DIFFERENTIATED SURGICAL STRATEGY FOR COMPLICATED FORMS OF ACUTE CHOLECYSTITIS: A COMPARATIVE ANALYSIS OF SHORT-TERM AND LONG-TERM CLINICAL OUTCOMES

Abstract

Complicated forms of acute cholecystitis, including pericholecystic infiltrate, abscess, perforation with peritonitis, obstructive jaundice, cholangitis, and Mirizzi syndrome, occur in 30–45% of hospitalized patients and are associated with mortality rates reaching 8–15% among elderly patients with comorbidities. The selection of an optimal surgical strategy for this nosological group remains a subject of ongoing debate. Objective. To evaluate the efficacy of a purpose-designed differentiated system for the surgical management of complicated acute cholecystitis through a comparative analysis of short-term and long-term clinical outcomes. Materials and methods. A prospective controlled comparative study was conducted involving 288 patients with complicated forms of acute cholecystitis (Kashkadarya  Regional Multidisciplinary Medical Center, 2016–2025). The control group comprised 136 patients treated using a traditional approach between 2016 and 2020, whereas the study group consisted of 152 patients managed according to the differentiated algorithm from 2021 to 2025. The algorithm incorporated multiparametric diagnostic assessment according to TG18/TG23, a scoring system for cholecystectomy method selection (DGU 03904), diagnostic laparoscopy utilizing the DIFFICULT score, proactive conversion for a DIFFICULT score ≥4 or >50 min of duct identification, novel balloon drainage of the cystic duct stump, and extracorporeal detoxification for Grade III cholangitis. The study protocol was approved by the Bioethics Committee of Bukhara State Medical Institute. Informed consent was obtained from all participants, adhering to the WMA Declaration of Helsinki (2013). Statistical analyses were performed using IBM SPSS Statistics 26.0, employing Pearson’s χ² test, Fisher’s exact test, Student’s t-test, odds ratios (OR) with 95% confidence intervals (CI), and ROC analysis. A p-value <0.05 was considered statistically significant. This study was conducted as a component of the research project at Bukhara State Medical Institute, Development of Improved Methods for the Diagnosis and Surgical Treatment of Patients with Complicated Forms of Acute Cholecystitis (2021–2025). Results. In the study group, the proportion of minimally invasive interventions increased from 59.6% to 92.8% (OR = 8.70; p < 0.001), with laparoscopic cholecystectomy (LCE) rising from 16.9% to 51.3% (OR = 5.26; p < 0.001). Iatrogenic complications during conversion occurred in 0% versus 29.4% of cases (p = 0.003). Early complications were observed in 5.9% compared to 20.6% (OR = 0.24; p < 0.001). Bile leakage rates were 2.6% versus 10.3% (OR = 0.23; p = 0.009). Reoperations were required in 0% versus 5.1% (p = 0.005). Mortality rates were 1.3% compared to 4.4%. The total hospital stay was 6.0 ± 0.8 days versus 13.6 ± 0.9 days (p < 0.001). Cumulative postcholecystectomy syndrome (PCS) in the long term was 22.3% versus 41.8% (p = 0.003), with organic PCS occurring in 7.8% compared to 20.9% (p = 0.006). Conclusions. A differentiated surgical strategy based on TG18/TG23, the DGU 03904 scoring system, the critical view of safety (CVS) principle, balloon drainage of the cystic duct stump, and algorithmized detoxification significantly reduces the incidence of early complications, mortality, reoperation rates, and iatrogenic biliary injuries, concurrently shortening hospital stay and decreasing the long-term incidence of PCS.