Acute calculous cholecystitis is a common acute surgical condition and an important cause of hospital admission and urgent operative intervention. The disease usually results from obstruction of the cystic duct by gallstones, followed by gallbladder inflammation that may range from localized disease to severe systemic illness. Accurate diagnosis and assessment of disease severity are therefore important for determining the appropriate timing and safety of surgical treatment. The Tokyo Guidelines established standardized diagnostic criteria and severity grading for acute cholecystitis, with the severity classification subsequently validated against clinically relevant outcomes including mortality, length of hospital stay, and conversion to open surgery.1,2 Laparoscopic cholecystectomy is the established definitive treatment for acute calculous cholecystitis. Historically, however, surgery was frequently deferred until resolution of the acute inflammatory episode because of concerns regarding difficult dissection, operative complications, and conversion to open surgery. This approach resulted in the widespread use of interval cholecystectomy after initial conservative management. Early laparoscopic cholecystectomy, in contrast, provides definitive treatment during the index admission and avoids a second planned admission for surgery. Early comparative studies demonstrated that laparoscopic cholecystectomy could be safely performed during acute inflammation and that early intervention could reduce total hospital stay.3,4 Subsequent randomized trials and meta-analyses have provided substantial evidence regarding the comparative safety and effectiveness of the two approaches. A Cochrane review found that early laparoscopic cholecystectomy shortened total hospital stay by approximately three days without significant differences in mortality, bile duct injury, conversion to open surgery, or other major outcomes.5 Meta-analyses of randomized trials subsequently reported similar findings, with early surgery associated with shorter total hospitalization and, in some analyses, fewer wound infections, while mortality, bile duct injury, bile leakage, conversion, and overall complications were generally comparable between strategies.6-8 Evidence from observational studies has also demonstrated shorter hospitalization and lower rates of several adverse outcomes with early intervention, although differences between observational and randomized evidence emphasize the importance of study design when interpreting these findings.9 The precise definition of “early” surgery has remained variable. Different studies have used thresholds ranging from 24 hours after admission to several days after symptom onset, making direct comparison between studies difficult. A meta-analysis specifically examining the timing of early laparoscopic cholecystectomy found that surgery performed within 72 hours of symptom onset was associated with fewer postoperative complications than delayed surgery, whereas an additional benefit from performing surgery within 24 hours of admission was not demonstrated.10 Conversely, a randomized trial evaluating patients presenting after more than 72 hours of symptoms found that early surgery could still be performed without the disadvantages traditionally associated with delayed presentation.12 These findings suggest that the timing of surgery should be considered alongside clinical severity and operative suitability rather than being determined solely by an isolated time threshold. Disease severity and patient selection are particularly relevant when considering early surgery. The Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy for appropriately selected patients with Grade I and Grade II disease and allow early surgery in selected Grade III patients when suitable physiological criteria, surgical expertise, and institutional resources are available.13 The 2020 World Society of Emergency Surgery guidelines similarly identified early laparoscopic cholecystectomy as the preferred treatment whenever feasible, including in appropriately selected high-risk patients.14 Operative safety also remains central to the management of acute cholecystitis. Inflammation and fibrosis can distort the hepatocystic anatomy and make identification of the cystic duct and artery difficult. TG18 therefore emphasizes achievement of the critical view of safety before division of the cystic structures and recommends bailout procedures, including subtotal cholecystectomy or conversion to open surgery, when safe anatomical identification cannot be achieved.14 Despite extensive evidence supporting early intervention, differences in operative difficulty, postoperative recovery, hospital utilization, and short-term morbidity may occur across patient populations and treatment settings. Moreover, comparisons incorporating cumulative hospital stay, rather than postoperative stay alone, are particularly relevant because interval management involves an initial admission followed by a separate surgical admission. Therefore, the present study compared early and interval laparoscopic cholecystectomy in patients with acute calculous cholecystitis, with emphasis on disease severity, clinical and ultrasonographic characteristics, operative findings, postoperative recovery, cumulative hospital stay, and 30-day postoperative outcomes.

