Gaps and insights toward evidence-based management for acute cholecystitis patients at high surgical risk

Acute cholecystitis (AC) is one of the most common causes of emergency admission to surgical wards. Since 2007, the Tokyo guidelines have provided valuable insights into severity assessment and paved the way for clinical trials of tailored treatments. Although laparoscopic cholecystectomy is widely regarded as the standard and most frequently performed procedure, the optimal management of AC patients at high surgical risk due to significant comorbidities or advanced age remains a largely neglected challenge. Many existing studies have failed in their aim to optimize the management. In this review, we highlight 5 underrecognized problems in practice: limited evidence base due to lack of prospective research; inconsistent definitions of high surgical risk; the technical "black box" related to gallbladder drainage; limited consideration of patients' values and preferences; and the complexity of managing individuals from special populations. We discuss each of these 5 gaps thoroughly, referring to examples, and propose approaches to overcome these limitations. Our review thus offers new perspectives on standardized management strategies and promote the development of trustworthy guidelines for AC management in patients at high surgical risk. Efforts are particularly needed to conduct more prospective real-world research, standardize the definitions, and enhance communication between patients and healthcare professionals.