Early (≤4 Weeks) Versus Delayed (>4 Weeks) Interval Cholecystectomy After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis: A Real-World Surgical Reassessment Cohort

Early (≤4 Weeks) Versus Delayed (>4 Weeks) Interval Cholecystectomy After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis: A Real-World Surgical Reassessment Cohort | 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 Early (≤4 Weeks) Versus Delayed (>4 Weeks) Interval Cholecystectomy After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis: A Real-World Surgical Reassessment Cohort Ricardo A. González-Jaramillo, Eduardo Jordán García, Cristina Peralta Rivera, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8876749/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Management of high-risk acute cholecystitis increasingly relies on percutaneous cholecystostomy (PC) as a bridging strategy when immediate surgery is not feasible; however, real-world surgical data guiding reassessment and timing of interval cholecystectomy remain limited. Understanding how timing decisions are implemented in routine hepatobiliary practice may provide clinically meaningful insight beyond traditional comparative analyses. Methods: This pragmatic single-center retrospective cohort included adult patients with acute cholecystitis initially managed with PC who subsequently underwent definitive cholecystectomy between January 2016 and December 2025. Patients were categorized according to surgical timing: early (≤4 weeks) or delayed (>4 weeks). Primary exploratory outcomes included operative duration and estimated blood loss, while secondary descriptive outcomes comprised conversion to open surgery, postoperative complications, and mortality. Analyses were conducted descriptively in accordance with STROBE recommendations. Results: Twenty-seven patients underwent interval cholecystectomy (15 early vs. 12 delayed). Earlier surgery descriptively coincided with shorter operative duration and lower estimated blood loss. Conversion to open surgery and postoperative complications occurred in both groups. Mortality events occurred exclusively in the delayed group; however, given the descriptive design and baseline clinical heterogeneity, no causal inference regarding surgical timing can be established. Conclusions: These findings provide practice-informing real-world surgical insight into multidisciplinary reassessment after percutaneous cholecystostomy and support individualized hepatobiliary decision-making rather than fixed temporal thresholds. Trial registration: Open Science Framework (OSF). Registration DOI: https://doi.org/10.17605/OSF.IO/GR5DT Clinical trial number: Not applicable. Acute cholecystitis Percutaneous cholecystostomy Interval cholecystectomy High-risk patients Laparoscopic cholecystectomy Figures Figure 1 Figure 2 Introduction Acute cholecystitis remains one of the most common indications for emergency surgical admission worldwide. Early laparoscopic cholecystectomy is considered the standard treatment; however, a subset of patients presents with advanced comorbidities or physiological instability that precludes immediate surgery. Percutaneous cholecystostomy provides effective source control in high-risk scenarios and is supported by international guidelines; however, it is not definitive therapy and recurrent biliary events remain possible while the gallbladder remains in situ [1,2]. The optimal timing of interval cholecystectomy after percutaneous cholecystostomy remains uncertain, particularly in frail surgical populations where randomized evidence is limited and real-world operative pathways remain underreported. The four-week threshold was selected pragmatically based on commonly reported clinical reassessment intervals in hepatobiliary practice. Rather than attempting to establish comparative effectiveness, the present study intentionally prioritizes transparent reporting of real-world surgical reassessment patterns in a high-risk population frequently underrepresented in randomized trials. In contemporary hepatobiliary practice, understanding how timing decisions are implemented in real-world surgical pathways may be as clinically relevant as comparative effectiveness analyses. Accordingly, this exploratory study aimed to describe perioperative trends associated with interval cholecystectomy timing following PC in high-risk patients. METHODS Study design and setting Pragmatic observational retrospective cohort conducted at a tertiary referral center between January 2016 and December 2025. The study adhered to STROBE reporting recommendations for observational research. Participants Adult patients with acute cholecystitis initially managed with percutaneous cholecystostomy who subsequently underwent definitive cholecystectomy were included. Exposure definition Patients were categorized according to surgical timing: Early interval cholecystectomy (≤4 weeks) Delayed interval cholecystectomy (>4 weeks) Surgical timing reflected multidisciplinary reassessment based on clinical recovery, comorbidity burden, anesthetic risk, and operative feasibility rather than predefined institutional protocols. Data collection Demographics, disease severity, imaging findings, operative variables, and postoperative outcomes were extracted from electronic records using standardized institutional documentation. Primary exploratory outcomes included operative duration and