Surgical Management of Acute Cholecystitis in Critically Ill Patients: Early Cholecystectomy, Percutaneous Drainage, And Individualized Source Control

Acute cholecystitis in critically ill patients represents a complex source-control problem in which the benefits of definitive surgery must be balanced against active sepsis, organ dysfunction, and anesthetic risk. Early laparoscopic cholecystectomy is generally preferred when patients can tolerate an operation, whereas percutaneous cholecystostomy offers rapid decompression for individuals with refractory shock or prohibitive physiological instability. The multicenter CHOCOLATE randomized trial demonstrated substantially fewer major complications with laparoscopic cholecystectomy than with catheter drainage among high-risk patients suitable for randomization, but its findings should not be directly generalized to patients with uncontrolled multiorgan failure. Percutaneous drainage remains valuable as a bridge to stabilization and delayed surgery, although catheter-related events, prolonged hospitalization, and recurrent biliary disease complicate definitive nonoperative management. Endoscopic gallbladder drainage offers an internal alternative in selected patients at specialized centers, while open or bailout surgical strategies remain necessary for complex inflammation and unsafe operative anatomy. The timing of interval cholecystectomy should be individualized after recovery from sepsis rather than determined solely by an arbitrary interval. Acalculous cholecystitis requires particular attention because drainage may occasionally serve as definitive therapy after systemic recovery. This narrative review examines clinical risk stratification, operative and nonoperative source control, comparative evidence, post-drain management, and multidisciplinary decision-making in critically ill patients with acute cholecystitis.