Predictors of In-Hospital Mortality After Percutaneous Cholecystostomy in Acute Cholecystitis

Predictors of In-Hospital Mortality After Percutaneous Cholecystostomy in Acute 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 Predictors of In-Hospital Mortality After Percutaneous Cholecystostomy in Acute Cholecystitis Ayhan SENOL, Seyhmus KAVAK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9130949/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Background Acute cholecystitis is a frequent cause of emergency surgical admission. Percutaneous cholecystostomy (PC) is commonly used as a minimally invasive treatment option in patients considered unsuitable for early cholecystectomy. However, predictors of mortality and the role of radiologic disease severity in determining outcomes remain incompletely understood. Methods We conducted a retrospective cohort study including consecutive adult patients who underwent image-guided PC for acute cholecystitis at a tertiary referral hospital between January 2022 and December 2025. Clinical, laboratory, radiologic, and procedural variables were analyzed. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. A radiologic severity score (RSS) was constructed using predefined imaging findings including pericholecystic fluid, gallbladder perforation, emphysematous cholecystitis, and gallbladder wall thickness ≥ 7 mm. Associations between RSS and inflammatory response or clinical outcomes were evaluated. Results A total of 266 patients were included (mean age 64.9 ± 17.1 years; 56.4% male). The overall in-hospital mortality rate was 7.5%. Independent predictors of mortality included age (OR 1.07 per year), malignancy (OR 9.19), LDH (OR 1.006), and post-procedural day-3 CRP (OR 1.016). The predictive model demonstrated excellent discrimination with an AUC of 0.914. Internal validation using cross-validation yielded an AUC of 0.895. Higher RSS values were significantly associated with reduced CRP decline following PC (p = 0.041), suggesting slower inflammatory resolution. However, RSS was not significantly associated with mortality or hospital length of stay. Conclusion In patients undergoing PC for acute cholecystitis, mortality is largely determined by baseline patient vulnerability and early inflammatory dynamics. Radiologic severity reflects local inflammatory burden and may complement laboratory markers in predicting inflammatory recovery. Trial Registration Not applicable Cholecystostomy Cholecystitis Risk Factors Mortality C-Reactive Protein Lactate Dehydrogenase Aged Neoplasms Figures Figure 1 Figure 2 Figure 3 1. Background Acute cholecystitis (AC) is one of the most common causes of emergency surgical admissions worldwide and represents a major contributor to morbidity and urgent biliary interventions, particularly among elderly and medically complex patients. Current evidence indicates that although early laparoscopic cholecystectomy remains the definitive treatment for most patients, a substantial subgroup cannot safely undergo immediate surgery due to advanced age, severe sepsis, organ dysfunction, or significant comorbid conditions ( 1 – 3 ). As the global population continues to age and multimorbidity becomes increasingly prevalent, the number of patients considered high risk for operative intervention is steadily increasing. Consequently, alternative treatment strategies are receiving growing attention ( 4 , 5 ). Percutaneous cholecystostomy (PC) has emerged as a well-established minimally invasive option for source control in high-risk patients with acute cholecystitis. The procedure enables rapid decompression of the inflamed gallbladder, facilitates infection control, and can be performed under imaging guidance with high technical success rates and relatively low immediate complication rates ( 6 – 8 ). In contemporary clinical practice, PC is used either as a temporary bridge to delayed cholecystectomy or as definitive treatment in patients considered permanently unfit for surgery. However, despite its favorable procedural safety profile, clinical outcomes after PC remain heterogeneous. While many patients demonstrate rapid clinical improvement, others experience persistent systemic inflammation, clinical deterioration, the need for reintervention, or in-hospital death ( 9 ). Reported mortality rates following PC vary substantially across studies, reflecting differences in patient selection, baseline physiologic reserve, infection severity, and institutional treatment algorithms. Recent systematic reviews and cohort analyses emphasize that mortality in this population is primarily driven by underlying patient-related factors rather than the technical aspects of the intervention itself ( 10 , 11 ). This observation highlights an important clinical reality: PC is most often performed in patients who are already critically ill or physiologically fragile, making early prognostic assessment particularly important. Accurate early identification of patients at high risk of adverse outcomes following PC has important clinical implications. Reliable risk stratification may guide decisions regarding the level of monitoring, need for intensive care admission, optimization of antimicrobial therapy, and timing—or even avoidance—of definitive surgical intervention. Furthermore, objective predictive models may assist clinicians in counseling patients and their families, facilitating shared decision-making, and optimizing allocation of limited healthcare resources. Despite this clear clinical need, existing prognostic data remain inconsistent, and widely accepted predictive tools specifically tailored for patients undergoing PC are lacking ( 12 ). Routine laboratory biomarkers represent a promising and pragmatic approach to outcome prediction because they are inexpensive, universally available, and rapidly obtainable. Inflammatory markers reflecting the systemic response to infection, such as C-reactive protein (CRP) and leukocyte count, as well as biochemical indicators of tissue injury or physiologic stress, such as lactate dehydrogenase (LDH), have been investigated as prognostic indicators in acute inflammatory and septic conditions. Emerging evidence suggests that dynamic changes in these markers—particularly early post-intervention trends—may provide more meaningful prognostic information than baseline values alone ( 10 ). Nevertheless, the prognostic significance of early laboratory trajectories after PC remains insufficiently characterized, and data integrating clinical, biochemical, and imaging variables into a unified predictive framework are limited. In addition to systemic biomarkers, radiologic findings reflecting the local inflammatory burden may also provide complementary prognostic information. Imaging features such as gallbladder perforation, emphysematous cholecystitis, pericholecystic fluid, and gallbladder wall thickening have been associated with more severe disease presentations and complicated clinical courses ( 1 , 13 , 14 ). However, the role of radiologic severity in predicting outcomes following percutaneous cholecystostomy remains incompletely understood ( 15 ). Therefore, there is a clear need for a simple, clinically applicable, and evidence-based model capable of identifying patients at increased risk of mortality after percutaneous cholecystostomy. Addressing this gap is essential for improving early clinical decision-making and tailoring management strategies in this vulnerable population. This study, beyond identifying clinical and laboratory predictors of mortality, also aimed to investigate whether radiologic severity markers could be integrated into a simplified radiologic severity score and whether this score is associated with mortality risk or early inflammatory response following PC. 2. Materials and Methods 2.1 Study Design and Population This retrospective observational cohort study was conducted at a tertiary referral center and included consecutive adult patients who underwent image-guided percutaneous cholecystostomy for the treatment of acute cholecystitis between January 1, 2022 and December 31, 2025. The study protocol was approved by the University of Health Sciences, Gazi Yaşargil Training and Research Hospital Institutional Ethics Committee (Approval No:03.02.2026-105), and the requirement for informed consent was waived due to the retrospective nature of the study. The study was conducted in accordance with the Declaration of Helsinki and relevant reporting guidelines for observational studies. Patients and relevant demographic, laboratory, and radiological data were obtained from the hospital electronic medical record system. Inclusion criteria Patients meeting all of the following criteria were included: Age ≥ 18 years Diagnosis of acute cholecystitis based on clinical, laboratory, and imaging findings Treatment with percutaneous cholecystostomy Exclusion criteria Patients were excluded if they met any of the following criteria: Missing essential clinical or laboratory data Cholecystostomy performed for non-inflammatory etiologies (e.g., malignant biliary obstruction without cholecystitis) Previous gallbladder intervention, including prior PC or biliary surgery 2.2 Percutaneous Cholecystostomy Procedure All procedures were performed under imaging guidance (ultrasound and/or fluoroscopy) by two experienced interventional radiologists (A.S. and Ş.K.) using standard sterile technique and local anesthesia, with or without conscious sedation. The access route (transhepatic or transperitoneal), catheter diameter (6F, 8F, or 10F), and technical approach were determined by the operator, taking into account patient anatomy and clinical conditions. Technical success was defined as successful placement of a drainage catheter within the gallbladder lumen with immediate bile drainage. Procedure-related complications included: pericholecystic abscess or fluid collection catheter dislodgement or obstruction hemorrhage through the catheter tract or intra-abdominal bleeding severe pain preventing catheter tolerance 2.3 Data Collection To minimize bias, all consecutive eligible patients within the study period were included. Predefined variables were systematically collected, and patients with missing key data were excluded. Demographic, clinical, laboratory, radiologic, and procedural variables were extracted from electronic medical records. Demographic and clinical variables age sex comorbidities (diabetes mellitus, hypertension, cardiac disease, pulmonary disease, renal disease, neurologic disease, liver disease, malignancy) Laboratory parameters Inflammatory markers: white blood cell count (WBC) platelet count (PLT) C-reactive protein (baseline and day 3) Hepatopancreatobiliary function tests: alanine aminotransferase (ALT) aspartate aminotransferase (AST) alkaline phosphatase (ALP) gamma-glutamyl transferase (GGT) amylase bilirubin levels (total, direct, indirect) international normalized ratio (INR) Renal function tests: blood urea nitrogen (BUN) creatinine Tissue injury markers: lactate dehydrogenase (LDH) creatine kinase (CK) 2.4 Radiologic Severity Score To quantify the radiologic burden of gallbladder inflammation, a radiologic severity score (RSS) was constructed based on predefined imaging findings derived from previous radiologic severity descriptions in acute cholecystitis ( 13 – 15 ). One point was assigned for each of the following radiologic features: presence of pericholecystic fluid gallbladder perforation emphysematous