Acute cholecystitis, primarily caused by gallstones, is a serious condition that may lead to severe complications. The optimal timing of surgery for acute cholecystitis is still under debate. Early cholecystectomy is generally preferred to prevent complications and improve postoperative outcomes. This study aimed to evaluate the impact of early, intermediate, and delayed laparoscopic cholecystectomy on postoperative quality of life (QoL) in patients with acute cholecystitis.

This retrospective study included 201 patients who underwent laparoscopic cholecystectomy for acute cholecystitis between May 2019 and February 2023. Patients were categorized into three groups based on the timing of surgery: early (within one week), intermediate (1-6 weeks), and delayed (after six weeks). The Gastrointestinal Quality of Life Index (GIQLI) was used to evaluate QoL six months postoperatively. Data on patient demographics, surgery timing, and cholecystitis severity (based on the Tokyo Guidelines) were analyzed using univariate and multivariate regression models.

The mean age of patients was 56.0 ± 14.9 years, and 65.7% were female. Early cholecystectomy was performed in 30.8% of cases, intermediate in 16.9%, and delayed in 52.2%. The median GIQLI score was 116. Patients who underwent early surgery had significantly higher GIQLI scores compared to those in the intermediate group (p < 0.001). No significant difference was observed between early and delayed surgery (p = 0.199). Multivariate analysis showed that intermediate surgery negatively affected QoL (p < 0.001), while cholecystitis severity was also a significant factor (p = 0.006).

Early laparoscopic cholecystectomy significantly improves postoperative QoL compared to intermediate surgery. Delayed surgery provides similar QoL outcomes to early surgery. However, intermediate cholecystectomy may lead to poorer QoL due to heightened surgical complexity and increased complications. Early intervention should be prioritized to optimize patient outcomes.

Gallbladder perforation occurs in 2% to 11% of patients with acute cholecystitis, with associated mortality estimated to be at 12% to 42%. Because of its low incidence, the data on management remain sparse. There is a lack of evidence to suggest whether early or delayed cholecystectomy is superior in the treatment of perforated cholecystitis. We hypothesize that an early definitive operation is associated with decreased total hospital length of stay (THLOS).

Using the National Surgical Quality Improvement Program database from the American College of Surgery, we identified patients who underwent laparoscopic cholecystectomy for gallbladder perforation on an urgent or emergent basis from 2012 to 2021. We divided them into those who underwent early (<2 days from the date of admission to the date of operation) and delayed cholecystectomy (≥2 days from the date of admission to the date of operation). Our primary outcome was the THLOS. We created multivariate regression models to assess for the association of early versus delayed operation and THLOS.

The THLOS was found to be 2.94 days longer in the delayed group compared with the early group (p < 0.05). In those who did not present with sepsis on admission, the THLOS was noted to be 4.71 days longer in the delayed group compared with the early group (p < 0.05). Early versus delayed operation was not associated with a difference in the postoperative length of stay, 30-day postoperative complications, rate of readmission, and reoperation, regardless of preoperative sepsis status.

Early laparoscopic cholecystectomy for gallbladder perforation is associated with decreased THLOS, and there were no other differences in outcomes compared with delayed laparoscopic cholecystectomy. Patients with gallbladder perforation would likely benefit from an early operation within 2 days of admission.

Therapeutic/Care management; Level IV.

Non-operative management (NOM) of acute cholecystitis (ACC) may be preferable in patients with advanced inflammation, long duration of symptoms or severe comorbidities. This study aims to investigate time to recurrence and patient factors predicting relapse in gallstone complications after NOM.

Records of 1634 patients treated for ACC at three Swedish centres between 2017 and 2020 were analysed, with 909 managed non-operatively. Data were linked to the National Gallstone Surgery registry for those who later underwent surgery. The time to relapse of gallstone complications was calculated and Cox proportional hazards regression was used to analyse new gallstone complications and adjust for multiple variables.

Of the 909 non-operatively managed patients, 348 patients suffered a new gallstone complication. The median time to recurrence was 82 days. Of those who recurred, 27% did so within 30 days, 17% between 31 and 60 days, 27% between 61 days and 6 months, 16% between 6 months and 1 year and 13% later than 1 year. Younger patients with their first gallstone complication had a lower risk of new complications compared with those with previous gallstone complications. In older individuals, there was no difference in the risk of relapse regardless of previous gallstone complications, but they were more likely to be readmitted than younger patients.

Delayed cholecystectomy should be prioritised for younger patients with a history of gallstone disease if early cholecystectomy is not feasible. Delayed cholecystectomy should be scheduled without a prior outpatient clinic visit to minimise delays.

While emergency cholecystectomy is the preferred treatment for acute cholecystitis, conservative management can be used as a bridge to definitive surgical management in situations where emergency surgical services are limited. The objective of this systematic review is to identify factors associated with conservative management failure as defined as either failed resolution of symptoms on initial presentation, or the recurrence of symptoms whilst awaiting an elective cholecystectomy. This study aims to allow clinicians to make evidence-based recommendations for conservative versus operative management.

A systematic review of the Medline database was conducted in May 2022 to identify studies analysing the success of non-operative management of acute cholecystitis. Two independent reviewers selected studies based on predefined criteria, and the risk of bias was evaluated. Out of the initial 1344 studies retrieved, 12 studies met the inclusion criteria.

Factors significantly associated with persistence of symptoms in at least one study on multivariable analysis included diabetes mellitus, age >70, tachycardia, elevated temperature, elevated white cell count >15 000/uL and a distended gallbladder >5 cm. Factors significantly associated with recurrence of symptoms included Age <40 or >80, male sex, acute cholecystitis grade 2 or 3, elevated creatinine, serum albumin <4 g/dL, thickened gallbladder wall >5 mm.

Several factors have been identified which may facilitate future evidence-based recommendations for tailored management strategies for patients with acute cholecystitis.

 Acute cholecystitis (AC) is one of the most frequent gastrointestinal emergencies, necessitating prompt definitive treatment. Laparoscopic cholecystectomy (LC) has become the gold standard for management, although the timing of surgery remains controversial. Early laparoscopic cholecystectomy (ELC) is performed within 72 hours of symptom onset, while delayed laparoscopic cholecystectomy (DLC) is undertaken after a period of conservative management. The purpose of this study is to assess the complications and outcomes of early vs delayed laparoscopic cholecystectomy in patients with acute cholecystitis.

 To evaluate perioperative outcomes, including complications, operative time, conversion rates, and hospital stay, between patients undergoing early vs delayed laparoscopic cholecystectomy for acute cholecystitis.

This prospective non-randomized comparative study was conducted in the surgical department of Hayatabad Medical Complex (HMC), Peshawar. The study was carried out during a 15-month period, from June 1, 2023, to August 30, 2024. A total of 118 individuals with acute cholecystitis, age ranged between 18 to 60 years, were included. Acute cholecystitis was diagnosed based on imaging examinations, laboratory tests, and the patient's history.

