The influence of Percutaneous Cholecystostomy Duration on Optimizing Surgical Outcomes and Timing of Interval Cholecystectomy in ASA II patients with grade II-III Acute Calculous Cholecystitis

The influence of Percutaneous Cholecystostomy Duration on Optimizing Surgical Outcomes and Timing of Interval Cholecystectomy in ASA II patients with grade II-III Acute Calculous Cholecystitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The influence of Percutaneous Cholecystostomy Duration on Optimizing Surgical Outcomes and Timing of Interval Cholecystectomy in ASA II patients with grade II-III Acute Calculous Cholecystitis Ali Bekraki, Ali Levent Işık, Oğuzhan Aydın, Muhammet Mustafa Vural, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6514192/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract Objective: Despite substantial medical advancements in recent decades, the optimal management of Grade II-III acute calculous cholecystitis in patients with an ASA II classification remains a subject of ongoing debate, even with laparoscopic cholecystectomy established as the standard of care. Background: The optimal timing of cholecystectomy (early vs. delayed) remains debated regarding morbidity, risk-benefit balance, and cost. While percutaneous cholecystostomy is supported as definitive management for ASA III/IV patients, its efficacy as a bridge to cholecystectomy in ASA II medically refractory grade II-III acute cholecystitis is unclear. Moreover, the optimal interval between percutaneous cholecystostomy and interval laparoscopic cholecystectomy in this specific group is not well-established. Methods: This retrospective cohort study aimed to elucidate the impact of percutaneous cholecystostomy, performed as an initial intervention, on the subsequent elective cholecystectomy in patients classified as ASA II and diagnosed with Grade II-III acute calculous cholecystitis. Specifically, the study evaluated the influence of prior percutaneous cholecystostomy on the timing, duration, and type of the subsequent elective cholecystectomy procedure. Of the 186 patients managed with percutaneous cholecystostomy for severe acute calculous cholecystitis, 97 patients, classified as ASA II, who subsequently underwent interval elective cholecystectomy at our institution, constituted the study cohort. Results: 77% experienced prolonged laparoscopic cholecystectomy, defined as being longer than 60 minutes, when operated after 8 weeks of cholecystostomy placement. The complexity and the difficulty of surgery were significantly increased in this group. Conclusion: Liberal use of percutaneous cholecystostomy for grade II-III acute calculous cholecystitis is discouraged. Early laparoscopic cholecystectomy is preferred for most ASA II acute cholecystitis cases, reserving percutaneous cholecystostomy for intractable cases or those with contraindications to immediate surgery. Acute cholecystitis percutaneous cholecystostomy interval laparoscopic cholecystectomy duration of cholecystostomy optimal timing of surgery Figures Figure 1 Introduction Many studies describe percutaneous cholecystostomy as a method that can provide either a permanent treatment for severe acute cholecystitis when immediate surgery is not feasible, or serve as a bridge to elective laparoscopic cholecystectomy [1]. Several authors have emphasized that cholecystostomy can significantly reduce the patient’s quality of life while they await definitive surgery. Additionally, the development of fibrosis during the healing process makes laparoscopic cholecystectomy more difficult and complicated. Conversely, percutaneous cholecystostomy has been recognized as an effective way to manage acute cholecystitis in cases where surgical intervention is either permanently or temporarily unmanageable [2]. Various modern grading scales for acute cholecystitis are available in the literature. The Tokyo Guidelines, updated in 2013 and 2018, provide a grading system for acute cholecystitis based on inflammation and imaging [3]. They recommend tailored treatment, with percutaneous cholecystostomy favored in severe cases and patients with high ASA scores. In contrast to the Tokyo Guidelines, the World Society of Emergency Surgery (WSES) published its first guidelines for acute calculous cholecystitis in 2016, proposing diagnostic and therapeutic algorithms that differ from the established recommendations [4]. The WSES guidelines promote surgical intervention as the gold standard treatment for all patients with acute calculous cholecystitis, including those with grade III severity, except for individuals deemed very high-risk or physiologically fragile. However, lack of agreement on surgical management in the elderly, and whether old age can be considered a contraindication criterion for surgery, remains an unsolved issue, highlighting the need for further high-quality studies on this topic [5]. The management of high-risk patients, such as those with severe cardiopulmonary disease, as well as those diagnosed with stage III acute calculous cholecystitis, has been the subject of many trials and studies. A growing body of evidence suggests that cholecystostomy may not offer significant advantages over early cholecystectomy in the treatment of acute cholecystitis, and that its routine use must be questioned even in high-risk patients with moderate-severe cholecystitis [6]. Similarly, early cholecystectomy has been found to be a feasible treatment for elderly patients with acute cholecystitis, provided careful selection is applied. Otherwise, alternative treatment modalities, including percutaneous cholecystostomy, may be more appropriate for elderly patients with comorbidities that render them unfit for surgical intervention [7]. Materials and methods A retrospective cohort study was conducted, analyzing data from 186 patients admitted to the General Surgery Department of Başakşehir Çam and Sakura City Hospital, a tertiary referral center in Istanbul, Türkiye, between July 2020 and October 2023. The inclusion criteria for this study were patients diagnosed with severe refractory acute calculous cholecystitis, classified as Tokyo grade II or III, who underwent percutaneous cholecystostomy followed by interval laparoscopic cholecystectomy. Given the anticipated surgical complexity and elevated postoperative morbidity and mortality risk, all patients underwent ultrasound-guided percutaneous transhepatic cholecystostomy in the interventional radiology department to facilitate effective gallbladder drainage. Microbiological analysis and antibiogram testing were performed routinely on gallbladder aspirates obtained after cholecystostomy placement. Empiric broad-spectrum antibiotic therapy was initiated promptly upon admission, with subsequent modification based on culture results of the gallbladder aspirate, guided by infectious diseases consultation, to optimize antibiotic selection. A standardized management protocol was implemented for all patients. Following a mean hospital stay of 4 days (range, 2-6 days), patients were discharged upon demonstrating clinical improvement and a reduction in acute phase reactants. Ten patients were excluded from the analysis: eight due to loss to follow-up within the study period, and two due to development of bile peritonitis requiring immediate surgical intervention post-catheter placement. The remaining 176 patients were stratified according to the American Society of Anesthesiologists (ASA) physical status classification. Ninety-seven patients, classified as ASA II, underwent percutaneous cholecystostomy for severe acute cholecystitis refractory to medical and conservative management and subsequently underwent interval elective cholecystectomy at our institution. Seventy-nine patients, classified as ASA III-IV, underwent cholecystostomy; however, as the majority of these patients did not proceed to surgical cholecystectomy, they were excluded from this study. Ethics Approval and Consent to Participate: This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee in Çam and Sakura City Hospital, (Approval Number: E-96317027-514.10-266503571, Date of Approval: 22.01.2025). Statistical Analysis Statistical analyses were performed using SPSS version 27 (IBM Corp., Armonk, NY, USA). The normality of continuous variables was assessed using a combination of descriptive statistics (skewness, kurtosis, standard deviation/mean), graphical methods (Q-Q plots, histograms), and formal statistical tests. Categorical variables were summarized using frequencies and percentages (n, %), while continuous variables