estimated blood loss. Secondary descriptive outcomes comprised conversion to open surgery, postoperative complications, and mortality. Statistical approach Given the exploratory real-world design, limited sample size, and absence of randomized allocation, analyses were intentionally restricted to descriptive reporting without hypothesis testing or causal modeling. This analytical strategy was predefined to avoid overinterpretation of observational trends and to preserve clinical transparency within a real-world framework. Results Participant characteristics Twenty-seven patients underwent interval cholecystectomy (15 early vs. 12 delayed). Baseline differences reflected individualized clinical decision-making rather than protocol-driven allocation. Baseline characteristics are summarized in Table 1, disease severity in Table 2, and patient flow in Figure 1. Operative outcomes Earlier interval cholecystectomy descriptively coincided with shorter operative duration and lower estimated blood loss. These operative trends are illustrated in Figure 2A and Figure 2B, while detailed operative metrics are summarized in Table 3. Postoperative recovery Complications occurred in both groups without a consistent pattern indicating superiority. Mortality events occurred exclusively in the delayed group; however, given the exploratory descriptive design and baseline clinical heterogeneity, no causal inference regarding surgical timing can be established. Discussion Within this exploratory cohort, earlier interval cholecystectomy descriptively coincided with shorter operative duration and reduced estimated blood loss; however, these observations likely reflect individualized patient selection rather than intrinsic advantages of surgical timing. Similar descriptive trends have been suggested in observational hepatobiliary literature, where delayed surgery may be associated with fibrosis and distorted surgical planes, although causal relationships remain uncertain [2–5]. By explicitly avoiding causal claims and focusing on transparent descriptive reporting, this study aligns with current calls for high-quality real-world surgical data that complement randomized evidence in complex hepatobiliary populations. Importantly, the present investigation was not designed to evaluate comparative effectiveness or statistical superiority between timing strategies. Instead, it provides a transparent real-world description of institutional practice patterns and multidisciplinary reassessment pathways in frail hepatobiliary populations. Future multicenter prospective studies incorporating standardized frailty metrics and perioperative risk stratification are required to clarify whether surgical timing independently influences outcomes after percutaneous cholecystostomy. Within this context, the current findings should be interpreted as hypothesis-generating clinical observations intended to inform future collaborative research rather than definitive comparative conclusions. LIMITATIONS Retrospective design, potential selection bias, limited sample size precluding inferential statistical analysis, and residual confounding inherent to non-randomized surgical decision-making cannot be excluded. CLINICAL IMPLICATIONS Real-world descriptive cohorts remain valuable for informing individualized hepatobiliary surgical decision-making where randomized trials are difficult to perform. Conclusion These findings contribute practice-informing real-world insight into surgical reassessment strategies after percutaneous cholecystostomy and support individualized hepatobiliary decision-making in high-risk populations. Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Research and Ethics Committee. Due to the retrospective observational design, the requirement for informed consent was waived. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors’ contributions Ricardo A. González-Jaramillo: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Project administration. Eduardo Jordán García: Supervision, Clinical expertise, Critical revision. Cristina Peralta Rivera: Investigation, Data validation, Writing – review & editing. Carlos Javier Mata Quintero: Senior supervision, Methodological oversight, Final approval. Acknowledgements Not applicable. Registration: Open Science Framework (OSF). https://doi.org/10.17605/OSF.IO/GR5DT References Yokoe M, Takada T, Strasberg SM, et al. Tokyo Guidelines 2018: management strategies for acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:87–95. Winbladh A, Gullstrand P, Svanvik J, Sandström P. Systematic review of cholecystostomy as treatment of acute cholecystitis. HPB (Oxford). 2009;11:183–193. Altieri MS, Yang J, Obeid N, et al. Early cholecystectomy after percutaneous cholecystostomy is safe. Surg Endosc. 2019;33:3716–3722. Loftus TJ, Moore FA, VanZant EL, et al. Percutaneous cholecystostomy as a bridge to surgery. Surg Endosc. 2017;31:4907–4914. Loozen CS, Oor JE, van Santvoort HC, et al. Percutaneous drainage versus emergency cholecystectomy in high-risk patients. Surg Endosc. 