In Group 1, the mean age of patients was 42.5±10.3 years, and it was 44.1±9.8 years in Group 2. Gender distribution was similar in both groups, with a slight predominance of females (Group 1: 35 females, 25 males; Group 2: 34 females, 24 males). In Group 1, the most common presenting symptoms were right upper quadrant pain (55, 92.4%), nausea (47, 78.8%), and fever (27, 45.8%). Similarly, in Group 2, these symptoms were reported in 53 (91.4%), 46 (79.3%), and 27 (46.6%) patients, respectively. Duration of symptoms prior to surgery was 3.2±1.1 days in Group 1 and 4.1±1.3 days in Group 2.

In comparison to delayed laparoscopic cholecystectomy, early laparoscopic cholecystectomy is associated with fewer complications, fewer readmissions, and shorter hospital stays. These findings have led to the recommendation of early intervention as the best strategy for treating acute cholecystitis.

The prolonged use of percutaneous cholecystostomy tubes (PCTs) in patients with acute cholecystitis, deemed inoperable, is fraught with complications. Transpapillary cholecystoduodenal stenting (TCDS) is an alternative technique that restores the physiologic outflow of bile, avoiding the need for an external drain. However, the long-term safety and efficacy of this approach remain unclear. We sought to prospectively assess the safety and efficacy of this procedure, performed via percutaneous or endoscopic approach, in high-risk patients presenting with acute cholecystitis.

This prospective study included consecutive patients with acute cholecystitis and long-lasting, prohibitive surgical risk, in whom TCDS was offered at two partnering tertiary care centers between August 1, 2018, and December 31, 2022. Patients with a need for endoscopic retrograde cholangiopancreatography (ERCP) underwent ERCP-guided TCDS. In patients without a need for ERCP, a temporary PCT was followed by fluoroscopic-guided TCDS 4 weeks to 6 weeks later. Interval cholecystectomy was performed in patients who became surgical candidates later. All patients were followed up until January 1, 2023.

Transpapillary cholecystoduodenal stenting was successful in 67 (percutaneous in 45/50; endoscopic in 22/23) of 73 patients (92%) attempted. Over a median follow-up period of 17 months (7, 26), 10 patients (15%) developed stent blockage or migration; all but two had their stent successfully replaced. Five patients (7%) developed mild, self-limited pancreatitis. Five (7%) patients underwent interval cholecystectomy at a median time of 7 months.

Transpapillary cholecystoduodenal stenting is a safe and promising definitive alternative to chronic PCT in high-risk patients with acute cholecystitis that eliminates the discomfort and complications of long-term external drainage.

Therapeutic/Care Management; Level II.

International guidelines for management of acute biliary pathology recommend emergency cholecystectomy (EmC), citing improved outcomes compared to elective cholecystectomy (ElC) based on trials which may not reflect the capacity constraints in clinical practice, nor selection based on multiple prior attendances with emergency biliary pathology or attendances following a decision for ElC. We therefore conducted a longitudinal retrospective study evaluating all attendances with biliary pathology prior to cholecystectomy with the aim of assessing whether EmC is justified in this context.

Data was collected on patients undergoing cholecystectomy between 2016 and 2021 at four centres. Patients who had an emergency presentation with a biliary pathology prior to cholecystectomy up to 2010 were included. Patients were divided into EmC and ElC groups, EmC was defined as cholecystectomy occurring during an emergency admission with biliary pathology. Multilevel regression modelling was used to identify independent predictors for time to surgery from index presentation, number of re-attendances and length of stay (LoS).

2,056 patients were included: 1,786 (86.9%) had ElC and 270 (13.1%) EmC. EmC was independently associated with a reduction in time to surgery (-112.32 days [95% CI -140.22 to -84.42]). However, there was a significant increase in both post-operative and overall LoS (+ 3.34 days [95% CI 1.81-4.86]) across all admissions with EmC. EmC did not significantly reduce rates of emergency re-attendance prior to surgery overall.

Although EmC reduces time to surgery, it does not reduce the number of emergency re-attendances and increases LoS. In the context of limited emergency theatre capacity, it may be beneficial to prioritise those who benefit most from EmC.

Cholecystectomies are very common in general surgery practice. A small percentage of these will present with factors that pose operative difficulty. The surgeon should have a high index of suspicion based on preoperative factors of patients that may present an operative challenge and have necessary equipment available and the surgical skill to provide the best surgical outcome for the patient if a total cholecystectomy is unable to be performed.

Background/Objectives: Acute cholecystitis (AC) presents a significant burden in emergency surgical settings. Early laparoscopic cholecystectomy (ELC) is the standard of care for AC, yet its implementation varies. This study aims to assess the impact of preoperative waiting time (WT) on postoperative length of stay (LOS) in patients undergoing urgent cholecystectomy. Methods: From June 2021 to September 2022, data on patients undergoing urgent cholecystectomy for AC or pancreatitis were collected from two university hospitals. Patients were categorized into early (ELC) or delayed (DLC) cholecystectomy groups based on WT. The primary outcome was the assessment of the variables influencing LOS via univariate and multivariate analyses. Results: This study included 170 patients, predominantly female, with a median age of 64.50 years. ELC was performed in 58.2% of cases, with a median WT of 0 days, while DLC was performed in 41.8%, with a median WT of 3 days. Postoperative complications occurred in 21.8% of cases, with LOS being significantly shorter in the ELC group (median 5 days vs. 9 days; p = 0.001). Multivariate analysis confirmed that WT (OR 8.08 (1.65-77.18; p = 0.033)) was the most important predictor of LOS. Conclusions: ELC is associated with a shorter LOS and with DLC, aligning with the WSES recommendations. Earlier surgery reduces the risk of complications and overall hospital costs. An extended WT contributes to a prolonged LOS, underscoring the importance of timely access to operating theaters for acute biliary pathologies.

The gold standard for treating acute cholecystitis is an early laparoscopic cholecystectomy. However, whether this still applies for a > 7-day existing cholecystitis remains heavily debated. Therefore, this systematic review investigates the safety of early laparoscopic cholecystectomy for a > 7-day existing cholecystitis.

PubMed and Embase were systematically searched for all studies comparing early laparoscopic cholecystectomy in patients with 0-7 versus > 7-day existing cholecystitis at time of surgery. Meta-analyses were performed on dichotomous and continuous outcomes with risk difference (RD) and mean difference (MD) as measures of effect.

A total of 3007 studies were screened, resulting in the inclusion of 13 non-randomised studies comprising 5481 patients. Of these, 4690 received cholecystectomy within 7 days, and 791 after 7 days. Operating times (MD -11.8 min; 95% CI [-18.4; -5.2]) and total hospital stay (MD -2.7 days; 95% CI [-4.0; -1.4]) were longer in the > 7-day group. However, no significant risk difference was found for combined major complications: bile duct injury/leakage and bowel injury (RD -1.0%; 95% CI [-2.3; 0.3]), for complications graded Clavien-Dindo ≥ 3 (RD -0.3%; 95% CI [-2.5; 1.9]), or for conversions (RD -1.5%; 95% CI [-3.9; 0.9]).

