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

doi:10.21203/rs.3.rs-4649552/v1

Download PDF

Research Article

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

https://doi.org/10.21203/rs.3.rs-4649552/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

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.

early cholecystectomy

severe acute cholecystitis

Tokyo guidelines 2018

Acute cholecystitis (AC) is a common disease that requires surgical intervention¹ in accordance with the criteria^{2, 3} established by the Tokyo Guidelines 2013. Previous studies and the Tokyo Guidelines 2013 suggested that the optimal timing for surgery is 72 hours from symptom onset^{4, 5}. AC severity is graded as mild (grade I), moderate (grade II), or severe (grade III), and these grades are associated with postoperative outcomes and the rates of conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC)^{6, 7}. The revised Tokyo Guidelines 2018 (TG18) proposed treatment strategies for AC according to its severity⁸. Grade III AC is a systemic infectious condition with local inflammation that has a significantly higher mortality rate than grade I and grade II AC⁹. Because organ dysfunction is caused by systemic infection associated with grade III AC, the TG18 recommend initial treatment comprising antibiotics and multidisciplinary methods.

According to the TG18 flowchart for grade III AC, early LC is only recommended when it can be performed at an advanced laparoscopic surgery center, when there is a possibility of organ system failure, and when the patients do not have risk factors that preclude such treatment. LC has several advantages over OC for AC; for example, LC reduces intraoperative bleeding, shortens the postoperative hospital stay, and reduces postoperative complications^{10, 11}. Early LC is recommended by the TG18 for grade I and grade II AC; however, the optimal surgical timing for grade III is unclear. Early LC is strongly associated with shorter hospital stays and fewer postoperative complications¹². According to the TG18 treatment strategy for grade III AC, preoperative percutaneous cholecystostomy (PC) is a possible approach for patients with a severe general condition as determined by the ASA classification and Charlson comorbidity index⁶. Because grade III AC presents with systemic infection and local inflammation, a poor general condition complicates the decision of whether to perform upfront surgery or PC after LC. Thus, the efficacy of preoperative PC for grade III AC is controversial. During this study, we aimed to determine the optimal surgical intervention and efficacy of preoperative PC for grade III AC.

Patient population and selection

A total of 142 patients diagnosed with AC after cholecystectomy according to the TG18 between May 2011 and August 2021 were enrolled in this study. The measured variables were sex, age, body mass index, American Society of Anesthesiologists (ASA) physical status, and Charlson comorbidity index. Laboratory data and computed tomography (CT) findings were collected preoperatively. Emergency magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were routinely performed to observe the anatomy of the extrahepatic bile duct, prevent intraoperative injury to the common bile duct, and detect an accessory hepatic duct. This study was approved by the local review board, and written informed consent was obtained from all patients.

Surgical and PC procedures

The consultant surgeon determined whether to perform LC, bailout surgery, or OC. These operative methods have been described previously(¹²). The first choice of treatment was LC using the widely accepted four-port procedure. The decision to convert LC to bailout surgery was made by the attending surgeon. Bailout surgery comprised open conversion, subtotal cholecystectomy, and fenestration. PC was performed under local anesthesia using transabdominal ultrasonography. A drainage tube was inserted in the gallbladder (8-Fr pigtail) and kept open until the completion of surgery.

Preoperative CT findings

CT was performed to analyze nine parameters of AC according to previously reported measurements¹³. These parameters included poor contrast of the gallbladder wall, gallbladder neck wall thickness, gallbladder neck wall with poor contrast, severe inflammation around the gallbladder, gallstone in the gallbladder neck, disruption of the cystic artery, enhancement of the liver bed, and duodenal edema. The gallbladder neck wall thickness was defined as ≥ 4 mm. An increased concentration of fatty tissue around the gallbladder was defined as severe inflammation around the gallbladder. Duodenal edema was defined as thickening of the intestinal wall confined to the area adjacent to the gallbladder. CT evaluations were performed within 14 days before surgery, and CT images were interpreted by two surgeons.

Morbidity and complications

Complications were defined according to the classification described by Clavien et al.¹⁴. During this study, postoperative complications were defined as those classified as grade IIIa or higher. Hospital death was defined as death that occurred within 90 days postoperatively.