2017;31:795–802. Tables Table 1. Baseline characteristics Characteristic Early (n=15) Delayed (n=12) Age (years) 72.2 ± 11.1 79.9 ± 10.0 Male sex 11 (73.3%) 7 (58.3%) BMI (kg/m²) 23.9 ± 3.0 26.9 ± 5.9 ASA ≥ III 8 (53.3%) 3 (25.0%) Hypertension 14 (93.3%) 14 (93.3%) CAD 7 (46.7%) 4 (33.3%) CHF 3 (20.0%) 5 (41.7%) COPD/Asthma 3 (20.0%) 3 (25.0%) CKD 1 (6.7%) 3 (25.0%) Diabetes 9 (60.0%) 5 (41.7%) Table 2. Disease severity and imaging findings Characteristic Early Delayed Tokyo grade III 8 (53.3%) 4 (33.3%) APACHE II 14.9 ± 5.8 13.8 ± 4.3 Leukocytes 13.3 ± 4.6 14.6 ± 5.0 Empyema 10 (66.7%) 6 (50.0%) Perforation 3 (20.0%) 1 (8.3%) Gangrenous 6 (40.0%) 6 (50.0%) Table 3. Operative outcomes Characteristic Early Delayed Operative time (min) 83.5 ± 36.4 120.8 ± 31.9 Estimated blood loss (mL) 185.8 ± 131.3 305.0 ± 143.3 Conversion to open 2 (13.3%) 4 (33.3%) Any complication 2 (13.3%) 4 (33.3%) Surgical site infection 0 2 (16.7%) Biliary leak 0 1 (8.3%) DVT 0 1 (8.3%) Mortality 0 6 (50.0%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8876749","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595700942,"identity":"004e74c9-1136-4cf8-8c17-50f2d11d9b55","order_by":0,"name":"Ricardo A. 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Early laparoscopic cholecystectomy is considered the standard treatment; however, a subset of patients presents with advanced comorbidities or physiological instability that precludes immediate surgery. Percutaneous cholecystostomy provides effective source control in high-risk scenarios and is supported by international guidelines; however, it is not definitive therapy and recurrent biliary events remain possible while the gallbladder remains in situ [1,2].\u003c/p\u003e\n\u003cp\u003eThe optimal timing of interval cholecystectomy after percutaneous cholecystostomy remains uncertain, particularly in frail surgical populations where randomized evidence is limited and real-world operative pathways remain underreported. The four-week threshold was selected pragmatically based on commonly reported clinical reassessment intervals in hepatobiliary practice. Rather than attempting to establish comparative effectiveness, the present study intentionally prioritizes transparent reporting of real-world surgical reassessment patterns in a high-risk population frequently underrepresented in randomized trials. In contemporary hepatobiliary practice, understanding how timing decisions are implemented in real-world surgical pathways may be as clinically relevant as comparative effectiveness analyses.\u003c/p\u003e\n\u003cp\u003eAccordingly, this exploratory study aimed to describe perioperative trends associated with interval cholecystectomy timing following PC in high-risk patients.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePragmatic observational retrospective cohort conducted at a tertiary referral center between January 2016 and December 2025. The study adhered to STROBE reporting recommendations for observational research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdult patients with acute cholecystitis initially managed with percutaneous cholecystostomy who subsequently underwent definitive cholecystectomy were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExposure definition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were categorized according to surgical timing:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eEarly interval cholecystectomy (≤4 weeks)\u003c/li\u003e\n \u003cli\u003eDelayed interval cholecystectomy (\u0026gt;4 weeks)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSurgical timing reflected multidisciplinary reassessment based on clinical recovery, comorbidity burden, anesthetic risk, and operative feasibility rather than predefined institutional protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographics, disease severity, imaging findings, operative variables, and postoperative outcomes were extracted from electronic records using standardized institutional documentation.\u003c/p\u003e\n\u003cp\u003ePrimary exploratory outcomes included operative duration and estimated blood loss. Secondary descriptive outcomes comprised conversion to open surgery, postoperative complications, and mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the exploratory real-world design, limited sample size, and absence of randomized allocation, analyses were intentionally restricted to descriptive reporting without hypothesis testing or causal modeling. This analytical strategy was predefined to avoid overinterpretation of observational trends and to preserve clinical transparency within a real-world framework.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-seven patients underwent interval cholecystectomy (15 early vs. 12 delayed). Baseline differences reflected individualized clinical decision-making rather than protocol-driven allocation. Baseline characteristics are summarized in Table 1, disease severity in Table 2, and patient flow in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEarlier interval cholecystectomy descriptively coincided with shorter operative duration and lower estimated blood loss. These operative trends are illustrated in Figure 2A and Figure 2B, while detailed operative metrics are summarized in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplications occurred in both groups without a consistent pattern indicating superiority. Mortality events occurred exclusively in the delayed group; however, given the exploratory descriptive design and baseline clinical heterogeneity, no causal inference regarding surgical timing can be established.