Acute calculous cholecystitis (ACC) is an inflammatory disease of the gallbladder, which is associated with the blockage of the cystic duct by gallstones and is one of the most common indications for emergency surgical admission globally. A significant percentage of the adult population suffer from gallstone disease, and the disease adds a significant burden of healthcare as a result of the occurrence of recurrent biliary symptoms, emergency visits and surgery. Asymptomatic gallstones progress to acute cholecystitis through complex interactions of mechanical obstruction, gallbladder distension, ischemia and inflammatory responses. Acute cholecystitis is one of the biggest clinical problems encountered in patients with symptomatic gallstone disease, and it is important to be able to diagnose this condition at an early stage and to treat it appropriately with surgery [1]. Since its introduction, laparoscopic cholecystectomy has become the standard surgical treatment for symptomatic gallstone disease. It has been accepted as a gold standard procedure for the treatment of gallstone-related disease and has effectively replaced open cholecystectomy due to the numerous benefits it provides in terms of reduced postoperative pain, shorter hospital stay, faster recovery, better cosmesis and overall lower morbidity. Historically, surgeons preferred delayed surgery because of concerns regarding inflammation, distorted anatomy and operative complications, altered anatomy and risk of complications (liver injury, bile duct injury, conversion to open surgery). The conventional strategy was conservative treatment with antibiotics, pain-killers and supportive care followed by delayed laparoscopic cholecystectomy a few weeks after acute inflammation had settled [2]. But with the advancements in the laparoscopic technique, perioperative care and the skill of surgery, this conventional approach has been challenged. Early laparoscopic cholecystectomy, typically done during the initial 24–72 hours of onset of symptoms or hospital admission, is becoming a more standard approach for appropriate patients with acute calculous cholecystitis. The benefits of early surgery are to prevent a second attack, prevent complications from delayed treatment, minimise total hospitalisation, and lower healthcare costs [3]. There have been several RCTs and systematic reviews showing that the early laparoscopic cholecystectomy is safe and has no difference in the postoperative complication rate from delayed surgery [4]. Surgery timing is important, as both have their advantages and disadvantages. Laparoscopic cholecystectomy can be performed at the time of initial hospitalization and the risk of recurrent biliary events can be avoided if early. On the other hand, surgery may be more difficult if there is inflammation, and it may be easier to dissect if the surgery is delayed, allowing the inflammation to pass. Patients are at risk of recurrent pain attacks, re-admission for pain, further complications from gallstones and further health services use if surgery is not performed early enough, however [5]. Based on studies comparing the two, many studies now support early laparoscopic cholecystectomy. Early surgery was found to significantly improve total hospital stay with a parallel reduction in the rate of bile duct injury, postoperative complications, and conversion to open surgery in a meta-analysis of RCTs [6]. In the same way others systematic reviews have shown that there is no difference in surgical safety results and patient recovery between early and delayed management [7]. These findings have had an impact on international guidelines such as those of surgical societies which recommend early laparoscopic cholecystectomy, when possible, in patients with acute calculous cholecystitis [8]. While there is growing evidence that early surgery is effective, there is still a lack of uniformity of practice, especially in resource-limited settings. Availability of emergency operating rooms, surgeon expertise, anesthetic support, patient comorbidities, and institutional protocols can impact the decision of early versus delayed approach. Delayed laparoscopic cholecystectomy is still performed in some developing health care systems due to the fear of difficulty of the procedure and limited surgical facilities. For this reason, it is still beneficial to have institution-specific comparisons of the outcomes of early versus delayed procedures. Patient age, inflammation severity, symptom duration, gallbladder wall thickness, presence of adhesions, surgical time and surgeon experience are variables that may affect surgical outcome after laparoscopic cholecystectomy. Other surgical outcomes that are relevant to the various surgical strategies are complications including bile leakage, surgical site infection, postoperative pain, open surgery, and length of hospitalization [9]. Knowing the influence of surgery timing on these outcomes will aid patient selection and help enhance perioperative care. Laparoscopic cholecystectomy has been stressed as the treatment of choice for acute calculous cholecystitis in appropriate patients based on the severity of the disease and the condition of the patient, according to the Tokyo Guidelines. It is important to note, in these guidelines, that early surgical intervention can optimize results in an effort to manage the source of inflammation and inhibit disease progression [10]. In more seriously ill patients, however, with high levels of inflammation or with high risk of complications, treatment needs to be tailored to the individual patient. Comparing outcomes between early and delayed laparoscopic cholecystectomy has been a priority in previous studies, which have mostly been conducted in Western populations, with less work to be conducted in South Asian healthcare settings. Treatment outcome may be affected by variation in patient factors, access to health care, time of presentation and operative facilities. Hence, it is important to conduct local clinical studies to identify if international recommendations are applicable in local healthcare environments. Although international evidence supports early laparoscopic cholecystectomy, limited prospective comparative data are available from Pakistan, particularly from tertiary-care hospitals in Khyber Pakhtunkhwa. Differences in operating-room availability, surgeon expertise, delayed presentation, patient comorbidities and institutional practices may influence the applicability of international findings in local healthcare settings. Therefore, institution-specific evidence is required to compare the effectiveness and safety of early and delayed laparoscopic cholecystectomy, The objective of this study was to compare operative outcomes, postoperative complications, total hospital stay, recurrent biliary symptoms, return to normal activity and patient satisfaction between early and delayed laparoscopic cholecystectomy in patients with acute calculous cholecystitis.