were presented as means and standard deviations. Between-group comparisons for continuous variables were conducted using independent samples t-tests. For ordinal and nominal variables, chi-square tests (Pearson's chi-square and Fisher's exact test) were employed. Univariate binary logistic regression was utilized to evaluate the association between cholecystostomy duration and prolonged surgery. The diagnostic performance of cholecystostomy duration in predicting prolonged surgery was assessed using Receiver Operating Characteristic (ROC) curve analysis. The optimal cut-off value for cholecystostomy duration was determined using the Youden index. Diagnostic performance metrics included the area under the ROC curve (AUC), sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. All statistical tests were two-sided, with a significance level of p < 0.05 and a 95% confidence interval. Results The study cohort of 97 patients classified as ASA II had a mean age of 55.9 ± 13 years (range, 29-82), with 59 (61%) being male. All patients underwent surgical procedures after initial percutaneous cholecystostomy placement. The mean surgical duration was 102.6 ± 44.6 minutes (range, 30-275), with 75 patients (77%) experiencing prolonged surgery (defined as >60 minutes). The mean cholecystostomy duration was 77.6 ± 39.2 days (range, 20-210). Among these patients, 51 (53%) had a diagnosed chronic disease, 86% underwent laparoscopic surgery, 10 (10.3%) required conversion to open surgery because of severe inflammatory reactions and inability to proceed with laparoscopic dissection, and 7 (7.2%) experienced preoperative complications mainly dislocation or obstruction of cholecystostomy tube, and recurrent cholecystitis attack. Although not statistically significant (p > 0.05), all patients requiring conversion to open surgery (n = 10) and 3 of the 4 patients planned for initial open surgery had prolonged surgical durations (p = 0.110-0.179). However, a statistically significant association was observed between cholecystostomy duration and prolonged surgery (t = 4.910, p < 0.001) (Table 1). A one-day increase in cholecystostomy duration increased the odds of prolonged surgery by 1.037 (95% CI: 1.013-1.062, OR = 1.037, R²N = 0.217). The optimal cholecystostomy duration cutoff for predicting prolonged surgery was 56 days, with an AUC of 0.742 (95% CI: 0.636-0.848, p = 0.001). Using this cutoff, the sensitivity, specificity, and accuracy for predicting prolonged surgery were 76%, 59.1%, and 72.2%, respectively (Table 2, Figure 1). Comparing the complication rates of percutaneous cholecystostomy between ASA II (n= 97) and ASA III-IV (n = 79) patients, as expected, the ASA II group had a significantly lower complication rate (7.2% vs. 36.7%, p < 0.001) (Table 3). Discussion Acute cholecystitis is one of the most significant diseases that affects mainly patients with gallstones and elderly adults in the whole world. Because of its high socioeconomic impact and the risk of subsequent episodes of cholecystitis, lots of controversies exist about the best way of management. Although laparoscopic cholecystectomy is assumed to be the gold standard of treatment, the timing of surgery remains a topic of discussion. The debate centers around whether to perform early surgery within 10 days of symptom onset and within 7 days of hospital admission, or to initially manage the condition with conservative treatment using antibiotics, followed by a delayed cholecystectomy a few weeks later after the inflammation has completely resolved [4]. The percutaneous placement of a tube by interventional radiologists, guided by either ultrasound or computed tomography, is a minimally invasive procedure. This approach can be done through either the transperitoneal or transhepatic route to effectively drain the gallbladder lumen. It allows for efficient drainage of the gallbladder and serves as a temporary measure before elective surgery in acute cases. However, concerns about the waiting period have raised issues such as higher morbidity and mortality rates, decreased quality of life, increased management costs, and longer hospital stays. As a result, the routine use of percutaneous cholecystostomy without strict protocols is limited. The effectiveness of percutaneous cholecystostomy in critically ill and elderly patients, as well as those who do not respond to conservative medical management, is supported by case series that have varied in their inclusion criteria. While there is no definitive evidence advocating for the use of percutaneous cholecystostomy over cholecystectomy in ASA III and IV patients with acute cholecystitis, this situation differs for ASA I and II patients. In these cases, early cholecystectomy should be performed as soon as possible, without much hesitation. Still, percutaneous cholecystostomy is a safe and efficient treatment modality for severe acute cholecystitis classified as grade II and III that does not respond to antibiotic treatment in selected patients. Numerous studies proclaimed that this procedure is safe for elderly and critically ill patients, enhances prognosis, and makes later elective laparoscopic cholecystectomy more feasible with low mortality rates. On the other hand, there are still potential procedure-related complications including bile leak, local abscess, generalized peritonitis, drain dislodgement, tube blockage, and bleeding. Such complications remain common despite increasing experience and continued technological developments. In a systemic review of 312,085 patients, El Sharif et al. reported four percutaneous cholecystostomy-related deaths, resulting in an overall mortality rate of 0.001%. The percentage of procedure-related morbidities were as follows: drain dislodgement (7.2-29.6%), minor bleeding (2.4-7.2%), minor bile leak (1.1-10.4%), and tube blockage (0.6-7%) [8]. Additionally, another systemic review by Winbladh et al. demonstrated that cholecystostomy has a low-mortality rate of 0.36%, a high success rate of 85.6%, and the ability to convert septic cholecystitis into a non-septic condition when combined with antibiotic treatment [9]. In our study, percutaneous cholecystostomy was not associated with mortality. However, a total of seven cholecystostomy-related complications were observed. Specifically, catheter dislocation occurred in four patients (4.1%), with one case manifesting as an anterior abdominal wall abscess. Catheter obstruction was noted in two patients (2.1%), and a single patient (1.0%) experienced a recurrent acute cholecystitis attack. These complications represented 57.1%, 28.6%, and 14.3% of the total complication burden, respectively (Table 1). Cheruvu et al. demonstrated that 28% of patients with acute gallstone disease required readmission before planned cholecystectomy, with no significant difference observed between those treated with percutaneous cholecystostomy and those receiving antibiotics [10]. The use of percutaneous cholecystostomy was significantly associated with a longer length of hospital stay, extending by approximately 50%, and higher 30-day and one-year mortality rates among patients with a non-severe disease severity index (DSI). Conversely, this association did not apply to patients with organ dysfunction and severe DSI, highlighting the necessity to reassess the decision to perform percutaneous cholecystostomy in patients who remain unresponsive to conservative therapy, even after a disease duration exceeding seven days [11]. While most guidelines advocate for early operative intervention in acute cholecystitis, a subset of patients presents with complicated gallbladder conditions involving acute or chronic inflammation, fibrosis, anatomical variations, adhesions, gangrene, empyema of the gallbladder, or Mirizzi syndrome. These factors can complicate laparoscopic cholecystectomy, rendering the procedure more challenging and riskier [12]. It is reported that approximately 16% of patients undergoing laparoscopic cholecystectomy are classified as having difficult gallbladder conditions [13]. Additionally, a significant number of patients requiring conversion to an open procedure has been reported by Bhatt et al. to be around 32%, which is consistent with an earlier study by Pang et al. in 2016 that indicated a conversion rate of about 27% [14]. In our study, the laparoscopic cholecystectomy procedure was converted to open surgery in 10 out of 97 patients (10.3%). Among these conversions, four patients underwent subtotal cholecystectomy due to severe inflammation and complex anatomical challenges, which