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Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study



A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis.


The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO.

Materials and methods

This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC.


1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC.


Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.


Acute cholecystitis (ACC) is a very common pathology, and accounts for between 3 and 7% of the causes of urgent consultation for abdominal pain [1,2,3]. The morbidity rate in surgical treatment of ACC ranges between 7.2 and 26%, and the mortality rate between 0 and 10%. Due to the high prevalence of the condition, reducing the post-operatve morbidity and mortality is a priority issue and would have a great impact in this area of health management [2].

The high variability in the morbidity and mortality figures are due to several factors. Some of them are patient-specific such as age and associated comorbidities, the duration of the condition, and its form of presentation (i.e., associated with liver abscess, perforated, gangrenous, emphysematous, etc.). Mortality associated with ACC is especially high in elderly patients, with associated cardiovascular comorbidity and with complicated forms of the disease [2].

The management and treatment of ACC has been standardized in recent years with the publication of the Tokyo Guidelines in 2013 and 2018, and the WSES in 2020 [1, 5, 6]. According to these guidelines, the therapeutic decision depends on the general condition of the patient and the time of evolution of the clinical picture [1, 7]. Early laparoscopic cholecystectomy (ELC, i.e., within 72 h of the onset of symptoms), in the absence of severity criteria that contraindicate it, constitutes the gold standard for the current management of ACC [1, 5, 6, 8].Since ELC seems significantly reduce intra-operative laparoscopic conversion to open, bile duct injury and post-operative length of stay (LOS) and a significantly greater proportion of ELC is undertaken in high-volume centres, it could be suggested that if ACC is operated on exclusively by high-volume emergency laparoscopist surgeons, the results obtained could be improved[4].

Textbook outcome (TO) is a multidimensional measure used to assess the quality of surgical practice. It reflects an "ideal" surgical result, based on a series of benchmarks or established reference points that may vary depending on the pathology [9]. The first time this management tool was mentioned in the literature was in 2013, when Kolfschoten et al. defined eight parameters that characterized TO in colorectal cancer surgery [9]. Since then, numerous publications have emerged defining TO in other areas of cancer surgery (e.g., pancreatic, hepatobiliary, esophagogastric surgery, etc.) [10,11,12,13,14].

References to TO in the literature in benign diseases are scarce. The few reports that are available were all published very recently [15,16,17]. In the case of ACC, there is no established consensus regarding the parameters that should be included in the definition of TO [17, 18]. There is only one article that defines TO in acute cholecystitis [18], and one that defines it in scheduled laparoscopic cholecystectomy [17]. Based on these two manuscripts, the items for achieving TO in urgent early cholecystectomy (UEC) include no Clavien-Dindo complication (< I), hospital stay less than the 75th percentile, no mortality or readmission within 30 days of surgery and the laparoscopic approach. All patients who presented these variables were considered TO in UEC [9].


The primary endpoint was to identify factors related to achieving TO in patients with urgent early cholecystectomy (UEC) for ACC. Secondary objectives were to provide an international proposal for defining the parameters for defining TO in the surgical treatment of this condition.


The SPRiMACC study is a prospective multicenter observational study run by the World Society of Emergency Surgery (WSES). From 1 September 2021 to 1 September 2022, consecutive patients admitted to 79 centers located in 19 different countries were included. The study was registered on with the following identifier: NCT04995380 [19].

Inclusion criteria were: 1: a diagnosis of ACC as defined by 2018 TG criteria, 2: being a candidate for UEC during the index admission (other surgical techniques, either open or bailout procedures such as subtotal cholecystectomy, were not reasons for intraoperative exclusion), 3: age ≥ 18 years old, 4: being stratified for the risk of common bile duct stones, and, if confirmed, reception of preoperative ERCP, 5: providing a signed and dated informed consent form, and 6: willingness to comply with all study procedures, and being available for the duration of the study.

