Percutaneous versus surgical treatment of acute cholecystitis

A recent meta-analysis by Fanchulli et al. concluded that cholecystectomy (CC) is associated with lower mortality and readmission than percutaneous cholecystostomy (PC) for acute cholecystitis, but this interpretation is limited by confounding by indication to management. The pooled evidence in this article consists predominantly of observational cohorts where crude or minimally adjusted comparisons are vulnerable to case-mix imbalance; even the CHOCOLATE randomised trial, which supports laparoscopic cholecystectomy in selected high-risk but eligible patients (ASA III-IV, age ≥ 70 or comorbidity, excluding peritonitis/septic shock), does not validate interchangeability across the broader PC and CC populations synthesised in unadjusted meta-analyses. Future evidence synthesis should prioritise adjusted estimates, stratification by Tokyo severity/ASA class, and, where feasible, individual participant data meta-analysis; clinically, CC remains preferred for appropriate surgical candidates, whereas PC should be reserved as a bridge or salvage strategy in selected high-risk patients.