Timing of surgery in acute cholecystitis

The Tokyo Guidelines 2018 are the standard for diagnosis and severity grading, and most trials and other guidelines use them (Yokoe et al., J Hepatobiliary Pancreat Sci 2018). Guideline Mortality figures are from the Japanese and Taiwanese cohorts used to derive TG18 and vary with the population. The American Association for the Surgery of Trauma (AAST) grades anatomical severity instead (grade I acute cholecystitis; II empyema, gangrene or emphysema; III perforation with local contamination; IV perforation with abscess or fistula; V perforation with generalised peritonitis), which correlates better with operative difficulty than the Tokyo grade (Madni et al., J Trauma Acute Care Surg 2019). The 2020 multi-society consensus suggests using TG18, AAST or another validated system. Guideline

• The Cochrane review of six randomised trials (488 patients) found no difference in bile duct injury or serious complications between early laparoscopic cholecystectomy (within 7 days of presentation) and delayed surgery (after 6 weeks). Early surgery shortened the total hospital stay by about 4 days, and about 18 percent of delayed patients needed an urgent operation while waiting (Gurusamy et al., Cochrane 2013).
• The German ACDC trial randomised 618 patients to cholecystectomy within 24 hours of admission or to antibiotics and surgery at 7 to 45 days. Morbidity at 75 days was 11.8 percent with immediate surgery and 34.4 percent with delayed treatment, with shorter stay and lower cost in the early group (Gutt et al., Ann Surg 2013).
• NICE Quality Standard 104 requires laparoscopic cholecystectomy within one week of diagnosis, or, if this cannot be done, after the episode has settled, more than four weeks later (NICE QS104). Guideline
• WSES 2020 strongly recommends early laparoscopic cholecystectomy as soon as possible: within 7 days of admission and within 10 days of symptom onset, provided the surgeon is experienced. It recommends delaying beyond 6 weeks only when early surgery is not possible (Pisano et al., WSES 2020). Guideline

The 72-hour question. Operating within 72 hours of symptom onset is easier, and the 2020 multi-society consensus gives a conditional recommendation for surgery within 72 hours for mild disease (Brunt et al., Ann Surg 2020). Patients presenting later than 72 hours still do better with surgery on the same admission than with delayed surgery, with higher conversion and subtotal rates as the price. The consensus made no recommendation on timing for moderate or severe disease because the evidence was insufficient. Contested Whether surgery remains safe beyond 7 to 10 days of symptoms is genuinely uncertain: observational data suggest higher conversion and complication rates. Operate early where possible, accept that day 8 to 10 will be harder, and keep a low threshold for bail-out in the late presenter.

Flowchart: Okamoto et al., 2018. Guideline TG18 also lists the safe steps for the operation and the bail-out options when the Critical View of Safety cannot be obtained (Wakabayashi et al., 2018). The Delphi work behind TG18 identified 25 intra-operative findings that define difficulty, described on the difficulty page.

The CHOCOLATE trial randomised 142 high-risk patients (APACHE II score 7 to 14) with acute calculous cholecystitis to laparoscopic cholecystectomy or percutaneous drainage. Major complications occurred in 12 percent of the surgery group and 65 percent of the drainage group. Reintervention was needed in 12 percent versus 66 percent, and recurrent biliary disease occurred in 5 percent versus 53 percent. The trial was stopped early for benefit (Loozen et al., BMJ 2018). WSES recommends laparoscopic cholecystectomy over percutaneous drainage in operable high-risk patients (strong recommendation, high-quality evidence). TG18 uses a different, grade-specific pathway incorporating CCI, ASA-PS, organ dysfunction and advanced-centre expertise; it should not be described as the same recommendation. See the TG18 criteria above. CHOCOLATE should not be extrapolated to patients too unstable or unfit to meet its selection criteria. Guideline

Endoscopic drainage (transpapillary stenting, or endoscopic-ultrasound-guided drainage with a lumen-apposing metal stent) is an alternative in centres with the expertise. WSES suggests it may be preferred to percutaneous drainage where available (Pisano et al., WSES 2020; Mori et al., TG18 drainage). Contested Long-term data and the question of later cholecystectomy through a stented gallbladder are unresolved.

After a cholecystostomy. If the patient recovers and is fit, interval cholecystectomy is suggested, usually at 6 to 8 weeks (some units operate earlier). The tube is kept until then or until a tube cholangiogram shows a patent cystic duct. In patients who remain unfit, the tube can be removed after a cholangiogram shows a patent cystic duct and no stones, accepting a risk of recurrence. The 2020 multi-society consensus suggests interval cholecystectomy for fit patients and non-surgical management for unfit patients. Guideline

AMBROSE prospective cohort: AMBROSE Collaborative, Ann Surg 2025. Systematic review of 99 studies and 326,517 patients: mortality after laparoscopic cholecystectomy about seven times higher in the elderly, with roughly twice the complication and conversion rates (Kamarajah et al., Surg Endosc 2020).