Early laparoscopic cholecystectomy for cholecystitis after the 7-day barrier might be harder, as reflected by longer operating times. However, a significant increase in complications or conversions was not found. Due to the risk of bias and lack of well-powered studies directly comparing early cholecystectomy after 7 days with alternative strategies, strong recommendations cannot be made. Meanwhile, it is advised to carefully weigh the treatment options in case of a > 7-day existing cholecystitis, based on patient's characteristics and surgeon's experience.

Introduction Acute cholecystitis, commonly caused by gallstones, is a prevalent surgical emergency worldwide. Laparoscopic cholecystectomy (LC) is the gold standard for treatment, but the timing is crucial, with early surgery (within seven days) reducing complications. Identifying prognostic factors such as age, sex, white blood cell (WBC) count, C-reactive protein (CRP), and gallbladder wall thickness can help predict outcomes and reduce the need for conversion to open surgery. Methods A prospective longitudinal observational study was conducted at Sree Balaji Medical College and Hospital, Chennai, on 60 patients diagnosed with acute cholecystitis. The inclusion criteria involved clinical signs (right upper abdominal tenderness, temperature >37.5°C, WBC >10,000 cells/mm³) and ultrasound findings (gallstones, thickened gallbladder, sonographic Murphy's sign). Data on prognostic factors (WBC, CRP, ultrasound, intraoperative findings) were collected and analyzed using IBM SPSS Statistics for Windows, Version 28.0 (Released 2021; IBM Corp., Armonk, New York, United States), with chi-squared tests to evaluate associations between these factors and surgical outcomes. Results Patients aged 18-30 had the highest success rate for early LC, with only 10.5% converting to open surgery, whereas older patients (>50 years) had a higher conversion rate (33.3%). A higher body mass index (BMI) (>30) was linked to increased conversions (26.3%), as was the presence of hypertension (23.1%) and diabetes (22.2%). Elevated WBC and CRP levels were significant predictors of conversion (24.2% and 22.2%, respectively). Intraoperative factors such as gallbladder wall thickening (>4 mm) and pericholecystic fluid were associated with conversion rates of 20.8% and 25%, respectively. Converted cases had longer operative times and extended recovery periods. The predictive model for conversion showed a sensitivity of 88.9% and a specificity of 90%. Conclusion Key prognostic factors influencing the success of early LC include age, BMI, comorbidities, and inflammatory markers such as WBC and CRP. Younger patients had higher success rates, whereas older and obese patients were at greater risk of conversion. Preoperative optimization and early surgical intervention are critical for reducing conversion rates and improving outcomes. The predictive model's accuracy provides clinicians with a valuable tool for surgical planning.

Implicit bias may prevent patients with abdominal pain from receiving optimal workup and treatment. We hypothesized that patients from socially disadvantaged backgrounds would be more likely to experience delays in receiving operative treatment for cholecystitis. To study this question, we examined factors related to having a prior emergency department presentation for abdominal pain (prior emergency department visit) within 3 months of urgent cholecystectomy.

We performed a retrospective analysis of consecutive patients who received an urgent cholecystectomy at an urban safety net public hospital between July 2019 and December 2022. The main outcome of interest was prior emergency department visit within 3 months of index cholecystectomy. We examined patient age, sex, race, ethnicity, preferred language, insurance, and employment status. Bivariate comparisons and logistic regression were used to determine the relationship between patient factors and prior emergency department visit.

Of 508 cholecystectomy patients, 138 (27.2%) had a prior emergency department visit in the 3 months preceding their surgery. In bivariate analysis, younger age, Black race, Hispanic ethnicity, non-English preferred language, and type of insurance (P < .05) were associated with prior emergency department visit. In regression, younger age, Black race, Hispanic ethnicity, and having Medicare or being uninsured were associated with higher odds of having a prior emergency department visit.

More than 1 in 4 patients had an evaluation for abdominal pain within 3 months of having an urgent cholecystectomy, and these patients were more likely to be from socially disadvantaged backgrounds. Standardized evaluation pathways for abdominal pain are needed to reduce disparities from institutional or implicit bias.

Severe acute cholecystitis (AC) is a challenging disease because it comprises coexisting systemic infections that lead to vital organ dysfunction. This study evaluated the optimal surgical timing and efficacy of preoperative percutaneous cholecystostomy (PC) for patients with severe AC.

Data of 142 patients who underwent cholecystectomy for severe AC between 2011 and 2021 were retrospectively collected from the multi-institutional database of the Hiroshima Surgical Study Group of Clinical Oncology. Patients were divided into the early cholecystectomy (EC) group (within 72 h of symptom onset) and delayed cholecystectomy (DC) group. They were also subdivided into the upfront cholecystectomy group and preoperative PC before cholecystectomy group. The diagnosis and severity of AC were graded according to the Tokyo Guidelines 2018. Clinicopathological variables and outcomes were compared.

No significant differences in age, body mass index, American Society of Anesthesiologists (ASA) classification, and Charlson comorbidity index between the EC and DC groups were observed. Preoperative drainage was more commonly performed for the DC group than for the EC group. Local severe AC features were more commonly detected in the DC group than in the EC group. The postoperative outcomes of the EC and DC groups were comparable. Compared to the PC before cholecystectomy group, the upfront cholecystectomy group included more patients with ASA physical status ≥ 3 and more patients who used oral warfarin. Warfarin usage and cardiovascular dysfunction rates of the PC after cholecystectomy group were higher than those of the upfront cholecystectomy group. PC was associated with significantly less intraoperative bleeding and shorter hospital stays.

Patients who can tolerate general anesthesia are good candidates for EC. Patients who use warfarin and those with cardiovascular dysfunction are considered to be at high risk for postoperative complications; therefore, to prevent AC recurrence during the waiting period, PC before cholecystectomy during the same admission is more appropriate than upfront cholecystectomy for these patients.

Laparoscopic cholecystectomy (LC) is the preferred treatment for acute cholecystitis (AC). However, the optimal timing for LC in AC management remains uncertain, with early cholecystectomy (EC) and interval cholecystectomy (IC) being two common approaches influenced by various factors.

This retrospective study, conducted at a tertiary care teaching hospital in Karachi, Pakistan, aimed to compare the outcomes of EC vs. IC for AC management. Patient data from January 2019 to September 2019 were analyzed with a focus on operative complications, duration of surgery, and postoperative hospital stay. The inclusion criteria were based on the Tokyo Guidelines, and patients underwent LC within 3 days of symptom onset in the EC group and after 6 weeks in the IC group.

Among 147 eligible patients, 100 underwent LC (50 in each group). No significant differences were observed in the sex distribution or mean age between the two groups. The EC group experienced fewer operative complications (12%) than the IC group (34%), with statistically significant differences observed. Nevertheless, no substantial variations in operative time or postoperative hospital stay were observed between the groups.

Reduced complications in the EC group underscore its safety and efficacy. Nonetheless, further validation through multicenter studies is essential to substantiate these findings.

Peritonsillar abscess (PTA) is a common deep neck infection traditionally managed with conservative measures. Quinsy Tonsillectomy (QT) is recognized as a definitive treatment but remains variably utilized. We aimed to investigate PTA management strategies and attitudes toward QT among otolaryngologists.