cholecystitis gallbladder wall thickness ≥ 7 mm The total score ranged from 0 to 4 points. Patients were categorized into three groups: Low severity: RSS 0–1 Intermediate severity: RSS = 2 High severity: RSS 3–4 The association between RSS and clinical outcomes including hospital length of stay and inflammatory response (CRP reduction) was evaluated. Procedural variables catheter size used for PC bile culture results need for revision or additional intervention 2.5 Outcome Measures The primary endpoint of the study was in-hospital mortality after PC. Secondary outcomes included: the relationship between radiological severity score and mortality clinical recovery status at discharge need for subsequent cholecystectomy PC-related complications 2.6 Statistical Analysis The distribution of continuous variables was assessed using the Kolmogorov–Smirnov test and visual inspection of histograms. Normally distributed variables were reported as mean ± standard deviation, whereas non-normally distributed variables were expressed as median and interquartile range (IQR). Categorical variables were summarized as frequencies and percentages. Comparisons between survivors and non-survivors were performed using Student’s t-test or Mann–Whitney U test for continuous variables, and chi-square or Fisher’s exact test for categorical variables. For analyses involving the radiologic severity score, differences in hospital length of stay and CRP reduction across RSS categories were assessed using the Kruskal–Wallis test. When appropriate, Spearman correlation analysis was used to evaluate relationships between continuous radiologic variables (e.g., gallbladder wall thickness) and laboratory parameters. Variables demonstrating statistical significance in univariable analyses or considered clinically relevant were entered into multivariable logistic regression analysis to identify independent predictors of in-hospital mortality. Effect estimates were reported as odds ratios (OR) with 95% confidence intervals (CI). Model discrimination was assessed using receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC). Internal validation of the predictive model was performed using k-fold cross-validation. A two-tailed p value < 0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics version 24. 3.Results 3.1. Patient Characteristics A total of 357 patients who underwent percutaneous cholecystostomy (PC) for acute cholecystitis were initially screened. Among them, 91 patients were excluded due to missing data (n = 58), previous history of PC (n = 20), or cholecystostomy performed for non-inflammatory etiologies (n = 13). Consequently, 266 patients were included in the final analysis (Fig. 1 ). The mean age was 64.9 ± 17.1 years, and 150 patients (56.4%) were male. Gallstones were present in 81.6% of cases, pericholecystic fluid in 60.5%, gallbladder perforation in 19.5%, and emphysematous cholecystitis in 3.8%. The catheter size was 8F in 75.9%, 6F in 15.4%, and 10F in 8.6% of procedures. Positive bile culture growth was detected in 42.5% of patients, with Escherichia coli (28.2%) being the most frequently isolated organism. Procedure-related complications occurred in 23 patients (8.6%). Subsequent cholecystectomy was performed in 53.8% of cases. The overall in-hospital mortality rate was 7.5% (n = 20) (Tables 1 A and 1 B). 3.2. Comparison Between Survivors and Non-Survivors Patients who died during hospitalization were significantly older than survivors (median 78 vs 65 years, p < 0.001). Several laboratory parameters were significantly higher in non-survivors, including: LDH (median 305 vs 224 U/L, p < 0.001) CRP on post-procedural day 3 (median 135.1 vs 71.3 mg/L, p < 0.001) Urea (median 62 vs 38 mg/dL, p < 0.01) AST (48 vs 29 U/L, p < 0.05) WBC (16.5 vs 12.4 ×10³/µL, p < 0.05)(Table 2 A). Malignancy was significantly more frequent in the non-survivor group (p < 0.001). Other chronic comorbidities did not show a statistically significant difference between groups. Radiological severity findings such as gallbladder perforation, pericholecystic fluid, and emphysematous cholecystitis were numerically more frequent among non-survivors but did not reach statistical significance (Table 2 B). 3.3. Multivariable Predictors of In-Hospital Mortality Variables demonstrating statistical significance or clinical relevance in univariable analyses were entered into a multivariable logistic regression model. The final parsimonious model identified four independent predictors of mortality: Age LDH Post-procedural day-3 CRP Presence of malignancy These findings suggest that both baseline patient vulnerability (age, malignancy) and early biochemical response to treatment (CRP day 3 and LDH) independently predict mortality after PC (Table 3 A and 3 B)(Fig. 2 ). 3.4. Predictive Performance of the Model The multivariable model demonstrated excellent discriminative ability, with an apparent ROC-AUC of 0.914. Internal validation using 5-fold cross-validation yielded a corrected AUC of 0.895, indicating robust predictive performance with minimal overfitting (Fig. 3 ). 3.5. Secondary Outcomes The presence of gallstones and gallbladder perforation were significantly associated with prolonged hospital stay (p = 0.009 and p = 0.029, respectively). Pericholecystic fluid was significantly associated with a greater reduction in CRP levels following percutaneous cholecystostomy (p < 0.001). No significant association was observed between gallbladder wall thickness and either hospital length of stay or CRP reduction. Procedure-related complications occurred in 23 patients (8.6%). No significant association was observed between catheter size or access route and mortality. Patients who subsequently underwent cholecystectomy were significantly younger and had fewer comorbid conditions. Notably, all patients who underwent surgery survived. 3.6 Radiologic Severity Score and Clinical Outcomes A radiologic severity score ranging from 0 to 4 was calculated for all patients. Increasing RSS values were associated with differences in inflammatory response following percutaneous cholecystostomy. Absolute CRP reduction differed significantly across RSS categories (p = 0.041), as did percentage CRP reduction (p = 0.029). Patients with higher RSS values demonstrated a less pronounced reduction in inflammatory markers during early follow-up. In contrast, although hospital length of stay tended to increase with higher RSS categories, the overall difference did not reach statistical significance (p = 0.100). These findings suggest that radiologic disease burden may be more closely related to early inflammatory recovery than to crude hospital discharge timing. 4.Discussion In this retrospective cohort study of patients undergoing percutaneous cholecystostomy for acute cholecystitis, we identified age, malignancy, LDH level, and post-procedural day-3 CRP as independent predictors of in-hospital mortality. Importantly, the predictive model demonstrated excellent discrimination, highlighting the combined prognostic importance of baseline patient vulnerability and early inflammatory dynamics. Over the past decade, PC has become an established treatment modality for high-risk patients with acute cholecystitis who are considered unsuitable for immediate surgery ( 16 , 17 ). Several studies have reported technical success rates exceeding 90%, supporting PC as a reliable method for rapid gallbladder decompression and infection control ( 18 – 20 ). However, mortality after PC remains clinically significant and largely reflects the underlying physiologic status of the treated population rather than procedural complications ( 21 – 23 ). The mortality rate observed in our cohort (7.5%) is consistent with contemporary studies reporting mortality rates ranging from 5% to 10% in similar patient populations ( 24 ). Importantly, previous investigations have shown that systemic illness severity—rather than local gallbladder pathology—is the dominant determinant of outcome in patients undergoing PC. Our results further reinforce the critical role of patient frailty, particularly advanced age and malignancy. Age has repeatedly been identified as one of the strongest predictors of mortality in patients with acute cholecystitis managed with PC ( 25 ). Elderly patients typically exhibit reduced physiologic reserve and a higher burden of cardiovascular, metabolic, and renal comorbidities, all of which may contribute to poorer outcomes ( 7 , 11 , 26 ). The presence of malignancy emerged as the strongest independent predictor of mortality (OR > 9). This finding is consistent with current reports showing significantly worse outcomes in oncologic patients undergoing PC, likely due to immunosuppression, systemic inflammation, malnutrition, and limited physiological reserve ( 9 , 10 ). Importantly, in this context, malignancy-related mortality may reflect the overall disease burden rather than solely biliary sepsis, highlighting the need for discussions of individualized care goals in this subgroup. Another key finding of this study is the prognostic importance of early inflammatory dynamics, particularly CRP levels measured on the third day after PC. Although baseline CRP has been investigated previously, emerging evidence suggests that post-intervention trends may better reflect treatment response and the adequacy of source control ( 1 , 2 ). Persistent elevation of inflammatory markers following source control may indicate ongoing infection, inadequate drainage, or systemic inflammatory dysregulation. Monitoring early CRP trends may therefore provide valuable information regarding treatment response and the need for intensified monitoring or therapeutic escalation. LDH also emerged as an independent predictor of mortality. Although rarely evaluated in PC-specific studies, LDH is widely recognized as a marker of cellular injury, tissue hypoxia, and systemic stress ( 27 ). Elevated LDH levels may therefore reflect global physiologic compromise rather than localized gallbladder inflammation. An additional finding of this study is the relationship between radiologic severity and early inflammatory resolution. By integrating key imaging features into a simplified radiologic severity score, we observed that higher radiologic severity was associated with less pronounced reductions in CRP following percutaneous cholecystostomy. These findings suggest that imaging-defined local inflammatory burden may influence the biological response to drainage even when it does not independently determine mortality. Previous studies have suggested that radiologic indicators such as gallbladder perforation, pericholecystic fluid, and emphysematous cholecystitis may reflect more advanced local inflammation and may be associated with complicated disease courses ( 1 , 13 , 14 ). However, few studies have examined how these imaging findings relate specifically to outcomes following PC. More recently, imaging-based predictive approaches have been proposed to support early recognition of complicated cholecystitis, suggesting that radiologic severity may contribute to structured bedside risk stratification even when used alongside clinical and laboratory variables ( 15 ). Interestingly, in our cohort, radiologic severity was not independently associated with mortality. This observation aligns with contemporary sepsis literature suggesting that systemic host response often outweighs local anatomical severity in determining clinical outcomes ( 15 , 28 , 29 ). In