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWithin this exploratory cohort, earlier interval cholecystectomy descriptively coincided with shorter operative duration and reduced estimated blood loss; however, these observations likely reflect individualized patient selection rather than intrinsic advantages of surgical timing. Similar descriptive trends have been suggested in observational hepatobiliary literature, where delayed surgery may be associated with fibrosis and distorted surgical planes, although causal relationships remain uncertain [2–5].\u003c/p\u003e\n\u003cp\u003eBy explicitly avoiding causal claims and focusing on transparent descriptive reporting, this study aligns with current calls for high-quality real-world surgical data that complement randomized evidence in complex hepatobiliary populations. Importantly, the present investigation was not designed to evaluate comparative effectiveness or statistical superiority between timing strategies. Instead, it provides a transparent real-world description of institutional practice patterns and multidisciplinary reassessment pathways in frail hepatobiliary populations.\u003c/p\u003e\n\u003cp\u003eFuture multicenter prospective studies incorporating standardized frailty metrics and perioperative risk stratification are required to clarify whether surgical timing independently influences outcomes after percutaneous cholecystostomy. Within this context, the current findings should be interpreted as hypothesis-generating clinical observations intended to inform future collaborative research rather than definitive comparative conclusions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRetrospective design, potential selection bias, limited sample size precluding inferential statistical analysis, and residual confounding inherent to non-randomized surgical decision-making cannot be excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCLINICAL IMPLICATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReal-world descriptive cohorts remain valuable for informing individualized hepatobiliary surgical decision-making where randomized trials are difficult to perform.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThese findings contribute practice-informing real-world insight into surgical reassessment strategies after percutaneous cholecystostomy and support individualized hepatobiliary decision-making in high-risk populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Research and Ethics Committee. Due to the retrospective observational design, the requirement for informed consent was waived.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions\u003c/p\u003e\n\u003cp\u003eRicardo A. González-Jaramillo: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft, Writing – review \u0026amp; editing, Project administration.\u003c/p\u003e\n\u003cp\u003eEduardo Jordán García: Supervision, Clinical expertise, Critical revision.\u003c/p\u003e\n\u003cp\u003eCristina Peralta Rivera: Investigation, Data validation, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eCarlos Javier Mata Quintero: Senior supervision, Methodological oversight, Final approval.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eRegistration: Open Science Framework (OSF). https://doi.org/10.17605/OSF.IO/GR5DT\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eYokoe M, Takada T, Strasberg SM, et al. Tokyo Guidelines 2018: management strategies for acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:87\u0026ndash;95.\u003c/li\u003e\n \u003cli\u003eWinbladh A, Gullstrand P, Svanvik J, Sandstr\u0026ouml;m P. Systematic review of cholecystostomy as treatment of acute cholecystitis. HPB (Oxford). 2009;11:183\u0026ndash;193.\u003c/li\u003e\n \u003cli\u003eAltieri MS, Yang J, Obeid N, et al. Early cholecystectomy after percutaneous cholecystostomy is safe. Surg Endosc. 2019;33:3716\u0026ndash;3722.\u003c/li\u003e\n \u003cli\u003eLoftus TJ, Moore FA, VanZant EL, et al. Percutaneous cholecystostomy as a bridge to surgery. Surg Endosc. 2017;31:4907\u0026ndash;4914.\u003c/li\u003e\n \u003cli\u003eLoozen CS, Oor JE, van Santvoort HC, et al. Percutaneous drainage versus emergency cholecystectomy in high-risk patients. Surg Endosc. 2017;31:795\u0026ndash;802.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Baseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCharacteristic\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEarly (n=15)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDelayed (n=12)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAge (years)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.2 \u0026plusmn; 11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e79.9 \u0026plusmn; 10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMale sex\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (73.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBMI (kg/m\u0026sup2;)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.9 \u0026plusmn; 3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.9 \u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eASA \u0026ge; III\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (53.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHypertension\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (93.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (93.