Abstract
Backgrounds/Aims
Laparoscopic cholecystectomy (LC) is the standard therapy for acute calculous cholecystitis (ACC). However, high-risk patients often require percutaneous gallbladder drainage (PGBD) as a bridge to surgery. The optimal interval between PGBD and LC remains uncertain.
Methods
We retrospectively reviewed 177 patients who underwent LC after PGBD for ACC at Nhan dan Gia Dinh Hospital (2018–2024). Patients were stratified by drainage-to-surgery interval: Q1, ≤ 9 days; Q2, 10–17 days; Q3, 18–32 days; Q4, ≥ 32 days. Primary outcomes were operative time, conversion, intraoperative bleeding, postoperative stay, and Clavien-Dindo complications. Multivariable logistic regression was performed after adjusting for age, Charlson Comorbidity Index (CCI), TG18 severity, sex, prior endoscopic retrograde cholangiopancreatography, and Concurrent PGBD and LC during the same admission.
Results
Median operative time, conversion rate, and postoperative stay were similar across intervals. Crude bleeding differed significantly (p = 0.019), being the highest in Q4 (68.2%) and the lowest in Q2 (36.4%). Q3 showed the shortest operative time (median: 90 min) and the lowest complication rate (11.4%). In adjusted analysis, only CCI independently predicted bleeding (adjusted odds ratio: 1.42; 95% confidence interval: 1.02–2.03), while timing lost its statistical significance.
Conclusions
Scheduling LC 18–32 days after PGBD offers the most balanced surgical profile, whereas delaying beyond 32 days increases bleeding without added benefit. Comorbidity burden rather than calendar interval per se appears to increase bleeding risk. Prospective studies are warranted to confirm the intermediate 2- to 4-week window.
Keywords: Acute cholecystitis; Cholecystectomy, laparoscopic; Cholecystostomy; Drainage; Postoperative complications
INTRODUCTION
Acute calculous cholecystitis (ACC), a common cause of abdominal emergencies, is frequently encountered in surgical practice. Early laparoscopic cholecystectomy (LC) within 72 hours of symptom onset is widely recognized as the gold standard for treating uncomplicated ACC as it can significantly reduce morbidity and recurrence rates [1,2]. However, in high-risk patient populations, such as the elderly or individuals with significant comorbidities, urgent surgical intervention may pose substantial risks, potentially leading to increased complications and/or mortality [2]. In these clinical scenarios, percutaneous gallbladder drainage (PGBD) has emerged as an effective interim measure to stabilize patients by resolving acute inflammation, thereby facilitating a safer delayed surgery [1,3].
Although PGBD is effective in controlling symptoms and reducing immediate morbidity and mortality, substantial debate persists regarding the optimal timing of subsequent LC following drainage [4]. Early surgery, typically performed within two weeks after PGBD, has been proposed to reduce recurrent biliary complications and hospital readmissions [5]. Conversely, delayed surgery—often performed after four to eight weeks—allows inflammation to subside more completely, potentially easing operative process and decreasing operative difficulty and complications such as bleeding and bile duct injuries [6,7]. Existing literature provides conflicting evidence, with some retrospective analyses suggesting benefits for early intervention within two weeks [8], whereas others advocate for delayed surgery to minimize intraoperative complications [9,10].
Due to these conflicting findings, clinical consensus remains elusive, highlighting the need for further evidence to define the optimal surgical interval after PGBD [4]. Current clinical practice often relies heavily on individual surgical experience and patient-specific conditions, leading to considerable variability in timing recommendations. To address this clinical uncertainty, this retrospective study was conducted to examine surgical outcomes associated with different timing intervals between gallbladder drainage and subsequent LC. Specifically, this study aimed to evaluate and compare intraoperative parameters (such as operative time, bleeding, conversion rates to open surgery), postoperative outcomes (hospital stay, complications), and overall surgical effectiveness across different surgical timing groups. By providing clearer evidence on the optimal interval for LC following PGBD, our findings aim to enhance clinical decision-making, reduce complication rates, and improve overall outcomes for high-risk patients with ACC.