other words, once drainage has been achieved, systemic physiological reserve and inflammatory response may play a more dominant role than the initial anatomic extent of gallbladder disease. Nevertheless, the association between radiologic severity and inflammatory resolution observed in this study suggests that imaging findings may still provide useful complementary information regarding disease burden and early treatment response. Integrating radiologic severity with clinical and laboratory markers may therefore represent a more comprehensive strategy for risk stratification in patients undergoing percutaneous cholecystostomy. From a clinical perspective, the integration of age, malignancy, LDH, and day-3 CRP into a simple predictive framework may facilitate early risk stratification. Because these parameters are routinely available in clinical practice, the model could assist clinicians in identifying patients requiring closer monitoring, early intensive care evaluation, or reassessment of treatment strategy. The strong discriminative performance of the combined model (AUC 0.914) suggests that integrating simple clinical and laboratory parameters may allow reliable bedside risk stratification in patients undergoing percutaneous cholecystostomy. Visualization of the model using a forest plot and simplified nomogram further highlights its potential clinical applicability, while decision curve analysis demonstrates that the model provides meaningful net clinical benefit across clinically relevant threshold probabilities. Strengths and Limitations This study has several strengths. First, it includes a relatively large consecutive cohort of patients undergoing PC. Second, comprehensive clinical, laboratory, and radiologic data were analyzed. Third, the predictive model demonstrated strong discriminative ability and was internally validated using cross-validation techniques. Nevertheless, several limitations should be acknowledged. The retrospective single-center design may limit generalizability. Additionally, although the event rate was sufficient for multivariable modeling, external validation in independent cohorts will be necessary before clinical implementation. 5. Conclusion In patients undergoing percutaneous cholecystostomy for acute cholecystitis, in-hospital mortality appears to be primarily driven by baseline physiologic vulnerability and early systemic inflammatory response rather than procedural factors alone. A predictive model incorporating age, malignancy, LDH, and post-procedural day-3 CRP demonstrated strong prognostic performance and may facilitate early risk stratification in this high-risk population. Radiologic severity markers were associated with early inflammatory recovery but showed limited association with mortality or hospital length of stay. These findings suggest that imaging-derived severity scores may provide complementary information regarding disease burden and treatment response when integrated with clinical and laboratory predictors. Prospective multicenter studies are warranted to externally validate these findings and further refine integrated prognostic models in patients undergoing percutaneous cholecystostomy. Abbreviations AC Acute Cholecystitis ALP Alkaline phosphatase ALT Alanine aminotransferase AST Aspartate aminotransferase AUC Area under the curve BUN Blood urea nitrogen CI Confidence intervals CK Creatine kinase CRP C-reactive protein GGT Gamma-glutamyl transferase INR International normalized ratio LDH Lactate dehydrogenase OR Odds ratios PC Percutaneous cholecystostomy PLT Platelet count ROC Receiver operating characteristic RSS Radiologic severity score WBC White blood cell Declarations Ethics approval and consent to participate: The study protocol was approved by the University of Health Sciences, Gazi Yaşargil Training and Research Hospital Institutional Ethics Committee (Approval No:03.02.2026-105), and the requirement for informed consent was waived due to the retrospective nature of the study. The study was conducted in accordance with the Declaration of Helsinki and relevant reporting guidelines for observational studies. Consent for publication: Not applicable Competing interests: The authors declare that they have no competing interests. Funding: No funding is required for the study. Author Contribution - **Conceptualization:** AS, SK- **Data curation:** AS, SK- **Formal analysis:** AS, SK- **Funding acquisition:** None- **Investigation:** AS, SK- **Methodology:** AS, SK- **Project administration:** AS, SK- **Resources:** AS, SK- **Software:** AS, SK- **Supervision:** AS, SK- **Validation:** AS, SK- **Visualization:** AS, SK- **Writing-original draft:** AS, SK- **Writing-review & editing:** AS, SK Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Mencarini L, Vestito A, Zagari RM, Montagnani M. The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach. J Clin Med. 2024;13:2695. Fugazzola P, Podda M, Tian BW, Cobianchi L, Ansaloni L, Catena F. 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Continuous variables Variable Median (IQR) Mean±SD Age (years) 67.0 (54.0–80.0) 64.9±17.1 Stay duration (days) 5.0 (4.0–6.0) 6.2±5.5 WBC (10 3 /µL) 12.7 (10.0–16.8) 13.9±6.4 PLT (10 3 /µL) 246.0 (195.0–318.8) 259.2±107.6 CRP 0. day (mg/L) 216.0 (104.7–327.8) 215.1±121.3 CRP 3rd day (mg/L) 72.6 (43.9–107.5) 78.6±50.2 Urea (mg/dL) 39.0 (26.0–57.0) 51.8±31.0 Creatinin (mg/dL) 0.9 (0.7–1.2) 1.1±0.9 AST (U/L) 31.0 (22.0–55.0) 82.7±142.3 ALT (U/L) 28.0 (15.0–60.0) 73.3±121.1 Total bilirubin (mg/dL) 1.0 (0.6–1.9) 2.2±2.3 Direct bilirubin (mg/dL) 0.7 (0.4–1.6) 1.3±1.7 INR 1.3 (1.1–1.4) 1.3±0.3 WBC: White Blood Cell, PLT: Platelet , CRP: C-reactive protein , AST: Aspartate Aminotransferase , ALT: Alanine Aminotransferase, INR: The international normalised ratio . Table 1B. Categorical variables Variable Category n (%) Gender Male 150 (56.4%) Female 116 (43.6%) Gallstones Yes 217 (81.6%) No 49 (18.4%) Pericholecystic fluid Yes 161 (60.5%) No 105 (39.5%) Gallbladder perforation Yes 52 (19.5%) No 214 (80.5%) Emphysematous cholecystitis Yes 10 (3.8%) No 256 (96.2%) PC Complication Yes 23 (8.6%) No 243 (91.4%) Bile Culture * Yes 113 (42.5%) No 153 (57.5%) Malignancy Yes 28 (10.5%) No 238 (89.5%) Surrgery Yes 143 (53.8%) No 123 (46.2%) Hospital outcome Discharged 246 (92.5%) Exitus 20 (7.5%) * Bile culture obtained from the gallbladder , PC: Percutaneous Cholecystostomy. Table 2A. Evaluation of continuous variables using the Mann-Whitney U test. Discharge Group (n=246) Exitus Group (n=20) Variable Median (IQR) Median (IQR) p Age (years) 65.0 (52.0–79.0) 78.0 (71.0–83.0) 0.001 CRP 0. day (mg/L) 217.8 (111.5–328.7) 186.1 (69.8–265.7) 0.096 CRP 3rd day (mg/L) 71.3 (41.5–103.9) 135.2 (75.6–147.5) 0.001 WBC (10 3 /µL) 12.4 (9.8–16.6) 16.5 (12.4–19.3) 0.019 Urea (mg/dL) 38.0 (26.0–55.0) 62.0 (43.2–91.2) 0.001 LDH 224.0 (97-815) 305.0 (220-2369) 0.001 Total bilirubin (mg/dL) 0.9 (0.6–1.8) 1.2 (0.9–3.0) 0.041 AST (U/L) 29.0 (21.0–52.0) 48.0 (34.8–87.0) 0.001 ALT(U/L) 26.1 (14.0–57.1) 40.0 (32.0–73.2) 0.032 Stay duration (days) 5.0 (4.0–6.0) 9.0 (4.0–16.0) 0.010 CRP: C-reactive protein, WBC: White Blood Cell, LDH: Lactate dehydrogenase , AST: Aspartate Aminotransferase , ALT: Alanine Aminotransferase. Table 2B. Evaluation of categorical variables using Fisher's exact test. Discharged Group (n=246) Exitus Group (n=20) Variable (%) (%) p Gender (Male) 135 (54.9%) 15 (75.0%) 0.102 Presence of gallstones (Yes) 199 (80.9%) 18 (90.0%) 0.547 Pericholecystic effusion (Yes) 147 (59.8%) 14 (70.0%) 0.478 Bile Culture a (Yes) 107 (43.5%) 6 (30.0%) 0.347 PC Complication (Yes) 23 (9.3%) 0 (0.0%) 0.233 Malignancy (Yes) 20 (8.1%) 8 (40.0%) <0.001 Operation (Yes) 143 (58.1%) 0 (0.0%) <0.001* a Bile culture obtained from the gallbladder. PC: Percutaneous Cholecystostomy. * Caution should be exercised when interpreting results for the operation variable due to the possibility of time bias (mentioned in the discussion below). Table3A. Multivariate logistic regression for in-hospital mortality. Variable OR %95 GH p Age (per 10-year increase) 2.06 1.25–3.39 <0.01 LDH (per 100 U/L increase) 1.86 1.23–2.81 <0.01 CRP day 3 (per 50 mg/L increase) 2.17 1.32–3.55 <0.01 Malignancy 9.19 2.71–31.22 <0.001 LDH: Lactate dehydrogenase, CRP: C-reactive protein. Table 3B. Candidate Predictors Predictor Direction of Risk Older age ↑ mortality Malignancy ↑↑ mortality Higher LDH ↑ mortality Higher CRP day 3 ↑ mortality LDH: Lactate dehydrogenase , CRP: C-reactive protein. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 11 May, 2026 Reviews received at journal 08 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 08 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers invited by journal 05 Apr, 2026 Editor invited by journal 21 Mar, 2026 Editor assigned by journal 19 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 15 Mar, 2026 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9130949","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617969376,"identity":"cd89497b-5df8-4c25-96ab-32680348cf36","order_by":0,"name":"Ayhan SENOL","email":"","orcid":"","institution":"University of Health Sciences, Gazi Yasargil Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ayhan","middleName":"","lastName":"SENOL","suffix":""},{"id":617969377,"identity":"cb861cee-ec1a-40ce-a81e-51476de4b7ac","order_by":1,"name":"Seyhmus KAVAK","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYBADAyBmZvjYAGIzNh4gWgvjzAYGCaCWBuK1MPOCtTAw4NUi38B8+OPXtnvG/DOSHxvb7rCp020/DLSlxiYap+kH2BKMZduKzSRupBkn555JkzA7kwjUciwttwGng3gMkiXbEmwYzhwwPpzbdljC7ABQC2PDYZxa5Bt4DA6DtMifOf75sCVIy/mH+LUwHOAxbPzYlmBmcLzHOJkRpOUGAVsMDrMlMzOcSzA2PN5TbNjblia57QbQlgQ8fpFvbz788UdZguG8w+ybJX622fCbnU9/+OBDjQ1uhzEDEQ+GaAIu5VDA+IOAglEwCkbBKBjhAAA1il+53Y4xEwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Health Sciences, Gazi Yasargil Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Seyhmus","middleName":"","lastName":"KAVAK","suffix":""}],"badges":[],"createdAt":"2026-03-15 20:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9130949/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9130949/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106728255,"identity":"f31020ed-faa3-43d7-9d2b-7f561152920d","added_by":"auto","created_at":"2026-04-12 18:42:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89520,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow diagram of patient selection and inclusion.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9130949/v1/bb95f734240ad9ac55683a66.png"},{"id":106702763,"identity":"cb0b2ef1-d022-4ba7-8287-3fe32e92cfaf","added_by":"auto","created_at":"2026-04-12 07:35:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24046,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot showing the odds ratios and 95% confidence intervals of independent predictors of in-hospital mortality identified in the multivariable logistic regression model.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9130949/v1/bc43f74350d516f38d0febef.png"},{"id":106702764,"identity":"7d333226-9720-4ae5-843f-fa6c2ee938be","added_by":"auto","created_at":"2026-04-12 07:35:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":43481,"visible":true,"origin":"","legend":"\u003cp\u003eROC curves for predictors of in-hospital mortality after percutaneous cholecystostomy.\u003cbr\u003e\nThe combined model (age, malignancy, LDH, and day-3 CRP) demonstrated the highest discriminative.