Study design and setting This was a prospective comparative observational study conducted in the Department of General Surgery of a tertiary-care teaching hospital. The study was conducted over a period of 12 months, from March 2021 and February 2022. The study included consecutive adult patients presenting with acute calculous cholecystitis who were considered suitable for laparoscopic cholecystectomy. Patients underwent either early laparoscopic cholecystectomy (Early LC) during the index admission or interval laparoscopic cholecystectomy (Interval LC) following resolution of the acute episode. The decision regarding the timing of surgery was made by the treating surgical team according to the patient's clinical condition, disease severity, operative suitability, and institutional practice. The study compared perioperative characteristics, operative findings, postoperative recovery, cumulative hospital stay, and 30-day outcomes between the two treatment strategies. The study was conducted in accordance with the ethical principles applicable to research involving human participants and the Declaration of Helsinki. Ethical approval was obtained from the Institutional Ethics Committee of the participating tertiary-care hospital before commencement of the study, and written informed consent was obtained from all participants. Patient confidentiality was maintained throughout the study. Study population Adult patients presenting to the surgical emergency or outpatient services with a clinical and ultrasonographic diagnosis of acute calculous cholecystitis were assessed for eligibility. Acute cholecystitis was diagnosed on the basis of compatible clinical features, laboratory findings, and imaging findings. Ultrasonography was performed as the principal imaging investigation and was used to document gallstones, gallbladder wall thickness, gallbladder distension, pericholecystic fluid, impacted gallbladder-neck stones, sonographic Murphy's sign, common bile duct diameter, and the presence of common bile duct stones. Disease severity was categorized according to the Tokyo Guidelines 2018 (TG18) severity grading system.1 Eligibility criteria Inclusion criteria Patients were eligible if they fulfilled all of the following criteria: 1. Age ≥18 years. 2. Clinical diagnosis of acute calculous cholecystitis. 3. Ultrasonographic evidence of gallstone disease with features compatible with acute cholecystitis. 4. Considered suitable for laparoscopic cholecystectomy by the treating surgical team. 5. Underwent an attempted laparoscopic cholecystectomy either during the index admission or as an interval procedure. 6. Provided written informed consent for participation and follow-up. Exclusion criteria Patients were excluded if they had: 1. Acalculous cholecystitis. 2. Suspected or confirmed gallbladder malignancy. 3. Acute pancreatitis as the primary presenting condition. 4. Isolated choledocholithiasis without acute calculous cholecystitis. 5. Previous major upper abdominal surgery precluding planned laparoscopic access. 6. Pregnancy. 7. Severe medical illness rendering the patient unsuitable for laparoscopic surgery. 8. Primary open cholecystectomy without an attempt at laparoscopic surgery. 9. Inability or unwillingness to provide informed consent or complete the required follow-up. Sample size and sampling The required sample size was estimated a priori for comparison of a continuous hospital-stay outcome between two independent groups. Assuming a moderate standardized difference of approximately 0.5, a two-sided α level of 0.05, and 80% statistical power, the minimum required sample was approximately 128 participants. Allowing for a small proportion of incomplete observations or loss to follow-up, the recruitment target was set at 135 participants. A consecutive sampling approach was used, whereby eligible patients presenting during the study period were recruited until the planned sample size was achieved. A total of 135 patients were included in the analysis, comprising 75 patients in the Early LC group and 60 patients in the Interval LC group. Definition of treatment groups Early laparoscopic cholecystectomy: Early LC was defined as laparoscopic cholecystectomy performed during the index admission and within 72 hours of symptom onset, according to the predefined study protocol. Patients were clinically assessed and stabilized before surgery. Appropriate perioperative management, including intravenous fluids, analgesia, antiemetics, and antibiotics when clinically indicated, was provided.13 Interval laparoscopic cholecystectomy: Interval LC was defined as laparoscopic cholecystectomy performed after resolution of the acute episode, with surgery scheduled after an interval of at least 6 weeks from the index episode. Patients received initial conservative treatment during the acute episode and were discharged after clinical improvement before subsequent elective readmission for laparoscopic cholecystectomy. The interval from the index episode to surgery was recorded in days.13 Preoperative assessment All enrolled patients underwent a standardized preoperative assessment. Demographic and clinical variables included age, sex, BMI, diabetes mellitus, hypertension, previous biliary attacks, previous episodes of acute cholecystitis, fever, vomiting, jaundice, clinical