ArticleSurgical endoscopy2026
Revisiting the seven-day rule: an international retrospective analysis of laparoscopic cholecystectomy for acute cholecystitis.
Article in Surgical endoscopy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundAlthough early laparoscopic cholecystectomy is the gold standard for acute calculous cholecystitis, its safety in patients presenting more than seven days after symptom onset remains debated. Concerns over increased surgical difficulty and complication rates often results in delaying cholecystectomy, yet evidence supporting this seven-day threshold is lacking. Therefore, this study evaluated the safety of early laparoscopic cholecystectomy in patients operated within versus beyond seven days of symptom onset.
methodsThis international retrospective cohort included patients who underwent early laparoscopic cholecystectomy for acute calculous cholecystitis at two high-volume centers between 2015 and 2021. Patients were categorized by symptom duration: ≤ 7 days or > 7 days. Multivariable analyses compared major complications (bile duct injury/leakage, bowel injury, bleeding, or postoperative complication Clavien-Dindo grade ≥ 3a), conversions, operative time, and postoperative hospital stay.
resultsA total of 1421 patients were included. Of these, 1312 patients (92%) had ≤ 7 days of symptoms, and 109 (8%) > 7 days. There were no significant differences in major complications, conversion to open surgery, or operative time. Major complications occurred in 7.9% of the ≤ 7 days group vs 5.5% of the > 7 days group (adjusted OR 0.88, 95% CI 0.36-2.14), conversion to open surgery in 3.4% vs 2.8% (adjusted OR 0.77, 95% CI 0.23-2.56), and median operative time was 73 vs 78 min (adjusted geometric mean ratio 0.97; 95% CI 0.90-1.05). Postoperative hospital stay was shorter in the > 7 days group (median 1 [IQR 1-2] vs 1 [IQR 1-2] days; adjusted rate ratio 0.80, 95% CI 0.65-0.97), although this difference was not statistically significant in a sensitivity analysis excluding outliers.
conclusionLaparoscopic cholecystectomy performed beyond seven days from symptom onset was safe, with outcomes comparable to patients with a shorter symptom duration. These findings challenge the necessity of the seven-day threshold in experienced centers. A randomized trial is warranted to determine whether early surgery offers advantages over conservative treatment in patients with prolonged symptoms.
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