Noguchi Daisuke, Hayasaki Aoi, Ito Takahiro, Iizawa Yusuke, Fujii Takehiro, Tanemura Akihiro, Murata Yasuhiro, Kuriyama Naohisa, Kishiwada Masashi, Mizuno Shugo
Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
J Hepatobiliary Pancreat Sci. 2025 Jun;32(6):452-464. doi: 10.1002/jhbp.12145. Epub 2025 Apr 10.
The Tokyo Guidelines 2018 introduced the Surgical Difficulty Score (TGDS18) to assess laparoscopic cholecystectomy (LC) difficulty based on intraoperative findings. This study aimed to predict surgical difficulty preoperatively using clinical factors correlated with TGDS18.
Of 369 LC cases for cholecystitis (Jan 2014-Jul 2024), 106 with operative video data were analyzed. Multivariate analysis of 69 with preoperative CT (≤14 days) evaluated the association between preoperative clinical findings and TGDS18 sub-scores (around the gallbladder, Calot's triangle, gallbladder bed, additional findings, unrelated to inflammation).
TGDS18 was positively correlated with operative time, blood loss, and hospital stay (all p < .001). Patients undergoing subtotal cholecystectomy had higher TGDS18 scores (median 20, p < .001). Six preoperative findings strongly associated with TGDS18 sub-scores were identified: calcified stone in cystic duct, TG18 Grade ≥2, preoperative gallbladder drainage, urgent operation, pericholecystic inflammation, and age-adjusted Charlson comorbidity index ≥7. The rate of subtotal cholecystectomy increased with the number of findings linked to the "Calot's triangle" sub-score-cystic duct stone and TG18 Grade ≥2. (0% with no findings, 8% with one finding, and 23% with both, p = .009). Similarly, the risk of cholecystectomy requiring the posterior wall left can be predicted by the number of clinical findings related to the 'Gallbladder bed' sub-score (p = .009).
The clinical findings linked to TGDS18 allow tailored preoperative strategies for acute cholecystitis.
《东京指南2018》引入了手术难度评分（TGDS18），以根据术中发现评估腹腔镜胆囊切除术（LC）的难度。本研究旨在使用与TGDS18相关的临床因素术前预测手术难度。
在369例胆囊炎的LC病例（2014年1月至2024年7月）中，分析了106例有手术视频数据的病例。对69例术前CT（≤14天）病例进行多变量分析，评估术前临床发现与TGDS18子评分（胆囊周围、胆囊三角、胆囊床、其他发现、与炎症无关）之间的关联。
TGDS18与手术时间、失血量和住院时间呈正相关（均p＜0.001）。接受胆囊次全切除术的患者TGDS18评分更高（中位数20，p＜0.001）。确定了六个与TGDS18子评分密切相关的术前发现：胆囊管钙化结石、TG18≥2级、术前胆囊引流、急诊手术、胆囊周围炎症和年龄校正的Charlson合并症指数≥7。胆囊次全切除术的发生率随着与“胆囊三角”子评分相关的发现数量增加而增加——胆囊管结石和TG18≥2级。（无发现为0%，一项发现为8%，两项发现为23%，p = 0.009）。同样，需要保留后壁的胆囊切除术风险可通过与“胆囊床”子评分相关的临床发现数量来预测（p = 0.009）。
与TGDS18相关的临床发现可为急性胆囊炎制定个性化的术前策略。
