Percutaneous cholecystostomy is increasingly being used for definitive treatment of acalculous cholecystitis and as a bridge to surgery in case of calculous cholecystitis in a patient with a high risk of surgery due to comorbidities or sometimes ongoing septic shock. [16-20]. There is ongoing controversy about the optimal time of cholecystectomy after percutaneous cholecystostomy in the case of calculous cholecystectomy.
In this systematic review and meta-analysis, we tried to evaluate the optimal timing of cholecystectomy after percutaneous cholecystostomy in the case of calculous cholecystitis.. We evaluated conversion to open, overall complications after cholecystectomy, biliary complications, 90-day mortality, hospital stay after cholecystectomy performed in various time frames after cholecystostomy based on available literature.
After a systematic search described in methodology and removing duplicates, we found six articles [11-17], which evaluated the timing of cholecystectomy after percutaneous cholecystostomy. There was a lack of uniformity about the timing of cholecystectomy after percutaneous cholecystostomy in the available literature, so we evaluated different time frames in our meta-analysis.
As per findings of the meta-analysis, there was no increase in conversion to open, and overall complications of cholecystectomy are performed within 72 hours of percutaneous cholecystostomy, biliary complications were lesser if cholecystectomy is performed within 72 hours of percutaneous cholecystostomy. However, 90 days mortality was slightly higher (p=0.05) if cholecystectomy is performed within 72 hours but we are not sure this is due to cholecystectomy or due to underlying conditions. [figure 3].
We found no increase in mortality, overall complications, biliary complications, and conversion to open if cholecystectomy is performed within 7 and 10 days after percutaneous cholecystostomy. [figure 4,5]. Only one study  evaluated cholecystectomy within or after two weeks of percutaneous cholecystostomy, which also showed early cholecystectomy reduced overall complications without increasing mortality and biliary complications. [supplement figure 1].
Maximum benefit is observed as per our meta-analysis when cholecystectomy is performed within 4 weeks of percutaneous cholecystostomy. It reduced overall complications, biliary complications, 90 days mortality, hospital stay without increasing conversion to open cholecystectomy. [figure 6].
In studies comparing cholecystectomy within or after 8 weeks of percutaneous cholecystostomy [15,16], overall complications and hospital stay were significantly more in cholecystectomy in less than 8 weeks compared to cholecystectomy in more than 8 weeks. There was no difference in conversion to open, 90-day mortality and need for subtotal cholecystectomy between the groups.[figure 7]
Based, on these findings, it seems that less than 4 weeks is the ideal time for cholecystectomy after percutaneous cholecystostomy for calculus cholecystitis.
There were certain limitations in our meta-analysis, first, we could include only a limited number of studies as there is still a limited number of studies done in this research question. Three studies [12,15,16] had the majority of patients and other studies included a very limited number of patients and hence results can be skewed by the weight given to those three studies during various analyses. Also, the time duration of cholecystectomy after cholecystostomy varied widely across the studies. So, we had to analyze various time frames.
To our knowledge, this is the first meta-analysis evaluating the optimal time duration of cholecystectomy after percutaneous cholecystostomy. Also, analysis across various time frames confirmed that earlier cholecystectomy is not harmful as it was thought. The ideal time duration from our analysis seems earlier than 4 weeks, most probably 1-4 weeks. The most favorable findings are fewer overall and biliary complications in early cholecystectomy without increased need to convert to open cholecystectomy. However, still, studies with a larger number of patients or randomized control trials are needed to confirm our findings.
In conclusion, early cholecystectomy preferably within 4 weeks after cholecystostomy is safe and probably beneficial to the patients. However, further studies are still needed to confirm the findings of this meta-analysis.