Statistical analysis

Continuous variables are presented as medians and ranges, and categorical variables are presented as numbers (percentages). Continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using Fisher’s exact test. Data were analyzed using a one-way analysis of variance. P < 0.05 was considered statistically significant. The cutoff values for albumin and C-reactive protein were estimated according to a receiver-operating characteristic curve analysis. Statistical analyses were performed using IBM Statistical Package for Social Sciences for Windows version 22.0 (IBM Corp., Armonk, NY, USA).

A total of 142 patients enrolled in this study underwent emergency cholecystectomy for grade III AC between April 2011 and December 2021. Of these patients, 91 (64%) were male and 41 (36%) were female. Eighty-five (60%) of these patients were older than 80 years of age at the time of surgery. Grade III dysfunctions were defined as cardiovascular (n = 30), neurological (n = 20), respiratory (n = 14), renal (n = 45), hepatic (n = 51), and hematological (n = 51).

Comparison of perioperative characteristics of patients with grade III AC in the early cholecystectomy and delayed cholecystectomy groups

Table 1 presents the characteristics of patients with grade III AC after early cholecystectomy (EC) (n = 81) and delayed cholecystectomy (DC) (n = 61). Significant differences in sex (p = 0.02), albumin level (p = 0.02), and direct oral anticoagulant usage (p = 0.03) were observed. Grade III severity was compared between the EC and DC groups. Preoperative CT findings such as abdominal abscess (p = 0.03), inflammation around the gallbladder (p = 0.04), ascites (p < 0.01), and pleural effusion (p < 0.01) were more frequently detected in the DC group than in the EC group. No significant differences in intraoperative bleeding, operative time, and bailout surgery were observed between these groups (Table 2). Postoperative complications with Clavien-Dindo classification III-IV occurred in 12 (15%) patients in the EC group and 8 (13%) patients in the DC group. Three patients in the EC group and three patients in the DC group experienced 90-day mortality.

Comparison of perioperative characteristics of patients with grade III AC in the upfront surgery and preoperative PC groups

The preoperative PC group included significantly fewer patients with ASA physical status ≥ 3 than the EC group (p = 0.004) (Table 3). Eight (19%) patients in the preoperative PC group and seven (7%) patients in the upfront surgery group used warfarin (p = 0.03). Among the various types of grade III AC dysfunction, cardiovascular dysfunction (p = 0.02) occurred more frequently in the preoperative PC group than in the upfront surgery group. The preoperative CT findings and surgical types were similar in these two groups. LC was performed for 44 (44%) patients in the upfront surgery group and 23 (55%) patients in the preoperative PC group (Table 4). Bailout surgery was performed for 44 (44%) patients in the upfront surgery group and 17 (40%) patients in the preoperative PC group. The intraoperative bleeding volume in the PC group was lower than that in the upfront surgery group (p = 0.04). Although the operative times of the two groups were equal, the length of the hospital stay of the PC group was significantly shorter than that of the upfront surgery group (p < 0.01). Postoperative complications such as bile duct injury did not differ between these two groups. Ninety-day morality did not occur in the PC group; however, six (6%) patients in the upfront surgery group died. The median time from PC to cholecystectomy was 8 days (0–60 days) (Fig. 1), and no postoperative complications occurred 7 days after PC.

The postoperative complications and hospital stays of patients with grade III AC in this study indicated that both EC and DC were safely performed. Additionally, preoperative PC reduced intraoperative bleeding and the need for blood transfusions, but upfront surgery did not. Compared to upfront surgery, preoperative PC resulted in significantly shorter postoperative hospital stays. Importantly, patients who underwent preoperative PC did not experience 90-day postoperative mortality. This is the first multi-institutional study to evaluate the optimal surgical timing and efficacy of preoperative PC specifically for grade III AC.

Gut et al. reported that EC is associated with shorter mean hospital stays and lower total hospital costs than those associated with DC¹⁵. Other studies have reported lower rates of bile duct injury and postoperative complications with EC than with DC^{4, 5, 16}. Surgical timing reported by several studies ranged from the day of symptom onset to within 7 days after symptom onset; however, these patients had grade I and grade II AC^{5, 12, 16, 17}. According to the TG18, antibiotics, correction of hydroelectrolytic disorders, and PC are recommended as the initial treatment for grade III AC⁶. EC is strictly limited to advanced laparoscopic centers. Our data suggested that the conversion rates and postoperative complication rates of EC and LC did not differ between patients with grade III AC. EC may be acceptable if the patient’s condition allows for general anesthesia. However, further randomized studies should be performed to evaluate the optimal surgical timing of AC because it has a high mortality rate.