An anonymous questionnaire was distributed to members of the local national Society of Otolaryngology, evaluating treatment strategies based on patient characteristics and clinical scenario.

A total of 108 otolaryngologists responded (response rate: 30.8%). Participants preferred to treat PTA patients as inpatients (89%) and predominantly offered incision and drainage (I&D) as the first (90.7%) and subsequent (98.1%) treatment plan. QT was favored as a primary treatment only in 1.9% of responders. QT adoption increased with multiple I&D failures, reaching 95.3% after four attempts. In patients with recurrent PTA or tonsillitis, 84.2% preferred I&D follows by interval elective tonsillectomy, while 15% considered QT. The most common reason (72.2%) to avoid QT was the perception of a high perioperative risk.

I&D was favored for initial PTA treatment. QT is considered after multiple failed I&D attempts, and its use is limited as a primary treatment, mainly due to concerns regarding perioperative risk.

Gallstones are common and affect up to 20% of the general adult population and >20% of them will develop symptoms or complications of cholelithiasis. The high risk of gallbladder stone formation can be reduced by ursodeoxycholic acid in the case of significant weight reduction resulting from diet or bariatric surgery. Laparoscopic cholecystectomy is indicated for symptomatic gallstones, as the risk of recurrence or complications increases over the course of the disease. Biliary colic is treated with nonsteroidal anti-inflammatory drugs and spasmolytics; opioids can also be used in cases of severe acute pain. Acute cholecystitis represents a common complication of gallbladder stones and a cholecystectomy should be performed early electively, i.e., within 24 hours of admission to hospital. Symptomatic bile duct stones are primarily treated endoscopically. Immediate anti-infective therapy is mandatory in acute cholangitis. Although knowledge on the genetics and pathophysiology of gallstones has increased, current treatment algorithms remain predominantly invasive, based on interventional endoscopy and surgery. Future efforts should focus on novel strategies to prevent the development of gallstones.

Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines.

Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure.

Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified.

As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

As the age increases particularly above the age of 50 years, there is a significantly higher risk of developing gallstone-related complications especially cholecystitis and common bile duct stones with its associated consequences. Complications that arise after surgical operations for cholecystitis have been reported to have negative impacts on senior patients. These effects include a higher rate of complications, a longer hospital stay, higher expenditures, and decreased patient satisfaction. Therefore, finding the most effective treatment for cholecystitis in older patients is still a challenge. The aim of the study was carried out in order to identify many approaches that can be taken in the treatment of cholecystitis and stones in the common bile duct in older patients. A search was conducted through Medline (PubMed), EMBASE, ProQuest, and Cochrane using relevant Medical Subject Heading (MeSH) terms and keywords (elderly, age over 50, cholecystitis, bile duct stones, cholecystectomy, ERCP, surgical, conservative management, and open). The searches were limited to studies on elderly individuals over 50 who had cholecystectomy and endoscopic retrograde cholangiopancreatography between January 2000 and December 2022. The meta-analysis used the Mantel-Haenszel odds ratio (MHOR) and 95% confidence interval (CI). Aries Systems Corporation's Editorial Manager® (Aries Systems Corporation, North Andover, USA) and ProduXion Manager® (Aries Systems Corporation, North Andover, USA) facilitated the study. Out of 102 citations, 39 studies were selected for further study. After that, 18 studies were eliminated, leaving 21 for meta-analysis. The study found a protective risk of cholecystitis in cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). Developing cholecystitis was substantially lower in early cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). There was no significant difference in cholecystitis risk between open and laparoscopic surgery (MHOR = 0.65; 95%, CI = 0.41 to 1.04; p 0.07). Cholecystectomy performed at an earlier stage protects elderly patients from developing recurrent cholecystitis. In contrast to late cholecystitis, in which the patient would experience several attacks of cholecystitis, early cholecystectomy protects against the recurrence of the condition.

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature.

Adult patients with cholecystitis who do not undergo cholecystectomy on index admission have worse outcomes, however, there is a paucity of data of the role of cholecystectomy during index hospitalization in the pediatric population. Our aim was to determine outcomes and readmission rates among pediatric patients with cholecystitis who underwent index cholecystectomy versus those who did not.

We performed a retrospective study of pediatric (< 18 years old) admitted with acute cholecystitis (AC) requiring hospitalization using the 2018 National Readmission Database (NRD). Exclusion criteria included age ≥ 18 years and death on index admission. Multivariable logistic regression was performed to identify factors associated with 30-day readmissions.

We identified 550 unique index acute cholecystitis admissions. Mean age was 14.6 ± 3.0 years. Majority of patients were female (n = 372, 67.6%). Index cholecystectomy was performed in (n = 435, 79.1%) of cases. Thirty-day readmission rate was 2.8% in patients who underwent index cholecystectomy and 22.6% in those who did not (p < 0.001). On multivariable analysis, patients who did not undergo index cholecystectomy had higher odds of 30-day readmission than those who did not (OR 10.66, 95% CI 5.06-22.45, p < 0.001). Female patients also had higher odds of 30-day readmission compared to males (OR 3.37, 95% CI 1.31-8.69).

Patients who did not undergo index cholecystectomy had over tenfold increase in odds of 30-day readmission. Further research is required to understand the barriers to index cholecystectomy despite society recommendations and clear clinical benefit.

Early laparoscopic cholecystectomy (ELC) is the standard treatment for acute cholecystitis (AC). However, predicting the difficulty of this procedure remains challenging. The present study aimed to develop an improved prediction model for surgical difficulty during ELC, surpassing the current Tokyo Guidelines 2018 (TG18) grading system.

We analyzed data from 201 consecutive patients who underwent ELC for AC between 2019 and 2021. Surgical difficulty was defined as the failure to achieve the critical view of safety (non-CVS). We developed a scoring system by conducting multivariate analysis on demographics, symptoms, laboratory data, and radiographic findings. The predictive accuracy of our scoring system was compared to that of the TG18 grading system (Grade I vs. Grade II/III).

Through multivariate logistic regression analysis, a novel scoring system was formulated. This system incorporated preoperative C-reactive protein (CRP) values (≥5: 1 pt, ≥10: 2 pts, ≥15: 3 pts) and TG18 grading score (duration >72 h: 1 pt, image criteria for Grade II AC: 1 pt). Our model, a cutoff score of ≥3, exhibited a significantly elevated area under the curve (AUC) of 0.721 compared to the TG18 grading system alone (AUC 0.609) (p = 0.001).

Combining preoperative CRP values with TG18 grading criteria can enhance the accuracy of predicting intraoperative difficulty in ELC for AC.

The existing risk stratification for early cholecystectomy in patients with acute cholecystitis (AC) is complex. This study aims to establish a simpler risk assessment for surgical complications after cholecystectomy based on age group.

This single-center retrospective observational study enrolled 350 patients diagnosed with AC who underwent early cholecystectomy within 72 h of diagnosis from 2013 to 2021. Patients were divided into three subgroups based on age: young (<65 years), elderly (65-79 years), and very elderly (≥80 years). Since no mortality was observed, risk factors for the Clavien-Dindo (CD) grade ≥ II complications were identified within the entire cohort and in each subgroup.