Murphy's sign, and ASA-PS. Laboratory investigations included total leukocyte count, CRP, total bilirubin, AST, ALT, ALP, serum creatinine, platelet count, and serum albumin. The timing of symptom onset, hospital admission, and surgery was also documented. Assessment of disease severity The severity of acute cholecystitis was classified according to the Tokyo Guidelines 2018 (TG18)1 severity grading system: • Grade I: mild acute cholecystitis • Grade II: moderate acute cholecystitis • Grade III: severe acute cholecystitis TG18 grade was recorded at baseline to describe the severity profile of the two groups and was not used as a criterion for assignment to Early or Interval LC. Ultrasonographic assessment Preoperative abdominal ultrasonography was performed in all patients. The number of gallstones, largest gallstone diameter, gallbladder wall thickness, gallbladder distension, pericholecystic fluid, impacted gallbladder-neck stone, sonographic Murphy's sign, common bile duct diameter, and presence of common bile duct stone were recorded from the preoperative ultrasound assessment. Operative procedure All patients underwent an attempted laparoscopic cholecystectomy under general anesthesia using standard laparoscopic techniques. Pneumoperitoneum was established and laparoscopic ports were placed according to the operating surgeon's preference. The gallbladder was dissected from the liver bed following identification of the cystic duct and cystic artery. Particular attention was paid to achieving the critical view of safety (CVS) before division of the cystic structures.14 Operative duration, estimated blood loss, achievement of CVS, difficult CVS, dense adhesions, difficult Calot's triangle dissection, fundus-first dissection, subtotal cholecystectomy, conversion to open surgery, and drain placement were recorded. When standard dissection was considered unsafe because of severe inflammation, adhesions, or distorted anatomy, an appropriate bailout strategy was adopted according to intraoperative judgment. Subtotal cholecystectomy or fundus-first dissection was performed when considered appropriate. Conversion to open surgery was recorded whenever laparoscopic completion was abandoned and an open procedure was performed.14 Postoperative assessment Patients were monitored postoperatively until discharge. Early postoperative recovery was assessed using 24-hour pain intensity measured by the numerical rating scale, time to oral intake, time to ambulation, postoperative length of hospital stay, return to normal activity, and return to work. Postoperative length of stay was calculated from the date of surgery to discharge. For patients undergoing Interval LC, the hospital stay during the index acute episode and the subsequent admission for interval surgery were recorded separately. Cumulative hospital stay was calculated as the total inpatient hospital days attributable to the acute cholecystitis episode and its surgical management. Follow-up and postoperative outcomes Patients were followed for 30 days after surgery. The following outcomes were recorded: any 30-day postoperative complication, bile leak, wound infection, intra-abdominal collection, 30-day readmission, 30-day reintervention, and 30-day mortality. Any 30-day complication was defined as the occurrence of at least one of the prespecified postoperative complications: bile leak, wound infection, or intra-abdominal collection. Readmission and reintervention were recorded separately and were not included in this composite variable. Study variables and outcomes The primary outcome was cumulative hospital stay, expressed in days. Secondary outcomes included operative time, estimated blood loss, achievement of CVS, difficult CVS, dense adhesions, difficult Calot's dissection, fundus-first dissection, subtotal cholecystectomy, conversion to open surgery, drain placement, postoperative pain, time to oral intake, time to ambulation, postoperative length of stay, return to normal activity, return to work, 30-day complications, bile leak, wound infection, intra-abdominal collection, 30-day readmission, 30-day reintervention, and 30-day mortality. Baseline demographic characteristics, comorbidities, ASA-PS, TG18 grade, clinical findings, laboratory parameters, and ultrasonographic findings were treated as descriptive and comparative preoperative variables. Statistical analysis Data were entered into a computerized database and analyzed using statistical software. Continuous variables were assessed for distribution before analysis. Approximately symmetrically distributed continuous variables were expressed as mean ± SD and compared using the independent-samples t test, with Welch's correction where appropriate. Skewed continuous variables and ordinal variables were expressed as median (IQR) and compared using the Mann–Whitney U test. Categorical variables were presented as frequency and percentage. Between-group comparisons were performed using the Pearson chi-square test when expected cell counts were adequate and Fisher's exact test when expected frequencies were small. All tests were two-sided, and P < 0.05 was considered statistically significant. No multivariable regression analysis was performed; the analysis was restricted to predefined unadjusted between-group comparisons.