Study Design and Setting This prospective comparative observational study was conducted in the Department of Surgery, Ayub Teaching Hospital, Abbottabad, Pakistan, over six months, from June 1, 2025, to December 31, 2025. The study compared the operative outcomes, postoperative complications, and recovery patterns of early and delayed laparoscopic cholecystectomy in patients diagnosed with acute calculous cholecystitis. Study Population and Sampling Adult patients presenting with acute calculous cholecystitis during the study period were enrolled using a non-probability consecutive sampling technique. A total of 75 patients fulfilling the eligibility criteria were included. Of these, 38 underwent early laparoscopic cholecystectomy, while 37 underwent delayed laparoscopic cholecystectomy. Sample-Size Calculation The sample size was calculated using the formula for comparing two independent means. The calculation was based on an anticipated difference of 2.0 days in total hospital stay, a common standard deviation of 3.0 days, a confidence level of 95%, a statistical power of 80%, and a 1:1 allocation ratio. The minimum required sample was calculated as 72 patients. After allowing for possible incomplete data, 75 patients were enrolled. Inclusion Criteria Patients were included when they met the following criteria: • Age between 18 and 75 years. • Diagnosis of acute calculous cholecystitis based on clinical findings, laboratory investigations, and abdominal ultrasonography. • Presence of gallstones with features of acute gallbladder inflammation. • Fitness for general anesthesia and laparoscopic surgery. • Provision of written informed consent. Exclusion Criteria Patients were excluded if they had: • Acalculous cholecystitis. • Common bile duct stones or acute cholangitis. • Acute gallstone pancreatitis. • Suspected or confirmed gallbladder malignancy. • Pregnancy. • Severe uncontrolled medical comorbidities. • American Society of Anesthesiologists physical status class IV or V. • Previous major upper-abdominal surgery. • Contraindication to general anesthesia. • Refusal to participate or incomplete clinical records. Diagnosis and Initial Assessment Acute calculous cholecystitis was diagnosed based on right upper-quadrant pain or tenderness, fever, elevated inflammatory markers, and ultrasonographic evidence of gallstones with gallbladder wall thickening, pericholecystic fluid, gallbladder distension, or a positive sonographic Murphy sign. Baseline information, including age, sex, duration of symptoms, presenting complaints, comorbidities, and previous biliary symptoms, was recorded on a structured data-collection proforma. All patients underwent routine preoperative investigations, including: • Complete blood count. • Liver function tests. • Renal function tests. • Serum electrolytes. • Coagulation profile. • Abdominal ultrasonography. Group Allocation Patients were allocated non-randomly to the early or delayed surgery group according to their clinical condition, operating-room availability, surgeon assessment, and patient preference. The early laparoscopic cholecystectomy group included 38 patients who underwent surgery during the index hospital admission and within 72 hours of hospital admission. The delayed laparoscopic cholecystectomy group included 37 patients who initially received conservative management and subsequently underwent interval laparoscopic cholecystectomy after 6–8 weeks, following resolution of the acute inflammatory episode. Conservative Management Patients in the delayed surgery group were initially managed according to the departmental protocol with intravenous fluids, antibiotics, analgesics, antiemetics, bowel rest, and clinical monitoring. They were discharged after improvement in acute symptoms and were scheduled for elective laparoscopic cholecystectomy after 6–8 weeks. Any recurrent biliary pain, emergency visit, readmission, or additional antibiotic requirement during the waiting period was documented. Operative Procedure Laparoscopic cholecystectomy was performed under general anesthesia using the standard four-port technique. All procedures were performed by, or under the supervision of, experienced consultant general surgeons. Operative time was measured from the initial skin incision to completion of skin closure. Intraoperative findings and outcomes included: • Operative duration. • Difficulty in Calot’s triangle dissection. • Drain placement. • Intraoperative complications. • Conversion to open cholecystectomy. Conversion to open surgery was performed when safe laparoscopic dissection could not be achieved because of severe inflammation, dense adhesions, unclear anatomy, uncontrolled bleeding, or suspected bile duct injury. Outcome Measures The primary outcome was total hospital stay, defined as the combined duration of the initial admission and subsequent operative admission, where applicable. Secondary outcomes included: • Operative time. • Conversion to open surgery. • Intraoperative complications. • Postoperative hospital stay. • Time to oral intake. • Postoperative complications. • Return to normal activity. • Readmission. • Recurrent biliary symptoms. • Additional emergency visits. • Additional antibiotic requirements. • Patient satisfaction. Postoperative complications included bile leakage, surgical-site infection, postoperative fever, and other complications occurring within 30 days after surgery. Patient Satisfaction Patient satisfaction was assessed at the postoperative follow-up visit using a five-point Likert scale, ranging from 1, very dissatisfied, to 5, very satisfied. Patients who selected a score of 4 or 5 were categorized as satisfied. Follow-Up Patients were followed for 30 days after surgery through outpatient clinic visits and telephone contact. Patients in the delayed group were also monitored during the interval between their initial admission and definitive surgery. Information regarding recurrent symptoms, emergency visits, antibiotic use, postoperative complications, readmission, and return to normal activities was recorded. Statistical Analysis Data were entered and analyzed using IBM SPSS Statistics version 26.0. Continuous variables were assessed for normality using the Shapiro–Wilk test and visual inspection of histograms. Normally distributed continuous variables were presented as mean ± standard deviation and compared using the independent-samples t-test. Non-normally distributed continuous variables were presented as median and interquartile range and compared using the Mann–Whitney U test. Categorical variables were presented as frequencies and percentages. The chi-square test was used for categorical comparisons, while Fisher’s exact test was applied when expected cell counts were less than five. Mean differences, relative risks, and risk differences were reported with 95% confidence intervals, where appropriate. All statistical tests were two-sided, and a p-value of less than 0.05 was considered statistically significant. Ethical Considerations Ethical approval was obtained from the Institutional Ethical Review Committee of Ayub Medical College, Abbottabad. Written informed consent was obtained from every participant before enrollment. Patient identity, confidentiality, privacy, and the right to withdraw from the study were maintained throughout the research process.