There were 120 young, 130 elderly, and 100 very elderly patients. The overall prevalence of complications with CD grade ≥ II was 11.1%. Age and Tokyo Guidelines 18 (TG18) severity were independent risk factors for surgical complications in the whole cohort. Subgroup analysis revealed that there was no independent risk factor in the young group. Meanwhile, age and poor physical status were independent risk factors in the elderly group, and TG18 severity in the very elderly group.

Evaluation of only age, physical status, and TG18 severity may be sufficient for risk stratification of surgical complications of AC.

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

Although the past decade has witnessed unprecedented medical progress, no consensus has been reached on the optimal approach for patients with acute cholecystitis. Herein, we conducted a systematic review and meta-analysis to assess the differences in patient outcomes between Early Laparoscopic Cholecystectomy (ELC) and Delayed Laparoscopic Cholecystectomy (DLC) in the treatment of acute cholecystitis. Our protocol was registered in the PROSPERO database (registration number: CRD42023389238).

We sought to investigate the differences in efficacy, safety, and potential benefits between ELC and DLC in acute cholecystitis patients by conducting a systematic review and meta-analysis.

The online databases PubMed, Springer, and the Cochrane Library were searched for randomized controlled trials (RCTs) and retrospective studies published between Jan 1, 1999 and Jan 1, 2022.

21 RCTs and 13 retrospective studies with a total of 7,601 cases were included in this research. After a fixed-effects model was applied, the pooled analysis showed that DLC was associated with a significantly high conversion rate (OR: 0.6247; 95%CI: 0.5115-0.7630; z = -4.61, p < 0.0001) and incidence of postoperative complications (OR: 0.7548; 95%CI: 0.6197-0.9192; z = -2.80, p = 0.0051). However, after applying a random-effects model, ELC was associated with significantly shorter total hospitalization duration than DLC (MD: -4.0657; 95%CI: -5.0747 to -3.0566; z = -7.90, p < 0.0001).

ELC represents a safe and feasible approach for acute cholecystitis patients since it shortens hospitalization duration and decreases the incidence of postoperative complications of laparoscopic cholecystectomy.

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=389238, identifier (CRD42023389238).

The prevalence of acute cholecystitis among elderly patients is increasing. The aim of this study was to compare laparoscopic cholecystectomy (LC) to antibiotics in elderly patients with acute cholecystitis.

A randomized multicenter clinical trial including patients over 75 years with acute calculous cholecystitis was conducted in four hospitals in Finland between January 2017 and December 2019. Patients were randomized to undergo LC or antibiotic therapy. Due to patient enrollment challenges, the trial was prematurely terminated in December 2019. To assess all eligible patients, we performed a retrospective cohort study including all patients over 75 years with acute cholecystitis during the study period. The primary outcome was morbidity. Predefined secondary outcomes included mortality, readmission rate, and length of hospital stay.

Among 42 randomized patients (LC n = 24, antibiotics n = 18, mean age 82 years, 43% women), the complication rate was 17% (n = 4/24) after cholecystectomy and 33% (n = 6/18, 5/6 patients underwent cholecystectomy due to antibiotic treatment failure) after antibiotics (p = 0.209). In the retrospective cohort (n = 630, mean age 83 years, 49% women), 37% (236/630) of the patients were treated with cholecystectomy and 63% (394/630) with antibiotics. Readmissions were less common after surgical treatment compared with antibiotics in both randomized and retrospective cohort patients (8% vs 44%, p < 0.001% and 11 vs 32%, p < 0.001, respectively). There was no 30-day mortality within the randomized trial. In the retrospective patient cohort, overall mortality was 6% (35/630).

LC may be superior to antibiotic therapy for acute cholecystitis in the selected group of elderly patients with acute cholecystitis.

Introduction  Acute gallstone diseases are common surgical emergencies, accounting for approximately one-third of emergency surgical admissions. Laparoscopic cholecystectomy is the standard choice of treatment for gallstone diseases and is currently one of the most commonly performed surgical procedures in the United Kingdom. Majority of these procedures are carried out as elective cases. National Institute of Clinical Excellence (NICE) guidelines and other upper gastrointestinal surgery specialty bodies encourage early emergency surgery in acute symptomatic gallstone disease. We assessed emergency laparoscopic cholecystectomies performed at Birmingham Heartlands Hospital, United Kingdom and compared the practice against NICE and British Benign Upper Gastrointestinal Surgery Society (BBUGSS) recommendations. Methods This is a snapshot retrospective audit, assessing emergency laparoscopic cholecystectomy practice over a nine-month period from November 2022 to July 2023. Variables assessed were demographics, duration of symptoms prior to surgery, imaging modality, indications, C-reactive protein (CRP) levels, operative difficulty, intraoperative and postoperative complications, length of hospital stay and readmission rates. These variables were compared against both NICE and BBUGSS standards. We aimed to establish baseline data to encourage emergency laparoscopic cholecystectomies in our hospital and reduce repeated hospital visits for patients with acute gallbladder disease. Results Forty-eight patients had emergency laparoscopic cholecystectomy in the period reviewed, mean age was 44.3 years and females accounted for approximately 71% (n=34) of the group. 66.7% (n=32) of patients had their surgery within seven days of diagnosis with acute gallstone disease; 50% (n=24) of patients had no adverse intraoperative event. No patient had biliary tract injury despite a high number of difficult cases. Overall there was no correlation between duration before surgery and intraoperative difficulty or readmission rates.

Acute cholecystitis in patients on anti-thrombotic therapy (ATT) presents a clinical dilemma at the intersection between conflicting guidelines, specifically between timing of early operative management (OM) versus time-to-reversal of certain ATT agents. With growing recognition that nonoperative management (NOM) is associated with considerable morbidity, and evidence in the literature that early OM in patients on ATT is safe, we reviewed our own practice to examine how we addressed these conflicting guidelines.

We performed a retrospective review of patients with acute cholecystitis between December 2017 and March 2022. Patients were classified as ATT or non-ATT; ATT patients were subdivided into anticoagulation (AC) and antiplatelet (AP) groups. Rates of OM were compared.

502 patients with acute cholecystitis were identified, 464 non-ATT and 38 ATT. 30 ATT patients were on AC, 7 on AP, and 1 on both. Non-ATT patients were significantly more likely to receive OM at index presentation compared to those on ATT: 89.9 % vs 63.2 % (p < 0.05). Subgroup analysis of the ATT group showed AP patients were significantly less likely to receive OM compared to those on AC, 12.5 % vs 77 % (p < 0.05).

At our institution, patients on ATT were significantly less likely to undergo OM for acute cholecystitis compared with non-ATT patients. Those on AC received OM significantly more than patients on AP. Further study is needed to better define the management of this growing population so that acute cholecystitis guidelines might address this issue in the future.

There is growing evidence for reduced post-operative complications, and lower hospital costs associated with early cholecystectomy for acute calculus cholecystitis (AC) compared to delayed surgery. Limited high-quality evidence exists for how early, if at all, should surgeons be operating emergently for AC based on symptom onset.