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCAD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCHF\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOPD/Asthma\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCKD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eDiabetes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Disease severity and imaging findings\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCharacteristic\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEarly\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDelayed\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eTokyo grade III\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (53.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAPACHE II\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.9 \u0026plusmn; 5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.8 \u0026plusmn; 4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLeukocytes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.3 \u0026plusmn; 4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.6 \u0026plusmn; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEmpyema\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePerforation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eGangrenous\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Operative outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCharacteristic\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEarly\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDelayed\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOperative time (min)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83.5 \u0026plusmn; 36.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e120.8 \u0026plusmn; 31.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEstimated blood loss (mL)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e185.8 \u0026plusmn; 131.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e305.0 \u0026plusmn; 143.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eConversion to open\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAny complication\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSurgical site infection\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBiliary leak\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eDVT\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMortality\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute cholecystitis, Percutaneous cholecystostomy, Interval cholecystectomy, High-risk patients, Laparoscopic cholecystectomy","lastPublishedDoi":"10.21203/rs.3.rs-8876749/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8876749/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eManagement of high-risk acute cholecystitis increasingly relies on percutaneous cholecystostomy (PC) as a bridging strategy when immediate surgery is not feasible; however, real-world surgical data guiding reassessment and timing of interval cholecystectomy remain limited. Understanding how timing decisions are implemented in routine hepatobiliary practice may provide clinically meaningful insight beyond traditional comparative analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis pragmatic single-center retrospective cohort included adult patients with acute cholecystitis initially managed with PC who subsequently underwent definitive cholecystectomy between January 2016 and December 2025. Patients were categorized according to surgical timing: early (≤4 weeks) or delayed (\u0026gt;4 weeks). Primary exploratory outcomes included operative duration and estimated blood loss, while secondary descriptive outcomes comprised conversion to open surgery, postoperative complications, and mortality. Analyses were conducted descriptively in accordance with STROBE recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eTwenty-seven patients underwent interval cholecystectomy (15 early vs. 12 delayed). Earlier surgery descriptively coincided with shorter operative duration and lower estimated blood loss. Conversion to open surgery and postoperative complications occurred in both groups. Mortality events occurred exclusively in the delayed group; however, given the descriptive design and baseline clinical heterogeneity, no causal inference regarding surgical timing can be established.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThese findings provide practice-informing real-world surgical insight into multidisciplinary reassessment after percutaneous cholecystostomy and support individualized hepatobiliary decision-making rather than fixed temporal thresholds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eOpen Science Framework (OSF).\u003cstrong\u003e\u003cbr\u003e\nRegistration DOI: \u003c/strong\u003ehttps://doi.org/10.17605/OSF.IO/GR5DT\u003cstrong\u003e\u003cbr\u003e\nClinical trial number: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Early (≤4 Weeks) Versus Delayed (\u0026gt;4 Weeks) Interval Cholecystectomy After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis: A Real-World Surgical Reassessment Cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 16:13:25","doi":"10.21203/rs.3.rs-8876749/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb126d41-94e4-452e-adf4-81935b53c8f4","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T12:54:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 16:13:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8876749","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8876749","identity":"rs-8876749","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}