A total of 75 patients with acute calculous cholecystitis who underwent laparoscopic cholecystectomy were included in the study. Patients were divided into two groups according to the timing of surgery: early laparoscopic cholecystectomy (ELC) performed during the initial admission (n=38) and delayed laparoscopic cholecystectomy (DLC) performed after conservative management and interval follow-up (n=37). The demographic characteristics of both groups were comparable, with no statistically significant differences in age and gender distribution (p>0.05). The mean age of patients in the early surgery group was 46.2 ± 12.8 years, while the delayed surgery group had a mean age of 47.5 ± 13.4 years. Females represented the majority of patients in both groups.

Table 1: Demographic Characteristics of Study Participants

The comparison of operative outcomes demonstrated that patients undergoing early laparoscopic cholecystectomy had a shorter overall treatment period and reduced hospitalization compared with those undergoing delayed surgery. Although the operative duration was slightly longer in the early surgery group due to active inflammation and difficult dissection, the difference was not statistically significant.

Table 2: Comparison of Operative Outcomes Between Early and Delayed Groups

Postoperative recovery parameters showed significant advantages in the early laparoscopic cholecystectomy group. Patients undergoing early surgery experienced a significantly shorter total hospital stay compared with the delayed group. The mean postoperative hospital stay was 2.8 ± 1.1 days in the early group compared with 5.6 ± 2.3 days in the delayed group (p<0.001). Additionally, the total duration of hospitalization, including initial admission and readmission for surgery, was significantly lower among patients treated with early surgery.