Whether preoperative gallbladder drainage is necessary for patients with grade III AC is uncertain. Compared to LC and OC, PC tube placement was associated with fewer postoperative complications and lower hospital costs for patients with acalculous AC¹⁸. Patients who use direct oral anticoagulants and warfarin and require percutaneous transhepatic gallbladder aspiration are at high risk for postprocedural complications such as bleeding. Percutaneous transhepatic gallbladder aspiration is a bridging therapy that allows the safe performance of cholecystectomy. Percutaneous transhepatic gallbladder aspiration is performed to decompress the gallbladder; therefore, recurring AC caused by insufficient drainage during percutaneous transhepatic gallbladder aspiration is problematic. However, because percutaneous transhepatic gallbladder aspiration is safe and minimally invasive, it is widely used for patients with AC^{19, 20}. Abe et al. reported that preoperative cholecystostomy is useful and safe, especially for grade III AC²¹. Another study reported that patients who underwent PC had higher rates of postprocedural morbidity and mortality and longer hospital stays²². This study emphasized that older patients with AC should undergo cholecystectomy unless there are prohibitive surgical risks. Upfront surgery is not optimal for patients who are at high risk because of their age, ASA physical status, and severe local inflammation. Intraoperative bleeding and blood transfusions were significantly reduced among patients who underwent preoperative PC rather than upfront surgery. Preoperative PC can ease severe local inflammation caused by gallbladder drainage and strongly reduce intraoperative bleeding.

Bile duct injury is the most alarming complication. When bile duct injury occurs, repeated endoscopic retrograde cholangiopancreatography, liver resection, and liver transplantation could be required. Bailout surgery comprises various procedures, including conversion from LC to open surgery, the fundus-first approach, and subtotal cholecystectomy. However, the optimal approach is unclear. Conrad et al. recommended the fundus-first approach with partial cholecystectomy to avoid bile duct injury²³. Compared with the ordinal approach, the fundus-first approach can reduce the incidence of bile duct injury²⁴. In contrast, subtotal cholecystectomy is the most efficacious and safest procedure for preventing bile duct injury when a critical view of safety cannot be achieved. During our previous study, we found that laparoscopic bailout surgery, including that comprising the fundus-first approach or subtotal approach, was associated with less excessive intraoperative bleeding and shorter hospital stays compared to those associated with conversion surgery. During this study, approximately 50% of cases required bailout surgery, and this may have contributed to the prevention of bile duct injury associated with grade III AC.

Although this study had some strengths, such as the use of a multi-institutional database, it also had some limitations. This was a retrospective study with a relatively small number of patients. The attending surgeons chose the surgical approach and determined whether to perform gallbladder drainage or upfront surgery based on their previous experience. Surgical timing after gallbladder drainage was strongly dependent on the policy of the facility. Further prospective studies should be performed to evaluate the optimal surgical timing and efficacy of preoperative gallbladder drainage for grade III AC.

In conclusion, preoperative PC can prevent excessive bleeding and shorten the postoperative hospital stay. When a surgical approach to necrotizing cholecystitis is required and conservative treatment is unsuccessful, EC should be considered.

Ethical Approval

This study was approved by the ethics committee of Hiroshima University Hospital [Approval No.: E2023-0050].

Consent to Participate

All methods were performed in accordance with the relevant guidelines and regulations and informed consent was obtained from all participants.

Consent for Publication

Not applicable

Funding

None.

Competing Interests

The authors declare that they have no competing interests.

Data Availability statement

The datasets used and/or during current study are available from the corresponding author on reasonable request.

Acknowledgments

We would like to thank the Center of Life Science at Hiroshima University for the use of their facilities. We would also like to thank all the individuals who contributed to this work.

Disclosure of potential conflicts of interest

The following authors declare that they have no conflicts of interest:

Tomoyuki Abe, MD, PhD; Tsuyoshi Kobayashi, MD, Ph.D.; Shintaro Kuroda, MD, Ph.D.; Michinori Hamaoka, MD, PhD.; Hiroaki Mashima, MD, Ph.D.; Takashi Onoe, MD, Ph.D, Naruhiko Honmyo, MD, Ph.D.; Koichi Oishi, MD, Ph.D.; Hideki Ohdan, MD, Ph.D.