A total of 135 patients were included in the analysis, comprising 75 patients in the Early LC group and 60 in the Interval LC group. The two groups were broadly comparable with respect to demographic characteristics, metabolic comorbidities, previous biliary history, ASA-PS, and TG18 severity grade. The mean age was 43.08 ± 13.59 years in the Early LC group and 44.08 ± 10.73 years in the Interval LC group (P = 0.632), while BMI was also similar between groups (P = 0.158). Diabetes and hypertension showed no significant between-group differences. Previous acute cholecystitis was reported in 22.7% and 20.0% of patients, respectively (P = 0.708). The distribution of TG18 severity grades was comparable, with Grade I disease predominating in both groups. Grade III disease accounted for 4.0% of the Early LC group and 3.3% of the Interval LC group. ASA-PS distribution was also similar, with ASA-PS II being the most frequent category in both groups (Table 1). Table 1. Baseline characteristics and disease severity Variable Early LC (n=75) Interval LC (n=60) P value Age, years 43.08 ± 13.59 44.08 ± 10.73 0.632 BMI, kg/m² 24.69 ± 2.89 24.00 ± 2.78 0.158 Sex Female 54 (72.0%) 41 (68.3%) 0.643 Male 21 (28.0%) 19 (31.7%) Diabetes No 68 (90.7%) 54 (90.0%) 0.896 Yes 7 (9.3%) 6 (10.0%) Hypertension No 56 (74.7%) 48 (80.0%) 0.464 Yes 19 (25.3%) 12 (20.0%) Previous biliary attacks 0 26 (34.7%) 16 (26.7%) 0.507 1 25 (33.3%) 25 (41.7%) 2 20 (26.7%) 14 (23.3%) 3 3 (4.0%) 5 (8.3%) 5 1 (1.3%) 0 Previous acute cholecystitis No 58 (77.3%) 48 (80.0%) 0.708 Yes 17 (22.7%) 12 (20.0%) ASA-PS I 15 (20.0%) 15 (25.0%) 0.612 II 43 (57.3%) 35 (58.3%) III 17 (22.7%) 10 (16.7%) TG18 grade I 42 (56.0%) 40 (66.7%) 0.449 II 30 (40.0%) 18 (30.0%) III 3 (4.0%) 2 (3.3%) Continuous variables are presented as mean ± SD and categorical variables as n (%). Clinical manifestations were frequent in both groups. Fever was present in 56.0% of Early LC patients and 65.0% of Interval LC patients, while a positive Murphy's sign was observed in 72.0% and 78.3%, respectively. Vomiting was reported in approximately half of patients in each group. Jaundice was uncommon, occurring in 8.0% of Early LC patients and 5.0% of Interval LC patients. Mean WBC counts and CRP concentrations were similar between groups. Most biochemical parameters were also comparable, including bilirubin, ALT, ALP, creatinine, platelet count, and albumin. AST was higher in the Interval LC group (43.61 ± 14.35 vs 37.07 ± 14.97 U/L; P = 0.011) (Table 2). Table 2. Clinical presentation and laboratory findings Variable Early LC (n=75) Interval LC (n=60) P value Fever 42 (56.0%) 39 (65.0%) 0.289 Vomiting 40 (53.3%) 38 (63.3%) 0.242 Positive Murphy's sign 54 (72.0%) 47 (78.3%) 0.400 Jaundice 6 (8.0%) 3 (5.0%) 0.731 WBC, ×10⁹/L 11.84 ± 3.02 12.08 ± 2.74 0.624 CRP, mg/L 40.82 ± 20.39 43.92 ± 18.66 0.358 Total bilirubin, mg/dL 1.17 ± 0.56 1.25 ± 0.52 0.391 AST, U/L 37.07 ± 14.97 43.61 ± 14.35 0.011 ALT, U/L 44.91 ± 21.05 42.43 ± 19.59 0.480 ALP, U/L 133.91 ± 40.79 129.64 ± 39.56 0.540 Creatinine, mg/dL 0.89 ± 0.20 0.89 ± 0.14 0.991 Platelets, ×10⁹/L 246.52 ± 56.47 260.63 ± 54.82 0.145 Albumin, g/dL 3.59 ± 0.37 3.70 ± 0.38 0.095 Ultrasonographic findings demonstrated broadly similar gallbladder morphology in the two groups. The median number of gallstones was 4 in both groups, and the median largest stone diameter was approximately 11 mm. Gallbladder wall thickness was also comparable. A distended gallbladder was identified in 50.7% of Early LC patients and 40.0% of Interval LC patients, while pericholecystic fluid was present in 52.0% and 43.3%, respectively. An impacted neck stone was observed in 53.3% of Early LC patients and 46.7% of Interval LC patients. Sonographic Murphy's sign was present in approximately 60–63% of patients. CBD diameter and the presence of CBD stones were also not significantly different between groups (Table 3). Table 3. Ultrasonographic characteristics Variable Early LC (n=75) Interval LC (n=60) P value Stone count 4.0 (2.0–5.0) 4.0 (2.0–5.0) 1.000 Largest stone, mm 10.9 (8.2–13.8) 11.0 (8.3–14.2) 0.905 GB wall thickness, mm 4.3 (3.8–4.8) 4.2 (3.5–4.9) 0.596 Distended gallbladder 38 (50.7%) 24 (40.0%) 0.217 