Exclusion criteria were 1: pregnancy or lactation, 2: acute cholecystitis not related to a gallstone etiology, 3: onset of symptoms > 10 days before cholecystectomy (patients with ACC associated with common bile duct stones who underwent preoperative ERCP were included if they had received EC within 10 days of onset of symptoms), 4: concomitant cholangitis or pancreatitis, 5: intraoperative treatment of common bile duct stones, or 6: any other factors that might increase the risk for the patient or preclude their full compliance with the execution of the study.

The following items were analysed: gender, age, body mass index (BMI), and the following scores: POSSUM Physiological Score [20, 21], APACHE II [22], ASA [23], Charlson Comorbidity Index [24], and modified frailty index [25]; clinical data: pulse (rate per minute), systolic blood pressure (mmHg), temperature (°C degrees); hypertension requiring treatment, diabetes mellitus treated with insulin or oral medication, liver disease, previous abdominal surgical procedures, time since symptoms and surgery (days), duration of symptoms > 72 h, palpable tender mass in the right upper abdominal quadrant, leukocytes > 18,000/mm3, hemoglobin (gr/dl), platelet count, INR, creatinine, bilirubin; data regarding ACC: previous percutaneous cholecystostomy, common bile duct stones confirmed by EUS or MRI, gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, ACC grade according to TG guidelines [1, 6] operative time (minutes), bail-out procedure, Chole-Risk score [26], POSSUM Operative Risk Score [20], postoperative complications measured by Clavien-Dindo score at 30 days [27], readmission at 30 days and hospital stay. Complications with Clavien Dindo score CD ≤ II were considered minor, and those with CD ≥ IIIa major.

The criteria used to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications (any CD ≥ I is considered non-TO), no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. The cholecystectomies performed through an initial open approach or with conversion after initial laparoscopy were considered non-TO. Patients who cumulatively presented all the characteristics listed were considered to be TOUEC.

The characteristics of the TO and non-TO groups were compared using IBM® SPSS version 25.0 (SPSS Inc). Continuous variables without normal distribution were expressed as medians with interquartile range (IQR), using the Mann–Whitney U test. Categorical variables were reported as frequencies and proportions and compared using the χ2 test. Subsequently, univariate and multivariate logistic regressions were performed to identify the independent factors associated with obtaining TO. A p < 0.05 was considered statistically significant.


A total of 1253 patients were studied, but seven were excluded due to incomplete data for analysis. Therefore, 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The parameter with the most impact on achieving TOUEC was the existence of complications, followed by length of stay, laparoscopic approach and 30-day readmission; the one with the least impact on TOUEC was mortality.

Complications at 30 days were recorded in 209 patients (16.7%), meaning that 1037 patients (83.22%) did not present complications at this time point. The complications were minor (CD < II) in 123 patients (9.9%) and major (CD ≥ IIIa) also in 83 patients (6.6%). The surgical approach was laparoscopic in 1048 patients (84.1%), and open in the remaining 15.9%. Fourteen patients had died at 30 days, a mortality rate of 1.1%. Forty-one patients (3.3%) were readmitted at 30 days. The data for achieving TO are shown in Fig. 1, in which each column represents a TOUEC parameter and the blue line shows the cumulative incidence of TOUEC.

Fig. 1
figure 1

Textbook outcome in emergent cholecystectomy due to acute cholecystitis

Comparison of the TO and non-TO groups revealed several significant differences. The patients that achieved TOUEC were a median of 11 years younger and were more frequently female. TOUEC patients had significantly lower scores (p.000) on all the risk scales analysed (ASA, POSSUM Physiological Score. Charlson Score, Frailty Score, Chole-Risk score, and POSSUM Operative score). Temperature and pulse were also significantly lower in the TOUEC group. Patients with diabetes, hypertension, or heart, liver, and lung diseases were less likely to achieve TOUEC. Prior abdominal surgeries and BMI did not show differences between groups. In the serological tests, TOUEC patients had lower values for creatinine, sodium, potassium, INR, bilirubin, and leukocytosis than non-TOUEC patients.