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9130949/v1/e05e1a58667f1bd98915b976.png"},{"id":106728747,"identity":"7274de9f-7e56-4ca9-953a-f12bf8084722","added_by":"auto","created_at":"2026-04-12 18:44:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1387374,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9130949/v1/856a933f-219e-4c4c-b98e-7cf47ac83161.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of In-Hospital Mortality After Percutaneous Cholecystostomy in Acute Cholecystitis","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAcute cholecystitis (AC) is one of the most common causes of emergency surgical admissions worldwide and represents a major contributor to morbidity and urgent biliary interventions, particularly among elderly and medically complex patients. Current evidence indicates that although early laparoscopic cholecystectomy remains the definitive treatment for most patients, a substantial subgroup cannot safely undergo immediate surgery due to advanced age, severe sepsis, organ dysfunction, or significant comorbid conditions (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). As the global population continues to age and multimorbidity becomes increasingly prevalent, the number of patients considered high risk for operative intervention is steadily increasing. Consequently, alternative treatment strategies are receiving growing attention (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePercutaneous cholecystostomy (PC) has emerged as a well-established minimally invasive option for source control in high-risk patients with acute cholecystitis. The procedure enables rapid decompression of the inflamed gallbladder, facilitates infection control, and can be performed under imaging guidance with high technical success rates and relatively low immediate complication rates (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In contemporary clinical practice, PC is used either as a temporary bridge to delayed cholecystectomy or as definitive treatment in patients considered permanently unfit for surgery. However, despite its favorable procedural safety profile, clinical outcomes after PC remain heterogeneous. While many patients demonstrate rapid clinical improvement, others experience persistent systemic inflammation, clinical deterioration, the need for reintervention, or in-hospital death (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReported mortality rates following PC vary substantially across studies, reflecting differences in patient selection, baseline physiologic reserve, infection severity, and institutional treatment algorithms. Recent systematic reviews and cohort analyses emphasize that mortality in this population is primarily driven by underlying patient-related factors rather than the technical aspects of the intervention itself (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This observation highlights an important clinical reality: PC is most often performed in patients who are already critically ill or physiologically fragile, making early prognostic assessment particularly important.\u003c/p\u003e \u003cp\u003eAccurate early identification of patients at high risk of adverse outcomes following PC has important clinical implications. Reliable risk stratification may guide decisions regarding the level of monitoring, need for intensive care admission, optimization of antimicrobial therapy, and timing\u0026mdash;or even avoidance\u0026mdash;of definitive surgical intervention. Furthermore, objective predictive models may assist clinicians in counseling patients and their families, facilitating shared decision-making, and optimizing allocation of limited healthcare resources. Despite this clear clinical need, existing prognostic data remain inconsistent, and widely accepted predictive tools specifically tailored for patients undergoing PC are lacking (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRoutine laboratory biomarkers represent a promising and pragmatic approach to outcome prediction because they are inexpensive, universally available, and rapidly obtainable. Inflammatory markers reflecting the systemic response to infection, such as C-reactive protein (CRP) and leukocyte count, as well as biochemical indicators of tissue injury or physiologic stress, such as lactate dehydrogenase (LDH), have been investigated as prognostic indicators in acute inflammatory and septic conditions. Emerging evidence suggests that dynamic changes in these markers\u0026mdash;particularly early post-intervention trends\u0026mdash;may provide more meaningful prognostic information than baseline values alone (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Nevertheless, the prognostic significance of early laboratory trajectories after PC remains insufficiently characterized, and data integrating clinical, biochemical, and imaging variables into a unified predictive framework are limited.\u003c/p\u003e \u003cp\u003eIn addition to systemic biomarkers, radiologic findings reflecting the local inflammatory burden may also provide complementary prognostic information. Imaging features such as gallbladder perforation, emphysematous cholecystitis, pericholecystic fluid, and gallbladder wall thickening have been associated with more severe disease presentations and complicated clinical courses (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, the role of radiologic severity in predicting outcomes following percutaneous cholecystostomy remains incompletely understood (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, there is a clear need for a simple, clinically applicable, and evidence-based model capable of identifying patients at increased risk of mortality after percutaneous cholecystostomy. Addressing this gap is essential for improving early clinical decision-making and tailoring management strategies in this vulnerable population.\u003c/p\u003e \u003cp\u003eThis study, beyond identifying clinical and laboratory predictors of mortality, also aimed to investigate whether radiologic severity markers could be integrated into a simplified radiologic severity score and whether this score is associated with mortality risk or early inflammatory response following PC.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design and Population\u003c/h2\u003e \u003cp\u003eThis retrospective observational cohort study was conducted at a tertiary referral center and included consecutive adult patients who underwent image-guided percutaneous cholecystostomy for the treatment of acute cholecystitis between January 1, 2022 and December 31, 2025.\u003c/p\u003e \u003cp\u003eThe study protocol was approved by the University of Health Sciences, Gazi Yaşargil Training and Research Hospital Institutional Ethics Committee (Approval No:03.02.2026-105), and the requirement for informed consent was waived due to the retrospective nature of the study. The study was conducted in accordance with the Declaration of Helsinki and relevant reporting guidelines for observational studies.\u003c/p\u003e \u003cp\u003ePatients and relevant demographic, laboratory, and radiological data were obtained from the hospital electronic medical record system.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePatients meeting all of the following criteria were included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;18 years\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDiagnosis of acute cholecystitis based on clinical, laboratory, and imaging findings\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTreatment with percutaneous cholecystostomy\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePatients were excluded if they met any of the following criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMissing essential clinical or laboratory data\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCholecystostomy performed for non-inflammatory etiologies (e.g., malignant biliary obstruction without cholecystitis)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePrevious gallbladder intervention, including prior PC or biliary surgery\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Percutaneous Cholecystostomy Procedure\u003c/h2\u003e \u003cp\u003eAll procedures were performed under imaging guidance (ultrasound and/or fluoroscopy) by two experienced interventional radiologists (A.S. and Ş.K.) using standard sterile technique and local anesthesia, with or without conscious sedation.\u003c/p\u003e \u003cp\u003eThe access route (transhepatic or transperitoneal), catheter diameter (6F, 8F, or 10F), and technical approach were determined by the operator, taking into account patient anatomy and clinical conditions.\u003c/p\u003e \u003cp\u003eTechnical success was defined as successful placement of a drainage catheter within the gallbladder lumen with immediate bile drainage.\u003c/p\u003e \u003cp\u003eProcedure-related complications included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003epericholecystic abscess or fluid collection\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ecatheter dislodgement or obstruction\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ehemorrhage through the catheter tract or intra-abdominal bleeding\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003esevere pain preventing catheter tolerance\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection\u003c/h2\u003e \u003cp\u003eTo minimize bias, all consecutive eligible patients within the study period were included. Predefined variables were systematically collected, and patients with missing key data were excluded.\u003c/p\u003e \u003cp\u003eDemographic, clinical, laboratory, radiologic, and procedural variables were extracted from electronic medical records.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDemographic and clinical variables\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eage\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003esex\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ecomorbidities (diabetes mellitus, hypertension, cardiac disease, pulmonary disease, renal disease, neurologic disease, liver disease, malignancy)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLaboratory parameters\u003c/b\u003e \u003c/p\u003e \u003cp\u003eInflammatory markers:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ewhite blood cell count (WBC)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eplatelet count (PLT)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eC-reactive protein (baseline and day 3)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eHepatopancreatobiliary function tests:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ealanine aminotransferase (ALT)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003easpartate aminotransferase (AST)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ealkaline phosphatase (ALP)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003egamma-glutamyl transferase (GGT)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eamylase\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ebilirubin levels (total, direct, indirect)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003einternational normalized ratio (INR)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eRenal function tests:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eblood urea nitrogen (BUN)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ecreatinine\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTissue injury markers:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003elactate dehydrogenase (LDH)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ecreatine kinase (CK)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Radiologic Severity Score\u003c/h2\u003e \u003cp\u003eTo quantify the radiologic burden of gallbladder inflammation, a radiologic severity score (RSS) was constructed based on predefined imaging findings derived from previous radiologic severity descriptions in acute cholecystitis (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne point was assigned for each of the following radiologic features:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003epresence of pericholecystic fluid\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003egallbladder perforation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eemphysematous cholecystitis\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003egallbladder wall thickness\u0026thinsp;\u0026ge;\u0026thinsp;7 mm\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe total score ranged from 0 to 4 points.