Authors Contributions

TA and SK wrote the manuscript. The remaining authors contributed to data collection, analysis, and interpretation. TK, MH, MH, MM, TO, AH, OK, HM, NH, KO and HO performed the surgeries. All authors conceived the study, participated in its design and coordination, and helped draft the manuscript. All authors have read and approved the final manuscript for publication.

Wadhwa V, Jobanputra Y, Garg SK, Patwardhan S, Mehta D, Sanaka MR. Nationwide trends of hospital admissions for acute cholecystitis in the United States. Gastroenterol Rep (Oxf). 2017;5:36–42.
Sekimoto M, Takada T, Kawarada Y, Nimura Y, Yoshida M, Mayumi T, Miura F, Wada K, Hirota M, Yamashita Y, Strasberg S, Pitt HA, Belghiti J, de Santibanes E, Gadacz TR, Hilvano SC, Kim SW, Liau KH, Fan ST, Belli G, Sachakul V. Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14:11–4.
Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, itt HA, Gouma DJ, Garden OJ, Büchler MW, Kiriyama S, Kimura Y, Tsuyuguchi T, Itoi T, Yoshida M, Miura F, Yamashita Y, Okamoto K, Gabata T, Hata J, Higuchi R, Windsor JA, Bornman PC, Fan ST, Singh H, de Santibanes E, Kusachi S, Murata A, Chen XP, Jagannath P, Lee S, Padbury R, Chen MF, Tokyo Guidelines Revision Committee. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci. 2012;19:578–85.
Blohm M, Osterberg J, Sandblom G, Lundell L, Hedberg M, Enochsson L. (2017) The sooner, the better? The importance of optimal timing of cholecystectomy in acute cholecystitis: data from the National Swedish Registry for Gallstone Surgery, GallRiks. J Gastrointest Surg 2017;21:33–40.
Polo M, Duclos A, Polazzi S, Payet C, Lifante JC, Cotte E, Barth X, Glehen O, Passot G. Acute cholecystitis-optimal timing for early cholecystectomy: a French Nationwide Study. J Gastrointest Surg. 2015;19:2003–10.
Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, Iwashita Y, Hibi T, Pitt HA, Umezawa A, Asai K, Han HS, Hwang TL, Mori Y, Yoon YS, Huang WS, Belli G, Dervenis C, Yokoe M, Kiriyama S, Itoi T, Jagannath P, Garden OJ, Miura F, Nakamura M, Horiguchi A, Wakabayashi G, Cherqui D, de Santibañes E, Shikata S, Noguchi Y, Ukai T, Higuchi R, Wada K, Honda G, Supe AN, Yoshida M, Mayumi T, Gouma DJ, Deziel DJ, Liau KH, Chen MF, Shibao K, Liu KH, Su CH, Chan ACW, Yoon DS, Choi IS, Jonas E, Chen XP, Fan ST, Ker CG, Giménez ME, Kitano S, Inomata M, Hirata K, Inui K, Sumiyama Y, Yamamoto M. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:55–72.
Paul Wright G, Stilwell K, Johnson J, Hefty MT, Chung MH. Predicting length of stay and conversion to open cholecystectomy for acute cholecystitis using the 2013 Tokyo Guidelines in a US population. J Hepatobiliary Pancreat Sci. 2015;22:795–801.
Yokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, Kozaka K, Endo I, Deziel DJ, Miura F, Okamoto K, Hwang TL, Huang WS, Ker CG, Chen MF, Han HS, Yoon YS, Choi IS, Yoon DS, Noguchi Y, Shikata S, Ukai T, Higuchi R, Gabata T, Mori Y, Iwashita Y, Hibi T, Jagannath P, Jonas E, Liau KH, Dervenis C, Gouma DJ, Cherqui D, Belli G, Garden OJ, Giménez ME, de Santibañes E, Suzuki K, Umezawa A, Supe AN, Pitt HA, Singh H, Chan ACW, Lau WY, Teoh AYB, Honda G, Sugioka A, Asai K, Gomi H, Itoi T, Kiriyama S, Yoshida M, Mayumi T, Matsumura N, Tokumura H, Kitano S, Hirata K, Inui K, Sumiyama Y, Yamamoto M. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25:41–54.
Gonzalez-Munoz JI, Franch-Arcas G, Angoso-Clavijo M, Sanchez-Hernandez M, Garcia-Plaza A, Caraballo-Angeli M, Muñoz-Bellvís L. Risk-adjusted treatment selection and outcome of patients with acute cholecystitis. Langenbecks Arch Surg. 2017;402:607–14.
