Acute cholecystitis in high-risk patients: a systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma (EAST).

Abstract

Background: High-risk patients with acute calculous cholecystitis (ACC) require an individualized approach and may not be eligible for cholecystectomy. The aim of this systematic review was to evaluate the management of ACC in patients with either high operative risk or delayed presentation.

Methods: An evidence-based systematic review was performed to answer the Population, Intervention, Comparator, Outcomes (PICO) questions. This systematic review was registered with PROSPERO (CRD42024610156). An academic health science librarian and lead authors developed the search strategy. The search was conducted in Medline (Ovid), Embase (Elsevier), Cochrane CENTRAL (Ovid), and Web of Science. The search strategy was written for Medline and translated using each database's syntax, subject headings, and search fields. An initial search, conducted on August 3, 2020, was updated on June 5, 2025.

Results: A total of 25 studies were identified. We conditionally recommend that high-risk patients with ACC undergo treatment with antibiotics alone versus using percutaneous cholecystostomy (PC) and antibiotics. No recommendation was made to treat patients with ACC with more than 5 days of symptoms with either cholecystectomy or antibiotics. No recommendation was made to treat patients with ACC with more than 5 days of symptoms with PC or antibiotics. We conditionally recommend removing the PC catheter without performing cholecystectomy after resolution of ACC in high-risk patients who have evidence of cystic duct patency.

Conclusion: Risks of cholecystectomy and PC must be balanced in patients who are high-risk for operative management.

Level of evidence: Level III, systematic review and meta-analysis.