Seven hundred seventy-four patients who had cholecystectomy performed by a single surgeon between January 2015-October 2022 were retrospectively reviewed. Five hundred fourty-one patients were analysed. Patients were divided into three groups based on symptom onset: Group 1: 0-72 hours (n= 305), Group 2: 72 hrs-1 week (n= 154) and Group 3: >1 week (n= 82).

Median operative time was most prolonged in Group 2 (96.5 minutes), and had the greatest proportion of reconstituting 95% cholecystectomies (n= 22/154, 14.29%) compared to Group 1 (p> 0.05). The conversion to open was between 0.65-1.64% in all groups. The greatest proportion of bile leak occurred in Group 1 (n= 7/305, 2.3%) followed by Group 3 (n= 1/82, 1.22%) (p> 0.05). All were successfully managed with ERCP and biliary stent. Median hospital stay was significantly prolonged in Group 2 (2.3 days) compared to Group 1 (2 days) (p= 0.03). The proportion of 95% cholecystectomies in Group 2 and 3 were not significant compared to Group 1.

Early cholecystectomy for calculus cholecystitis, irrespective of the timing of symptoms appears to have safe postoperative outcomes. Surgeons do not necessarily need to limit early cholecystectomy for within 72 hours of symptom onset.

In the Tokyo Guidelines 2018 (TG18), emergency laparoscopic cholecystectomy is recognized as a crucial early treatment option for acute cholecystitis. However, early laparoscopic intervention in patients with moderate-to-severe acute cholecystitis or those with severe comorbidities may increase the risk of complications. Therefore, in the present study, we investigated the association between early laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) in moderate-to-severe acute cholecystitis patients.

We retrospectively analyzed 835 TG18 grade II or III acute cholecystitis patients who underwent laparoscopic cholecystectomy at 4 tertiary medical centers in the Republic of Korea. Patients were classified into 2 groups according to whether PTGBD was performed before surgery, and their short-term postoperative outcomes were analyzed retrospectively.

The patients were divided into 2 groups, and 1:1 propensity score matching was conducted to establish the PTGBD group (n = 201) and the early laparoscopic cholecystectomy group (n = 201). The PTGBD group experienced significantly higher rates of preoperative systemic inflammatory response syndrome (24.9% vs. 6.5%, P < 0.001), pneumonia (7.5% vs. 3.0%, P = 0.045), and cardiac disease (67.2% vs. 57.7%, P = 0.041) than the early operation group. However, there was no difference in biliary complication (hazard ratio, 1.103; 95% confidence interval, 0.519-2.343; P = 0.799) between the PTGBD group and early laparoscopic cholecystectomy group.

In most cases of moderate-to-severe cholecystitis, early laparoscopic cholecystectomy was relatively feasible. However, PTGBD should be considered if patients have the risk factor of underlying disease when experiencing general anesthesia.

Aims: Lumen-apposing metal stents (LAMSs) in ultrasonography-guided gallbladder drainage (EUS-GBD) have become increasingly important for high-risk surgical patients. Our study aims to evaluate the technical and clinical success, safety, and feasibility of endoscopic ultrasonography-guided gallbladder drainage using a new dedicated LAMS. Methods: This is a retrospective multicenter study that included all consecutive patients not suitable for surgery who were referred to a tertiary center for EUS-GBD using a new dedicated electrocautery LAMS for acute cholecystitis at eight different centers. Results: Our study included 54 patients with a mean age of 76.48 years (standard deviation: 12.6 years). Out of the 54 endoscopic gallbladder drainages performed, 24 (44.4%) were cholecysto-gastrostomy, and 30 (55.4%) were cholecysto-duodenostomy. The technical success of LAMS placement was 100%, and clinical success was achieved in 23 out of 30 patients (76.67%). Adverse events were observed in two patients (5.6%). Patients were discharged after a median of 5 days post-stenting. Conclusions: EUS-GBD represents a valuable option for high-surgical-risk patients with acute cholecystitis. This new dedicated LAMS has demonstrated a high rate of technical and clinical success, along with a high level of safety.

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.

Retrospective and single-center studies have demonstrated that early cholecystectomy is associated with shorter length of stay in patients with mild gallstone pancreatitis. However, these studies are not powered to detect differences in adverse events. Using a nationally representative cohort, we evaluated the association of timing for cholecystectomy with clinical outcomes and resource use in patients with gallstone pancreatitis.

All adult hospitalizations for gallstone pancreatitis were tabulated from the 2016-2019 Nationwide Readmissions Database. Using International Classification of Disease, 10th Revision codes, patient comorbidities and operative characteristics were determined. Patients with end-organ dysfunction or cholangitis were excluded to isolate those with only mild gallstone pancreatitis. Major adverse events were defined as a composite of 30-day mortality and perioperative (cardiovascular, respiratory, neurologic, infectious, and thromboembolic) complications. Timing of laparoscopic cholecystectomy was divided into Early (within 2 days of admission) and Late (>2 days after admission) cohorts. Multivariable logistic and linear regression were then used to evaluate the association of cholecystectomy timing with major adverse events and secondary outcomes of interest, including postoperative hospital duration of stay, costs, non-home discharge, and readmission rate within 30 days of discharge.

Of an estimated 129,451 admissions for acute gallstone pancreatitis, 25.6% comprised the Early cohort. Compared to patients in the Early cohort, Late cohort patients were older (56 [40-69] vs 53 [37-66] years, P < .001), more likely male (36.6 vs 32.8%, P < .001), and more frequently underwent preoperative endoscopic retrograde cholangiopancreatography (22.2 vs 10.9%, P < .001). In addition, the Late cohort had higher unadjusted rates of major adverse events and index hospitalization costs, compared to Early. After risk adjustment, late cholecystectomy was associated with higher odds of major adverse events (adjusted odds ratio 1.40, 95% confidence interval 1.29-1.51) and overall adjusted hospitalization costs by $2,700 (95% confidence interval 2,400-2,800). In addition, compared to the Early group, those in the Late cohort had increased odds of 30-day readmission (adjusted odds ratio 1.12, 95% confidence interval 1.03-1.23) and non-home discharge (adjusted odds ratio 1.42, 95% confidence interval 1.31-1.55).

Cholecystectomy >2 days after admission for mild gallstone pancreatitis was independently associated with increased major adverse events, costs, 30-day readmissions, and non-home discharge. Given the significant clinical and financial consequences, reduced timing to surgery should be prioritized in the overall management of this patient population.

Laparoscopic cholecystectomy within one week of acute cholecystitis is considered safe and advantageous. Surgery beyond first week is reserved for non-resolving attack or complications. To compare clinical outcomes of patients undergoing laparoscopic cholecystectomy in the first week and between two to six weeks of an attack of acute cholecystitis.

In an analysis of a prospectively maintained database, all patients who underwent laparoscopic cholecystectomy for acute cholecystitis were divided into two groups: group A, operated within one week; and group B, operated between two to six weeks of an attack. Main variables studied were mean operative time, conversion to open cholecystectomy, morbidity profile, and duration of hospital stay.