significantly elevated the risk of bile duct injury during attempts at total cholecystectomy. Another two cases had Mirizzi syndrome type I and II that complicated the operational progress and ended with conversion to open surgery. It is worth to remind that conversion to open cholecystectomy is a valid surgical decision, not a failure, and that surgeons must prioritize patient safety over exclusively laparoscopic completion. For experienced surgeons, the average operative time for a laparoscopic cholecystectomy typically ranges from 30 to 60 minutes [15, 16, 17]. In a study conducted by Lowndes et al. involving 24,099 patients from the National Surgical Quality Improvement Program (NSQIP) database, it was shown that an operative duration exceeding 60 minutes is a consistent indicator of a “difficult cholecystectomy” [15]. Additionally, Subhas et al. described the term “prolonged laparoscopic cholecystectomy” for procedures that extend beyond 3 hours in their study of 3,126 cholecystectomies [16]. Giger et al. demonstrated that each 30-minute increase in operative time correlated with a 1.68-fold rise in intraoperative complications, a 1.28-fold rise in local postoperative complications, and a 1.16-fold rise in systemic postoperative complications [17]. Consistent with these findings, studies have indicated an approximately four-fold increased risk of perioperative complications in laparoscopic cholecystectomy procedures exceeding two hours in length compared to those completed within one hour, a finding that appears independent of surgeon expertise and experience. [16, 17]. The optimal interval between percutaneous cholecystostomy and interval laparoscopic cholecystectomy for stage II-III acute cholecystitis is poorly defined due to limited high-quality evidence. While inflammation may resolve around 63 days post-cholecystostomy, the ideal timing for interval laparoscopic cholecystectomy remains ambiguous, necessitating further rigorous investigation. Hung et al. accepted an interval of 9 to 10 weeks between cholecystostomy and laparoscopic cholecystectomy for stage II and III acute cholecystitis patients based on clinical course and sequential pathological changes in the gallbladder [18]. On the other hand, Woodard et al. proposed an optimal window of 4 to 8 weeks for interval cholecystectomy following percutaneous cholecystostomy placement. However, their study's applicability is limited by the lack of precise staging of the included acute cholecystitis cases and the significant proportion of open cholecystectomies (>50%) performed [19]. Conversely, a statewide retrospective analysis by Altieri et al. demonstrated that interval laparoscopic cholecystectomy performed beyond 8 weeks after percutaneous cholecystostomy placement was associated with a reduced incidence of complications and a shorter postoperative length of stay [20]. Nevertheless, this study is constrained by the inclusion of all acute cholecystitis patients receiving cholecystostomy, irrespective of subsequent surgical approach (open or laparoscopic) and without stratification for disease severity, potentially introducing information bias. Further complicating the evidence landscape, a nationwide database study by Sakamoto et al. suggested an optimal timing for cholecystectomy of 7 to 26 days post-percutaneous cholecystostomy [21]. However, this study's conclusions are weakened by significant institutional heterogeneity, encompassing a wide range of medical facilities from rural hospitals to tertiary referral centers, and the absence of data on acute cholecystitis severity, rendering it a low-strength evidence-based work. In this study, patients undergoing laparoscopic cholecystectomy following percutaneous cholecystostomy were stratified by cholecystostomy duration. Patients with percutaneous cholecystostomy duration ≤ 56 days (n=68) exhibited a mean operative time of 96.59 ± 45.7 minutes and a median operative time of 90 minutes (IQR: 61-120 minutes). Conversely, patients with cholecystostomy duration exceeding 56 days (n=29) demonstrated a significantly prolonged mean operative time of 116.55 ± 38.99 minutes and a median operative time of 110 minutes (IQR: 88-135 minutes) (Table 4). Statistical analysis demonstrated that increased percutaneous cholecystostomy duration significantly prolonged surgical time and was consequently associated with an elevated risk of perioperative complications. Contemporary literature increasingly supports laparoscopic cholecystectomy as the primary intervention for acute cholecystitis, encompassing even severe presentations. This evidence challenges the traditional practice of percutaneous cholecystostomy as a temporizing measure prior to surgical intervention. This paradigm shift necessitates a critical reassessment of the clinical indications for interventional drainage in this patient population. Our study aimed to identify factors that may supersede the established indications for percutaneous cholecystostomy in grade II and III acute cholecystitis cases unresponsive to comprehensive conservative management. Furthermore, this research sought to determine the optimal interval between percutaneous cholecystostomy placement and subsequent interval laparoscopic cholecystectomy, considering both the duration and complexity of the laparoscopic procedure, while maintaining a minimal rate of conversion to open surgery. Conclusion Routine use of percutaneous cholecystostomy for moderate to severe acute cholecystitis, even in high-risk patients, is discouraged. It should be reserved for cases where surgery is contraindicated (e.g., metastatic malignancy, extreme frailty, life-threatening systemic disease). Early surgery is preferred, as percutaneous cholecystostomy increases complications, operative difficulty, and conversion rates, limiting its effectiveness as a bridging strategy. Conversely, percutaneous cholecystostomy is absolutely indicated in patients with severe comorbidities, sepsis-induced physiological derangement, complicated cholecystitis (including gangrenous or perforated gallbladder), and stage III acute cholecystitis intractable to conservative management. In these cases, percutaneous cholecystostomy serves as a temporizing measure to stabilize patients before definitive surgery. Crucially, our study suggests that interval cholecystectomy should ideally be performed within 56 days (8 weeks). Delays beyond this timeframe are associated with increased operative time and technical difficulty during laparoscopic cholecystectomy, leading to a greater risk of surgical complications and undermining the rationale for using percutaneous cholecystostomy as a bridge to elective laparoscopic cholecystectomy. Declarations Conflict of Interest disclosure: All authors declare that they have no conflicts of interest. References Cartı EB and Kutlutürk K. Should percutaneous cholecystostomy be used in all cases difficult to manage? Ulus Travma Acil Cerrahi Dergisi. 2020;26(2):186-190 DOİ: 10. 14744/tjtes.2020.73557 Hung YL, Sung CM, Fu CY, Liao CH, Wang SY, Hsu JT, et al. Management of Patients with acute cholecystitis after percutaneous cholecystostomy: from the acute stage to definitive surgical treatment. Front. Surg. 2021; 8:616320 Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading ofacute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018; 25:41–54 Pisano M, Allievi N, Gurusamy K, Borzellino G, Cimbanassi S, Boerna D, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. 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Altieri MS, Yang J, Yin D, Brunt LM, Talamini MA, Pryor AD. Early cholecystectomy (≤ 8 weeks) following percutaneous cholecystostomy tube placement is associated with higher morbidity. Surg Endosc. 2020; b34(7):3057-63. doi: 10.1007/s00464-019-07050-z. Epub 2019 Aug 1. PMID: 31372890. Sakamoto T, Fujiogi M, Matsui H, Fushimi K, Yasunaga H. Timing of cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis: a nationwide inpatient database study. HPB (Oxford). 