Regarding the characteristics of the disease itself, the TOUEC group had lower rates of complicated cholecystitis (gangrenous, liver abscess, biliary peritonitis, choledocholithiasis, and emphysematous cholecystitis). Preoperative percutaneous cholecystostomy was less frequently performed in the patients who later emerged as TOUEC. As for surgical time, a shorter duration was also associated with a greater likelihood of achieving TOUEC (see Table 1).

Table 1 Characteristics of patients who achieve TO versus non-TO

The results of the univariate logistic regression showed significant differences in numerous variables. Younger age was a protective factor for achieving TOUEC, while female sex increased the possibility of obtaining TOUEC by 1.6 times. However, neither parameter reached significance in the multivariate regression model. Table 2 shows the results of the logistic regression.

Table 2 Univariate and multivariate analysis of factors related to achieve to

In the multivariate logistic regression, the independent risk factors for achieving TOUEC were pulse (no tachycardia), low total score on the POSSUM scale, the absence of hypertension, creatinine < 2 mg/dL, the absence of oliguria, short operative time, absence of palpable mass in right upper quadrant, absence of gangrenous cholecystitis, no perivascular abscess, low ASA score, no prior percutaneous cholecystostomy, absence of choledocholithiasis confirmed by EUS or MRI, low POSSUM physiological score and POSSUM Operative Severity Score < 15. Patients who met these parameters were the most likely to achieve TOUEC.


Textbook outcome (TO) is a multidimensional measure for managing the quality of surgical procedures. It allows comparisons between groups and is easy to interpret. One of the main criticisms of TO is that it is an “all or nothing” indicator. Nevertheless, it is a useful tool that has proven to be an independent indicator of survival in the field of cancer surgery. Obviously, patients with TO represent lower costs for the health system [11, 13, 18, 28, 29]. Information on the use of TO in benign pathology is limited.

In our multicenter prospective series of 1246 early urgent cholecystectomies for ACC, 63.3% of patients achieved TOUEC. Due to the practically non-existent literature on TO in gallstones and the absence of internationally accepted parameters for TO in ACC, it is difficult to compare our results with those of other series. We used the following criteria for defining TOUEC: no 30-day mortality, no 30-day postoperative complications (any CD ≥ I was considered non-TO), no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile) and full laparoscopic surgery. In our definition of TOEUC we did not consider reinterventions, since these are performed in patients classified as Clavien-Dindo IIIb and were thus already included; nor did we consider intraoperative complications since their presence tends to be associated with a higher complication rate in the postoperative period and longer hospital stay. The gold standard for cholecystectomy is the laparoscopic approach, and so we believe it is important that this parameter be included in TO, excluding conversions and open cholecystectomies. Unlike Lucocq et al. in their series of elective cholecystectomies [17], we did not exclude subtotal cholecystectomy since it is a resource used in ACC.

The only studies available at present are two single-center retrospective series. In the study by Lucocq et al. just mentioned, a TO rate of 85.5% was obtained in 2166 patients undergoing elective cholecystectomies, and Iseda et al. reported a rate of 81.5% in their study of 189 patients with ACC [17, 18]. We believe the better results recorded in those series are due to the fact that our TO criteria were stricter. In our definition of TOUEC we included only patients with no complications (CD = 0), while both Lucocq and Iseda included patients with CD ≤ 2 [17, 18].

If we had included minor complications, we would have obtained a TOUEC of 90.1%, even though our series included patients undergoing emergency surgery. In our view, in cholecystectomy, the ideal postoperative period is one without complications. Furthermore, among their criteria Iseda et al. included a non-prolonged stay of ≥ 10 days, without specifying the reason for using this cut-off; in our case, in accordance with the most widely accepted definition of prolonged stay in TO [9] we considered a period of ≥ 7 days (75th percentile of the stay in our series). Mortality in our series was 1.1% higher than that reported by Lucocq et al. (0.3%), while Iseda et al. recorded zero mortality; our increased rate is probably attributable to the multicenter nature of our study in emergency surgical procedures.

