Letter to the Editor: commentary on “Proactive emergency laparoscopic cholecystectomy for complex acute cholecystitis: a prospective cohort at a national emergency center in China”

Dear Editor, We have carefully read the article recently published by Liu et al[1], which explores the feasibility and safety of performing active emergency laparoscopic cholecystectomy (ELC) in patients with complex acute cholecystitis (AC). This prospective cohort study, which included 721 consecutive patients, is one of the largest studies of its kind to date, providing important real-world evidence for the surgical management of complex AC. The authors’ rigor in research design and data analysis is highly commendable. The most prominent advantage of this study lies in its large sample size and prospective design. The study subjects included elderly patients (≥80 years old), prolonged disease duration (≥7 days), and severe inflammation (Tokyo guidelines II/III grade), directly challenging the traditional view that complex or longer disease duration AC patients should prefer conservative or staged treatment strategies (such as percutaneous transhepatic gallbladder puncture and drainage or oronasal external drainage)[2]. The results showed an extremely low conversion rate to open surgery (1.0%), no bile duct injury, and an acceptable complication rate (only 1.2% for severe complications), strongly demonstrating the feasibility and safety of active ELC in high-level centers. Additionally, the introduction of indocyanine green fluorescence cholangiography (ICGC) in the study is particularly noteworthy. Data show[3,4] that intravenous injection of ICGC during anesthesia induction can significantly reduce bleeding at the incision site during free gallbladder removal and the probability of residual small gallbladder during the operation, highlighting its potential in improving surgical safety and accuracy. However, this study also has areas that warrant further exploration. Firstly, this study is a single-center study, and the implementing hospital is a national referral center. The results may not be directly applicable to medical institutions with lower surgical volume or limited resources. Secondly, the use of ICGC is determined by the surgeon’s choice rather than random allocation, which may introduce researcher bias: the surgeon may be more inclined to use ICGC in complex cases (but because each surgeon’s level is different, for the same case, the difficulty of the surgery before judgment may vary), thereby affecting the observed results. Thirdly, this study mainly focuses on short-term perioperative outcomes and lacks follow-up data on long-term recurrence rate, quality of life, and cost-effectiveness, limiting the comprehensive assessment of active ELC as a health policy promotion. Fourthly, from a surgical perspective, the indications for EST + LC in patients with gallbladder stones combined with common bile duct stones should be strictly controlled to avoid excessive damage to the Oddi sphincter, which may lead to catastrophic complications in the long term. Fifthly, from my clinical practice perspective, emergency laparoscopic cholecystectomy, even if the disease duration is within 2 weeks, is only the edema of the gallbladder wall during the operation and is not tightly adhered to the common bile duct and the gallbladder bed, almost not affecting the dissection of the gallbladder, but will slightly to moderately increase bleeding. Sixthly, for patients with tall build, obesity, or a posterior position of the gallbladder triangle, moving the 30-degree laparoscope puncture hole upward will broaden the field of vision, making the dissection smoother, and don’t forget to add an assistant to help absorb blood and expose during the dissection. Looking to the future, related research can expand in the following aspects: Firstly, in multi-center, large-sample, prospective or randomized controlled studies, further verify the comparative effects of active ELC with other treatment strategies (such as percutaneous drainage or elective surgery); Secondly, establish and promote standardized operating procedures and training systems for the inclusion and exclusion criteria of ICGC application to improve the replicability and fairness of the results; Thirdly, combine factors such as patient comorbidities, disease severity, and institutional capabilities to construct a surgical risk prediction model to further optimize patient selection and treatment decisions. In conclusion, the research by Liu et al has provided strong prospective evidence for the safety and feasibility of active ELC in patients with complex AC, and emphasized the value of ICGC in enhancing surgical safety. This study has promoted the treatment concept of transforming complex acute cholecystitis into “early radical surgery,” and also highlighted the importance of centralized treatment and surgical innovation in the management of high-risk acute abdominal conditions. Our assessment is in accordance with the transparency – TITAN guidelines stipulated in the AI report[5].