The 48-h window of opportunity: patient and health system-related predictors of surgical severity in symptomatic cholelithiasis.

INTRODUCTION

Cholelithiasis is a primary cause of surgical morbidity in Ecuador. While the Parkland Grading Scale (PGS) is a validated tool for intraoperative severity, the influence of time-to-surgery and healthcare system barriers remains poorly understood in regional contexts. This study aimed to evaluate the association between patient-dependent factors, health system-related factors, and surgical severity in Cuenca, Ecuador.

METHODS

This analytical, retrospective cross-sectional study included 259 patients (> 15 years) who underwent laparoscopic cholecystectomy at a tertiary hospital in 2023. The primary outcome was surgical severity (PGS ≥ 3). Exposure variables were categorized into patient-dependent (pain duration, age, sex) and health system-related (history of recurrent biliary colic). Multivariable analysis was performed using Generalized Linear Models (Poisson family) to estimate adjusted Prevalence Ratios (aPR). Pain duration was modeled using Restricted Cubic Splines (RCS) to identify non-linear risk thresholds.

RESULTS

Severe cholelithiasis (PGS 3-5) was present in 31.7% of cases. Multivariable analysis identified recurrent biliary colic-a health system-related factor-as a major predictor of severity (aPR 2.07; 95% CI 1.27-3.38; p = 0.003). Among patient-dependent factors, male sex (aPR 1.50; p = 0.020) and advanced age (aPR 1.01 per year; p = 0.005) were significantly associated with severity. The RCS model revealed a critical 48-h "window of opportunity"; the predicted probability of surgical severity escalated from 18.5% at 24 h to 28.3% at 48 h, reaching 40.5% by 72 h (p = 0.004 for non-linearity).

CONCLUSIONS

Surgical severity is driven by a combination of late presentation and system failures in resolving recurrent symptomatic episodes. The rapid escalation of risk after 48 h of pain underscores the need for same-admission surgical protocols within 48 h of paint onset. Prioritizing early intervention within this threshold and addressing the management of recurrent biliary colic are essential strategies to reduce surgical complexity and improve clinical outcomes in overburdened healthcare systems.