Bail Out Procedures in Acute Cholecystitis: Risk Factors and Optimal Approach.

Background: For difficult cholecystectomies, bail out procedures (BOP) are performed to mitigate risk of patient harm.

Objective: This study sought to identify risk factors for BOP for acute cholecystitis and to compare outcomes by type of BOP performed. Patients with acute cholecystitis who underwent cholecystectomy were included (2020-2022). Demographics, clinical data, and outcomes were collected. Primary outcome was <30-day complication rate. Groups were defined by surgery performed: BOP vs Laparoscopic Complete Cholecystectomy (LCC). BOPs were defined as any deviation from laparoscopic complete cholecystectomy. Univariate analyses compared outcomes between groups. Multivariable analysis identified independent factors associated with BOP. Subgroup analysis compared outcomes of laparoscopic BOP vs open BOP.

Results: Of 728 patients, 659 (91%) underwent LCC and 69 (9%) underwent BOP: 34 (49%) laparoscopic BOP and 35 (51%) open BOP. Independent predictors of BOP included admission total bilirubin >0.2 mg/dL (OR 5.80, = .017), >7 days of symptoms at time of cholecystectomy (OR 1.96, = .019), and arrival heart rate >100 bpm (OR 1.82, = .032). On subgroup analysis, laparoscopic vs open BOP demonstrated no difference in operative time ( = .536) and overall ( = .733) or gallbladder-related complications ( = .364), including bile leaks ( = .090). Laparoscopic BOP was associated with shorter postoperative lengths of stay ( = .005).

Conclusion: The risk factors for BOP identified in this study may help inform patient consent and operative planning. Laparoscopic BOP incurred equivalent complications to open BOP but with shorter hospital stays, challenging conventional dogma that conversion to open is the optimal approach for complicated acute cholecystitis.