The influence of percutaneous cholecystostomy duration on optimizing surgical outcomes and timing of interval cholecystectomy in ASA II patients with grade II-III acute calculous cholecystitis.

Abstract

Purpose: Despite medical progress and laparoscopic cholecystectomy being standard for Grade II-III acute calculous cholecystitis in ASA II patients, optimal management, especially the timing of cholecystectomy (early vs. delayed) considering morbidity, risk-benefit, and cost, is still debated. While percutaneous cholecystostomy is definitive for ASA III/IV patients, its role as a bridge to cholecystectomy and the ideal interval in ASA II medically refractory cases remain unclear.

Methods: This retrospective study assessed the impact of initial percutaneous cholecystostomy on the timing, duration, and type of subsequent elective cholecystectomy in ASA Class II patients with Tokyo Grade II-III acute calculous cholecystitis. Percutaneous cholecystostomy was performed in patients with moderate cholecystitis unresponsive to conservative management and in those with severe cholecystitis presenting with negative predictive factors indicating a high risk of conservative treatment failure and perioperative complications. In both groups, the procedure served as a bridging intervention to stabilize patients before definitive surgery. The primary aim was to evaluate the effects of this strategy on surgical timing, complexity, and overall treatment outcomes.

Results: Of the 176 patients initially admitted with acute cholecystitis, 97 met the inclusion criteria, comprising those with Tokyo Grade II-III disease and classified as ASA II. Among patients who underwent laparoscopic cholecystectomy more than eight weeks after percutaneous cholecystostomy, 77% experienced prolonged operative durations, defined as procedures exceeding 60 min. Delayed surgical intervention in this specific cohort was consistently associated with a marked increase in both intraoperative complexity and technical difficulty during the laparoscopic cholecystectomy.

Conclusions: The liberal use of percutaneous cholecystostomy in patients with Tokyo Grade II-III acute calculous cholecystitis is not recommended. When percutaneous cholecystostomy is necessary as a bridging intervention prior to definitive surgical management, early laparoscopic cholecystectomy should remain the preferred approach in the majority of ASA II cases. Percutaneous cholecystostomy should be reserved for patients who are unresponsive to conservative treatment or present with contraindications to immediate surgery.