Percutaneous cholecystostomy for acute cholecystitis: not so safe after all

I read with interest the paper by Molavi and colleagues,1 entitled “Clinical and operative outcomes of patients with acute cholecystitis who are treated initially with image-guided cholecystostomy.” Any examination of the use of percutaneous cholecystostomy and resultant outcomes is appreciated. However, a large, multi-centre, randomized controlled trial (the CHOCOLATE trial), referenced by Molavi and colleagues, has been conducted to address whether percutaneous cholecystostomy had advantages over early laparoscopic cholecystectomy for high-risk patients (APACHE-II score 7–15) with acute cholecystitis. What is omitted from Molavi and colleagues’ discussion is the fact that in 2016 the CHOCOLATE trial had to be terminated prematurely after interim analysis had raised concerns about the negative effects of percutaneous cholecystostomy. There was a markedly significantly lower rate of the primary composite endpoint (major complications, readmission, reintervention and death) in high-risk patients treated with early laparoscopic cholecystectomy compared with percutaneous cholecystostomy. Consequently, I question the characterization by Molavi and colleagues of percutaneous cholecystostomy as a safe procedure with low morbidity (despite not reporting all morbidities or outcomes in their review). The question is: safe compared to what