MATERIALS AND METHODS
Data source
This retrospective cohort study was conducted using clinical data obtained from electronic medical records and surgical registries at the Department of Hepato-Biliary-Pancreatic Surgery, Nhan dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam. All eligible patients diagnosed with ACC who underwent PGBD followed by interval LC from January 2018 through October 2024 were included. The study protocol was approved by the Institutional Review Board and Ethics Committee of Nhan dan Gia Dinh Hospital (approval number: 147/NDGĐ-HĐĐĐ). Patient confidentiality was strictly protected throughout the research process.
Study design and outcomes
Patients who underwent interval LC following successful PGBD were identified retrospectively and categorized into four groups according to the timing interval between drainage and surgery: group Q1, within 9 days (early interval); group Q2, 10 to 17 days, group Q3, 18 to 32 days; and group Q4, 32 days or later (delayed interval). Primary outcomes analyzed included operative time, rate of conversion to open surgery, intraoperative bleeding, occurrence of bile duct injury, length of postoperative hospital stay, and postoperative complications graded according to the Clavien-Dindo classification. The main objective was to evaluate and compare surgical outcomes among timing intervals to identify the optimal timing for performing LC after PGBD.
Patient population and variable definitions
Patients aged 18 years or older with a confirmed diagnosis of ACC based on clinical presentation, laboratory results, and diagnostic imaging who subsequently underwent successful PGBD were included in this study. Following drainage, all patients underwent an elective LC at our institution within the defined study period. Inclusion required availability of complete medical records containing detailed operative information and documented postoperative outcomes. Patients were excluded if LC was performed concurrently with other intra-abdominal procedures such as common bile duct exploration, ventral hernia repair, or extensive adhesiolysis. Patients with previous complex hepatobiliary interventions that could influence surgical outcomes, those with incomplete follow-up data, and those who developed multiorgan failure or died prior to the scheduled surgery were also excluded.
Operative time was defined as the duration from the initial incision or insertion of the first laparoscopic trocar until completion of wound closure, recorded in minutes. Intraoperative bleeding was quantified by the surgeon’s estimate based on the amount of blood aspirated, blood absorbed in gauze pads, and any visible blood loss categorized as minor or major bleeding. Major intraoperative bleeding was a priori defined as an estimated blood loss ≥ 200 mL, as recorded by the attending anaesthesiologist on the intraoperative flowsheet and confirmed in the operative note. Blood loss < 200 mL was classified as minor. Conversion to open surgery was documented when the laparoscopic approach had to be converted to open laparotomy due to technical difficulties or intraoperative complications. Bile duct injury included any identified injury involving the extrahepatic biliary tree that occurred during or after surgery. Postoperative complications were recorded and classified according to the Clavien-Dindo grading system (Grade 0–V), with specific attention given to complications requiring medical, endoscopic, or surgical intervention (Grade II or higher). Postoperative hospital stay was measured as the total number of days the patient remained hospitalized following surgery until discharge. Baseline demographic and clinical characteristics such as age, sex, comorbidities as assessed by the Charlson Comorbidity Index (CCI), and severity grading of ACC based on the Tokyo Guidelines 2018 (TG18) were also documented and analyzed.
Statistical analysis
Statistical analysis was performed using the statistical software R, version 4.2.3 (R Foundation for Statistical Computing). Continuous variables are reported as medians with interquartile ranges (IQRs) or as means with standard deviations, depending on the normality of data distribution assessed by the Shapiro-Wilk test. Categorical variables are expressed as frequencies and percentages. Comparative analyses among timing interval groups were performed using the Kruskal-Wallis test or one-way analysis of variance (ANOVA) for continuous variables, and chi-squared test or Fisher’s exact test for categorical variables, as appropriate. Statistical significance was considered when a p-value was less than 0.05. To control for potential confounding factors such as age, CCI, and severity grading according to TG18, multivariable logistic regression analysis was performed where appropriate. Multivariable modeling was performed only for outcomes that fulfilled the following criteria: (1) a significant univariable association with the drainage-to-surgery quartile (p < 0.05), and (2) at least 15 events, ensuring an events-per-variable ratio ≥ 10.
