Approaches to Cholecystitis: Surgical, Endoscopic, and Percutaneous Management.

Acute cholecystitis (AC) is associated with significant morbidity and mortality. Minimally invasive laparoscopic cholecystectomy remains the gold standard of treatment. Therapeutic endoscopy for management of AC continues to emerge as a favorable alternative to percutaneous gallbladder drainage in patients with prohibitive operative risk. Endoscopic management of AC includes transpapillary and transmural stenting. When patient-specific factors prevent both surgical and endoscopic treatment, percutaneous cholecystostomy tube (PCT) placement is an option. Early studies show PCT to have worse outcomes when compared against all other described treatment options for the management of AC.

Laparoscopic Cholecystectomy in Cardiogenic Shock And Heart Failure.

Background: Patients with cardiogenic shock (CS) or heart failure can develop ischemic cholecystitis from a systemic low-flow state. Cholecystectomy in high-risk patients is controversial. Percutaneous cholecystostomy tube (PCT) is often the chosen intervention; however, data on PCT as definitive treatment are conflicting. Data on cholecystectomy in these patients are limited. This study discusses outcomes following laparoscopic cholecystectomy (LC) in this patient population. Methods: This is a retrospective review of patients who underwent LC from 2015 to 2019 while hospitalized for CS or heart failure. Surgical services are provided by fellowship-trained minimally invasive surgeons at a single, academic, tertiary-care center. Patient characteristics are reported as frequencies' percentages for categorical variables. Odds ratio is used to determine the association between comorbidities and complications. Results: Twenty-four patients underwent LC. Around 83% were white and 79% were male. Many were anticoagulated (88%), with Class IV heart failure (63%), and required vasopressors (46%) at the time of surgery. Fourteen of 24 (58%) had at least one circulatory device at the time of surgery: extracorporeal membrane oxygenation, left ventricular assist device, Impella, tandem heart, and total artificial heart. Four patients (17%) had PCT preoperatively. Fifteen days were the average interval between diagnosis and surgery. Pneumoperitoneum was tolerated by all, and 0% converted to open. Most common complication was bleeding (52%). Nine patients (37.5%) underwent 21 reoperations, one of which (4%) was related to cholecystectomy. Mortality occurred in 5 patients (20.8%); interval between cholecystectomy and mortality ranged 6-30 days. Conclusion: Although high risk, LC is a treatment option in patients with ischemic cholecystitis at risk for death from sepsis.

Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis.

BACKGROUND: Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. METHODS: This was a retrospective (2018-2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7-9, 10-13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. RESULTS: There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13-0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC. CONCLUSION: Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC.

Part 1: Current Concepts in Radiologic Imaging and Intervention in Acute Cholecystitis.

Acute calculous cholecystitis and acute acalculous cholecystitis are encountered commonly among critically ill, often elderly, patients. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, infectious disease physicians, gastroenterologists, and endoscopists able to contribute to patient care. In this article intended predominantly for intensivists, we will review the imaging findings and radiologic treatment of critically ill patients with acute calculous cholecystitis and acute acalculous cholecystitis.

Enhancing biliary structure identification using percutaneous cholecystostomy drain delivery of indocyanine green: a glowing two case review.

The use of indocyanine green for fluorescent cholangiography in patients with cholecystitis initially treated with percutaneous cholecystostomy drainage catheters was described in this two case series. Two patients underwent robotic assisted cholecystectomy with fluorescent cholangiography and indocyanine green through percutaneous cholecystostomy drainage catheters. The patients were diagnosed with acute cholecystitis. Directed injection of indocyanine green allowed for direct visualization of the biliary system allowing for a safe identification of the critical view of safety. Injection of indocyanine green for fluorescent cholangiography through percutaneous cholecystostomy drainage catheters is reliable to assess the critical view of safety and allows for improved identification of the biliary tree anatomy. Administration of indocyanine green through the percutaneous cholecystostomy drainage catheters avoided background hepatic fluorescence and increased contrast between biliary structures.

The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach.

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature.

Percutaneous cholecystostomy in acute complicated versus uncomplicated cholecystitis; is there a difference in outcomes? A single-center experience.

