Reappraisal of Real‐World Management of Acute Cholecystitis in Elderly Patients Based on the Adherence to Tokyo Guidelines 2018 ( <scp>TG18</scp> ): A Multicenter Study on Anzu <scp>HPB</scp> Surgical Meeting

ABSTRACT Background Although the Tokyo Guidelines 2018 (TG18) recommend optimal management for acute cholecystitis (AC) using an age‐adjusted index, the implementation and outcomes of treatment strategies in elderly patients with AC remain unclear. Methods A total of 461 patients aged ≥ 70 years with AC from five institutions were retrospectively analyzed, including those who underwent early surgery ( n = 247) and later, elective surgery with ( n = 114) or without ( n = 100) preoperative gallbladder drainage. Patients were classified into three groups based on treatment strategy: A (consistent with TG18 recommendations, n = 206), B (more aggressive than TG18 recommendations, n = 135), and C (more conservative than TG18 recommendations, n = 120). Multivariate analyses were performed to identify potential surgical complication predictors. Results Among Grade I/II AC patients, overall complication rates in Groups A, B, and C were 16.4%, 34.0%, and 8.3%, respectively (A vs. B: p &lt; 0.001, A vs. C: p = 0.052) and major complication rates were 3.1%, 9.4%, and 5.0%, respectively (A vs. B: p = 0.029, A vs. C: p = 0.382). Laparoscopic approaches were most frequent in Group C (A, 59.7% vs. B, 22.6% vs. C, 96.6%, p &lt; 0.001). Anticoagulant/antiplatelet therapy independently predicted major complications (odds ratio 3.10, p = 0.023). Conclusion In the present trial, treatment for AC was consistent with TG18 recommendations in 45% of patients. Compared with TG18‐aligned treatment, more conservative treatment was associated with comparable morbidities, while more aggressive treatment was associated with a higher incidence of major morbidities.