2020; 22(6):920-926. doi: 10.1016/j.hpb.2019.10.2438. Epub 2019 Nov 13. PMID: 31732466. Tables Table 1. Comparison of patient characteristics according to the presence of prolonged surgery Long-term surgery Variable No (≤60 min ) Yes (>60 min ) All P -value Number of patients, n(%) 22(22.7) 75(77.3) 97(100) Operation duration(min), mean(SD) 54.1(11.2) 116.8(40.5) 102.6(44.6) Age(y), mean(SD) 55.5(14.6) 56(12.5) 55.9(13) 0.878 b Sex, n(%) 0.493 a Male 12(54.5) 47(62.7) 59(60.8) Female 10(45.5) 28(37.3) 38(39.2) Chronic disease, n(%) 11(50) 40(53.3) 51(52.6) 0.783 a ASA classification, n(%) >0.999 c I 3(13.6) 9(12) 12(12.4) II 19(86.4) 66(88) 85(87.6) Complication, n(%) 1(4.5) 6(8) 7(7.2) >0.999 c Complication type, n(%) >0.999 c No 21(95.5) 69(92) 90(92.8) Dislocation 1(4.5) 3(4) 4(4.1) Obstruction 0(0) 2(2.7) 2(2.1) Recurrent attack 0(0) 1(1.3) 1(1) Conversion from laparoscopic to open surgery, n(%) 0(0) 10(13.3) 10(10.3) 0.110 c Surgery type, n(%) 0.179 c Laparoscopic surgery 21(95.5) 62(82.7) 83(85.6) Open surgery 1(4.5) 13(17.3) 14(14.4) Cholecystostomy duration(days), mean(SD) 53.8(19.4) 84.6(40.9) 77.6(39.2) <0.001 b * *p<0.001; a, Pearson chi-square test; b, Independent sample t-test; c, Fisher's exact test; SD, standard deviation. Table 2. Optimal cholecystostomy length of stay in determining the length of surgery (ROC curve analysis results) Statistic AUC (95% CI) 0.742 (0.636-0.848) * Cut-off points 56, day Sensitivity 76% Specificity 59.1% PPV 86.4% NPV 41.9% Accuracy 72.2% * P =0.001; NPV , Negative predictive value; PPV , Positive predictive value; CI , Confidence interval; AUC, Area under curve. Table 3. Comparison of patient complication rates according to ASA classification ASA classification Complication , n(%) I-II (n=97) III-IV(n=79) Total (n=176) P -value Yes 7(7.2) 29(36.7) 36(20.5) <0.001 a* No 90(92.8) 50(63.3) 140(79.5) *p<0.001; a, Pearson chi-square test Table 4. Operation duration(min) Cholecystostomy duration (days) n Mean±SD Median(IQR) P -value <56 68 96.59±45.70 90(61-120) 0.043 a * ≥56 29 116.55±38.99 110(88-135) *p<0.05; a , Independent sample t-test; SD , standard deviation Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Oct, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 22 Jun, 2025 Reviews received at journal 15 Jun, 2025 Reviews received at journal 11 Jun, 2025 Reviewers agreed at journal 08 Jun, 2025 Reviewers agreed at journal 04 Jun, 2025 Reviewers agreed at journal 03 Jun, 2025 Reviewers agreed at journal 03 Jun, 2025 Reviewers agreed at journal 03 Jun, 2025 Reviewers invited by journal 02 Jun, 2025 Editor assigned by journal 25 Apr, 2025 Submission checks completed at journal 24 Apr, 2025 First submitted to journal 23 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Additionally, the development of fibrosis during the healing process makes laparoscopic cholecystectomy more difficult and complicated. Conversely, percutaneous cholecystostomy has been recognized as an effective way to manage acute cholecystitis in cases where surgical intervention is either permanently or temporarily unmanageable [2].\u003c/p\u003e\n\u003cp\u003eVarious modern grading scales for acute cholecystitis are available in the literature. The Tokyo Guidelines, updated in 2013 and 2018, provide a grading system for acute cholecystitis based on inflammation and imaging [3]. They recommend tailored treatment, with percutaneous cholecystostomy favored in severe cases and patients with high ASA scores. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast to the Tokyo Guidelines, the World Society of Emergency Surgery (WSES) published its first guidelines for acute calculous cholecystitis in 2016, proposing diagnostic and therapeutic algorithms that differ from the established recommendations [4]. The WSES guidelines promote surgical intervention as the gold standard treatment for all patients with acute calculous cholecystitis, including those with grade III severity, except for individuals deemed very high-risk or physiologically fragile.\u0026nbsp;However, lack of agreement on surgical management in the elderly, and whether old age can be considered a contraindication criterion for surgery, remains an unsolved issue, highlighting the need for further high-quality studies on this topic [5].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The management of high-risk patients, such as those with severe cardiopulmonary disease, as well as those diagnosed with stage III acute calculous cholecystitis, has been the subject of many trials and studies. A growing body of evidence suggests that cholecystostomy may not offer significant advantages over early cholecystectomy in the treatment of acute cholecystitis, and that its routine use must be questioned even in high-risk patients with moderate-severe cholecystitis [6]. Similarly, early cholecystectomy has been found to be a feasible treatment for elderly patients with acute cholecystitis, provided careful selection is applied. Otherwise, alternative treatment modalities, including percutaneous cholecystostomy, may be more appropriate for elderly patients with comorbidities that render them unfit for surgical intervention [7]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA retrospective cohort study was conducted, analyzing data from 186 patients admitted to the General Surgery Department of Başakşehir \u0026Ccedil;am and Sakura City Hospital, a tertiary referral center in Istanbul, T\u0026uuml;rkiye, between July 2020 and October 2023. The inclusion criteria for this study were patients diagnosed with severe refractory acute calculous cholecystitis, classified as Tokyo grade II or III, who underwent percutaneous cholecystostomy followed by interval laparoscopic cholecystectomy.\u003c/p\u003e\n\u003cp\u003eGiven the anticipated surgical complexity and elevated postoperative morbidity and mortality risk, all patients underwent ultrasound-guided percutaneous transhepatic cholecystostomy in the interventional radiology department to facilitate effective gallbladder drainage. Microbiological analysis and antibiogram testing were performed routinely on gallbladder aspirates obtained after cholecystostomy placement. Empiric broad-spectrum antibiotic therapy was initiated promptly upon admission, with subsequent modification based on culture results of the gallbladder aspirate, guided by infectious diseases consultation, to optimize antibiotic selection.\u003c/p\u003e\n\u003cp\u003eA standardized management protocol was implemented for all patients. Following a mean hospital stay of 4 days (range, 2-6 days), patients were discharged upon demonstrating clinical improvement and a reduction in acute phase reactants. Ten patients were excluded from the analysis: eight due to loss to follow-up within the study period, and two due to development of bile peritonitis requiring immediate surgical intervention post-catheter placement.\u003c/p\u003e\n\u003cp\u003eThe remaining 176 patients were stratified according to the American Society of Anesthesiologists (ASA) physical status classification. Ninety-seven patients, classified as ASA II, underwent percutaneous cholecystostomy for severe acute cholecystitis refractory to medical and conservative management and subsequently underwent interval elective cholecystectomy at our institution. Seventy-nine patients, classified as ASA III-IV, underwent cholecystostomy; however, as the majority of these patients did not proceed to surgical cholecystectomy, they were excluded from this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and was approved by the\u003csup\u003e\u0026nbsp;\u003c/sup\u003eClinical Research Ethics Committee in \u0026Ccedil;am and Sakura City Hospital, (Approval Number: E-96317027-514.10-266503571, Date of Approval: 22.01.2025).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cu\u003eStatistical Analysis\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using SPSS version 27 (IBM Corp., Armonk, NY, USA). The normality of continuous variables was assessed using a combination of descriptive statistics (skewness, kurtosis, standard deviation/mean), graphical methods (Q-Q plots, histograms), and formal statistical tests. Categorical variables were summarized using frequencies and percentages (n, %), while continuous variables were presented as means and standard deviations. Between-group comparisons for continuous variables were conducted using independent samples t-tests. For ordinal and nominal variables, chi-square tests (Pearson\u0026apos;s chi-square and Fisher\u0026apos;s exact test) were employed.\u003c/p\u003e\n\u003cp\u003eUnivariate binary logistic regression was utilized to evaluate the association between cholecystostomy duration and prolonged surgery. The diagnostic performance of cholecystostomy duration in predicting prolonged surgery was assessed using Receiver Operating Characteristic (ROC) curve analysis. The optimal cut-off value for cholecystostomy duration was determined using the Youden index. Diagnostic performance metrics included the area under the ROC curve (AUC), sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. All statistical tests were two-sided, with a significance level of p \u0026lt; 0.05 and a 95% confidence interval.