---
title: Draining the gallbladder before surgery added a week in hospital and doubled ICU admission. It did not reduce complications
publication: Medical Insights Korea
section: news
category: Gallbladder
canonical_url: https://medicalinsightskorea.com/news/ptgbd-before-cholecystectomy-korean-outcomes
author: David Seo
published: 2026-09-01T10:40:00+09:00
modified: 2026-09-01T10:40:00+09:00
content_type: reporting
license: Quotation permitted with attribution to Medical Insights Korea and a link to the canonical URL.
---

# Draining the gallbladder before surgery added a week in hospital and doubled ICU admission. It did not reduce complications

Two propensity-matched Korean series of moderate-to-severe acute cholecystitis found no complication benefit from drainage before laparoscopic cholecystectomy. The delay that predicted harm was the patient's, not the surgeon's.

## Answer

In a propensity score-matched Korean series of 244 patients with grade II or III acute cholecystitis, percutaneous transhepatic gallbladder drainage before laparoscopic cholecystectomy was associated with a longer interval to surgery (10.1 versus 3.6 days), higher intensive care admission (44.3 versus 22.1 percent) and longer hospital stay (18.2 versus 11.3 days) without reducing postoperative complications.

## Key takeaways

- In a propensity-matched Korean series of 244 patients with grade II or III acute cholecystitis, drainage before surgery was associated with a longer interval to operation (10.1 versus 3.6 days), higher ICU admission (44.3 versus 22.1 percent) and longer hospital stay (18.2 versus 11.3 days), without reducing postoperative complications.
- In the same study, presenting to hospital more than four days after symptom onset independently tripled the odds of a postoperative complication (odds ratio 3.01, 95 percent confidence interval 1.16 to 7.81).
- A separate propensity-matched study across four Korean tertiary centres, covering 402 matched patients with grade II or III disease, found no difference in biliary complications between drainage and upfront surgery (hazard ratio 1.103, 95 percent confidence interval 0.519 to 2.343).
- The Tokyo Guidelines 2018 recommend early laparoscopic cholecystectomy for grade I and grade II acute cholecystitis in patients with a Charlson comorbidity index of 5 or less and an ASA physical status of 2 or less, reserving drainage for those who fall outside those criteria.
- Both Korean studies are retrospective, and in the four-centre study the drainage group remained significantly sicker after matching, so neither can establish that drainage itself caused the longer stays.

## Full article

When a gallbladder becomes acutely inflamed and the patient looks too fragile for an operation, the standard alternative is to put a drain in it. A needle through the liver into the gallbladder relieves the pressure, the fever settles, and surgery waits for a better day. It is a reasonable idea, it is done frequently in Korean hospitals, and two recent Korean studies have now measured what it costs.

Neither found the benefit the practice assumes.

### What the guideline actually says

The Tokyo Guidelines 2018, whose authorship includes several Korean hepatobiliary surgeons, set out a flowchart by severity grade. For grade I disease it recommends early laparoscopic cholecystectomy where the Charlson comorbidity index is 5 or less and the ASA physical status is 2 or less. For grade II it makes the same recommendation, adding that the operation should be performed by an experienced surgeon; only if those criteria are not met does it direct the patient to medical treatment and gallbladder drainage first. Grade III can still be operated on early, but under stricter conditions and at an advanced centre.

The guideline also dropped the older 72-hour window. Early now means within seven days of symptom onset rather than within three, a change that widened the group of patients eligible for immediate surgery.

> **The distinction that matters**  
> The guideline routes patients to drainage on the basis of anaesthetic and comorbidity risk, not on the basis of how inflamed the gallbladder looks. A patient can have grade II cholecystitis and still be a candidate for immediate surgery.

### The Hallym series: ten days instead of four

A team led from Hallym University Dongtan Sacred Heart Hospital reviewed 505 patients who underwent laparoscopic cholecystectomy for grade II or III acute cholecystitis between 2012 and 2022, then matched 122 who had received drainage against 122 who went straight to theatre. The results were published in the American Journal of Surgery.

**Propensity score-matched outcomes, grade II-III acute cholecystitis, 122 patients per group**

|  | Drainage first | Direct surgery |
| --- | --- | --- |
| Time to surgery | 10.1 days | 3.6 days |
| ICU admission | 44.3% | 22.1% |
| Hospital stay | 18.2 days | 11.3 days |
| Postoperative complications | No reduction observed | Reference |

**44.3% vs 22.1%** — intensive care admission after drainage before surgery, versus direct laparoscopic cholecystectomy, in matched patients with grade II-III acute cholecystitis  
_Source: Lee KJ et al., American Journal of Surgery, 2026_

The authors' conclusion is unusually plain for a surgical paper: drainage may extend hospitalisation and intensive care use without improving outcomes.

### The delay that predicted harm came before admission

The same analysis tested which delays mattered. The interval that independently predicted postoperative complications was not the wait between admission and operation. It was the wait before the patient arrived: presenting more than four days after symptoms began tripled the odds of a complication, with an odds ratio of 3.01 (95 percent confidence interval 1.16 to 7.81, p = 0.023).