Pericholecystic fluid 39 (52.0%) 26 (43.3%) 0.317 Impacted neck stone 40 (53.3%) 28 (46.7%) 0.441 Sonographic Murphy's sign 45 (60.0%) 38 (63.3%) 0.692 CBD diameter, mm 5.7 (4.8–6.3) 5.4 (4.7–6.4) 0.446 CBD stone 6 (8.0%) 1 (1.7%) 0.132 Continuous variables are presented as median (IQR) where non-parametric analysis was used; categorical variables as n (%). Early laparoscopic cholecystectomy was performed within the predefined 72-hour window from symptom onset, with a mean symptom-to-surgery interval of 56.99 ± 6.46 hours. Patients in the interval group underwent surgery after resolution of the acute episode, with a mean interval-to-surgery period of 60.70 ± 10.34 days. The mean operative time was similar between the Early and Interval groups (83.29 ± 19.47 vs. 85.07 ± 19.21 minutes). Estimated blood loss was also comparable. CVS was achieved in 90.7% of Early and 95.0% of Interval cases, while difficult CVS, dense adhesions, difficult Calot’s dissection, fundus-first dissection, subtotal cholecystectomy, conversion to open surgery, and drain placement showed no statistically significant differences between groups (Table 4). Table 4. Timing of surgery and intraoperative findings Variable Early LC (n=75) Interval LC (n=60) P value Timing of surgery Symptom-to-surgery, hours* 56.99 ± 6.46 — — Interval-to-surgery, days* — 60.70 ± 10.34 — Intraoperative findings Operative time, min 83.29 ± 19.47 85.07 ± 19.21 0.605 Estimated blood loss, mL† 38.0 (30.0–50.0) 38.5 (30.0–50.0) 0.805 CVS achieved, n (%) 68 (90.7) 57 (95.0) 0.517 Difficult CVS, n (%) 19 (25.3) 15 (25.0) 1.000 Dense adhesions, n (%) 12 (16.0) 8 (13.3) 0.800 Difficult Calot’s dissection, n (%) 14 (18.7) 13 (21.7) 0.661 Fundus-first dissection, n (%) 10 (13.3) 7 (11.7) 0.792 Subtotal cholecystectomy, n (%) 6 (8.0) 3 (5.0) 0.736 Conversion to open surgery, n (%) 1 (1.3) 2 (3.3) 0.590 Drain placed, n (%) 22 (29.3) 13 (21.7) 0.316 *Timing variables are reported according to the predefined timing definitions for each treatment strategy and are therefore not subjected to between-group testing. †Median (IQR); all other continuous variables are mean ± SD. Postoperative recovery parameters were broadly comparable between the two groups. Median pain score at 24 hours was 4.1 in the Early LC group and 4.0 in the Interval LC group (P = 0.439). Median time to oral intake was 12 hours in both groups, while median ambulation occurred at approximately 11 and 10 hours, respectively. Postoperative hospital stay was also similar, with a median of 3 days in both groups (P = 0.198). Return to normal activity and return to work showed no statistically significant differences. The principal difference was observed in cumulative hospital stay, which was substantially shorter with Early LC. Median cumulative hospital stay was 5 days (IQR 4–5) for Early LC compared with 8 days (IQR 7–9) for Interval LC, with a mean difference of approximately 3.54 days and P < 0.001 (Table 5). Table 5. Postoperative recovery and hospital stay Variable Early LC (n=75) Interval LC (n=60) P value Pain at 24 h, NRS 4.1 (3.4–5.0) 4.0 (3.3–4.6) 0.439 Time to oral intake, h 12.0 (9.0–14.5) 12.0 (9.0–14.0) 0.656 Time to ambulation, h 11.0 (8.0–12.0) 10.0 (7.8–13.0) 0.959 Postoperative LOS, days 3.0 (2.0–3.0) 3.0 (2.0–4.0) 0.198 Return to normal activity, days 10.0 (8.0–12.5) 11.0 (8.8–13.0) 0.387 Return to work, days 12.0 (10.0–15.0) 13.5 (10.0–15.2) 0.270 Cumulative hospital stay, days 5.0 (4.0–5.0) 8.0 (7.0–9.0) <0.001 Thirty-day adverse outcomes were uncommon in both groups. Any 30-day postoperative complication occurred in 3 patients (4.0%) following Early LC and 5 patients (8.3%) following Interval LC; this difference was not statistically significant (P = 0.466). Bile leak occurred in 1.3% of Early LC and 5.0% of Interval LC patients (P = 0.323). Wound infection occurred in 2.7% and 1.7%, respectively (P = 1.000), while intra-abdominal collection occurred in one Interval LC patient and none in the Early LC group. Thirty-day readmission occurred in two Interval LC patients and no Early LC patients (P = 0.196). One Interval LC patient underwent reintervention. No 30-day mortality was observed in either group (Table 6). Table 6. Postoperative complications and 30-day outcomes Outcome Early LC (n=75) Interval LC (n=60) P value Any 30-day complication 3 (4.0%) 5 (8.3%) 0.466 Bile leak 1 (1.3%) 3 (5.0%) 0.323 Wound infection 2 (2.7%) 1 (1.7%) 1.000 Intra-abdominal collection 0 1 (1.7%) 0.444 30-day readmission 0 2 (3.3%) 0.196 30-day reintervention 0 1 (1.7%) 0.444 30-day mortality 0 0 — Categorical variables are presented as n (%). Fisher's exact test was used where appropriate.