A total of 116 patients (74 in group A and 42 in group B) were included. Mean interval between onset of symptoms & surgery was five days (range, 1-7 days) in group A and 12 days (range, 8-20 days) in group B. Operative time and incidence of subtotal cholecystectomy were higher in group B (statistically not significant). Mean postoperative stay was 2 days in group A and 3 days in group B. Laparoscopy was converted to open cholecystectomy in two patients in each group. There was no incidence of biliary injury. One patient in group B died during the postoperative period due to continued sepsis and multiorgan failure.

In tertiary care setting, with adequate surgical expertise, laparoscopic cholecystectomy can be safely performed in patients with acute cholecystitis irrespective of the time of presentation.

Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients.

Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed.

In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001).

Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.

Early cholecystectomy is recommended for acute calculous cholecystitis to reduce complications and lower health care costs. However, not all patients admitted to emergency services due to acute calculous cholecystitis are considered for surgery immediately. Our intention was therefore to evaluate patient management and outcome parameters following cholecystectomy depending on the type of emergency service patients are primarily admitted to.

We performed a retrospective analysis of all patients that were treated for acute cholecystitis at our hospital between 2014 and 2021. Only patients that underwent surgical treatment for acute calculous cholecystitis were included. Patients with cholecystectomies that were performed due to other medical conditions were not incorporated. Primary outcomes were the perioperative length of stay and postoperative complications. Perioperative antimicrobial management and disease deterioration according to Tokyo Guidelines from 2018 due to inhouse organization were assessed as secondary outcome parameters.

Of 512 patients included in our final analysis, 334 patients were primarily admitted to a surgical emergency service (SAG) whereas 178 were initially treated in a medical service (MAG). The latency between admission and cholecystectomy was significantly prolonged in the MAG with a median time to surgery of 2 days (Q25 1, Q75 3.25, IQR 2.25) compared to the SAG with a median time to surgery of 1 day (Q25 1, Q75 2, IQR 1) (p < 0.001). The duration of surgery was comparable between both groups. Necrotizing cholecystitis (27.2% vs. 38.8%, p = 0.007) and pericholecystic abscess or gallbladder perforation (7.5% vs. 14.6% p = 0.010) were less frequently described in the SAG. In the SAG, 85.7% of CCEs were performed laparoscopically, 6.0% were converted to open, and 10.4% were performed as open surgery upfront. In the MAG, 80.9% were completed laparoscopically, while 7.2% were converted and 11.2% were performed via primary laparotomy (p = 0.743). Histologically gangrenous cholecystitis was confirmed in 38.0% of the specimen in the SAG compared to 47.8% in the MAG (p = 0.033). While the prolonged preoperative stay led to prolonged overall length of stay, the postoperative length of stay was similar at a median of 3 days in both groups.

To our knowledge, we present the largest single center cohort of acute calculous cholecystitis evaluating the perioperative management and outcome of patients admitted to either medical or surgical service prior to undergoing cholecystectomy. In patients that were primarily admitted to medical emergency services, we found disproportionately more gallbladder necrosis, perforation, and gangrene. Despite prolonged time intervals between admission and cholecystectomy in the MAG and advanced cases of cholecystitis, we did not record a prolonged procedure duration, conversion to open surgery, or complication rate. However, patients with acute calculous cholecystitis should either be primarily admitted to a surgical emergency service or at least a surgeon should be consulted at the time of diagnosis in order to avoid disease progression and unnecessary health care costs.

What sonographic variables are most predictive for acute cholecystitis? What variables differentiate acute and chronic cholecystitis?

The surgical pathology database was reviewed to identify adult patients who underwent cholecystectomy for cholecystitis and had a preceding ultrasound of the right upper quadrant within 7 days. A total of 236 patients were included in the study. A comprehensive imaging review was performed to assess for gallstones, gallbladder wall thickening, gallbladder distension, pericholecystic fluid, gallstone mobility, the sonographic Murphy's sign, mural hyperemia, and the common hepatic artery peak systolic velocity.

Of 236 patients with a cholecystectomy, 119 had acute cholecystitis and 117 had chronic cholecystitis on surgical pathology. Statistical models were created for prediction. The simple model consists of three sonographic variables and has a sensitivity of 60% and specificity of 83% in predicting acute versus chronic cholecystitis. The most predictive variables for acute cholecystitis were elevated common hepatic artery peak systolic velocity, gallbladder distension, and gallbladder mural abnormalities. If a patient had all three of these findings on their preoperative ultrasound, the patient had a 96% chance of having acute cholecystitis. Two of these variables gave a 73-93% chance of having acute cholecystitis. One of the three variables gave a 40-76% chance of having acute cholecystitis. If the patient had 0 of 3 of the predictor variables, there was a 29% chance of having acute cholecystitis.

Gallbladder distension, gallbladder mural abnormalities, and elevated common hepatic artery peak systolic velocity are the most important sonographic variables in predicting acute versus chronic cholecystitis.

The Parkland Grading Scale (PGS) is an intraoperative grading scale to stratify gallbladder disease severity during laparoscopic cholecystectomy (LC). We evaluated the usefulness of the PGS in predicting the difficulty levels of LC procedures using a novel approach.

A total of 261 patients diagnosed with cholelithiasis and cholecystitis who underwent LC were assessed. The PGS and the surgical difficulty grading system were used to evaluate surgical procedures by reviewing the operation videos. Clinical baseline characteristics and post-treatment outcomes were also recorded. Differences between the five PGS grades in terms of surgical difficulty scores were analyzed using the Jonckheere-Terpstra test. The relationship between PGS grades and surgical difficulty scores was assessed using Spearman's Rank correlation. Finally, the linear trends between morbidity scores and PGS grades were evaluated using the Mantel-Haenszel test.

There was a significant difference in the surgical difficulty scores for the five PGS grades (p < 0.001). In pairwise comparison, each grade (1-5) was significantly different from the others (p < 0.05) in terms of surgical difficulty, except Grade 2 vs. 3 (p = 0.07) and Grade 3 vs. 4 (p = 0.08). There was a significant correlation between PGS grades and surgical difficulty scores (r_s = 0.681, p < 0.001). There was also a significant linear association between morbidity and PGS grades (p < 0.001). Spearman's R value was 0.176 (p = 0.004).

The PGS can accurately assess the surgical difficulty level of LC. The precision and conciseness of the PGS make it suitable for use in future research.

Introduction Early laparoscopic cholecystectomy (ELC) is a treatment option for acute cholecystitis (AC). However, the timing of ELC is controversial. Delayed laparoscopic cholecystectomy (DLC) continues to be a common practice. This study aims to determine the optimal timing of ELC in AC. Materials and methods Patients who underwent surgery for AC between 2014 and 2020 were divided into three groups: immediate laparoscopic cholecystectomy (ILC), prolonged ELC (pELC), and DLC. The demographic, laboratory, radiological findings, and postoperative results of all patients were retrospectively reviewed. Results The study included 178 patients, with 63 in the ILC group, 27 in the pELC group, and 88 in the DLC group. Postoperative outcomes, excluding hospital stay, were similar between the groups. The total hospital stay was significantly longer in the pELC and DLC groups (p<0.05). In addition, postoperative hospital stay was longer in the pELC group (p<0.05), and 17.7% of the patients who waited for delayed surgery experienced recurrent attacks during the interval period. Conclusion ILC is recommended in AC to minimize hospital stays.