RESULTS
Between January 2018 and October 2024, a total of 213 patients underwent LC after PGBD at Nhan dan Gia Dinh Hospital. Of these, 177 patients who met the study criteria were included in the final analysis. Patients were grouped according to the timing interval from PGBD to LC into four nearly equal groups based on quartiles: Group Q1, ≤ 9 days, n = 45; Group Q2, 10–17 days, n = 44; Group Q3, 18–32 days, n = 44; and Group Q4, ≥ 32 days, n = 44 (Fig. 1).
Fig. 1.
Sample selection and categorization flow diagram used in this study. Q1–Q4 refer to quartiles of the interval between gallbladder drainage and surgery: Q1 ≤ 9 days; Q2 = 10–17 days; Q3 = 18–32 days; Q4 ≥ 32 days. LC, laparoscopic cholecystectomy; PGBD, percutaneous gallbladder drainage; ACC, acute calculous cholecystitis.
Baseline demographic and clinical characteristics (Table 1) showed significant differences in age among groups (p = 0.008). Patients in delayed surgery groups (Q3 and Q4) were significantly older, with median ages of 74 years (IQR: 64–82 years) and 76 years (IQR: 64–83 years), respectively, compared to those who underwent surgery earlier. Sex distribution (p = 0.801), history of endoscopic retrograde cholangiopancreatography (ERCP) performed prior to surgery (p = 0.676), and CCI scores (p = 0.426) were not significantly different among groups. However, a significantly higher proportion of patients underwent both drainage and surgery during the same hospitalization in early groups (86.7% in Q1) than in later groups (p < 0.001). Additionally, patients in delayed surgery groups (particularly Q3 and Q4) presented with higher frequencies of comorbidities such as diabetes mellitus and hypertension, although these differences were not statistically significant (p = 0.055 and p = 0.056, respectively). Severity grading of acute cholecystitis according to TG18 also varied significantly among groups (p = 0.046), with higher severity grades observed in groups undergoing surgery at later intervals.
Table 1.
Characteristics of the study population and four patient groups undergoing LC following PGBD
| Total (n = 177) |
Q1 (n = 45) |
Q2 (n = 44) |
Q3 (n = 44) |
Q4 (n = 44) |
Test | p-value | |
|---|---|---|---|---|---|---|---|
| Age (yr) | 70 (61–80) | 65 (56–78) | 69 (59–75) | 74 (64–82) | 76 (64–83) | KW | 0.008 |
| Male | 78 (44.1) | 22 (48.9) | 17 (38.6) | 20 (45.5) | 19 (43.2) | χ2 | 0.801 |
| Time from PGBD to LC (day) | 17 (9–32) | ||||||
| Preoperative ERCP | 21 (11.9) | 4 (8.9) | 6 (13.6) | 7 (15.9) | 4 (9.1) | χ2 | 0.676 |
| Concurrent PGBD and LC during the same admission | 64 (36.2) | 39 (86.7) | 22 (50.0) | 3 (6.8) | 0 (0) | χ2 | 0.001 |
| Diabetes mellitus | 69 (39.0) | 15 (33.3) | 16 (36.4) | 21 (47.7) | 17 (38.6) | χ2 | 0.542 |
| Hypertension | 116 (65.5) | 28 (62.2) | 26 (59.1) | 29 (65.9) | 33 (75.0) | F | 0.427 |
| Coronary artery disease, overall | 47 (26.6) | 11 (24.4) | 10 (22.7) | 10 (22.7) | 16 (36.4) | F | 0.402 |
| Coronary stenting | 8 (4.5) | 3 (6.7) | 0 (0) | 3 (6.8) | 2 (4.5) | F | 0.376 |
| CCI | 1 (0–1) | 1 (0–2) | 0.5 (0–1) | 1 (0–1) | 1 (0–1) | KW | 0.426 |
| TG18 Grade of cholecystitis | F | 0.046 | |||||
| Grade 1 | 7 (4.0) | 0 (0) | 3 (6.8) | 1 (2.3) | 3 (6.8) | ||
| Grade 2 | 139 (78.5) | 41 (91.1) | 36 (81.8) | 33 (75.0) | 29 (65.9) | ||
| Grade 3 | 31 (17.5) | 4 (8.9) | 5 (11.4) | 10 (22.7) | 12 (27.3) |
Values are presented as number (%) or median (interquartile range).