The present prospective comparative study evaluated early versus interval laparoscopic cholecystectomy in patients with acute calculous cholecystitis, with particular emphasis on cumulative hospital burden, operative findings, postoperative recovery, and short-term complications. The principal finding was that early laparoscopic cholecystectomy was associated with a substantially shorter cumulative hospital stay, while most baseline, operative, postoperative recovery, and 30-day safety outcomes were comparable between groups. These findings are broadly consistent with randomized evidence supporting early laparoscopic cholecystectomy during the index admission when appropriate surgical expertise and perioperative support are available.4, 15–17 The two groups were broadly comparable with respect to age, sex, BMI, diabetes, hypertension, previous biliary disease, ASA-PS, and TG18 severity grade. This comparability is important because disease severity and physiological reserve can influence both the decision to operate early and the difficulty of surgery. TG18 severity grading has been validated against clinically relevant outcomes including hospital stay and conversion, supporting its use as a standardized descriptor of disease severity.1 The similar distribution of Grade I, II, and III disease in the present cohort therefore suggests that the observed difference in cumulative hospital stay was not simply attributable to a major imbalance in baseline severity. Laboratory and clinical findings were also largely comparable. The only statistically significant laboratory difference was AST, although the difference was relatively modest and was not accompanied by corresponding differences in bilirubin, ALT, ALP, or other markers of systemic illness. The absence of major between-group differences in inflammatory markers supports the overall baseline comparability of the cohort. Importantly, the Tokyo Guidelines emphasize that management should incorporate disease severity, physiological status, and the patient's overall clinical condition rather than rely on a single laboratory parameter.1 The ultrasonographic findings showed no significant differences between groups for stone number, stone size, gallbladder wall thickness, gallbladder distension, pericholecystic fluid, impacted neck stone, sonographic Murphy sign, CBD diameter, or CBD stones. These variables were nevertheless clinically relevant because previous studies have demonstrated associations between sonographic features and technical difficulty. Gallbladder wall thickening, increased gallbladder volume, inflammatory changes, adhesions, and impacted stones have been associated with difficult dissection during laparoscopic cholecystectomy.18–21 The absence of significant differences in these features in the present study therefore provides additional support for the interpretation that the two treatment groups had broadly similar preoperative anatomical and inflammatory profiles. The operative findings further demonstrated comparable technical outcomes. Operative time, blood loss, achievement of CVS, difficult CVS, dense adhesions, difficult Calot’s dissection, fundus-first dissection, subtotal cholecystectomy, conversion to open surgery, and drain placement did not differ significantly. This is consistent with randomized evidence showing that early surgery may be technically demanding but does not necessarily increase conversion or overall postoperative morbidity.4,15,16 Earlier randomized studies similarly demonstrated that differences in operative time, blood loss, or technical difficulty did not translate into a consistent operative disadvantage for early surgery.4,16 The present findings therefore support the safety of early surgery in appropriately