BACKGROUND: Percutaneous cholecystostomy (PC) is a therapeutic intervention for acute cholecystitis. The benefits of cholecystostomy have been demonstrated in the medical literature, with up to 90% of acute cholecystitis cases shown to resolve postoperatively, and only 40% of patients subsequently undergoing an interval cholecystectomy. PURPOSE: To compare the survival outcomes between acute complicated and uncomplicated cholecystitis in patients undergoing PC as an initial intervention, as there is a paucity of evidence in the literature on this perspective. MATERIAL AND METHODS: A retrospective search was conducted of all patients who underwent PC for acute cholecystitis between August 2016 and December 2020 at a tertiary institution. A total of 100 patients were included in this study. RESULTS: The outcome, in the form of 30-day mortality, 90-day mortality, being alive after six months, and reintervention, was compared between complicated and uncomplicated cases using the chi-square test or Fisher's exact test. There was no statistically significant difference in any of the compared outcomes. The only variable that showed a statistically significant association with the risk of mortality was acute kidney injury (AKI) at admission. Patients who had stage 1, 2, or 3 AKI had a higher hazard for mortality as compared to patients with no kidney disease. CONCLUSION: Our results demonstrate that PC is a safe and effective procedure. Mortality is not affected by the presence of complications. The results have, however, highlighted the importance of recognizing and treating AKI, an independent risk factor affecting mortality.

Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives.

In recent years, therapeutic endoscopy has become a fundamental tool in the management of gallbladder diseases in light of its minimal invasiveness, high clinical efficacy, and good safety profile. Both endoscopic transpapillary gallbladder drainage (TGBD) and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) provide effective internal drainage in patients with acute cholecystitis unfit for cholecystectomy, avoiding the drawbacks of external percutaneous gallbladder drainage (PGBD). The availability of dedicated lumen-apposing metal stents (LAMS) for EUS-guided transluminal interventions contributed to the expansion of endoscopic therapies for acute cholecystitis, making endoscopic gallbladder drainage easier, faster, and hence more widely available. Moreover, EUS-GBD with LAMS opened the possibility of several cholecystoscopy-guided interventions, such as gallstone lithotripsy and clearance. Finally, EUS-GBD has also been proposed as a rescue drainage modality in malignant biliary obstruction after failure of standard techniques, with encouraging results. In this review, we will describe the TBGD and EUS-GBD techniques, and we will discuss the available data on clinical efficacy in different settings in comparison with PGBD. Finally, we will comment on the future perspectives of EUS-GBD, discussing the areas of uncertainty in which new data are more strongly awaited.

A Comparative Analysis of Erector Spinae Plane Block Versus Conscious Sedation in Managing Percutaneous Cholecystostomy Pain.

PURPOSE: This study investigates the efficacy of erector spinae plane block (ESPB) for managing perioperative and postoperative pain in patients undergoing percutaneous cholecystostomy (PC) for acute cholecystitis, particularly in high-risk elderly patients with extensive comorbidities and limited functional status. METHODS: In a retrospective single-center study, 58 high-risk patients scheduled for PC were assessed. ESPB was administered to 23 patients, while 22 received conscious sedation. Pain intensity was measured using the numeric rating scale before any analgesic or ESPB administration, during the procedure and at 1 and 12 h post-procedure and secondary outcomes included adverse effects and additional analgesic requirements. RESULTS: The ESPB group experienced significant pain reduction during and post-procedure compared to the conscious sedation group (p = 0.002). Procedure times were shorter (p = 0.015), and postoperative tramadol was less frequently needed in the ESPB group (p = 0.007). The incidence of nausea was also lower in the ESPB group (p = 0.001). No ESPB-related complications were reported. CONCLUSION: ESPB significantly alleviates perioperative and postoperative pain in PC patients, reducing additional analgesic use and side effects. It holds promise as a key component of pain management for high-risk surgical patients. LEVEL OF EVIDENCE: Level 3, Non-randomized controlled cohort/follow-up study.

Bedside Ultrasound-Guided Percutaneous Cholecystostomy in Critically Ill Patients-Outcomes in 51 Patients.