Q1–Q4 refer to quartiles of the interval between gallbladder drainage and surgery: Q1 ≤ 9 days; Q2 = 10–17 days; Q3 = 18–32 days; Q4 ≥ 32 days.
KW, Kruskal-Wallis test; χ², chi-squared test; F, Fisher’s exact test; PGBD, percutaneous gallbladder drainage; LC, laparoscopic cholecystectomy; ERCP, endoscopic retrograde cholangiopancreatography; CCI, Charlson Comorbidity Index; TG18, Tokyo Guidelines 2018.
Surgical outcomes (Table 2) demonstrated no significant differences among groups in terms of median operative time, although Group Q3 exhibited the shortest median operative duration of 90 minutes (IQR: 70–116 minutes) and Group Q4 showed the longest median operative time of 113 minutes (IQR: 80–163 minutes). However, these differences did not reach statistical significance (p = 0.147). The rate of conversion from laparoscopic to open surgery was low across all groups (overall: 1.7%, 3/177 cases), showing no statistically significant differences (p = 0.334). Subtotal cholecystectomy rates were also minimal (1.7%) and comparable among groups (p > 0.999).
Table 2.
Early postoperative outcomes of four patient groups undergoing LC following PGBD
| Q1 (n = 45) | Q2 (n = 44) | Q3 (n =44) | Q4 (n = 44) | Test | p-value | |
|---|---|---|---|---|---|---|
| Operative time (min) | 95 (85–130) | 100 (78–130) | 90 (70–116) | 113 (80–163) | KW | 0.147 |
| Conversion to open surgery | 0 (0) | 2 (4.5) | 0 (0) | 1 (2.3) | F | 0.334 |
| Subtotal cholecystectomy | 1 (2.2) | 0 (0) | 1 (2.3) | 1 (2.3) | F | > 0.999 |
| Intraoperative bleeding | 25 (55.6) | 16 (36.4) | 27 (61.4) | 30 (68.2) | χ2 | 0.019 |
| Major bleedinga) | 10 (22.2) | 6 (13.6) | 4 (9.1) | 12 (27.3) | χ2 | 0.111 |
| Bile duct injury | 1 (2.2) | 0 (0) | 1 (2.3) | 0 (0) | F | > 0.999 |
| Postoperative day | 4 (4–6) | 4 (3–5) | 4 (3–6) | 4 (3–6) | KW | 0.701 |
| Overall complications | 7 (15.6) | 7 (15.9) | 5 (11.4) | 9 (20.5) | χ2 | 0.713 |
| Clavien-Dindo classification | F | 0.912 | ||||
| Grade 0 | 38 (84.4) | 37 (84.1) | 39 (88.6) | 35 (79.5) | ||
| Grade I | 2 (4.4) | 1 (2.3) | 1 (2.3) | 1 (2.3) | ||
| Grade II | 3 (6.7) | 5 (11.4) | 4 (9.1) | 7 (15.9) | ||
| Grade IIIa | 1 (2.2) | 0 (0) | 0 (0) | 0 (0) | ||
| Grade IIIb | 1 (2.2) | 1 (2.3) | 0 (0) | 0 (0) | ||
| Grade IV | 0 (0) | 0 (0) | 0 (0) | 0 (0) | ||
| Grade V | 0 (0) | 0 (0) | 0 (0) | 1 (2.3) |
Values are presented as number (%) or median (interquartile range).