Table 3: Comparison of Postoperative Recovery Outcomes

Postoperative complications were observed in both groups; however, no statistically significant difference was found between early and delayed laparoscopic cholecystectomy. The overall complication rate was 10.5% in the early group and 8.1% in the delayed group (p=0.72). Bile leakage, wound infection, and postoperative fever were the most commonly observed complications.

Table 4: Postoperative Complications in Both Groups

The delayed surgery group demonstrated a higher frequency of recurrent biliary symptoms while awaiting definitive surgery. During the interval period, 6 patients (16.2%) experienced recurrent biliary pain episodes requiring medical attention, whereas no recurrence was observed in the early surgery group.

Table 5: Recurrence and Additional Healthcare Utilization

Figure 1: Distribution of Patients According to Surgical Timing

Overall, the findings demonstrated that early laparoscopic cholecystectomy provided comparable surgical safety with significantly improved recovery outcomes, shorter hospitalization, fewer recurrent symptoms, and better patient satisfaction compared with the delayed approach. Although operative difficulty and complication rates were similar between groups, early intervention reduced the total healthcare burden associated with acute calculous cholecystitis.

Acute calculous cholecystitis is still one of the most frequent surgical emergencies in the world and the timing of laparoscopic cholecystectomy is an important area of clinical research. This study compared the early laparoscopic cholecystectomy (ELC) with delayed laparoscopic cholecystectomy (DLC) in terms of surgical outcomes, postoperative complications, hospital stay and recovery in patients of acute calculous cholecystitis. The results showed that early laparoscopic cholecystectomy was associated with better outcomes regarding shorter total hospital stays, quicker restoration of normal activities, lower likelihood of recurrent biliary symptoms and higher patient satisfaction, and without any significant differences in safety compared to surgery delayed. The early laparoscopic cholecystectomy group showed a significantly reduced overall hospital stay as compared to the delayed group in the present study. The mean length of hospital stay (LOS) was 2.8 days for those who were operated upon early and 5.6 days for those in whom delayed surgery was performed. The results confirm previous evidence that early intervention saves overall hospitalization due to the absence of primary conservative management and subsequent readmission, and interval surgical admission. Gutt et al. performed a randomized clinical trial showing early laparoscopic cholecystectomy during the initial hospitalization phase was not inferior and overall treatment duration was shorter without increasing the amount of complications [16]. Another observation of the present study was that patients who underwent early laparoscopic cholecystectomy recovered faster than other patients, and returned to normal activity earlier. The early surgery patients were able to resume normal activity about six days before the delayed surgery patients. This enhancement is possibly a result of the elimination of repeated exposure to the symptoms of disease, repeated hospital visits and recurrent inflammation. Roulin et al also found shorter recovery times with early laparoscopic cholecystectomy and lower overall morbidity [17]. One of the largest concerns of early laparoscopic cholecystectomy is that the operation may be more difficult with inflammation and edema. The present study compared slight difference in operative time between the early surgery and delayed surgery but statistically insignificant. Moreover, there was no difference between the two groups in terms of conversion to open surgery and intraoperative complications. The data indicate that inflammation of the gallbladder in ACD does not necessarily increase surgical risk for laparoscopic surgery by experienced surgeons. Cao et al. did a meta-analysis that showed that early laparoscopy cholecystectomy is a safe procedure and does not increase the chances of conversion, bile duct injury, or complications after the operation [18]. The incidence of postoperative complications in the present study did not differ between early and delayed groups. There was no significant difference in the overall complication rate between the early group (10.5%) and the delayed group (8.1%). The incidences of common complications such as bile leakage, wound infection and postoperative fever were similar. This is in line with previous studies showing that surgery delays are not associated with a major benefit in preventing postoperative complications. In fact, early gallbladder removal may prevent further episodes of infection or inflammation to the gallbladder [19]. One of the other interesting results of this study was the higher incidence of recurrent biliary symptoms with delayed surgery. The percentage of patients with recurrence prior to definitive surgery was about 16% in the delayed group compared to none in the early surgery group. This means that when treatment is delayed, patients may end up suffering from recurrent pain, frequent emergency room visits and even complications like recurrent cholecystitis or pancreatitis. The findings of Gurusamy et al. in their systematic review suggested that patients who are waiting for delayed laparoscopic cholecystectomy are at risk of having recurrent gallstone-related complications during the waiting period, which means early definitive treatment should be pursued as much as possible [20]. The results of this study are also similar to the recommendations of international guidelines which are increasingly favoring the use of early laparoscopic cholecystectomy in appropriate patients with acute calculous cholecystitis. The Tokyo Guidelines highlight the importance of surgery at the right time and in the right clinical window in order to better outcomes, less health care burden, and no more episodes of recurrent disease. The selection of patients, however, is a crucial issue, especially for the severe disease, high comorbidities, and hemodynamic instability ones, who need individual-specific management strategies [21]. While early surgery has benefits, some caveats and practical issues need to be acknowledged. The immediate availability of trained surgeons, operating room facilities, anesthesia support and appropriate perioperative monitoring are essential for early laparoscopic cholecystectomy. These can affect the timing of surgical decisions in resource-poor health care environments. However, the findings of the present study suggest that if sufficient surgical expertise and facilities are available, early laparoscopic cholecystectomy can yield better clinical outcomes without sacrificing patient's safety. The findings also have significant implications for healthcare systems in developing nations where delayed surgery is commonly seen due to logistic difficulties. Minimizing unwarranted delays will help to lower hospital bed occupancy, hospital treatment costs, and patient quality of life. The same was observed by Siddiqui et al who reported that early laparoscopic cholecystectomy proved to be economically and clinically advantageous, by avoiding hospital admissions and recurrent gallstone-related events [22]. The findings of the present work also support early laparoscopic cholecystectomy as a successful treatment option in the acute calculous cholecystitis in a tertiary hospital setting. Both methods were equally safe for the surgery, but early intervention was associated with improved recovery time, hospital and to prevent recurrent symptoms. These results support the need to take into account early surgery as the best option in appropriate patients for laparoscopy. In summary, early LC seems to have improved benefits and Postoperative complication rates were similar between the groups, although the confidence intervals were wide because of the small number of events. Larger multicenter trials with longer follow-up periods are suggested to continue to assess the long-term outcome, cost-effectiveness, and applicability of this therapy in various clinical settings. LIMITATIONS This study has several limitations. First, it was conducted at a single tertiary-care hospital with a relatively small sample size, which limits the generalizability and statistical precision of the findings. Second, allocation to early and delayed surgery was non-randomized, creating a risk of selection bias and residual confounding. Third, the number of operative and postoperative complications was small, and the study may have been underpowered to detect meaningful differences in uncommon outcomes. Fourth, follow-up was limited to short-term recovery, and long-term recurrence, quality of life and cost-effectiveness were not assessed. Finally, differences in surgeon experience and operating-room availability may have influenced treatment allocation and outcomes. These limitations should be considered when interpreting the results.