Analysing the factors that influence the attainment of TOUEC in our study, we found numerous significant differences in the univariate regression. In Iseda et al.’s study, age > 70 years, hemoglobin < 11.9g/dL and leukocytosis > 18,000/µL were the only independent factors associated with failure to achieve TOUEC. In our series, age and analytical data were significant in the univariate analysis, but not in the multivariate study. The same was the case of bilirubin, INR and platelets. Other studies have established a direct relationship between bilirubin levels > 2 gr/dl and the degree of difficulty of the cholecystectomy, which may be related to the failure to achieve TO [26]. The only analytical parameter in our multivariate study associated with an increased risk of failure to attain TOUEC was creatinine > 2mg/dL.

In our series, probably due to the numerous variables recorded and the large sample size, the POSSUM physiological score, total POSSUM, and ASA all reached significance. The ASA score also independently influenced the achievement of TO in the scheduled cholecystectomies in Lucocq et al.’s study [17]. These data are in line with other published works which show that the higher the risk predictor scores, the higher the rates of morbidity and mortality, length of stay and readmission and that, as a result, the postoperative period is likely to be suboptimal [30,31,32,33,34,35,36,37]. Clinical variables such as tachycardia, pharmacologically treated hypertension, the presence of a palpable mass in the right hypochondrium and the presence of oliguria at diagnosis also reduce the likelihood of achieving TOUEC.

Forms of complicated cholecystitis such as abscesses, choledocholithiasis confirmed by EUS, gangrenous cholecystitis, and perivesicular abscesses were also identified as risk factors for the failure to achieve TOUEC. Previous percutaneous cholecystostomy also had a negative influence, although cholecystostomy has been widely used since the publication of the Tokyo Guidelines, numerous publications have noted its high associated morbidity, the difficulty of the laparoscopic approach, prolongation of hospital stay, and the high readmission rate. As a result, in spite of its value for managing acute episodes in fragile and high-risk patients, it should not be considered as innocuous, or as the gold standard treatment [38,39,40,41,42,43,44,45,46].

The operative time in our case was a decisive factor in attaining TOUEC: the shorter the postoperative time, the more likely TOUEC was to be achieved. This finding has already been reported in other articles which have demonstrated that prolonged surgical time increases the risk of surgical wound infection and the risk of pulmonary complications, and therefore also increases morbidity and mortality rates and lengthens hospital stay.

The main limitation of the study is the scarcity of literature on the topic and the lack of an internationally accepted definition of TO, which means that it difficult to make comparisons with other series and may have introduced certain biases in the collection of data. As its main strength, this is the first prospective multicenter study that analyses TO in cholecystectomy for acute cholecystitis.


Among modifiable factors, avoiding unnecessary percutaneous cholecystostomies, using a laparoscopic approach, and keeping surgical time as short as possible are all crucial for achieving TOUEC. Although the other independent factors are probably not modifiable, a rapid optimization of patients with acute cholecystitis is likely to improve postoperative outcomes. To our knowledge, this is the largest prospective series of TO in urgent cholecystectomy published to date. There is a clear need for an international consensus definition of the parameters that the TOUEC should include. Our proposal is: no 30-day mortality, no 30-day postoperative complications (any CD ≥ I is considered non-TO), no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile) and full laparoscopic surgery.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reason- able request.