KW, Kruskal-Wallis test; χ², Chi-squared test; F, Fisher’s exact test.
Q1–Q4 refer to quartiles of the interval between gallbladder drainage and surgery: Q1 ≤ 9 days; Q2 = 10–17 days; Q3 = 18–32 days; Q4 ≥ 32 days.
a)Major bleeding = estimated blood loss ≥ 200 mL.
Notably, significant differences were observed in intraoperative bleeding rates (p = 0.019). Group Q4 exhibited the highest incidence of intraoperative bleeding (68.2%), while Group Q2 presented the lowest rate (36.4%). Although not statistically significant, major intraoperative bleeding—defined as blood loss ≥ 200 mL—was the most frequent in Group Q4 (27.3%), followed by Q1 (22.2%), Q2 (13.6%), and Q3 (9.1%). Only two cases of bile duct injury were reported (one each in Groups Q1 and Q3), showing no significant differences across groups (p > 0.999).
Postoperative outcomes were favorable overall, with a median postoperative hospital stay of 4 days across all groups, showing no statistically significant difference (p = 0.701) among groups. Overall complication rates did not differ significantly among groups (p = 0.713), although Group Q4 had the highest complication rate (20.5%) and Group Q3 had the lowest rate (11.4%). When complications were classified using the Clavien-Dindo scale, most were minor (Grade I or II), requiring minimal to moderate medical intervention without the need for additional surgical procedures. One case of postoperative mortality (Clavien-Dindo Grade V) occurred in Group Q4, underscoring potential risks associated with prolonged delays prior to surgery, although this did not reach statistical significance (p = 0.912).
Multivariable logistic regression was applied only to “any” intraoperative bleeding, the only endpoint meeting both statistical and event-number thresholds. In the fully adjusted model with drainage-to-surgery quartile, age, CCI, TG18 grade, sex, one-stage procedure, and prior ERCP adjusted, only CCI retained independent significance (adjusted odds ratio [OR]: 1.42; 95% CI: 1.02–2.03; p = 0.047). Drainage interval (Q2–Q4 vs. Q1) did not reach statistical significance (p > 0.05), although prior ERCP showed a non-significant trend toward increased bleeding risk (OR: 2.44; p = 0.095) (Table 3). Other endpoints, including major bleeding, bile duct injury, and conversion to open surgery, had low event counts (≤ 15 cases each). Therefore, they were analyzed using univariable statistics only.
Table 3.
Results of multivariable logistic regression for intraoperative bleeding
| Variable | Adjusted OR | 95% CI | p-value |
|---|---|---|---|
| Q2 vs Q1 | 2.15 | 0.83–5.76 | 0.119 |
| Q3 vs Q1 | 0.71 | 0.21–2.37 | 0.578 |
| Q4 vs Q1 | 0.48 | 0.13–1.69 | 0.254 |
| Age (per year increase) | 0.995 | 0.970–1.020 | 0.725 |
| Charlson Comorbidity Index | 1.42 | 1.02–2.03 | 0.047 |
| TG18 Grade 2 vs Grade 1 | 0.21 | 0.010–1.51 | 0.176 |
| TG18 Grade 3 vs Grade 1 | 0.19 | 0.009–1.60 | 0.174 |
| Female vs Male | 0.96 | 0.49–1.86 | 0.895 |
| One-stage procedure vs staged | 0.88 | 0.32–2.35 | 0.789 |
| Prior ERCP vs no ERCP | 2.44 | 0.87–7.29 | 0.095 |
Q1–Q4 refer to quartiles of the interval between gallbladder drainage and surgery: Q1 ≤ 9 days; Q2 = 10–17 days; Q3 = 18–32 days; Q4 ≥ 32 days.
