cholecystitis. Grade I can also be defined as acute

cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making

cholecystectomy a safe and low-risk operative procedure

Moderate (grade II) acute cholecystitis

Grade II (moderate) acute cholecystitis

Associated with any one of the following conditions:

1. Elevated white cell count (>18,000/mm^3 )


2. Palpable tender mass in the right upper quadrant


3. Duration of complaints > 72 h


4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis,
   emphysematous cholecystitis)
   Grade III (severe) acute cholecystitis
   Associated with dysfunction of any one of the following organs/systems:


5. Cardiovascular dysfunction (hypotension requiring treatment with dopamine ≥5 mcg/kg/min, or any dose of
   norepinephrine)


6. Neurological dysfunction (decreased level of consciousness)


7. Respiratory dysfunction (PaO 2 /FiO 2 ratio <300)


8. Renal dysfunction (oliguria, creatinine >2.0 mg/dL)


9. Hepatic dysfunction (PT-INR >1.5)


10. Haematological dysfunction (platelet count <100,000/mm^3 )

Table 3. The 2013 Tokyo guidelines severity grading for acute cholecystitis (adapted from Yokoe et al. [34]).

46 Actual Problems of Emergency Abdominal Surgery