Acute cholecystitis


World society of emergency surgery


Early laparoscopic cholecystectomy


Post-operative length of stay


Textbook outcome


Urgent early cholecystectomy


Textbook outcome in urgent early cholecystectomy


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S.P.Ri.M.A.C.C. Collaborative Group: Goran Augustin (1), Trpimir Morić (1), Selmy Awad (2), Azzah M Alzahrani (2), Mohamed Elbahnasawy (3), Damien Massalou (4), Belinda De Simone (5), Zaza Demetrashvili (6), Athina‑Despoina Kimpizi (7), Dimitrios Schizas (8), Dimitrios Balalis (9), Nikolaos Tasis (10), Maria Papadoliopoulou (11), Petrakis Georgios (12), Konstantinos Lasithiotakis (13), Orestis Ioannidis (14), Lovenish Bains (15), Matteo Magnoli (16), Pasquale Cianci (17), Nunzia Ivana Conversano (17), Alessandro Pasculli (18), Jacopo Andreuccetti (19), Elisa Arici (19), Giusto Pignata (19), Guido A.M. Tiberio (20), Mauro Podda (21), Cristina Murru (22), Massimiliano Veroux (23),Costanza Distefano (23), Danilo Centonze (23), Francesco Favi (24), Vanni Agnoletti, Rafaele Bova (24), Girolamo Convertini (24), Andrea Balla (25), Diego Sasia (26), Giorgio Giraudo (26), Anania Gabriele (27), Nicola Tartaglia (28), Giovanna Pavone (28), Fabrizio D’Acapito (29), Nicolò Fabbri (30), Francesco Ferrara (31), Stefania Cimbanassi (32), Luca Ferrario (32), Stefano Ciof (32), Marco Ceresoli (33), Chiara Fumagalli (33), Luca Degrate (33), Maurizio Degiuli (34), Silvia Sofa (34), Leo Licari (35), Matteo Tomasoni, Tommaso Dominioni, Camilla Nikita Farè, Marcello Maestri, Jacopo Viganò, Benedetta Sargenti, Andrea Anderloni, Valeria Musella, Simone Frassini, Giulia Gambini, Mario Improta (36), Alberto Patriti (37), Diego Coletta (37), Luigi Conti (38), Michele Malerba (39), Muratore Andrea (40), Marcello Calabrò (40), Beatrice De Zolt (40), Gabriele Bellio (41), Alessio Giordano (42), Davide Luppi (43), Carlo Corbellini (44),Gianluca Matteo Sampietro (44), Chiara Marafante (45), Stefano Rossi (46), Andrea Mingoli (47), Pierfrancesco Lapolla (47), Pierfranco M Cicerchia (47), Leandro Siragusa (48), Michele Grande (48), Claudio Arcudi (49), Amedeo Antonelli (49), Danilo Vinci (49), Ciro De Martino (50), Mariano Fortunato Armellino (50), Enrica Bisogno (50), Diego Visconti (51), Mauro Santarelli (51), Elena Montanari (51), Alan Biloslavo (52), Paola Germani (52), Claudia Zaghi (53), Naoki Oka (54), Mohd Azem Fathi (55), Daniel Ríos‑Cruz (56), Edgard Efren Lozada Hernandez (57), Ibrahim Umar Garzali (58), Liliana Duarte (59), Ionut Negoi (60), Andrey Litvin (61), Sharfuddin Chowdhury (62), Salem M. Alshahrani (62), Silvia Carbonell‑Morote (63), Juan J. Rubio‑Garcia (63), Claudia Cristina Lopes Moreira (64), Iñigo Augusto Ponce (64), Fernando Mendoza‑Moreno (65), Anna Muñoz Campaña (66), Heura Llaquet Bayo (66), Andrea Campos Serra (66), Aitor Landaluce (67), Begoña Estraviz‑Mateos (67), Izaskun Markinez‑Gordobil (67), Mario Serradilla‑Martín (68), Antonio Cano‑ Paredero (68), Miguel Ángel Dobón‑Rascón (68), Hytham Hamid (69), Oussama Baraket (70), Emre Gonullu (71), Sezai Leventoglu (72), Yilmaz Turk (72), Çağrı Büyükkasap (72), Ulaş Aday (73), Yasin Kara (74), Hamit Ahmet Kabuli (75), Semra Demirli Atici (76), Elif Colak (77), Serge Chooklin (78), Serhii Chuklin (78), Federico Ruta (79), Marcello Di Martino (80), Francesca Dal Mas (81), Fikri M. Abu‑Zidan (82), Salomone Di Saverio (83), Ari Leppäniemi (84), Elena Martín‑Pérez, Ángela de la Hoz Rodríguez (85), Ernest E. Moore (86), Andrew B. Peitzman (87)

