Safety and Feasibility of Early Laparoscopic Cholecystectomy in High‐Risk Acute Cholecystitis: A Critical Evaluation of Tokyo Guidelines 2018 Risk Stratification

AIM: This study evaluated the safety and appropriateness of early laparoscopic cholecystectomy (LapC) for acute cholecystitis classified as high-risk according to the Tokyo Guidelines 2018 (TG18). METHODS: We retrospectively analyzed 126 patients who underwent early LapC between January 2023 and August 2024. Patients were classified into high-risk (n = 67) and low-risk (n = 59) groups based on TG18 criteria. Primary endpoints were in-hospital mortality and major complications (Clavien-Dindo ≥ IIIa). RESULTS: No in-hospital mortality occurred. Major complications were observed in seven patients (5.6%) with no significant difference between groups (6.0% vs. 5.1%, p = 0.467). Grade 3 cholecystitis was independently associated with overall complications (adjusted OR 3.12, 95% CI 1.03-21.47, p = 0.046). Among Grade 1-2 cases, neither age-adjusted Charlson Comorbidity Index (AA-CCI) nor American Society of Anesthesiologists Physical Status (ASA-PS) correlated with complications, whereas higher preoperative C-reactive protein was an independent predictor (adjusted OR 1.05, 95% CI 1.00-1.10, p = 0.037). CONCLUSION: In our single-center experience, early LapC was safely performed in TG18-defined high-risk patients with Grade 1-2 cholecystitis. Traditional static risk indicators (AA-CCI, ASA-PS) showed limited predictive value in our cohort, whereas dynamic inflammatory markers such as CRP showed potential for risk assessment, though further validation is needed.