OR, odds ratio; CI, confidence interval; TG18, Tokyo Guidelines 2018; ERCP, endoscopic retrograde cholangiopancreatography.
Model calibration: Hosmer–Lemeshow χ² = 4.5, df = 8, p = 0.85.
In summary, this analysis suggests that performing LC during an intermediate interval of approximately 2 to 4 weeks (Group Q3) after gallbladder drainage may offer the most favorable balance of surgical outcomes, including shorter operative times, lower complication rates, and the lowest crude rate of intraoperative bleeding. However, these differences were not statistically significant in adjusted analyses. Although patients in Group Q4 (interval ≥ 32 days) exhibited the highest rate of intraoperative bleeding in univariable comparisons, the association between longer delay and bleeding did not remain significant in the multivariable model. Only the CCI retained independent significance.
DISCUSSION
This retrospective cohort study involving 177 patients who underwent LC after initial PGBD for ACC determined the optimal timing interval between drainage and subsequent surgery. Our findings suggest that delaying LC for approximately 2 to 4 weeks (specifically 18–32 days post-drainage, Group Q3) is associated with more favorable surgical outcomes, characterized by shorter operative duration, lower intraoperative bleeding, and reduced postoperative complications compared to earlier or more prolonged intervals.
Previous studies evaluating the timing of LC after gallbladder drainage have yielded conflicting results. Early surgical intervention (within two weeks post-drainage) has been advocated by some authors due to theoretical advantages of reducing recurrence rates of acute inflammation, minimizing hospital readmissions, and potentially decreasing overall healthcare costs by eliminating the need for prolonged follow-up [8]. A systematic review and meta-analysis conducted by Vasavada et al. [11] has similarly demonstrated that performing LC within four weeks after drainage can significantly lower overall complication rates, mortality, and bile duct injuries compared to intervals exceeding four weeks. However, other studies have indicated that very early surgery—especially within the first week—can result in higher intraoperative complication rates, notably due to persistent inflammation, tissue edema, and increased vascularity [5,10]. In our cohort, the earliest group (≤ 9 days) indeed experienced relatively high intraoperative bleeding rates (55.6%), which was notably higher than those with intermediate intervals (10–17 days, 36.4%), but lower than those undergoing surgery beyond 32 days (68.2%).
In contrast, delayed surgical intervention (typically after 4–8 weeks) has been advocated by several other studies, emphasizing improved operative conditions attributed to diminished inflammation, reduced tissue adhesions, and better overall patient fitness due to prolonged medical stabilization [5,10]. Results of the present study aligned with this rationale, revealing that an interval between 18 and 32 days (approximately 2–4 weeks post-drainage) provided optimal balance. This timing window allows sufficient resolution of acute inflammation without extensive fibrosis or adhesions, reflected in favorable intraoperative metrics (shortest operative duration) and lowest postoperative complication rate (11.4%). This finding was consistent with results reported by Zhang et al. [12]. They observed that intermediate intervals (5–8 weeks) provided better outcomes in terms of operative ease, decreased blood loss, and fewer conversions to open surgery than either very early (≤ 4 weeks) or significantly delayed interventions (> 8 weeks) [12].
Extended delays beyond four weeks (≥ 32 days, Group Q4) were disadvantageous in our study as they were associated with significantly increased intraoperative bleeding and a trend toward higher complication rates, including one case of mortality. Such prolonged waiting periods likely contributed to extensive fibrosis, more severe adhesions, and increased difficulty during surgical dissection. Furthermore, several studies have reported that increased overall healthcare expenditures and complication rates are linked to longer intervals due to recurrent episodes of cholecystitis, cholangitis, or pancreatitis [11,13-15]. Wang et al. [16] have performed a population-based study from Taiwan and noted that total medical costs are substantially higher for patients undergoing delayed cholecystectomy (>8 weeks post-drainage) than for those with earlier intervals primarily due to recurrent admissions for biliary events. Additionally, prolonged waiting periods can substantially increase the risk of patients becoming medically unfit or unwilling to undergo surgery, ultimately resulting in permanent gallbladder drainage without definitive surgical treatment. Literature has consistently reported that 60% to 70% of patients initially managed by drainage alone do not return for elective cholecystectomy, placing them at continuous risk for recurrent biliary complications [17,18].