Purpose The aim of this study was to report technical and clinical success of bedside ultrasound-guided percutaneous cholecystostomy (PC) tube placement in intensive care unit (ICU). Materials and Methods This is a retrospective study of 51 patients (36 males:15 females, mean age: 67 years) who underwent ultrasound-guided PC from May 2015 to January 2020. The indication for cholecystostomy tube placement, comorbidities, imaging finding, technical success, clinical success, timing of surgery post-cholecystostomy tube placement, indwelling catheter time, complications, and follow-up were recorded. Results Indications for cholecystostomy tube placement were acute calculous cholecystitis ( n = 43; 84.3%), perforated cholecystitis ( n = 5; 9.8%), and emphysematous cholecystitis ( n = 3; 5.9%). Most of the patients had multiple comorbidities; these were diabetes mellitus, hypertension, cardiovascular disease, chronic renal disease, underlying malignancy, and multisystem disease with sepsis. All patients had undergone PC through transhepatic approach under ultrasound guidance in ICU. Technical success rate of the procedure was 100%. Clinical success rate was 92.1% (47/51) and among these 44/51 (86.2%) patients underwent definitive elective cholecystectomy, 3/51 (5.9%) patients had elective tube removal. Three of fifty-one (5.9%) patients did not improve; among these two underwent emergency surgery, while there was 1/51 (1.9%) mortality due to ongoing sepsis and multiorgan dysfunction. There were no procedure-related mortalities or procedure-related major complications. One patient had bile leak due to multiple attempts for cholecystostomy placement. Mean tube indwelling time was 13 days (range: 3-45 days). Conclusion Ultrasound-guided PC can be safely performed in ICU in critically ill patients unfit for surgery with high technical and clinical success rates. Early laparoscopic cholecystectomy should be preferred after stabilization of clinical condition following cholecystostomy.

Outcomes of Percutaneous Image-Guided and Laparoscopic Cholecystostomies in High-Risk Patients With Acute Calculus Cholecystitis: A Five-Year District General Hospital Experience.

Introduction Acute cholecystitis (AC), inflammation of the gall bladder, is one of the most common emergency surgical presentations. In the UK, approximately 15% of the population is estimated to have gallstones, and approximately 20% of them can develop AC. Laparoscopic cholecystectomy (LC) is considered the definitive management of AC. However, cholecystectomy carries a very high risk of morbidity and mortality in high-risk frail patients with multiple comorbidities who are deemed unfit for surgery. Percutaneous cholecystostomy (PC), both image-guided and laparoscopic, is generally acknowledged as an interim treatment measure before definitive management, which is the LC. Materials and methods This is a retrospective study from the Royal Albert Edward Infirmary, a district general hospital (DGH) based in Wigan, UK. The medical records of all the patients who were admitted to the surgical department and underwent PC between January 2017 and December 2022 were analyzed. Patients with previous hepato-pancreato-biliary (HPB) malignancy, who underwent open cholecystostomy, or those with abdominal ascites were excluded from the study. Information was collected regarding the age, gender, American Society of Anaesthesiologists (ASA) grades, success rates of both procedures as temporary or definitive management, duration of hospital stay, 30-day and 1-year mortality after the procedure, timing of the procedure, and long-term complications after the procedure, particularly those related to cholecystostomy tube dislodgment or blockage. Results Twenty-seven patients who underwent PC were divided into two groups: group A, consisting of 10 patients who underwent laparoscopic cholecystostomies, and group B, consisting of 17 patients who had ultrasound (US)-guided cholecystostomies. The mean age of the patients in group A was 66.7 as compared to 75.1 in group B. Most of the patients were in ASA groups III (14) and IV (10). About 74% of patients had procedures done during the day and 26% had PC at night time. The mean hospital stay was 13.5 days. About 55% of patients had planned elective LC as a definitive management. Following the treatment, two patients died within 30 days, and eight patients passed away within a year. About 40% of the patients had complications related to the tube dislodgment and blockage. Conclusion This study concludes that PC, using both laparoscopic and US-guided techniques, can serve as an interim as well as a definitive measure, particularly in patients who are at high risk for anesthesia and the procedure itself and have multiple comorbidities.

Chylous drainage through percutaneous cholecystostomy: an extremely rare complication.

Chyle leak is a rare but potentially morbid complication of abdominal surgery. There have been seven reported cases of chylous ascites following cholecystectomy, but no such occurrences are reported with percutaneous cholecystostomy tube (PCT) insertion. We report the case of a 67-year-old female with stage IVb recurrent uterine papillary serous carcinoma and extensive abdominal surgical history including a paraesophageal hernia repair, and a robotic hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, gastrocolic omentectomy, and hepatoduodenal lymphadenectomy. The patient presented with clinical findings suggestive of acute cholecystitis and decision was made to proceed with PCT placement. The PCT was dislodged and replaced during her course and several days after chylous output was noted from the PCT. The remainder of her hospital course was complicated by persistent distributive shock, adrenal insufficiency, and continued chyle leak. She ultimately was transitioned to inpatient hospice and died shortly after.