selected patients rather than suggesting that interval surgery provides a clear operative advantage. The most prominent difference was cumulative hospital stay: the median was 5 days in the early group compared with 8 days in the interval group (P<.001). This finding is consistent with multiple randomized trials and systematic reviews showing that early laparoscopic cholecystectomy substantially reduces total hospitalization compared with an interval strategy.4,5,15,17,22 In the meta-analysis by Menahem et al. (2015)22, mean hospital stay was 5.4 days with early surgery compared with 9.1 days with delayed surgery, with a pooled reduction of approximately 3.24 days. Importantly, the postoperative hospital stay itself was not significantly different in the present study, indicating that the principal reduction in hospital burden resulted from avoiding the additional admission associated with interval surgery rather than from markedly faster postoperative discharge. Similar observations have been reported in randomized studies in which early surgery reduced total hospitalization despite comparable postoperative recovery.4,15,16 Recovery measures including 24-hour pain, time to oral intake, ambulation, return to normal activity, and return to work were also comparable. Although the present study did not demonstrate statistically significant differences in these endpoints, previous randomized evidence has suggested that early surgery can reduce the overall period of hospitalization and time away from normal activities.4,5 The lack of significant differences in the present cohort may therefore reflect the relatively modest sample size and low variability in postoperative recovery rather than evidence that timing has no effect on functional recovery. Thirty-day outcomes were similarly reassuring. The composite complication rate was low in both groups, with no significant difference in bile leak, wound infection, intra-abdominal collection, readmission, reintervention, or mortality. These findings are compatible with randomized trials and meta-analyses demonstrating no consistent increase in major postoperative complications, bile duct injury, bile leak, or conversion with early compared with delayed surgery.5,15,17,22 Safe operative technique remains essential, particularly when inflammation obscures the anatomy. The use of the critical view of safety and appropriate bailout strategies is emphasized in contemporary surgical safety guidance as a means of reducing the risk of bile duct injury when conventional dissection becomes unsafe.14 The present study has several limitations. Treatment allocation was not randomized, and therefore selection by the treating surgical team may have introduced confounding. The sample size was modest, limiting the ability to detect differences in uncommon outcomes such as conversion, bile leak, reintervention, and mortality. Follow-up was restricted to 30 days, precluding assessment of longer-term quality of life or recurrent biliary events. Nevertheless, the prospective design, standardized recording of clinical, laboratory, ultrasonographic, operative, and recovery variables, and explicit distinction between index-admission and interval-surgery hospital burden strengthen the clinical interpretation of the findings..

Early laparoscopic cholecystectomy in appropriately selected patients with acute calculous cholecystitis was associated with a substantially shorter cumulative hospital stay than interval laparoscopic cholecystectomy. The two strategies demonstrated broadly comparable operative findings, postoperative recovery, and 30-day outcomes, with no significant differences in conversion, bailout procedures, postoperative length of stay, complications, readmission, or reintervention. The principal difference in hospital burden appeared to arise from avoidance of the additional admission required for interval surgery rather than from differences in postoperative recovery. Given the observational design and modest sample size, these findings should be interpreted as comparative associations rather than evidence of causation and should be confirmed in larger studies.

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