The CCI emerged as the sole independent predictor of any intraoperative bleeding in our multivariable model. However, this association must be interpreted cautiously as the absolute number of bleeding events was modest. CCI consolidates age-related and systemic comorbidities, factors biologically linked to impaired hemostasis or perioperative antithrombotic use. Thus, direction of signal is plausible. Even so, the limited sample size allowed for residual confounding and sampling error. Therefore, we regard this result as hypothesis-generating rather than definitive. Larger multi-center studies are warranted to confirm the prognostic value of CCI and to develop a composite bleeding-risk score that combines comorbidity with operative variables.
Although clinical outcomes were the focus of our analysis, the timing of LC after gallbladder drainage also carries important economic consequences. In our cohort, patients in Q4 not only exhibited the highest rate of major bleeding and complications, but also had a longer postoperative stay. These factors are directly associated with increased hospital resource utilization. These findings are consistent with prior studies from Taiwan and China demonstrating that delayed cholecystectomy beyond 8 weeks can significantly increase total healthcare expenditure due to recurrent biliary events, emergency admissions, and prolonged perioperative period [12,16]. While a formal cost-effectiveness model was beyond the scope of our study, the evidence suggests that earlier scheduling—ideally within 2 to 8 weeks—might offer both clinical and economic benefits.
Our study reinforces the existing literature advocating against excessively prolonged delays. Given these findings, we recommend an intermediate surgical interval (approximately 2–4 weeks post-drainage) as a clinically balanced approach. This timing appears to be optimal for safely and effectively managing ACC in high-risk patients initially managed by PGBD.
The current study has several notable strengths, including a relatively large and homogeneous patient population with clearly defined inclusion and exclusion criteria and rigorous outcome assessments using standardized complication grading (Clavien-Dindo classification). Nevertheless, we acknowledge certain limitations inherent to retrospective research, including potential biases from selection, incomplete data collection, and lack of randomization. Although multivariate analyses were considered to adjust for confounding variables (age, comorbidity index, severity grading), residual confounding effects could not be entirely excluded. Additionally, the single-institution setting potentially limited the generalizability of our findings. To validate these results, prospective, multi-center randomized controlled trials are necessary to provide stronger evidence for standardized clinical guidelines.
In conclusions, this retrospective study suggests that performing LC 2 to 4 weeks (approximately 18–32 days) after PGBD may provide a favorable balance between operative difficulty and postoperative safety in ACC. Within our cohort, this “intermediate” interval showed the lowest crude rates of intraoperative bleeding and overall complications, whereas delaying surgery beyond 4 weeks offered no additional benefit. After adjustment, however, the timing effect lost its statistical significant and CCI remained the only independent predictor of bleeding. These findings suggest that patient comorbidity, not calendar interval alone, might increase bleeding risk and that an intermediate timing window may optimize technical ease without incurring excess fibrosis. Prospective, adequately powered trials in the future are required to confirm the optimal interval and to refine patient selection.
ACKNOWLEDGEMENTS
The authors would like to express their sincere gratitude to the Department of Hepatopancreatobiliary Surgery at Nhan dan Gia Dinh Hospital for providing invaluable support throughout the study. We are deeply grateful to all patients and their families whose medical data contributed to this research. Without their cooperation, this study could not have been conducted.
Funding Statement
FUNDING None.
Footnotes
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conceptualization: KLL, HVN. Data curation: KLL, TQP, PCP, MQT, TNP, MTT, NKL. Methodology: KLL, HVN. Visualization: MQT, TNP. Writing - original draft: KLL. Writing - review & editing: HVN, TQP, NKL. All authors reviewed and approved the final version of the manuscript.
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