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study cohort of 97 patients classified as ASA II had a mean age of 55.9 \u0026plusmn; 13 years (range, 29-82), with 59 (61%) being male. All patients underwent surgical procedures after initial percutaneous cholecystostomy placement. The mean surgical duration was 102.6 \u0026plusmn; 44.6 minutes (range, 30-275), with 75 patients (77%) experiencing prolonged surgery (defined as \u0026gt;60 minutes). The mean cholecystostomy duration was 77.6 \u0026plusmn; 39.2 days (range, 20-210). Among these patients, 51 (53%) had a diagnosed chronic disease, 86% underwent laparoscopic surgery, 10 (10.3%) required conversion to open surgery\u0026nbsp;because of severe inflammatory reactions and inability to proceed with laparoscopic dissection, and 7 (7.2%) experienced preoperative complications mainly dislocation or obstruction of cholecystostomy tube, and recurrent cholecystitis attack. Although not statistically significant (p \u0026gt; 0.05), all patients requiring conversion to open surgery (n = 10) and 3 of the 4 patients planned for initial open surgery had prolonged surgical durations (p = 0.110-0.179). However, a statistically significant association was observed between cholecystostomy duration and prolonged surgery (t = 4.910, p \u0026lt; 0.001) (Table 1).\u003c/p\u003e\n\u003cp\u003eA one-day increase in cholecystostomy duration increased the odds of prolonged surgery by 1.037 (95% CI: 1.013-1.062, OR = 1.037, R\u0026sup2;N = 0.217). The optimal cholecystostomy duration cutoff for predicting prolonged surgery was 56 days, with an AUC of 0.742 (95% CI: 0.636-0.848, p = 0.001). Using this cutoff, the sensitivity, specificity, and accuracy for predicting prolonged surgery were 76%, 59.1%, and 72.2%, respectively (Table 2, Figure 1). Comparing the complication rates of percutaneous cholecystostomy between ASA II (n= 97) and ASA III-IV (n = 79) patients, as expected, the ASA II group had a significantly lower complication rate (7.2% vs. 36.7%, p \u0026lt; 0.001) (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAcute cholecystitis is one of the most significant diseases that affects mainly patients with gallstones and elderly adults in the whole world. Because of its high socioeconomic impact and the risk of subsequent episodes of cholecystitis, lots of controversies exist about the best way of management. Although laparoscopic cholecystectomy is assumed to be the gold standard of treatment, the timing of surgery remains a topic of discussion. The debate centers around whether to perform early surgery within 10 days of symptom onset and within 7 days of hospital admission, or to initially manage the condition with conservative treatment using antibiotics, followed by a delayed cholecystectomy a few weeks later after the inflammation has completely resolved [4]. The percutaneous placement of a tube by interventional radiologists, guided by either ultrasound or computed tomography, is a minimally invasive procedure. This approach can be done through either the transperitoneal or transhepatic route to effectively drain the gallbladder lumen. It allows for efficient drainage of the gallbladder and serves as a temporary measure before elective surgery in acute cases. However, concerns about the waiting period have raised issues such as higher morbidity and mortality rates, decreased quality of life, increased management costs, and longer hospital stays. As a result, the routine use of percutaneous cholecystostomy without strict protocols is limited.\u003c/p\u003e\n\u003cp\u003eThe effectiveness of percutaneous cholecystostomy in critically ill and elderly patients, as well as those who do not respond to conservative medical management, is supported by case series that have varied in their inclusion criteria. While there is no definitive evidence advocating for the use of percutaneous cholecystostomy over cholecystectomy in ASA III and IV patients with acute cholecystitis, this situation differs for ASA I and II patients. In these cases, early cholecystectomy should be performed as soon as possible, without much hesitation.\u003c/p\u003e\n\u003cp\u003eStill, percutaneous cholecystostomy is a safe and efficient treatment modality for severe acute cholecystitis classified as grade II and III that does not respond to antibiotic treatment in selected patients. Numerous studies proclaimed that this procedure is safe for elderly and critically ill patients, enhances prognosis, and makes later elective laparoscopic cholecystectomy more feasible with low mortality rates. On the other hand, there are still potential procedure-related complications including bile leak, local abscess, generalized peritonitis, drain dislodgement, tube blockage, and bleeding. Such complications remain common despite increasing experience and continued technological developments. In a systemic review of 312,085 patients, El Sharif et al. reported four percutaneous cholecystostomy-related deaths, resulting in an overall mortality rate of 0.001%. The percentage of procedure-related morbidities were as follows: drain dislodgement (7.2-29.6%), minor bleeding (2.4-7.2%), minor bile leak (1.1-10.4%), and tube blockage (0.6-7%) [8]. Additionally, another systemic review by Winbladh et al. demonstrated that cholecystostomy has a low-mortality rate of 0.36%, a high success rate of 85.6%, and the ability to convert septic cholecystitis into a non-septic condition when combined with antibiotic treatment [9].\u0026nbsp;In our study, percutaneous cholecystostomy was not associated with mortality. However, a total of seven cholecystostomy-related complications were observed. Specifically, catheter dislocation occurred in four patients (4.1%), with one case manifesting as an anterior abdominal wall abscess. Catheter obstruction was noted in two patients (2.1%), and a single patient (1.0%) experienced a recurrent acute cholecystitis attack. These complications represented 57.1%, 28.6%, and 14.3% of the total complication burden, respectively (Table 1).\u003c/p\u003e\n\u003cp\u003eCheruvu et al. demonstrated that 28% of patients with acute gallstone disease required readmission before planned cholecystectomy, with no significant difference observed between those treated with percutaneous cholecystostomy and those receiving antibiotics [10]. The use of percutaneous cholecystostomy was significantly associated with a longer length of hospital stay, extending by approximately 50%, and higher 30-day and one-year mortality rates among patients with a non-severe disease severity index (DSI). Conversely, this association did not apply to patients with organ dysfunction and severe DSI, highlighting the necessity to reassess the decision to perform percutaneous cholecystostomy in patients who remain unresponsive to conservative therapy, even after a disease duration exceeding seven days [11]. While most guidelines advocate for early operative intervention in acute cholecystitis, a subset of patients presents with complicated gallbladder conditions involving acute or chronic inflammation, fibrosis, anatomical variations, adhesions, gangrene, empyema of the gallbladder, or Mirizzi syndrome. These factors can complicate laparoscopic cholecystectomy, rendering the procedure more challenging and riskier [12]. It is reported that approximately 16% of patients undergoing laparoscopic cholecystectomy are classified as having difficult gallbladder conditions [13]. Additionally, a significant number of patients requiring conversion to an open procedure has been reported by Bhatt et al. to be around 32%, which is consistent with an earlier study by Pang et al. in 2016 that indicated a conversion rate of about 27% [14].\u0026nbsp;In our study, the laparoscopic cholecystectomy procedure was converted to open surgery in 10 out of 97 patients (10.3%). Among these conversions, four patients underwent subtotal cholecystectomy due to severe inflammation and complex anatomical challenges, which significantly elevated the risk of bile duct injury during attempts at total cholecystectomy. Another two cases had Mirizzi syndrome type I and II that complicated the operational progress and ended with conversion to open surgery. It is worth to remind that conversion to open cholecystectomy is a valid surgical decision, not a failure, and that surgeons must prioritize patient safety over exclusively laparoscopic completion.