TO THE EDITOR
We read with great interest the retrospective cohort study titled “Defining endpoints in percutaneous cholecystostomy: Catheter management, patient survival, and long-term outcomes from a twelve-year retrospective study” by Hassanesfahani et al[1] published in the recent issue of the World Journal of Gastroenterology Surgery. The authors are commended for addressing a clinically relevant and often overlooked dimension of percutaneous cholecystostomy (PC): How procedural timing and post-placement management translate into meaningful patient-centered outcomes[2]. This longitudinal perspective offers important lessons for surgeons and multidisciplinary teams caring for patients with high-risk acute cholecystitis. Beyond corroborating the value of early source control measures, this study reframes success after PC by juxtaposing short-term survival with downstream catheter-related and surgical endpoints that remain poorly standardized in routine practice.
A key contribution of this study is its demonstration that earlier PC placement is independently associated with improved survival[3]. This finding aligns with the fundamental principle of timely source control measures and is consistent with contemporary guideline frameworks. Both the Tokyo Guidelines 2018 (TG18)[4] and the World Society of Emergency Surgery (WSES) guidelines[5] emphasize early gallbladder decompression in patients with acute cholecystitis who are unsuitable for immediate surgery, particularly in the setting of sepsis or organ dysfunction. Additionally, the concept of PC as a source control procedure is further refined by international consensus frameworks[6], which stratify intervention timing (emergency, urgent, delayed) and categorize patients by physiological reserve and comorbidity burden (class A, B, C). These classifications help contextualize PC within the broader spectrum of gallbladder sepsis management and emphasize that both the urgency of drainage and the feasibility of subsequent definitive treatment are influenced by baseline patient characteristics and response to initial resuscitation. The present data add granularity to these recommendations by suggesting that delays after diagnosis may adversely affect outcomes even after adjusting for comorbidity burden and illness severity[7]. Clinically, this reinforces the need to view PC not as a discretionary rescue intervention but as a time-sensitive therapeutic step once non-operative management is deemed appropriate[8]. From a technical standpoint, PC can be performed via transhepatic or transperitoneal routes. The transhepatic approach is generally preferred due to lower risk of bile peritonitis and easier catheter stabilization, whereas the transperitoneal route may be associated with higher rates of bile leak and peritoneal irritation[9]. However, procedural success and overall outcomes are largely comparable when performed by experienced operators under appropriate imaging guidance. Route selection should be individualized based on gallbladder anatomy, operator expertise, and patient-specific factors such as coagulopathy or ascites[10]. These observations are also concordant with those of prior cohort analyses[11], demonstrating that diagnosis-to-drainage intervals, alongside indices such as APACHE II and Charlson Comorbidity scores, independently influence short-term outcomes after PC. It is also important to recognize the evolution of guideline-based recommendations. While the Tokyo Guidelines 2013[12] generally advocated drainage for severe cholecystitis and index cholecystectomy for mild-to-moderate cases, the revised TG18[4] acknowledged greater clinical heterogeneity. Some patients with severe cholecystitis improve with supportive care (fluids, antibiotics, analgesia) and become suitable for laparoscopic cholecystectomy without requiring PC, whereas some with mild-to-moderate cholecystitis may be systemically unwell due to significant comorbidities and benefit from gallbladder drainage[13]. This evolution underscores the importance of individualized decision-making that integrates disease severity, systemic factors, and local expertise, rather than relying on classification alone.
Beyond timing, this study highlights the persistent challenges in postprocedural care. The high prevalence of prolonged catheter dependence, relatively low rates of documented catheter removal, and limited use of interval cholecystectomy underscore the disconnection between initial stabilization and definitive disease resolution[14]. Although survival remains an indispensable short-term endpoint in patients that are critically ill or patients with sepsis, particularly during the acute phase of decision-making, it does not fully capture the long-term clinical burden experienced by survivors. Long-term catheter dependence is associated with recurrent infections, catheter-related complications, impaired quality of life, and repeated healthcare utilization[15]. These outcomes are particularly consequential in older adults and frail populations, in whom PC is most commonly employed. Notably, both the TG18[4] and the WSES guidelines[5] describe PC primarily as a bridge to definitive management rather than a destination therapy. Nevertheless, these frameworks are intended as guiding references rather than prescriptive mandates, and individualized clinical judgments and patient preferences inevitably shape real-world decision-making. The present study illustrates how, in routine practice, this distinction may be blurred in the absence of a structured follow-up. The observed variability in cholangiographic assessment, catheter management strategies, and loss to follow-up suggests that outcomes after PC are heavily influenced by system-level factors, in addition to patient characteristics[16]. Accordingly, early survival gains may be attenuated if the downstream care pathways are not planned or implemented consistently.
From a clinical perspective, these findings support the adoption of standardized algorithm-driven management after PC placement. Such pathways might include: (1) Early PC placement once guideline-based indications are met[2]; (2) Predefined reassessment within a specified timeframe (for example, 2-6 weeks) incorporating clinical status, laboratory markers, and imaging when appropriate; (3) Systematic monitoring for drain-related complications, including dislodgement (reported in approximately 10% of cases)[17], pericatheter leakage, and site infection; (4) Evidence-based antibiotic stewardship, with duration guided by clinical response, source control adequacy, and resolution of systemic inflammation, as outlined in contemporary sepsis management guidelines[18]; (5) Selective use of tube cholangiography (dye study via the gallbladder catheter) to assess cystic duct patency and common bile duct clearance, particularly in patients draining bilious fluid or those being considered for catheter removal without subsequent cholecystectomy. Patients draining predominantly mucous may reflect cystic duct obstruction and warrant closer surveillance for recurrent cholecystitis after catheter removal; (6) Explicit criteria for catheter clamping trials and removal, informed by drainage character, volume, clinical stability, and cholangiographic findings when available[19]; and (7) Mandatory multidisciplinary reviews involving surgeons, interventional radiologists, and anesthesiologists to facilitate timely reassessment of candidacy for interval cholecystectomy as patient conditions evolve.
Routine cholangiography to assess the cystic duct patency in selected patients and explicit criteria for catheter clamping and trial removal may help distinguish patients suitable for definitive catheter removal from those requiring prolonged drainage[20]. Importantly, the observation that no deaths occurred among patients who ultimately underwent catheter removal or cholecystectomy, while being observational and subject to selection effects, reinforces the potential value of pursuing definitive resolution whenever feasible. However, this association should be interpreted cautiously, as survivor bias and nonrandom patient selection likely favor more stable individuals reaching downstream interventions.
