Emergency Cholecystectomy in Patients Classified as High Risk According to the Tokyo Guidelines 2018: A Real‐World Analysis

ABSTRACT Aim Emergency cholecystectomy for acute cholecystitis remains controversial in patients classified as high risk by the Tokyo Guidelines 2018 (TG18), although surgery is often unavoidable in real‐world emergency settings. The perioperative risk profile of this TG18 non‐recommended population remains insufficiently defined. The objective of this study was to examine perioperative outcomes in patients undergoing emergency cholecystectomy against TG18 recommendations, while also exploring clinical factors associated with actual operative risk. Methods This retrospective cohort study included 252 consecutive patients who underwent emergency cholecystectomy for acute cholecystitis between 2018 and 2025. Patients were stratified into TG18 emergency‐surgery‐recommended and non‐recommended groups. Perioperative outcomes were compared, and independent risk factors of major postoperative complications, defined as Clavien‐Dindo grade≥III events, were evaluated. Results Major postoperative complications occurred in 11.9% of patients and were significantly more frequent in the TG18 non‐recommended group than in the recommended group (18.0% vs. 2.9%, p < 0.001). In multivariable analysis, American Society of Anesthesiologists physical status classification ≥ 3 and preoperative shock status were independent predictors of major postoperative complications, whereas age and Charlson Comorbidity Index were not. Exploratory stratification of the non‐recommended cohort demonstrated substantial heterogeneity in risk, with comparatively low complication rates observed in patients without physiological instability. Conclusion Emergency cholecystectomy may be feasible in carefully selected TG18 non‐recommended patients. Perioperative risk appears to be driven by physiological instability rather than chronological age or comorbidity burden, supporting a more individualized approach to surgical decision‐making.