Percutaneous thrombolysis via cholecystostomy catheter to dissolve biliary clots causing obstructive jaundice.

Haemobilia, or bleeding within the biliary tree, is rare. It can cause biliary obstruction secondary to blood clots. A comorbid 87-year-old was admitted to hospital with acute cholecystitis, choledocholithiasis, and an Escherichia coli bacteremia. He had a partial pancreatectomy and gastrojejunostomy 35 years prior for severe pancreatitis. He was treated with antibiotics and a percutaneous cholecystostomy. He developed atrial fibrillation and was subsequently commenced on warfarin. He re-presented 5 days after discharge with abdominal pain and fevers. Liver function tests revealed cholestasis and a supratherapeutic international normalised ratio. Imaging showed cholecystitis, biliary obstruction, and extensive biliary blood clots. He improved with antibiotics, vitamin K, and alteplase flushes through the percutaneous cholecystostomy. Repeat cholangiogram demonstrated dissolution of the biliary clots. Due to altered anatomy and comorbidities, alteplase flushes were utilized to relieve this patient's biliary obstruction. Thrombolytics may assist in treating biliary clots when first-line options are not possible or favourable.

Percutaneous cholecystostomy tube placement as a bridge to cholecystectomy for grade III acute cholecystitis: A national analysis.

Introduction: Percutaneous cholecystostomy (PCT) is an alternative to cholecystectomy (CCY) in high-risk surgical candidates with severe acute cholecystitis. A subset of these patients ultimately undergo delayed CCY. We therefore compared outcomes of delayed CCY in patients with grade III acute cholecystitis who received a PCT on index admission, to those who did not. Methods: Non-elective adult hospitalizations for grade III acute cholecystitis that underwent delayed CCY were identified in the 2016-2020 Nationwide Readmission Database. Patients who received a PCT during their index admission comprised the PCT group (others: Non-PCT). Outcomes were assessed for the CCY hospitalization. Entropy balancing was used to generate sample weights to adjust for differences in baseline characteristics. Regression models were created to evaluate the association between PCT and the outcomes of interest. Results: Of an estimated 13,782 patients, 13.3 % comprised PCT. Compared to Non-PCT, PCT were older (71.1 ± 13.1 vs 67.4 ± 15.3 years) and more commonly in the highest income quartile (22.5 vs 16.1 %, both p < 0.001). After risk adjustment, PCT was associated with reduced odds of respiratory (AOR 0.67, CI 0.54-0.83) and infectious (AOR 0.77, CI 0.62-0.96) complications after eventual CCY. Finally, PCT had comparable pLOS (ß +0.31, CI [-0.14, 0.77]) and operative hospitalization costs (ß $800, CI [-2300, +600]). Conclusion: In the present study, PCT was associated with decreased odds of perioperative complications and comparable resource utilization upon readmission CCY. Our findings suggest that PCT may be helpful in bridging patients with grade III acute cholecystitis to eventual CCY.

A Review on Endoscopic Management of Acute Cholecystitis: Endoscopic Ultrasound-Guided Gallbladder Drainage and Endoscopic Transpapillary Gallbladder Drainage.

A percutaneous cholecystostomy tube (PCT) is the conventionally favored nonoperative intervention for treating acute cholecystitis. However, PCT is beset by high adverse event rates, need for scheduled reintervention, and inadvertent dislodgement, as well as patient dissatisfaction with a percutaneous drain. Recent advances in endoscopic therapy involve the implementation of endoscopic transpapillary drainage (ETP-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which are increasingly preferred over PCT due to their favorable technical and clinical success combined with lower complication rates. In this article, we provide a comprehensive review of the literature on EUS-GBD and ETP-GBD, delineating instances when clinicians should opt for endoscopic management and highlighting potential risks associated with each approach.

Acquired Bronchobiliary Fistula in a Young Adult Patient With Sepsis: A Case Report.