Early laparoscopic cholecystectomy was associated with shorter total hospital stay, earlier return to normal activity and fewer recurrent biliary symptoms compared with delayed laparoscopic cholecystectomy. Operative time, conversion to open surgery and postoperative complication rates were not significantly different between the groups. These findings support the use of early laparoscopic cholecystectomy in eligible patients when experienced surgical teams and appropriate facilities are available. However, because this was a small, single-center, non-randomized study, larger multicenter studies are required to confirm these findings.

Recommendations

Tertiary-care hospitals should develop standardized protocols for the early assessment and same-admission laparoscopic management of eligible patients with acute calculous cholecystitis. Appropriate access to trained laparoscopic surgeons, anesthesia services and emergency operating-room facilities should be ensured. Diagnostic criteria, severity grading, operative findings, complications and follow-up outcomes should be recorded using standardized tools. Future research should include adequately powered multicenter prospective studies or randomized controlled trials with longer follow-up and assessment of quality of life, healthcare costs and long-term biliary outcomes.

Authors’ Contributions

Dr. Bahri Room, Dr. Abid Ali Khan, and Dr. Misbah Ullah contributed equally to this work. They were jointly involved in the conceptualization and design of the study, patient recruitment, clinical assessment, data collection, interpretation of the findings, and drafting and critical revision of the manuscript. Dr. Muhammad Ali contributed to patient monitoring, follow-up assessments, data documentation, and editing and reviewing the manuscript. Dr. Javed Ahmad provided clinical supervision, methodological guidance, validation of the clinical and surgical data, interpretation of the results, and substantive intellectual review of the manuscript. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.

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