Background : Nonoperative treatment was suggested in Tokyo guidelines for severe acute cholecystitis. However, some cases could not be stabilised in emergency departments or gastroenterology and required urgent surgical treatment during their medical treatment.

Methods : A single surgeon's records for cholecystectomy for Tokyo Guideline grade III acute cholecystitis were reviewed. The focus was the duration of diagnosis and medical treatment before consultation and cholecystectomy, the reasons for consultation for surgery, the hospital stay, and the severity of complications in the outcome.

Results : There were 41 cases of Tokyo Guideline grade III acute cholecystitis. The duration of medical diagnosis and treatment before cholecystectomy ranged from 1 day to 150 days, with a mean of 12 days and a medium of 5 days. The ninety percentile of these durations were within 18 days of medical treatment. About 44 per cent of the reasons for consultation were that nonoperative treatment could not be tried and percutaneous drainage could not be established due to dangerous gall bladder perforation, haemorrhage, or other difficulties, whether before or after percutaneous punctures. About 17 per cent of the reasons were that the gall bladder and the patient were not stabilised, but their disease and complications worsened during nonoperative treatment. About 22 per cent of the reasons were that the patient's vital signs and complications were once stabilised during nonoperative treatment. However, the objective data for their severity was still grade III, and their clinical doctors expected that further improvement would not happen in the hospital without surgery for the infection source. About 15 per cent of the reasons were other severe abdominal emergent diseases beyond the gall bladder that happened during nonoperative management. According to Clavien–Dindo classification, about 39 per cent of all these patients had postoperative complications of Dindo grade 3 or higher after their surgical operation. All of these complications are related to preoperative disease and preoperative complications. Ten patients had grade 5 complications. The medium hospital stay was 20 days [mean 29, range : 3-108].

Conclusions : Some patients with severe acute cholecystitis still need urgent surgery when nonoperative treatment is not successful in stabilising the patients. In my experience, three of four of them were saved at last. The author was not sure that death could be fewer if surgical operations were done earlier or if longer nonoperative treatments were insisted on.