Multicenter analysis of the efficacy of early cholecystectomy and preoperative cholecystostomy for severe acute cholecystitis: A retrospective study of data from the multi-institutional database of the Hiroshima Surgical Study Group of Clinical Oncology

Abstract Background Severe acute cholecystitis (AC) is a challenging disease because it comprises coexisting systemic infections that lead to vital organ dysfunction. This study evaluated the optimal surgical timing and efficacy of preoperative percutaneous cholecystostomy (PC) for patients with severe AC. Methods Data of 142 patients who underwent cholecystectomy for severe AC between 2011 and 2021 were retrospectively collected from a multi-institutional database of the Hiroshima Surgical Study Group of Clinical Oncology and divided into the early cholecystectomy (EC) group (within 72 hours of symptom onset) and delayed cholecystectomy (DC) group. Patients were also subdivided into the upfront cholecystectomy group and preoperative PC after cholecystectomy group. The diagnosis and severity of AC were graded according to the Tokyo Guidelines 2018. Clinicopathological variables and outcomes were compared. Results No significant differences in age, body mass index, American Society Anesthesiologist (ASA) classification, and Carlson comorbidity index were observed between the EC and DC groups. Preoperative drainage was more commonly performed in the DC group than in the EC group. Local severe AC features were more commonly detected in the DC group than in the EC group. The postoperative outcomes of the EC and DC groups were comparable. The upfront cholecystectomy group included more patients with ASA physical status ≥ 3 and patients who used oral warfarin than the preoperative PC after cholecystectomy group. Warfarin usage and cardiovascular dysfunction rates of the PC after cholecystectomy group were higher than those of the upfront cholecystectomy group. PC was associated with significantly less intraoperative bleeding and shorter hospital stays. Conclusions Patients who can tolerate general anesthesia are good candidates for EC. Patients who use warfarin and those with cardiovascular dysfunction are considered to be at high risk; therefore, PC after cholecystectomy is a better choice than upfront cholecystectomy for these patients.