That finding points somewhere other than the operating theatre. It is a statement about how quickly people with upper abdominal pain reach a hospital that can operate on them, which is a question of triage and referral rather than of surgical technique.

### Four centres, 835 patients, no difference in biliary complications

The larger of the two studies, published in Annals of Surgical Treatment and Research, drew on 835 patients with grade II or III disease treated at four Korean tertiary centres. After one-to-one matching it compared 201 patients who had drainage first against 201 who had early laparoscopic cholecystectomy, and found no difference in biliary complications: a hazard ratio of 1.103, with a confidence interval from 0.519 to 2.343 that comfortably spans no effect.

Its authors read this as evidence that early laparoscopic cholecystectomy is feasible in most cases of moderate-to-severe cholecystitis, while keeping drainage for patients whose underlying disease makes general anaesthesia itself the hazard. That is a narrower indication than current practice, not an argument against drainage.

### For patients who do get a drain, the interval is measurable

A single-centre study at Konyang University Hospital followed 695 patients with grade I or II cholecystitis who had drainage and then surgery between 2010 and 2019, and looked for the intervals at which outcomes deteriorated.

- In grade I disease, more than 3.5 days from symptom onset to drainage predicted a technically difficult operation.
- In grade I disease, more than 7.5 days from drainage to cholecystectomy predicted a poor postoperative outcome.
- In grade II disease, neither interval was statistically related to surgical difficulty or postoperative outcome.

The grade I thresholds are derived from receiver operating characteristic analysis in one hospital's records and have not been validated prospectively elsewhere. They are a starting point for scheduling, not a standard.

### What these studies cannot show

All three are retrospective, and they share one limitation that no amount of statistical adjustment removes.

1. Patients receive drains because they are judged too unwell for immediate surgery, so the drainage group is sicker before any treatment decision is recorded. Propensity matching corrects only for the characteristics that were measured.
2. The four-centre study shows this directly: after matching, the drainage group still had significantly more preoperative systemic inflammatory response syndrome (24.9 versus 6.5 percent), more pneumonia (7.5 versus 3.0 percent) and more cardiac disease (67.2 versus 57.7 percent) than the surgical group.
3. Longer stays and more intensive care in the drainage group are therefore consistent with two explanations that these designs cannot separate: that the drain delayed recovery, or that the patients who received drains were always going to need more care.

> **What would settle it**  
> A randomised comparison of drainage against upfront surgery in patients who are genuinely borderline, well enough that either decision is defensible, is the trial that would answer this. Until one is run, the Korean data establish that drainage is associated with substantially more hospital resource use and no measurable complication benefit, which is a reason to check the indication in each case rather than to abandon the procedure.

## Sources

- Lee KJ, Jung JH, Park SW, Park DH, Cha HW, Koh DH, et al. Clinical impact of percutaneous transhepatic gallbladder drainage followed by laparoscopic cholecystectomy in patients with moderate to severe acute cholecystitis: A propensity score-matched case-control study. American Journal of Surgery 2026;252:116737. doi:10.1016/j.amjsurg.2025.116737. PMID:41317682. https://doi.org/10.1016/j.amjsurg.2025.116737
- Lee O, Shin YC, Ryu Y, Yoon SJ, Kim H, Shin SH, et al. Comparison between percutaneous transhepatic gallbladder drainage and upfront laparoscopic cholecystectomy in patients with moderate-to-severe acute cholecystitis: a propensity score-matched analysis. Annals of Surgical Treatment and Research 2023;105(5):310-318. doi:10.4174/astr.2023.105.5.310. PMID:38023435. https://doi.org/10.4174/astr.2023.105.5.310
- Lee JS, Lee SJ, Choi IS, Moon JI. Optimal timing of percutaneous transhepatic gallbladder drainage and subsequent laparoscopic cholecystectomy according to the severity of acute cholecystitis. Annals of Hepato-Biliary-Pancreatic Surgery 2022;26(2):159-167. doi:10.14701/ahbps.21-125. PMID:35082174. https://doi.org/10.14701/ahbps.21-125
- Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences 2018;25(1):55-72. doi:10.1002/jhbp.516. PMID:29045062. https://doi.org/10.1002/jhbp.516
- Mishima K, Fujiyama Y, Wakabayashi T, Igarashi K, Ozaki T, Honda M, et al. Early laparoscopic cholecystectomy for acute cholecystitis following the Tokyo Guidelines 2018: a prospective single-center study of 201 consecutive cases. Surgical Endoscopy 2023;37(8):6051-6061. doi:10.1007/s00464-023-10094-x. PMID:37118031. https://doi.org/10.1007/s00464-023-10094-x

## Citation

David Seo (2026). "Draining the gallbladder before surgery added a week in hospital and doubled ICU admission. It did not reduce complications". Medical Insights Korea. https://medicalinsightskorea.com/news/ptgbd-before-cholecystectomy-korean-outcomes

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