Early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) poses multiple challenges. The Tokyo Guidelines 2018 (TG18) eliminated the time limit (< 72 h) and expanded the surgical indication to severe AC. This study aimed to evaluate the clinical outcomes of ELC for AC following the TG18 in a single high-volume center.

From 2019 to 2021, we managed all AC patients with a TG18 flowchart and prospectively enrolled those who underwent ELC within 7 days of symptom onset. The primary outcome was overall morbidity, with a comparison between mild (Grade I) and moderate/severe (Grade II/III) AC.

During the study period, 201 patients underwent ELC was for Grade I (56.2%), II (40.3%), and III (3.5%) ACs. Mean age was 69 ± 15.2 years and time to surgery from symptom onset was 0 (12.9%), 1-3 (66.7%), and 4-7 days (20.4%). Mean operative time and blood loss were 118.9 ± 42.7 min and 57.8 ± 99.4 mL, respectively. The critical view of safety (CVS) was achieved in 76.1% of patients, and bailout procedures were performed in 21.4%. There were no open conversions or bile duct injuries. Major morbidities (Clavien-Dindo classification ≥ IIIa) were observed in 5.5% of cases and mortality in 0.5%. Comparing Grades II/III to Grade I, operative time was longer (112.3 vs. 127.3 min, p = 0.014), blood loss was higher (40.3 vs. 80.1 mL, p = 0.005), the CVS rate was lower (83.2 vs. 67.0%, p = 0.012), and the major morbidity rate was higher (1.8 vs. 10.2%, p = 0.012). In the subgroup analysis of Grade II/III, there were no significant differences in major morbidities (p = 0.288) between the two groups (0-3 vs. 4-7 days).

ELC for AC following TG18 is feasible with low morbidity rates. However, ELC for Grade II/III ACs remains challenging, and surgeons must carefully assess intraoperative difficulties and surgical risks before proceeding.

To compare the efficacy and safety of laparoscopic cholecystectomy (LC) in the treatment of acute cholecystitis (AC) at different time points after percutaneous transhepatic gallbladder drainage (PTGBD).

PubMed, EMBASE, Cochrane Library, and Web of Science were searched from database inception to 1 May 2022. The last date of search was the May 30, 2022. The Newcastle-Ottawa scale (NOS) was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis.

A total of 12 studies and 4379 patients were analyzed. Compared with the < 2-week group, the ≥ 2-week group had shorter operation time, less intraoperative blood loss, shorter postoperative hospital stay, lower rate of conversion to laparotomy, and fewer complications. There was no statistical difference between the two groups regarding bile duct injury, bile leakage, and total cost.

The evidence indicates that the ≥ 2-week group has the advantage in less intraoperative blood loss, minor tissue damage, quick recovery, and sound healing in treating AC. It can be seen that LC after 2 weeks is safe and effective for AC patients who have already undergone PTGBD and is recommended, but further confirmation is needed in a larger sample of randomized controlled studies.

To challenge the risk factors described in Tokyo Guidelines in Acute Calculous Cholecystitis.

Retrospective single center cohort study with 963 patients with Acute Cholecystitis during a period of 5 years. Some 725 patients with a "pure" Acute Calculous Cholecystitis were selected. The analysis included 166 variables encompassing all risk factors described in Tokyo Guidelines. The Propensity Score Matching method selected two subgroups of patients with equal comorbidities, to compare the severe complications rate according to the initial treatment (Surgical vs Non-Surgical). We analyzed the Failure-to-rescue as a quality indicator in the treatment of Acute Calculous Cholecystitis.

the median age was 69 years (IQR 53-80). 85.1% of the patients were ASA II or III. The grade of the Acute Calculous Cholecystitis was mild in a 21%, moderate in 39% and severe in 40% of the patients. Cholecystectomy was performed in 95% of the patients. The overall complications rate was 43% and the mortality was 3.6%. The Logistic Regression model isolated 3 risk factor for severe complication: ASA > II, cancer without metastases and moderate to severe renal disease. The Failure-to-Rescue (8%) was higher in patients with non-surgical treatment (32% vs. 7%; P = 0.002). After Propensity Score Matching, the number of severe complications was similar between Surgical and Non-Surgical treatment groups (48.5% vs 62.5%; P = 0.21).

the recommended treatment for Acute Calculous Cholecystitis is the Laparoscopic Cholecystectomy. Only three risk factors from the Tokyo Guidelines list appeared as independent predictors of severe complications. The failure-to-rescue is higher in non-surgically treated patients.

Background In comparison to a traditional cholecystectomy (open), the laparoscopic cholecystectomy approach provides a number of benefits and has been demonstrated in some studies to have a greater complication rate. The conversion rate from laparoscopic to open surgery ranged between 2% and 15%. A preoperative scoring or grading system (based on age, sex, history, clinical examination, laboratory, and sonographic results) was developed by Nassar et al., to anticipate the challenge of laparoscopic cholecystectomy. So, we conducted this study to assess the degree of difficulty in faced during laparoscopic cholecystectomy using an intraoperative scoring system and validate the same using the preoperative scoring system. Methods We conducted this study in the department of General Surgery among 105 patients who underwent laparoscopic cholecystectomy during the defined study period of one year. We performed the preoperative workup for all patients. A preoperative scoring or grading system developed by Nassar et al., in 2020 was used. In our study, laparoscopic cholecystectomy was performed by surgeons having a minimum of eight years of hands-on experience in laparoscopic surgeries. An intraoperative scoring or grading system for the degree of difficulty during laparoscopic cholecystectomy, developed by Sugrue et al., in 2015 was used. The Chi-square test was applied to assess the association between preoperative variables and the intraoperative score grading. We have also performed the receiver operating characteristic (ROC) curve analysis to validate the preoperative score in predicting the intraoperative findings. All tests were considered statically significant if the p-value was < 0.05. Results In our study, a total of 105 patients were included in the study and the mean age of patients was 57.6±16.4 years. The male patients were 58.1% and the remaining 41.9% were females. The primary diagnosis was cholecystitis among 44.8% of patients and 2.9% of patients were diagnosed with pancreatitis. Among enrolled patients, laparoscopic cholecystectomy was done on an emergency basis among 2.9% of subjects. During the laparoscopic cholecystectomy, among 21.0% and 30.5% of patients, there was a severe and extreme degree of difficulty respectively. In our study, the conversion rate from laparoscopic to open cholecystectomy was 8.6%. In our study, we found that at a preoperative score of 6, the sensitivity and specificity for predicting easy cases were 88.2% and 73.8%, respectively, and had an accuracy of 88.6% for easy cases and 68.5% for difficult cases. Conclusion When grading the difficulties of doing a laparoscopic cholecystectomy and determining the severity of cholecystitis, this intraoperative scoring system is effective and accurate. Additionally, it signifies the need for conversion from laparoscopic to open cholecystectomy in cases of severe cholecystitis.