\u003c/p\u003e\n\u003cp\u003eFor experienced surgeons, the average operative time for a laparoscopic cholecystectomy typically ranges from 30 to 60 minutes [15, 16, 17]. In a study conducted by Lowndes et al. involving 24,099 patients from the National Surgical Quality Improvement Program (NSQIP) database, it was shown that an operative duration exceeding 60 minutes is a consistent indicator of a \u0026ldquo;difficult cholecystectomy\u0026rdquo; [15]. Additionally, Subhas et al. described the term \u0026ldquo;prolonged laparoscopic cholecystectomy\u0026rdquo; for procedures that extend beyond 3 hours in their study of 3,126 cholecystectomies [16]. Giger et al. demonstrated that each 30-minute increase in operative time correlated with a 1.68-fold rise in intraoperative complications, a 1.28-fold rise in local postoperative complications, and a 1.16-fold rise in systemic postoperative complications [17]. Consistent with these findings, studies have indicated an approximately four-fold increased risk of perioperative complications in laparoscopic cholecystectomy procedures exceeding two hours in length compared to those completed within one hour, a finding that appears independent of surgeon expertise and experience. [16, 17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe optimal interval between percutaneous cholecystostomy and interval laparoscopic cholecystectomy for stage II-III acute cholecystitis is poorly defined due to limited high-quality evidence. While inflammation may resolve around 63 days post-cholecystostomy, the ideal timing for interval laparoscopic cholecystectomy remains ambiguous, necessitating further rigorous investigation. Hung et al. accepted an interval of 9 to 10 weeks between cholecystostomy and laparoscopic cholecystectomy for stage II and III acute cholecystitis patients based on clinical course and sequential pathological changes in the gallbladder [18]. On the other hand, Woodard et al. proposed an optimal window of 4 to 8 weeks for interval cholecystectomy following percutaneous cholecystostomy placement. However, their study\u0026apos;s applicability is limited by the lack of precise staging of the included acute cholecystitis cases and the significant proportion of open cholecystectomies (\u0026gt;50%) performed [19].\u003c/p\u003e\n\u003cp\u003eConversely, a statewide retrospective analysis by Altieri et al. demonstrated that interval laparoscopic cholecystectomy performed beyond 8 weeks after percutaneous cholecystostomy placement was associated with a reduced incidence of complications and a shorter postoperative length of stay [20]. Nevertheless, this study is constrained by the inclusion of all acute cholecystitis patients receiving cholecystostomy, irrespective of subsequent surgical approach (open or laparoscopic) and without stratification for disease severity, potentially introducing information bias.\u003c/p\u003e\n\u003cp\u003eFurther complicating the evidence landscape, a nationwide database study by Sakamoto et al. suggested an optimal timing for cholecystectomy of 7 to 26 days post-percutaneous cholecystostomy [21]. However, this study\u0026apos;s conclusions are weakened by significant institutional heterogeneity, encompassing a wide range of medical facilities from rural hospitals to tertiary referral centers, and the absence of data on acute cholecystitis severity, rendering it a low-strength evidence-based work.\u003c/p\u003e\n\u003cp\u003eIn this study, patients undergoing laparoscopic cholecystectomy following percutaneous cholecystostomy were stratified by cholecystostomy duration. Patients with percutaneous cholecystostomy duration \u0026le; 56 days (n=68) exhibited a mean operative time of 96.59 \u0026plusmn; 45.7 minutes and a median operative time of 90 minutes (IQR: 61-120 minutes). Conversely, patients with cholecystostomy duration exceeding 56 days (n=29) demonstrated a significantly prolonged mean operative time of 116.55 \u0026plusmn; 38.99 minutes and a median operative time of 110 minutes (IQR: 88-135 minutes) (Table 4). Statistical analysis demonstrated that increased percutaneous cholecystostomy duration significantly prolonged surgical time and was consequently associated with an elevated risk of perioperative complications.\u003c/p\u003e\n\u003cp\u003eContemporary literature increasingly supports laparoscopic cholecystectomy as the primary intervention for acute cholecystitis, encompassing even severe presentations. This evidence challenges the traditional practice of percutaneous cholecystostomy as a temporizing measure prior to surgical intervention. This paradigm shift necessitates a critical reassessment of the clinical indications for interventional drainage in this patient population. Our study aimed to identify factors that may supersede the established indications for percutaneous cholecystostomy in grade II and III acute cholecystitis cases unresponsive to comprehensive conservative management. Furthermore, this research sought to determine the optimal interval between percutaneous cholecystostomy placement and subsequent interval laparoscopic cholecystectomy, considering both the duration and complexity of the laparoscopic procedure, while maintaining a minimal rate of conversion to open surgery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRoutine use of percutaneous cholecystostomy for moderate to severe acute cholecystitis, even in high-risk patients, is discouraged. It should be reserved for cases where surgery is contraindicated (e.g., metastatic malignancy, extreme frailty, life-threatening systemic disease). Early surgery is preferred, as percutaneous cholecystostomy increases complications, operative difficulty, and conversion rates, limiting its effectiveness as a bridging strategy.\u003c/p\u003e\n\u003cp\u003eConversely, percutaneous cholecystostomy is absolutely indicated in patients with severe comorbidities, sepsis-induced physiological derangement, complicated cholecystitis (including gangrenous or perforated gallbladder), and stage III acute cholecystitis intractable to conservative management. In these cases, percutaneous cholecystostomy serves as a temporizing measure to stabilize patients before definitive surgery. Crucially, our study suggests that interval cholecystectomy should ideally be performed within 56 days (8 weeks). Delays beyond this timeframe are associated with increased operative time and technical difficulty during laparoscopic cholecystectomy, leading to a greater risk of surgical complications and undermining the rationale for using percutaneous cholecystostomy as a bridge to elective laparoscopic cholecystectomy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest disclosure:\u003c/strong\u003e All authors declare that they have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCartı EB and Kutlut\u0026uuml;rk K. Should percutaneous cholecystostomy be used in all cases difficult to manage? Ulus Travma Acil Cerrahi Dergisi. 2020;26(2):186-190 DOİ: 10. 14744/tjtes.2020.73557\u003c/li\u003e\n\u003cli\u003eHung YL, Sung CM, Fu CY, Liao CH, Wang SY, Hsu JT, et al. Management of Patients with acute cholecystitis after percutaneous cholecystostomy: from the acute stage to definitive surgical treatment. Front. Surg. 2021; 8:616320\u003c/li\u003e\n\u003cli\u003eYokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading ofacute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018; 25:41\u0026ndash;54\u003c/li\u003e\n\u003cli\u003ePisano M, Allievi N, Gurusamy K, Borzellino G, Cimbanassi S, Boerna D, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World Journal of Emergency Surgery. 2020; 15:61 https://doi.org/10.1186/s13017-020-00336-x\u003c/li\u003e\n\u003cli\u003ePisano M, Ceresoli M, Cimbanassi S, Gurusamy K, Coccolini F, Borzellino G, et al. 2017 WSES and SİCG guidelines on acute calculous cholecystitis in elderly population. World J Wmerg Surg. 2019;14(1):1-16\u003c/li\u003e\n\u003cli\u003eGreca AL, Grezia MD, Magalini S, Giorgio AD, Lodoli C, Flumeri GD, et al. Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study. Eur Rev Med Pharmacol Sci. 2017;21(20):4668-4674\u003c/li\u003e\n\u003cli\u003eLoozen CS, Ramshorst BV, Santvoort HCV, Boerma D. Early Cholecystectomy for Acute Cholecystitis in the Elderly Population: A Systematic Review and Meta-Analysis. Dig Surg. 2017; 34:371\u0026ndash;379 DOI: 10.1159/000455241\u003c/li\u003e\n\u003cli\u003eElsharif M, Forouzanfar A, Oaikhinan K, Khetan N. Percutaneous cholecystostomy\u0026hellip; why, when, what next? A systemic review of past decade. Ann R Coll Surg Engl. 2018; 100:618-631 DOİ: 10. 