\u003c/p\u003e \u003cp\u003ePatients were categorized into three groups:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLow severity: RSS 0\u0026ndash;1\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntermediate severity: RSS\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHigh severity: RSS 3\u0026ndash;4\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe association between RSS and clinical outcomes including hospital length of stay and inflammatory response (CRP reduction) was evaluated.\u003c/p\u003e \u003cp\u003e \u003cb\u003eProcedural variables\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ecatheter size used for PC\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ebile culture results\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eneed for revision or additional intervention\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Outcome Measures\u003c/h2\u003e \u003cp\u003eThe primary endpoint of the study was in-hospital mortality after PC.\u003c/p\u003e \u003cp\u003eSecondary outcomes included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ethe relationship between radiological severity score and mortality\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eclinical recovery status at discharge\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eneed for subsequent cholecystectomy\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePC-related complications\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical Analysis\u003c/h2\u003e \u003cp\u003eThe distribution of continuous variables was assessed using the Kolmogorov\u0026ndash;Smirnov test and visual inspection of histograms.\u003c/p\u003e \u003cp\u003eNormally distributed variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, whereas non-normally distributed variables were expressed as median and interquartile range (IQR). Categorical variables were summarized as frequencies and percentages.\u003c/p\u003e \u003cp\u003eComparisons between survivors and non-survivors were performed using Student\u0026rsquo;s t-test or Mann\u0026ndash;Whitney U test for continuous variables, and chi-square or Fisher\u0026rsquo;s exact test for categorical variables.\u003c/p\u003e \u003cp\u003eFor analyses involving the radiologic severity score, differences in hospital length of stay and CRP reduction across RSS categories were assessed using the Kruskal\u0026ndash;Wallis test. When appropriate, Spearman correlation analysis was used to evaluate relationships between continuous radiologic variables (e.g., gallbladder wall thickness) and laboratory parameters.\u003c/p\u003e \u003cp\u003eVariables demonstrating statistical significance in univariable analyses or considered clinically relevant were entered into multivariable logistic regression analysis to identify independent predictors of in-hospital mortality. Effect estimates were reported as odds ratios (OR) with 95% confidence intervals (CI).\u003c/p\u003e \u003cp\u003eModel discrimination was assessed using receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC). Internal validation of the predictive model was performed using k-fold cross-validation. A two-tailed p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics version 24.\u003c/p\u003e \u003c/div\u003e"},{"header":"3.Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Patient Characteristics\u003c/h2\u003e \u003cp\u003eA total of 357 patients who underwent percutaneous cholecystostomy (PC) for acute cholecystitis were initially screened. Among them, 91 patients were excluded due to missing data (n\u0026thinsp;=\u0026thinsp;58), previous history of PC (n\u0026thinsp;=\u0026thinsp;20), or cholecystostomy performed for non-inflammatory etiologies (n\u0026thinsp;=\u0026thinsp;13). Consequently, 266 patients were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe mean age was 64.9\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1 years, and 150 patients (56.4%) were male. Gallstones were present in 81.6% of cases, pericholecystic fluid in 60.5%, gallbladder perforation in 19.5%, and emphysematous cholecystitis in 3.8%.\u003c/p\u003e \u003cp\u003eThe catheter size was 8F in 75.9%, 6F in 15.4%, and 10F in 8.6% of procedures. Positive bile culture growth was detected in 42.5% of patients, with Escherichia coli (28.2%) being the most frequently isolated organism.\u003c/p\u003e \u003cp\u003eProcedure-related complications occurred in 23 patients (8.6%). Subsequent cholecystectomy was performed in 53.8% of cases. The overall in-hospital mortality rate was 7.5% (n\u0026thinsp;=\u0026thinsp;20) (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Comparison Between Survivors and Non-Survivors\u003c/h2\u003e \u003cp\u003ePatients who died during hospitalization were significantly older than survivors (median 78 vs 65 years, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eSeveral laboratory parameters were significantly higher in non-survivors, including:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLDH (median 305 vs 224 U/L, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCRP on post-procedural day 3 (median 135.1 vs 71.3 mg/L, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUrea (median 62 vs 38 mg/dL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAST (48 vs 29 U/L, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWBC (16.5 vs 12.4 \u0026times;10\u0026sup3;/\u0026micro;L, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)(Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e2\u003c/span\u003eA).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eMalignancy was significantly more frequent in the non-survivor group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Other chronic comorbidities did not show a statistically significant difference between groups.\u003c/p\u003e \u003cp\u003eRadiological severity findings such as gallbladder perforation, pericholecystic fluid, and emphysematous cholecystitis were numerically more frequent among non-survivors but did not reach statistical significance (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Multivariable Predictors of In-Hospital Mortality\u003c/h2\u003e \u003cp\u003eVariables demonstrating statistical significance or clinical relevance in univariable analyses were entered into a multivariable logistic regression model.\u003c/p\u003e \u003cp\u003eThe final parsimonious model identified four independent predictors of mortality:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLDH\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePost-procedural day-3 CRP\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePresence of malignancy\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese findings suggest that both baseline patient vulnerability (age, malignancy) and early biochemical response to treatment (CRP day 3 and LDH) independently predict mortality after PC (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e3\u003c/span\u003eA and \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e3\u003c/span\u003eB)(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Predictive Performance of the Model\u003c/h2\u003e \u003cp\u003eThe multivariable model demonstrated excellent discriminative ability, with an apparent ROC-AUC of 0.914.\u003c/p\u003e \u003cp\u003eInternal validation using 5-fold cross-validation yielded a corrected AUC of 0.895, indicating robust predictive performance with minimal overfitting (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Secondary Outcomes\u003c/h2\u003e \u003cp\u003eThe presence of gallstones and gallbladder perforation were significantly associated with prolonged hospital stay (p\u0026thinsp;=\u0026thinsp;0.009 and p\u0026thinsp;=\u0026thinsp;0.029, respectively). Pericholecystic fluid was significantly associated with a greater reduction in CRP levels following percutaneous cholecystostomy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant association was observed between gallbladder wall thickness and either hospital length of stay or CRP reduction.\u003c/p\u003e \u003cp\u003eProcedure-related complications occurred in 23 patients (8.6%). No significant association was observed between catheter size or access route and mortality.\u003c/p\u003e \u003cp\u003ePatients who subsequently underwent cholecystectomy were significantly younger and had fewer comorbid conditions. Notably, all patients who underwent surgery survived.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Radiologic Severity Score and Clinical Outcomes\u003c/h2\u003e \u003cp\u003eA radiologic severity score ranging from 0 to 4 was calculated for all patients. Increasing RSS values were associated with differences in inflammatory response following percutaneous cholecystostomy.\u003c/p\u003e \u003cp\u003eAbsolute CRP reduction differed significantly across RSS categories (p\u0026thinsp;=\u0026thinsp;0.041), as did percentage CRP reduction (p\u0026thinsp;=\u0026thinsp;0.029). Patients with higher RSS values demonstrated a less pronounced reduction in inflammatory markers during early follow-up.\u003c/p\u003e \u003cp\u003eIn contrast, although hospital length of stay tended to increase with higher RSS categories, the overall difference did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.100).\u003c/p\u003e \u003cp\u003eThese findings suggest that radiologic disease burden may be more closely related to early inflammatory recovery than to crude hospital discharge timing.\u003c/p\u003e \u003c/div\u003e"},{"header":"4.Discussion","content":"\u003cp\u003eIn this retrospective cohort study of patients undergoing percutaneous cholecystostomy for acute cholecystitis, we identified age, malignancy, LDH level, and post-procedural day-3 CRP as independent predictors of in-hospital mortality. Importantly, the predictive model demonstrated excellent discrimination, highlighting the combined prognostic importance of baseline patient vulnerability and early inflammatory dynamics.