AC surgical management constitutes the gold standard in all severity levels, nevertheless, in patients with severe disease and considered as high risk such as elderly, with increased operative risk due to comorbidities other management approaches are considered including percutaneous drainage of the gallbladder . Other approaches different to LC do not offer definitive treatment and could lead to re-admissions, recurrent cholecystitis, and increased risk of biliary complications [9–12]. Tokyo guidelines 2018 established ASA-PS and negative predictive factors (Jaundice, respiratory and neurological dysfunction) in order to consider or not PC, recomending percutaneous cholecystostomy and supportive treatment in case of severe AC in high surgical risk patients. 
Few recent studies have compared both techniques (LC versus PC). Garcés-Albir et al showed in 461 patients from 2005 to 2016 an increased mortality risk, higher readmission and complications in patients that underwent PC . Only one randomized clinical trial has been published up to date, The CHOCOLATE trial, showing clear advantages towards EC in terms not only on clinical outcomes but also in economical considerations .
The CHOCOLATE trial  as mentioned before, is the only randomized clinical trial that analyzes the clinical outcomes of patients treated with PC or LC for high risk patients with AC. In terms of mortality rate, in our study 3.11% (n = 9) of patients that underwent LC died versus 2.82% (n = 8) of patients that follow PC, with no statistical differences (p value = 0.09 CI 95%); comparable results with the ones obtained by Loozen et al. .
Another clinical outcome, frequently analyzed in the literature, it’s the requirement of surgical complications and need of re-intervention. In our population, 2.47% of patients that were treated with LC versus 3.88% of the cases in patients that underwent PC required reintervention, in this case with significant statistical relationship. (p = 0.004 CI 95%), and with a 4.92 increased risk-fold to require surgical revision, our data it’s similar to the one reported in the CHOCOLATE trial .
It’s well known, according to Törnqvist et al  that patients with acute cholecystitis, inflammatory process and severe disease have twice the risk of bile duct injury, however our results shows that in high risk patients with severe disease, risk of bile duct injury does not vary between patients that underwent LC or PC (Overall rate 0.16%, p value 0.12 CI 95%).
Impact in the financial burden can be considered another valuable outcome usually related and measured with the in-hospital stay . In our population, patients that followed PC have an increased length of hospitalization compared with the cases that underwent LC (mean : 15.43 days versus 9.97) with significant statistical relationship (p = 0.000 CI 95%), similar to results showed by Loozen et al in their clinical trial (mean: 9 days versus 5 days p value < 0.001) .
Complications rate constitutes a corner stone when measuring and comparing any procedures. In our study the overall rate of complications was 5.95% after 30 days of follow up, similar to that described by Radunovic et al in their study that analyzed 740 patients from 2005 to 2014 who underwent LC without taking into account AC severity . However, CHOCOLATE trial, shows a higher complication rate (12%) compared with our data; and in contrast, patients that underwent PC shows a higher rate of complications of 65% in Loozen et al data , notwithstanding data differs in terms of lower rates in both groups,results can be considered similar due to an equal rate of complications in LC group compared to PC in patients with Tokyo III grade AC (4.24%) with no statistical relationship between outcome and approach (p = 0.1 CI 95%).
Besides of other retrospective studies that shows an increased risk of morbidity and mortality in patients that underwent emergency LC due to acute cholecystitis (Morbidity 30–41% and mortality 5–6%) [8, 14, 18, 19, 20] our data shows that in comparison with non-operative approach such as PC, surgical approach with LC could be a feasible and safe procedures with lesser rates of mortality, in-hospital stay, and requirement of re-intervention, and do not increase the risk of bile duct injury or complications, supporting the lack of data that’s followed by the report of CHOCOLATE trial, and increasing the evidence in favour to surgery in high risk patients in experienced centers.
Among limitations of our study includes the retrospective nature, and the non-possibility of follow-up biliary complications, because not all the patients have re-admission in our institution. However, the sample size, and the standardized treatment with a selected interventionist radiologist, and experienced group of general surgeons in a high volume institution are included in the strengtheness of our study.