1308/rcsann.2018.0150\u003c/li\u003e\n\u003cli\u003eWinbladh A, Gullstrand P, Svanvik J, Sandstrom P. Systemic review of cholecystostomy as a treatment option in acute cholecystitis. İnternational Hepato-Pancreato-Biliary Association. 2009; 11:183-193. Doi: 10.1111/j.1477-2574.2009.00052.x\u003c/li\u003e\n\u003cli\u003eCheruvu CV, Eyre-Brook İA. Consequences of prolonged wait before gallbladder surgery. Ann R Coll Surg Engl. 2002; 84:20-22\u003c/li\u003e\n\u003cli\u003eHazan D, Leibovitz E, Jazmawi M, Shimonov M. Does percutaneous cholecystostomy affect prognosis of patients with acute cholecystitis that are unresponsive to conservative treatment? Saudi Journal of Gastroenterology. 2023; 29:376-380. DOİ: 10.4103/sjg.sjg_87_23\u003c/li\u003e\n\u003cli\u003eAloraini A, Alanezi T, Alshahwan N. Subtotal laparoscopic cholecystectomy versus open total cholecystectomy for the difficult gallbladder: A systemic review and meta-analysis. Current problems in surgery. 2024; (61) 101607.\u003c/li\u003e\n\u003cli\u003eKimura Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, et al. TG13 current terminology, etiology and epidemiology of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013; 20(1):8-23. doi: 10.1007/s00534-012-0564-0.\u003c/li\u003e\n\u003cli\u003eBhatt MN, Ghio M, Sadri L, Sarkar S, Kasotakis G, Narsule C, et al. Percutaneous cholecystostomy in acute cholecystitis-predictors of recurrence and interval cholecystectomy. Journal of Surgical Research. 2018; 232:539-546. DOİ: 10.1016/jss.2018.06.051\u003c/li\u003e\n\u003cli\u003eLowndes B, Thiels C, Habermann E, Bingener J, Hallbeck S, Yu D. Impact of patient factors on operative duration during laparoscopic cholecystectomy: evaluation from the National Surgical Quality İmprovement Program Database. The American Journal Of Surgery. 2016; 212:289-296\u003c/li\u003e\n\u003cli\u003eSubhas G, Gupta A, Bhullar J, Dubay L, Ferguson L, Goriel Y, et al. Prolonged (Longer than 3 hours) laparoscopic cholecystectomy: Reasons and Results. The American Surgeon. 2011; 77:981-984\u003c/li\u003e\n\u003cli\u003eGiger UF, Michel JM, Opitz I, Inderbitzin DT, Kocher T, Krahenbuhl L. Risk factors for perioperative complications in patients undergoing laparoscopic cholecystectomy: Analysis of 22,953 consecutive cases from the swiss association of laparoscopic and thoracoscopic surgery database. J Am Coll Surg. 2006; 203:723- 728 DOİ: 10.1016/j.jamcollsurg.2006.07.018\u003c/li\u003e\n\u003cli\u003eHung YL, Chen HW, Tsai CY, Chen TC, Wang SY, Sung CM, et al. The optimal timing of interval laparoscopic cholecystectomy following percutaneous cholecystostomy based on pathological findings and the incidence of biliary events. J Hepatobiliary Pancreat Sci. 2021; 28(9):751-759. doi: 10.1002/jhbp.1012. Epub 2021 Jul 23. PMID: 34129718.\u003c/li\u003e\n\u003cli\u003eWoodward SG, Rios-Diaz AJ, Zheng R, McPartland C, Tholey R, Tatarian T, et al. Finding the Most Favorable Timing for Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: An Analysis of Institutional and National Data. J Am Coll Surg. 2021; 232(1):55-64. doi: 10.1016/j.jamcollsurg.2020.10.010. Epub 2020 Oct 21. PMID: 33098966.\u003c/li\u003e\n\u003cli\u003eAltieri MS, Yang J, Yin D, Brunt LM, Talamini MA, Pryor AD. Early cholecystectomy (\u0026le;\u0026thinsp;8 weeks) following percutaneous cholecystostomy tube placement is associated with higher morbidity. Surg Endosc. 2020; b34(7):3057-63. doi: 10.1007/s00464-019-07050-z. Epub 2019 Aug 1. PMID: 31372890.\u003c/li\u003e\n\u003cli\u003eSakamoto T, Fujiogi M, Matsui H, Fushimi K, Yasunaga H. Timing of cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis: a nationwide inpatient database study. HPB (Oxford). 2020; 22(6):920-926. doi: 10.1016/j.hpb.2019.10.2438. Epub 2019 Nov 13. PMID: 31732466.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Comparison of patient characteristics according to the presence of prolonged surgery\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"632\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLong-term surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (\u0026le;60 \u003csub\u003emin\u003c/sub\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (\u0026gt;60 \u003csub\u003emin\u003c/sub\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of patients,\u003cem\u003e\u0026nbsp;n(%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e22(22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e75(77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e97(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation duration(min), \u003cem\u003emean(SD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e54.1(11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e116.8(40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e102.6(44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge(y), \u003cem\u003emean(SD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e55.5(14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e56(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e55.9(13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.878\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.493\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e12(54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e47(62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e59(60.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e10(45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e28(37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e38(39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic disease, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e11(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e40(53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e51(52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.783\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA classification, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3(13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9(12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12(12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e19(86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e66(88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e85(87.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication, \u003cem\u003en(%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e6(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e7(7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication type, \u003cem\u003en(%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e21(95.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e69(92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e90(92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eDislocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3(4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4(4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eObstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2(2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eRecurrent attack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e1(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConversion from laparoscopic to open surgery, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e10(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e10(10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.110\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery type, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.179\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eLaparoscopic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e21(95.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e62(82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e83(85.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eOpen surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e13(17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e14(14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCholecystostomy duration(days), \u003cem\u003emean(SD)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e53.8(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 95px;\"\u003e\n \u003cp\u003e84.6(40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e77.6(39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*p\u0026lt;0.001; \u003cstrong\u003ea,\u0026nbsp;\u003c/strong\u003ePearson chi-square test;\u003cstrong\u003e\u0026nbsp;b,\u003c/strong\u003e Independent sample t-test;\u003cstrong\u003e\u0026nbsp;c,\u003c/strong\u003e Fisher\u0026apos;s exact test; \u003cstrong\u003eSD,\u0026nbsp;\u003c/strong\u003estandard deviation.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2.