\u003c/p\u003e \u003cp\u003eOver the past decade, PC has become an established treatment modality for high-risk patients with acute cholecystitis who are considered unsuitable for immediate surgery (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Several studies have reported technical success rates exceeding 90%, supporting PC as a reliable method for rapid gallbladder decompression and infection control (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, mortality after PC remains clinically significant and largely reflects the underlying physiologic status of the treated population rather than procedural complications (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mortality rate observed in our cohort (7.5%) is consistent with contemporary studies reporting mortality rates ranging from 5% to 10% in similar patient populations (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Importantly, previous investigations have shown that systemic illness severity\u0026mdash;rather than local gallbladder pathology\u0026mdash;is the dominant determinant of outcome in patients undergoing PC.\u003c/p\u003e \u003cp\u003eOur results further reinforce the critical role of patient frailty, particularly advanced age and malignancy. Age has repeatedly been identified as one of the strongest predictors of mortality in patients with acute cholecystitis managed with PC (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Elderly patients typically exhibit reduced physiologic reserve and a higher burden of cardiovascular, metabolic, and renal comorbidities, all of which may contribute to poorer outcomes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe presence of malignancy emerged as the strongest independent predictor of mortality (OR\u0026thinsp;\u0026gt;\u0026thinsp;9). This finding is consistent with current reports showing significantly worse outcomes in oncologic patients undergoing PC, likely due to immunosuppression, systemic inflammation, malnutrition, and limited physiological reserve (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Importantly, in this context, malignancy-related mortality may reflect the overall disease burden rather than solely biliary sepsis, highlighting the need for discussions of individualized care goals in this subgroup.\u003c/p\u003e \u003cp\u003eAnother key finding of this study is the prognostic importance of early inflammatory dynamics, particularly CRP levels measured on the third day after PC. Although baseline CRP has been investigated previously, emerging evidence suggests that post-intervention trends may better reflect treatment response and the adequacy of source control (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Persistent elevation of inflammatory markers following source control may indicate ongoing infection, inadequate drainage, or systemic inflammatory dysregulation. Monitoring early CRP trends may therefore provide valuable information regarding treatment response and the need for intensified monitoring or therapeutic escalation.\u003c/p\u003e \u003cp\u003eLDH also emerged as an independent predictor of mortality. Although rarely evaluated in PC-specific studies, LDH is widely recognized as a marker of cellular injury, tissue hypoxia, and systemic stress (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Elevated LDH levels may therefore reflect global physiologic compromise rather than localized gallbladder inflammation.\u003c/p\u003e \u003cp\u003eAn additional finding of this study is the relationship between radiologic severity and early inflammatory resolution. By integrating key imaging features into a simplified radiologic severity score, we observed that higher radiologic severity was associated with less pronounced reductions in CRP following percutaneous cholecystostomy. These findings suggest that imaging-defined local inflammatory burden may influence the biological response to drainage even when it does not independently determine mortality.\u003c/p\u003e \u003cp\u003ePrevious studies have suggested that radiologic indicators such as gallbladder perforation, pericholecystic fluid, and emphysematous cholecystitis may reflect more advanced local inflammation and may be associated with complicated disease courses (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, few studies have examined how these imaging findings relate specifically to outcomes following PC. More recently, imaging-based predictive approaches have been proposed to support early recognition of complicated cholecystitis, suggesting that radiologic severity may contribute to structured bedside risk stratification even when used alongside clinical and laboratory variables (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterestingly, in our cohort, radiologic severity was not independently associated with mortality. This observation aligns with contemporary sepsis literature suggesting that systemic host response often outweighs local anatomical severity in determining clinical outcomes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In other words, once drainage has been achieved, systemic physiological reserve and inflammatory response may play a more dominant role than the initial anatomic extent of gallbladder disease.\u003c/p\u003e \u003cp\u003eNevertheless, the association between radiologic severity and inflammatory resolution observed in this study suggests that imaging findings may still provide useful complementary information regarding disease burden and early treatment response. Integrating radiologic severity with clinical and laboratory markers may therefore represent a more comprehensive strategy for risk stratification in patients undergoing percutaneous cholecystostomy.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, the integration of age, malignancy, LDH, and day-3 CRP into a simple predictive framework may facilitate early risk stratification. Because these parameters are routinely available in clinical practice, the model could assist clinicians in identifying patients requiring closer monitoring, early intensive care evaluation, or reassessment of treatment strategy.\u003c/p\u003e \u003cp\u003eThe strong discriminative performance of the combined model (AUC 0.914) suggests that integrating simple clinical and laboratory parameters may allow reliable bedside risk stratification in patients undergoing percutaneous cholecystostomy. Visualization of the model using a forest plot and simplified nomogram further highlights its potential clinical applicability, while decision curve analysis demonstrates that the model provides meaningful net clinical benefit across clinically relevant threshold probabilities.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and Limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has several strengths. First, it includes a relatively large consecutive cohort of patients undergoing PC. Second, comprehensive clinical, laboratory, and radiologic data were analyzed. Third, the predictive model demonstrated strong discriminative ability and was internally validated using cross-validation techniques.\u003c/p\u003e \u003cp\u003eNevertheless, several limitations should be acknowledged. The retrospective single-center design may limit generalizability. Additionally, although the event rate was sufficient for multivariable modeling, external validation in independent cohorts will be necessary before clinical implementation.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn patients undergoing percutaneous cholecystostomy for acute cholecystitis, in-hospital mortality appears to be primarily driven by baseline physiologic vulnerability and early systemic inflammatory response rather than procedural factors alone.\u003c/p\u003e \u003cp\u003eA predictive model incorporating age, malignancy, LDH, and post-procedural day-3 CRP demonstrated strong prognostic performance and may facilitate early risk stratification in this high-risk population.\u003c/p\u003e \u003cp\u003eRadiologic severity markers were associated with early inflammatory recovery but showed limited association with mortality or hospital length of stay. These findings suggest that imaging-derived severity scores may provide complementary information regarding disease burden and treatment response when integrated with clinical and laboratory predictors.\u003c/p\u003e \u003cp\u003eProspective multicenter studies are warranted to externally validate these findings and further refine integrated prognostic models in patients undergoing percutaneous cholecystostomy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute Cholecystitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eALP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlkaline phosphatase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eALT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlanine aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAST\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAspartate aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAUC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArea under the curve\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBUN\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlood urea nitrogen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence intervals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCK\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCreatine kinase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCRP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGGT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGamma-glutamyl transferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eINR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational normalized ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eLDH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLactate dehydrogenase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds ratios\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous cholecystostomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePLT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePlatelet count\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eROC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReceiver operating characteristic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRSS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRadiologic severity score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWBC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWhite blood cell\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the University of Health Sciences, Gazi Yaşargil Training and Research Hospital Institutional Ethics Committee (Approval No:03.02.2026-105), and the requirement for informed consent was waived due to the retrospective nature of the study. The study was conducted in accordance with the Declaration of Helsinki and relevant reporting guidelines for observational studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eThe\u003c/strong\u003e authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eNo funding is required for the study.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003e- **Conceptualization:** AS, SK- **Data curation:** AS, SK- **Formal analysis:** AS, SK- **Funding acquisition:** None- **Investigation:** AS, SK- **Methodology:** AS, SK- **Project administration:** AS, SK- **Resources:** AS, SK- **Software:** AS, SK- **Supervision:** AS, SK- **Validation:** AS, SK- **Visualization:** AS, SK- **Writing-original draft:** AS, SK- **Writing-review \u0026amp;amp; editing:** AS, SK\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMencarini L, Vestito A, Zagari RM, Montagnani M. The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach. J Clin Med. 2024;13:2695.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFugazzola P, Podda M, Tian BW, Cobianchi L, Ansaloni L, Catena F. Clinical update on acute cholecystitis and biliary pancreatitis: between certainties and grey areas. EClinicalMedicine. 