(1) Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia; (2) Department of General Surgery, Mansoura University Hospitals, Mansoura, Egypt; (3) University Faculty of Medicine, Tanta, Egypt; (4) Acute care surgery, CHU de Nice, Nice, France; (5) Dpt of Emergency, Digestive and Metabolic Minimally invasive surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France; (6) State Medical University, Tbilisi, Georgia; (7) Hippocration General Hospital of Athens, Athens, Greece; (8) National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece; (9) Saint Savvas Cancer Hospital, Athens, Greece; (10) Naval and Veterans Hospital, Department of Surgery, Athens, Greece; (11) University General Hospital Attikon‑UoA, Chaidari, Greece; (12) Surgery Department, General Hospital of Chania—Saint George, Crete, Greece; (13) Surgery University Hospital of Heraklion, Medical School of Heraklion, Crete, Greece; (14) General Hospital George Papanikolaou, Thessaloniki, Greece; (15) Maulana Azad Medical College, New Delhi, India; (16) Chirurgia generale, Ospedale Monsignor Galliano, Acqui terme, Italy; (17) Lorenzo Bonomo Hospital, Andria, Italy; (18) University of Bari, Bari, Italy; (19) Chirurgia 2, ASST Spedali Civili of Brescia, Brescia, Italy; (20) Surgical Clinic, University of Brescia, Brescia, Italy; (21) Department of Surgical Science, University of Cagliari, Cagliari, Italy; (22) PO Santissima Trinità, Cagliari, Italy; (23) Azienda Policlinico Università di Catania, Catania, Italy; (24) Bufalini Hospital, Cesena, Italy; (25) UOC of General and Minimally Invasive Surgery, San Paolo Hospital, Civitavecchia, Italy; (26) Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy; (27) Azienda Ospedaliero‑Universitaria di Ferrara, Arcispedale Sant’Anna, Ferrara, Italy; (28) University Hospital, Foggia, Italy; (29) Ospedale Morgagni Pierantoni, Forlì, Italy; (30) Ospedale del Delta, Lagosanto, Italy; (31) ASST Santi Paolo e Carlo, Milano, Italy; (32) Chirurgia generale Trauma team, Ospedale Niguarda, Milano, Italy; (33) General and Emergency Surgery, School of Medicine and Surgery, Milano‑ Bicocca University, Monza, Italy; (34) Surgical oncology and digestive surgery, A.O.U. San Luigi Gonzaga, Orbas‑ sano, Italy; (35) FBF Buccheri La Ferla, Palermo, Italy; (36) Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; (37) AO Ospedali Riuniti Marche Nord, Pesaro, Italy; (38) G, Da Saliceto Hospital, Piacenza, Italy; (39) ASL2 Savonese, Pietra Ligure, Italy; (40) Chirurgia generale Ospedale E. Agnelli, Pinerolo, Italy; (41) Ospedale Immacolata Concezione, Piove di Sacco, Italy; (42) "S.Stefano" New Hospital, Prato, Italy; (43) ASMN, Reggio Emilia, Italy; (44) Ospedale di Rho—ASST Rhodense, Rho, Italy; (45) Chirurgia Generale Ospedale degli Infermi, Rivoli, Italy; (46) San Filippo Neri Hospital, Roma, Italy; (47) Policlinico Umberto I Sapienza, Roma, Italy; (48) University Tor Vergata, Roma, Italy; (49) UOC Chirurgia Bariatrica, Ospedale San Carlo di Nancy, Roma, Italy; (50) University Hospital "S. Giovanni di Dio e Ruggi d’Aragona", Salerno, Italy; (51) Chirurgia Generale d’Urgenza e PS, AOU Città della Salute e della Scienza, Torino, Italy; (52) General Surgery Department, Cattinara University Hospital, ASUGI, Trieste, Italy; (53) Ospedale San Bortolo, Vicenza, Italy; (54) Kurashiki Central Hospital, Kurashiki, Japan; (55) Department of