Glavic Z, Begic L, Simlesa D, Rukavina A. Treatment of acute cholecystitis. A comparison of open vs laparoscopic cholecystectomy. Surg Endosc. 2001;15:398–401.
Lujan JA, Parrilla P, Robles R, Marin P, Torralba JA, Garcia-Ayllon J. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study. Arch Surg. 1998;133:173–5.
Takemoto YK, Abe T, Amano H, Hanada K, Fujikuni N, Yoshida M, Kobayashi T, Ohdan H, Noriyuki T, Nakahara M. Propensity score-matching analysis of the efficacy of late cholecystectomy for acute cholecystitis. Am J Surg. 2017;214:262–6.
Hirohata R, Abe T, Amano H, Hanada K, Kobayashi T, Ohdan H, Noriyuki T, Nakahara M. 2020 Identification of risk factors for open conversion from laparoscopic cholecystectomy for acute cholecystitis based on computed tomography findings. Surg Today 50:1657–63.
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96.
Gutt CN, Encke J, Koninger J, Harnoss JC, Weigand K, Kipfmuller K, Schunter O, Götze T, Golling MT, Menges M, Klar E, Feilhauer K, Zoller WG, Ridwelski K, Ackmann S, Baron A, Schön MR, Seitz HK, Daniel D, Stremmel W, Büchler MW. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg. 2013;258:385–93.
Banz V, Gsponer T, Candinas D, Guller U. Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy. Ann Surg. 2011;254:964–70.
Shinke G, Noda T, Hatano H, Shimizu J, Hirota M, Takata A, Oshima K, Tanida T, Komori T, Morita S, Imamura H, Iwazawa T, Akagi K, Dono K. Feasibility and safety of urgent laparoscopic cholecystectomy for acute cholecystitis after 4 days from symptom onset. J Gastrointest Surg. 2015;19:1787–93.
Simorov A, Ranade A, Parcells J, Shaligram A, Shostrom V, Boilesen E, Goede M, Oleynikov D. Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study. Am J Surg. 2013;206:935–40. discussion 940–941.
Komatsu S, Tsukamoto T, Iwasaki T, Toyokawa A, Hasegawa Y, Tsuchida S, Takahashi T, Takebe A, Wakahara T, Watanabe A, Sugahara A, Mukai H. Role of percutaneous transhepatic gallbladder aspiration in the early management of acute cholecystitis. J Dig Dis. 2014;15:669–75.
Verbanck JJ, Demol JW, Ghillebert GL, Rutgeerts LJ, Surmont IP. Ultrasound-guided puncture of the gallbladder for acute cholecystitis. Lancet. 1993;341:1132–3.
Abe K, Suzuki K, Yahagi M, Murata T, Sako H, Ishii Y. The efficacy of PTGBD for acute cholecystitis based on the Tokyo Guidelines 2018. World J Surg. 2019;43:2789–96.
Schlottmann F, Gaber C, Strassle PD, Patti MG, Charles AG. Cholecystectomy vs. cholecystostomy for the management of acute cholecystitis in elderly patients. J Gastrointest Surg. 2019;23:503–9.
Conrad C, Wakabayashi G, Asbun HJ, Dallemagne B, Demartines N, Diana M, Fuks D, Giménez ME, Goumard C, Kaneko H, Memeo R, Resende A, Scatton O, Schneck AS, Soubrane O, Tanabe M, van den Bos J, Weiss H, Yamamoto M, Marescaux J, Pessaux P. IRCAD recommendation on safe laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci. 2017;24:603–15.
Cengiz Y, Lund M, Janes A, Lundell L, Sandblom G, Israelsson L. Fundus first as the standard technique for laparoscopic cholecystectomy. Sci Rep. 2019;9:18736.

Tables 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
19 Jul, 2024
Editor assigned by journal
18 Jul, 2024
Submission checks completed at journal
18 Jul, 2024
First submitted to journal
27 Jun, 2024

You are reading this latest preprint version

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

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Materials and Methods

Patient population and selection

Surgical and PC procedures

Preoperative CT findings

Morbidity and complications

Statistical analysis

Results

Discussion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1