2024;77:102880.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiura F, Okamoto K, Takada T, Strasberg SM, Asbun HJ, Pitt HA, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25:31\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:55\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDai F, Cai Y, Yang S, Zhang J, Dai Y. Global burden of gallbladder and biliary diseases (1990\u0026ndash;2021) with healthcare workforce analysis and projections to 2035. BMC Gastroenterol. 2025;25:249.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarakas HM, Yildirim G, Fersahoglu MM, Findik O. Percutaneous cholecystostomy: an update for the 2020s. North Clin Istanb. 2021;8:537\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFanciulli G, Favara G, Maugeri A, Barchitta M, Agodi A, Basile G. Comparing percutaneous treatment and cholecystectomy outcomes in acute cholecystitis patients: a systematic review and meta-analysis. World J Emerg Surg. 2025;20:50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadaka AH, Tseng JF, Itani KMF. Indications for and optimal management of percutaneous cholecystostomy drainage: a systematic review. JAMA Surg. 2025;160:1368\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDogrul AB, Oru\u0026ccedil; M, Ciftci T, Hayran KM, Abbasoglu O. Factors affecting interval cholecystectomy and mortality in percutaneous cholecystostomy patients. Ulus Travma Acil Cerrahi Derg. 2022;28:1696\u0026ndash;700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLau J, Sinha S. Outcome Predictors of Percutaneous Cholecystostomy as Definitive Versus Bridging Treatment. Cureus. 2023;15:e49962.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUllah N, Kannan V, Ahmed O, Geddada S, Ibrahiam AT, Al-Qassab ZM, Malasevskaia I. Effectiveness and Safety of Cholecystectomy Versus Percutaneous Cholecystostomy for Acute Cholecystitis in Older and High-Risk Surgical Patients: A Systematic Review. Cureus. 2024;16:e70537.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi U, Siddique K. Outcomes of Percutaneous Cholecystostomy as a Bridging or Definitive Treatment for Acute Cholecystitis. Cureus. 2026;18:e100668.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:41\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel R, Tse JR, Shen L, Bingham DB, Kamaya A. Improving Diagnosis of Acute Cholecystitis with US: New Paradigms. Radiographics. 2024;44:e240032.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Y, Kuo N, Lin HA, Chao CC, Lee S, Tsai CH, et al. Clinical and Imaging Characteristics to Discriminate Between Complicated and Uncomplicated Acute Cholecystitis: A Regression Model and Decision Tree Analysis. Diagnostics (Basel). 2025;15:1777.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorn T, Christensen SD, Kirkeg\u0026aring;rd J, Larsen LP, Knudsen AR, Mortensen FV.. Percutaneous cholecystostomy is an effective treatment option for acute calculous cholecystitis: A 10-year experience. HPB. 2015;17:326\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel M, Miedema BW, James MA, Marshall JB. Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis. Am Surg. 2000;66:33\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMir MA, Manzoor SV, Reshi FA, Zargar WA, Jeelani S, Ahmad FF, et al. Percutaneous Cholecystostomy in high risk patients with acute cholecystitis. Surg Sci. 2017;8:154\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinbladh A, Gullstrand P, Svanvik J, Sandstr\u0026ouml;m P. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford). 2009;11:183\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnsaloni L, Pisano M, Coccolini F, Peitzmann AB, Fingerhut A, Catena F, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11:25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleming CA, Ismail M, Kavanagh RG, Heneghan HM, Prichard RS, Geoghegan J, et al. Clinical and Survival Outcomes Using Percutaneous Cholecystostomy Tube Alone or Subsequent Interval Cholecystectomy to Treat Acute Cholecystitis. J Gastrointest Surg. 2020;24:627\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\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 J Emerg Surg. 2020;15:61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoushesh P, Ayaz T, Tullius T. Percutaneous cholecystostomy: procedural guidance and future directions for clinical management. Semin Intervent Radiol. 2024;41:460\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePtasnuka M, Lazdane I, Fokins V, Kolesova O, Plaudis H. A 10-Year Study on Percutaneous Cholecystostomy for Acute Cholecystitis at a Tertiary Referral Hospital. J Clin Med. 2026;15:413.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerrone A, Di Martino M, Saeidi S, Ranucci C, Di Saverio S, Giuliani A. Percutaneous cholecystostomy in elderly patients with acute cholecystitis: a systematic review and meta-analysis. Updates Surg. 2024;76:363\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeke E, Agca B, G\u0026uuml;neş Y, Teke GN, Yaz AS, Aydin MT, et al. Percutaneous cholecystostomy in elderly patients with acute cholecystitis: Factors influencing mortality, morbidity, and length of hospital stay. Ulus Travma Acil Cerrahi Derg. 2025;31:59\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQin C, Ma D, Pang L, Hu M, Lin S, Zhou Z, et al. Prognostic factors of sepsis: a systematic review and meta-analysis. BMC Infect Dis. 2025;25:1670.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng Z, Guo C, Tang F, Ding N. Lactate dehydrogenase is an indicator for outcomes of short-term and long-term in septic patients. PLoS ONE. 2025;20:e0337213.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKorkmaz İ, Peri B, Karaali R. Assessment of systemic immune-inflammatory index and other inflammatory parameters in predicting mortality in patients with acute cholecystitis: A retrospective observational study. J Acute Disease. 2024;13:150\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1A. Continuous variables\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.0 (54.0\u0026ndash;80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.9\u0026plusmn;17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eStay duration (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.0 (4.0\u0026ndash;6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.2\u0026plusmn;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWBC (10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.7 (10.0\u0026ndash;16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.9\u0026plusmn;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePLT (10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e246.0 (195.0\u0026ndash;318.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e259.2\u0026plusmn;107.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCRP 0. day (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e216.0 (104.7\u0026ndash;327.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e215.1\u0026plusmn;121.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCRP 3rd day (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e72.6 (43.9\u0026ndash;107.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e78.6\u0026plusmn;50.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrea (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39.0 (26.0\u0026ndash;57.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51.8\u0026plusmn;31.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCreatinin (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.9 (0.7\u0026ndash;1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.1\u0026plusmn;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAST (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.0 (22.0\u0026ndash;55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.7\u0026plusmn;142.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.0 (15.0\u0026ndash;60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73.3\u0026plusmn;121.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal bilirubin (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.0 (0.6\u0026ndash;1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.2\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDirect bilirubin (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.7 (0.4\u0026ndash;1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.3\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.3 (1.1\u0026ndash;1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.3\u0026plusmn;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eWBC:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eWhite Blood Cell,\u0026nbsp;\u003c/em\u003e\u003cstrong\u003ePLT:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Platelet\u003c/em\u003e\u003cstrong\u003e, CRP:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;C-reactive protein\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;, AST:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eAspartate Aminotransferase\u003c/em\u003e, \u003cstrong\u003eALT:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eAlanine Aminotransferase,\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eINR:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eThe international normalised ratio\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1B. Categorical variables\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e150 (56.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e116 (43.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eGallstones\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e217 (81.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e49 (18.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003ePericholecystic fluid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e161 (60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e105 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGallbladder perforation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52 (19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e214 (80.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eEmphysematous cholecystitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e256 (96.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003ePC Complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e243 (91.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBile Culture\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e113 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e153 (57.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eMalignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e238 (89.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eSurrgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e143 (53.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e123 (46.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eHospital outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDischarged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e246 (92.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003eExitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e20 (7.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003eBile culture obtained from the gallbladder\u003c/em\u003e, \u003cstrong\u003ePC:\u0026nbsp;\u003c/strong\u003e\u003cem\u003ePercutaneous Cholecystostomy.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2A. Evaluation of continuous variables using the Mann-Whitney U test.