Surgery, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia; (56) Instituto Mexicano del seguro social, Ciudad de México, Mexico; (57) Regional Hospital of High Speciality of Bajio, Leon Guanajuato, Mexico; (58) Aminu Kano Teaching Hospital, Kano, Nigeria; (59) Centro Hospitalar Tondela‑Viseu, Viseu, Portugal; (60) Emergency Hospital of Bucharest, Bucharest, Romania; (61) Immanuel Kant Baltic Federal University, Regional Clinic Hospital, Kalinin‑ grad, Russia; (62) General Surgery, King Saud Medical City, Riyadh, Saudi ArabiaPage 11 of 12; Fugazzola et al. World Journal of Emergency Surgery (2023) 18:20 ; (63) Department of Surgery and Liver Transplantation. Hospital General Uni‑ versitario Dr. Balmis, Alicante, Spain; (64) Hospital universitario Donostia, Donostia‑San Sebastian, Spain; (65) Hospital Universitario Príncipe de Asturias, Madrid, Spain; (66) Emergency Surgery Unit, Parc Tauli Hospital, Sabadell, Spain; (67) Urduliz Hospital, Urduliz, Spain; (68) Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain; (69) Kuwaiti Specialized Hospital, Khartoum, Sudan; (70) Bizerte hospital, Bizerte, Tunis; (71) Sakarya Training and Research Hospital, Adapazari/Sakarya, Turkey; (72) Gazi University, School of Medicine, Department of Surgery, Ankara, Turkey; (73) Department of Gastroenterological Surgery, Dicle University School of Medicine, Diyarbakir, Turkey; (74) Kanuni Sultan Süleyman Training and Research Hospital, Instanbul, Turkey; (75) Bakirkoy Dr Sadi Konuk Training and Research Hospital, Instanbul, Turkey; (76) Tepecik Training and Research Hospital, Konak/İzmir, Turkey; (77) Samsun Training and Research Hospital, Samsun, Turkey; (78) Regional Clinical hospital, Lviv, Ukraine; (79) Nursing Directorship, ASL BAT, Andria, Italy; (80) Hepato‑Biliary and Liver Transplantation Department, AORN Cardarelli, Napoli, Italy. ; (81) Department of Management, Ca’ Foscari University of Venice, Venice, Italy.; (82) The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates.; (83) Department of Surgery, Madonna Del Soccorso Hospital, San Benedetto del Tronto, Italy.; (84) Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.; (85) Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS‑IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.; (86) Denver Health System ‑ Denver Health Medical Center, Denver, USA.; (87) Department of Surgery, University of Pittsburgh School of Medicine, UPMC‑Presbyterian, Pittsburgh, USA. 15Department of Surgery



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All authors have met the ICMJE authorship criteria. Contributions: Conception and Design: Silvia Carbonell, Paola Fugazzola, Juan Jesus Rubio, Luca Ansaloni and JM Ramia ; Administrative support: All authors; Provision of study: All authors; Collection and assembly of data: Silvia Carbonell, Paola Fugazzola, Juan Jesus Rubio, Luca Ansaloni and JM Ramia; Data analysis and interpretation: Silvia Carbonell, Paola Fugazzola, Juan Jesus Rubio, Luca Ansaloni and JM Ramia; Manuscript writing: Silvia Carbonell and JM Ramia; Final approval of manuscript: All authors. All authors have read and agreed to the published version of the manuscript.

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Fugazzola, P., Carbonell-Morote, S., Cobianchi, L. et al. Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study. World J Emerg Surg 19, 12 (2024).

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