\u003c/strong\u003e Optimal cholecystostomy length of stay in determining the length of surgery (ROC curve analysis results)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"463\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\n \u003cp\u003eAUC (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e0.742 (0.636-0.848) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\n \u003cp\u003eCut-off points\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e56, day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\n \u003cp\u003eSensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\n \u003cp\u003eSpecificity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e59.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\n \u003cp\u003ePPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e86.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\n \u003cp\u003eNPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e41.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 275px;\"\u003e\n \u003cp\u003eAccuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 188px;\"\u003e\n \u003cp\u003e72.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e*\u003c/em\u003e\u003cem\u003eP\u003c/em\u003e\u003cem\u003e=0.001;\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;NPV\u003c/strong\u003e, Negative predictive value; \u003cstrong\u003ePPV\u003c/strong\u003e,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePositive predictive value;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI\u003c/strong\u003e,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eConfidence interval; \u003cstrong\u003eAUC,\u003c/strong\u003e Area under curve.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eComparison of patient complication rates according to ASA classification\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"588\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 117px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003cem\u003e, n(%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eI-II (n=97)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIII-IV(n=79)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n=176)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e7(7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e29(36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 117px;\"\u003e\n \u003cp\u003e36(20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003csup\u003ea*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 163px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e90(92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 111px;\"\u003e\n \u003cp\u003e50(63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 117px;\"\u003e\n \u003cp\u003e140(79.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*p\u0026lt;0.001; \u003cstrong\u003ea,\u003c/strong\u003e Pearson chi-square test\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 4.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation duration(min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 74px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCholecystostomy duration (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian(IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u0026lt;56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e96.59\u0026plusmn;45.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e90(61-120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003csup\u003ea\u003c/sup\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u0026ge;56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\n \u003cp\u003e116.55\u0026plusmn;38.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 112px;\"\u003e\n \u003cp\u003e110(88-135)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 74px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;*p\u0026lt;0.05; \u003cstrong\u003ea\u003c/strong\u003e, Independent sample t-test; \u003cstrong\u003eSD\u003c/strong\u003e, standard deviation\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Acute cholecystitis, percutaneous cholecystostomy, interval laparoscopic cholecystectomy, duration of cholecystostomy, optimal timing of surgery","lastPublishedDoi":"10.21203/rs.3.rs-6514192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6514192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eDespite substantial medical advancements in recent decades, the optimal management of Grade II-III acute calculous cholecystitis in patients with an ASA II classification remains a subject of ongoing debate, even with laparoscopic cholecystectomy established as the standard of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The optimal timing of cholecystectomy (early vs. delayed) remains debated regarding morbidity, risk-benefit balance, and cost. While percutaneous cholecystostomy is supported as definitive management for ASA III/IV patients, its efficacy as a bridge to cholecystectomy in ASA II medically refractory grade II-III acute cholecystitis is unclear. Moreover, the optimal interval between percutaneous cholecystostomy and interval laparoscopic cholecystectomy in this specific group is not well-established.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective cohort study aimed to elucidate the impact of percutaneous cholecystostomy, performed as an initial intervention, on the subsequent elective cholecystectomy in patients classified as ASA II and diagnosed with Grade II-III acute calculous cholecystitis. Specifically, the study evaluated the influence of prior percutaneous cholecystostomy on the timing, duration, and type of the subsequent elective cholecystectomy procedure. Of the 186 patients managed with percutaneous cholecystostomy for severe acute calculous cholecystitis, 97 patients, classified as ASA II, who subsequently underwent interval elective cholecystectomy at our institution, constituted the study cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e77% experienced prolonged laparoscopic cholecystectomy, defined as being longer than 60 minutes, when operated after 8 weeks of cholecystostomy placement. The complexity and the difficulty of surgery were significantly increased in this group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eLiberal use of percutaneous cholecystostomy for grade II-III acute calculous cholecystitis is discouraged. Early laparoscopic cholecystectomy is preferred for most ASA II acute cholecystitis cases, reserving percutaneous cholecystostomy for intractable cases or those with contraindications to immediate surgery.\u003c/p\u003e","manuscriptTitle":"The influence of Percutaneous Cholecystostomy Duration on Optimizing Surgical Outcomes and Timing of Interval Cholecystectomy in ASA II patients with grade II-III Acute Calculous Cholecystitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 08:23:12","doi":"10.21203/rs.3.rs-6514192/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-22T06:45:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-15T11:46:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-11T08:58:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277673058290171665963348965585021990630","date":"2025-06-08T06:27:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213450860113424431982970399847084356095","date":"2025-06-04T22:54:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59304939052677438763741709975575289040","date":"2025-06-03T15:20:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38320773251723137231552241256279833970","date":"2025-06-03T13:08:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127282279560795925068898599108984101318","date":"2025-06-03T05:21:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-02T19:27:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-25T04:22:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-25T00:42:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2025-04-23T15:50:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4cca7874-f630-41c8-af1c-3b18a73bdbf2","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:01:12+00:00","versionOfRecord":{"articleIdentity":"rs-6514192","link":"https://doi.org/10.1007/s00423-025-03822-5","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2025-10-01 15:57:20","publishedOnDateReadable":"October 1st, 2025"},"versionCreatedAt":"2025-06-09 08:23:12","video":"","vorDoi":"10.1007/s00423-025-03822-5","vorDoiUrl":"https://doi.org/10.1007/s00423-025-03822-5","workflowStages":[]},"version":"v1","identity":"rs-6514192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6514192","identity":"rs-6514192","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}