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarge Group (n=246)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExitus Group (n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e65.0 (52.0\u0026ndash;79.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e78.0 (71.0\u0026ndash;83.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCRP 0. day (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e217.8 (111.5\u0026ndash;328.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e186.1 (69.8\u0026ndash;265.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRP 3rd day (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e71.3 (41.5\u0026ndash;103.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e135.2 (75.6\u0026ndash;147.5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eWBC (10\u003csup\u003e3\u003c/sup\u003e/\u0026micro;L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e12.4 (9.8\u0026ndash;16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e16.5 (12.4\u0026ndash;19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrea (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e38.0 (26.0\u0026ndash;55.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e62.0 (43.2\u0026ndash;91.2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLDH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e224.0 (97-815)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e305.0 (220-2369)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eTotal bilirubin (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e0.9 (0.6\u0026ndash;1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e1.2 (0.9\u0026ndash;3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAST (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e29.0 (21.0\u0026ndash;52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e48.0 (34.8\u0026ndash;87.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eALT(U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e26.1 (14.0\u0026ndash;57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e40.0 (32.0\u0026ndash;73.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eStay duration (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003e5.0 (4.0\u0026ndash;6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e9.0 (4.0\u0026ndash;16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCRP:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;C-reactive protein,\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eWBC:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eWhite Blood Cell,\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eLDH:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eLactate dehydrogenase\u003c/em\u003e\u003cstrong\u003e,\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAST:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eAspartate Aminotransferase\u003c/em\u003e, \u003cstrong\u003eALT:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eAlanine Aminotransferase.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2B. Evaluation of categorical variables using Fisher\u0026apos;s exact test.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDischarged Group (n=246)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eExitus Group (n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (Male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e135 (54.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePresence of gallstones (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e199 (80.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.547\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePericholecystic effusion (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e147 (59.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.478\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBile Culture\u003csup\u003ea\u003c/sup\u003e (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e107 (43.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.347\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePC Complication (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMalignancy (Yes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20 (8.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e8 (40.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOperation (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e143 (58.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eBile culture obtained from the gallbladder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePC:\u0026nbsp;\u003c/strong\u003e\u003cem\u003ePercutaneous Cholecystostomy.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e* Caution should be exercised when interpreting results for the operation variable due to the possibility of time bias (mentioned in the discussion below).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable3A. Multivariate logistic regression for in-hospital mortality.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%95 GH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 236px;\"\u003e\n \u003cp\u003eAge (per 10-year increase)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.06\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1.25\u0026ndash;3.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 236px;\"\u003e\n \u003cp\u003eLDH (per 100 U/L increase)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.86\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1.23\u0026ndash;2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 236px;\"\u003e\n \u003cp\u003eCRP day 3 (per 50 mg/L increase)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e1.32\u0026ndash;3.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 236px;\"\u003e\n \u003cp\u003eMalignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9.19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2.71\u0026ndash;31.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLDH:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Lactate dehydrogenase,\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;CRP:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;C-reactive protein.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3B. Candidate Predictors\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDirection of Risk\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eOlder age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026uarr; mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eMalignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026uarr;\u0026uarr; mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eHigher LDH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026uarr; mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eHigher CRP day 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u0026uarr; mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLDH:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Lactate dehydrogenase\u003c/em\u003e, \u003cstrong\u003eCRP:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;C-reactive protein.\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cholecystostomy, Cholecystitis, Risk Factors, Mortality, C-Reactive Protein, Lactate Dehydrogenase, Aged, Neoplasms","lastPublishedDoi":"10.21203/rs.3.rs-9130949/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9130949/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAcute cholecystitis is a frequent cause of emergency surgical admission. Percutaneous cholecystostomy (PC) is commonly used as a minimally invasive treatment option in patients considered unsuitable for early cholecystectomy. However, predictors of mortality and the role of radiologic disease severity in determining outcomes remain incompletely understood.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study including consecutive adult patients who underwent image-guided PC for acute cholecystitis at a tertiary referral hospital between January 2022 and December 2025. Clinical, laboratory, radiologic, and procedural variables were analyzed. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. A radiologic severity score (RSS) was constructed using predefined imaging findings including pericholecystic fluid, gallbladder perforation, emphysematous cholecystitis, and gallbladder wall thickness\u0026thinsp;\u0026ge;\u0026thinsp;7 mm. Associations between RSS and inflammatory response or clinical outcomes were evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 266 patients were included (mean age 64.9\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1 years; 56.4% male). The overall in-hospital mortality rate was 7.5%. Independent predictors of mortality included age (OR 1.07 per year), malignancy (OR 9.19), LDH (OR 1.006), and post-procedural day-3 CRP (OR 1.016). The predictive model demonstrated excellent discrimination with an AUC of 0.914. Internal validation using cross-validation yielded an AUC of 0.895. Higher RSS values were significantly associated with reduced CRP decline following PC (p\u0026thinsp;=\u0026thinsp;0.041), suggesting slower inflammatory resolution. However, RSS was not significantly associated with mortality or hospital length of stay.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn patients undergoing PC for acute cholecystitis, mortality is largely determined by baseline patient vulnerability and early inflammatory dynamics. Radiologic severity reflects local inflammatory burden and may complement laboratory markers in predicting inflammatory recovery.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Predictors of In-Hospital Mortality After Percutaneous Cholecystostomy in Acute Cholecystitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-12 07:35:46","doi":"10.21203/rs.3.rs-9130949/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-11T07:27:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T19:48:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174832510811940549063159402215798841815","date":"2026-05-08T19:34:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T16:56:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310612404486797906031274009777479351055","date":"2026-04-28T04:23:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85661213527320007245213073758941115104","date":"2026-04-27T09:13:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T15:06:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168788544215974300674490046032538611558","date":"2026-04-13T06:39:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-06T03:16:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-21T19:37:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-19T12:20:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T12:20:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-03-15T20:10:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f2c6660d-04c6-4667-ac61-8f26944ffda0","owner":[],"postedDate":"April 12th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-11T07:27:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T19:48:35+00:00","index":65,"fulltext":""},{"type":"reviewerAgreed","content":"174832510811940549063159402215798841815","date":"2026-05-08T19:34:12+00:00","index":64,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T16:56:50+00:00","index":63,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T07:42:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-12 07:35:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9130949","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9130949","identity":"rs-9130949","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}