Removal of the gallbladder (cholecystectomy) is generally recommended for people with symptoms related to gallstones. People at high risk of surgical complications - that is, elderly people and people with co-existing illness - can become very unwell as a result of inflammation of the gallbladder. During anaesthesia and surgery, the body's ability to tolerate stress is lowered, particularly in elderly people and people with co-existing illness. Thus, surgery can be detrimental to these people who are already unwell. The optimal clinical management of these people is not known. External drainage of gallbladder contents with a tube using guidance from scans (percutaneous cholecystostomy) has been proposed as the one of the ways that these patients can be treated. By draining the contents of gallbladder, any infected material can be removed from the body and this might improve the health. Some consider percutaneous cholecystostomy as the only treatment required and perform cholecystectomy only in those who develop further complications while others recommend routine cholecystectomy following percutaneous cholecystostomy. We sought to review all the information available in the literature on this topic and obtained information from randomised clinical trials (studies designed to lower the risk of arriving at wrong conclusions due to researcher's favouritism or differences in the type of people undergoing the different treatments) to determine the optimal method of managing these people. Two review authors collected data independently as a way of quality control.

We identified two trials with 156 participants for this review. The comparisons included in these two trials were 1) percutaneous cholecystostomy plus laparoscopic cholecystectomy (key hole removal of gallbladder) immediately after the general condition improves (percutaneous cholecystostomy followed by early laparoscopic cholecystectomy) versus planned delayed laparoscopic cholecystectomy performed routinely (1 trial; 70 participants) and 2) percutaneous cholecystostomy versus conservative treatment (supportive treatment and antibiotic treatment) (1 trial; 86 participants). Both trials were at high risk of systematic error (prone to arrive at wrong conclusions because of the way the trials were designed and data were analysed). There was no significant difference in the proportion of participants who died or developed complications between any of the comparison groups. Quality of life was not reported in any of the trials. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy in the only comparison that reported this outcome (percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy). The mean total hospital stay and mean costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group. Because of the few trials included in this review and due to their low sample size, there is risk of random errors (play of chance). Based on the current available evidence, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for well-designed clinical trials with low risk of systematic error and random errors on this issue.