Predicting Acute Cholecystitis on Final Pathology to Prioritize Surgical Urgency: An Evaluation of the Tokyo Criteria and Development of a Novel Predictive Score

Limited operating room access in publicly funded institutions, particularly for emergencies, highlights the need for improved prioritization rules for common pathologies, including acute cholecystitis (AC). We compared the performance of our institution's surgical prioritization rules to the Tokyo diagnostic criteria and to develop a novel decision rule to predict AC on surgical pathology. All adult patients undergoing emergency cholecystectomy (EC) at a single academic institution (2017-2021) were reviewed. The primary outcome was the diagnosis of acute inflammation on final pathologic analysis. Multiple logistic regression was performed with a training subset using relevant clinical variables that were selected a priori. A simple weighted decision rule was created and compared to the Tokyo Guidelines and the institution's existing prioritization rules via an analysis of receiver operator curves. Among 756 patients undergoing EC, 97.6% met the criteria for AC as per Tokyo diagnostic criteria. Urgent booking category (area under the curve [AUC] = 0.58, sensitivity 89%, specificity 26%) and Tokyo criteria (AUC = 0.51, sensitivity 99%, specificity 3%) poorly discriminated for acute inflammation on final pathology. Discrimination of the hospital's case prioritization rules was moderate (AUC = 0.63, sensitivity 48%, specificity 78%), and a new decision rule was significantly higher (AUC = 0.71, sensitivity 72%, specificity 64%, P < 0.003). The Tokyo Guidelines were highly sensitive but nonspecific for the presence of acute inflammation on final pathology. An existing institutional case prioritization rule demonstrated moderate discrimination but was outperformed by a new rule incorporating clinical exam, fever, degree of leukocytosis, and inflammatory changes on imaging. These findings may aid AC prioritization in busy centers, though external validation is needed.