Bronchobiliary fistula (BBF) is a rare, highly morbid condition that results from an abnormal connection between biliary channels and the bronchial tree. In the past, this condition has been known to be caused by untreated hydatid cysts or hepatic abscesses that can erode through the diaphragm into the pleural cavity and bronchial tree, creating fistulation. However, the condition's spectrum has changed in recent years, and BBFs have also become associated with neoplasm, iatrogenic causes, and trauma. Cases of BBF are treated differently, either with simple conservative management or invasive surgery. We present a case of a 46-year-old male initially presenting with sepsis, who was found to have a BBF. The diagnosis was made after a hepatobiliary iminodiacetic acid scan showed the flow of a tracer in the lung fields. The condition was likely due to acute cholecystitis and prior biliary instrumentation. The patient was treated successfully with percutaneous cholecystostomy tube insertion followed by elective laparoscopic cholecystectomy several weeks after hospital discharge.

Percutaneous cholecystostomy in elderly patients with acute cholecystitis: a systematic review and meta-analysis.

Percutaneous cholecystostomy (PC) is often preferred over early cholecystectomy (EC) for elderly patients presenting with acute cholecystitis (AC). However, there is a lack of solid data on this issue. Following the PRISMA guidelines, we searched the Medline and Web of Science databases for reports published before December 2022. Studies that assessed elderly patients (aged 65 years and older) with AC treated using PC, in comparison with those treated with EC, were included. Outcomes analyzed were perioperative outcomes and readmissions. The literature search yielded 3279 records, from which 7 papers (1208 patients) met the inclusion criteria. No clinical trials were identified. Patients undergoing PC comprised a higher percentage of cases with ASA III or IV status (OR 3.49, 95%CI 1.59-7.69, p = 0.009) and individuals with moderate to severe AC (OR 1.78, 95%CI 1.00-3.16, p = 0.05). No significant differences were observed in terms of mortality and morbidity. However, patients in the PC groups exhibited a higher rate of readmissions (OR 3.77, 95%CI 2.35-6.05, p < 0.001) and a greater incidence of persistent or recurrent gallstone disease (OR 12.60, 95%CI 3.09-51.38, p < 0.001). Elderly patients selected for PC, displayed greater frailty and more severe AC, but did not exhibit increased post-interventional morbidity and mortality compared to those undergoing EC. Despite their inferior life expectancy, they still presented a greater likelihood of persistent or recurrent disease compared to the control group.

Percutaneous cholecystostomy: an unusual route of dissemination of gallbladder carcinoma

A 78-year-old male with high-risk surgical presented severe acute cholecystitis and required cholecystostomy. The patient was referred later for assessment of the surgical treatment. A cholangio-MRI revealed a lesion on the gallbladder fundus with hepatic lesions suggestive of metastatic gallbladder carcinoma, which was confirmed in the histological analysis. The tumor progressed despite the chemotherapy through the cholecystostomy tract and developed peritoneal carcinomatosis. The patient did not respond to chemotherapy and he died 12 months later. (AU)

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons.

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

Current status and therapeutic strategy of acute acalculous cholecystitis: Japanese nationwide survey in the era of the Tokyo guidelines.

PURPOSE: This study aimed to clarify the incidence, therapeutic modality, and prognosis of acute acalculous cholecystitis and to reveal its optimal treatment strategy. METHODS: As a project study of the Japanese Society for Abdominal Emergency Medicine, we performed a questionnaire survey of demographic data and perioperative outcomes of acute acalculous cholecystitis treated between January 2018 and December 2020 from 42 institutions. RESULTS: In this study, 432 patients of acute acalculous cholecystitis, which accounts for 7.04% of acute cholecystitis, were collected. According to the Tokyo guidelines severity grade, 167 (38.6%), 202 (46.8%), and 63 (14.6%) cases were classified as Grade I, II, and III, respectively. A total of 11 (2.5%) patients died and myocardial infarction/congestive heart failure was the only independent risk factor for in-hospital death. Cholecystectomy, especially the laparoscopic approach, had more preferable outcomes compared to their counterparts. The Tokyo guidelines flow charts were useful for Grade I and II severity, but in the cases with Grade III, upfront cholecystectomy could be suitable in some patients. CONCLUSIONS: The proportions of severity grade and mortality of acute acalculous cholecystitis were found to be similar to those of acute cholecystitis, and laparoscopic cholecystectomy is recommended as an effective treatment option. (UMIN000047631).