Interventional management of acute perforated cholecystitis: When is percutaneous transhepatic cholecystostomy a reasonable therapeutic option?

In the case of acute perforated cholecystitis, rapid control of the infection site is important for patient outcomes. For free perforation with generalized peritonitis, emergency laparoscopic cholecystectomy remains the gold standard therapy. Percutaneous transhepatic cholecystostomy (PTC) is an alternative damage-control option, particularly for frail, septic, or profoundly comorbid patients, either as a bridge to (early or interval) cholecystectomy or, in truly inoperable patients, as definitive palliation. Gallbladder perforations are categorized on the basis of the Niemeier classification. The therapeutic modality depends on the type of perforation. In this editorial, we present the actual guidelines and the findings from trials related to this issue. Moreover, we propose a pragmatic pathway that is based on clinical evidence. The following research gaps are identified: Randomized controlled trials aiming to compare emergency laparoscopic cholecystectomy with PTC as a bridge in cases of Niemeier I and Niemeier II disease are lacking; there are no standardized criteria for the use of PTC as a definitive therapy, such as frailty, sarcopenia or other markers; and there are no comparative studies of endoscopic ultrasound-guided gallbladder drainage vs PTC in cases of perforation.