Predicting Postoperative Complications After Cholecystectomy for Acute Cholecystitis: Comparative Performance of Disease-Specific and General Prognostic Scores

Background: Although early laparoscopic cholecystectomy represents the standard treatment for acute cholecystitis [AC], reliable preoperative risk stratification remains challenging. This study compared the discriminative performance of five prognostic scores: two disease-specific tools (Chole-Risk and a locally modified variant, Chole-Risk mod) and three general indices (POSSUM Physiological Score, APACHE II, and Charlson Comorbidity Index [CCI]) for predicting postoperative complications [POC] and prolonged hospital stay. Methods: This single-center retrospective study included 211 consecutive patients undergoing cholecystectomy for AC between 2015 and 2024. Primary endpoint: the occurrence of any POC. Secondary endpoint: prolonged length of stay (LOS), defined as postoperative hospitalization exceeding the 75th percentile (>6 days). Discrimination was assessed using the area under the receiver operating characteristic curve (AUC), with pairwise comparisons performed using the DeLong test. Calibration was evaluated graphically, and clinical utility was explored through decision curve analysis. Results: POC occurred in 60 patients (28.4%), and prolonged LOS in 51 (24.2%). Chole-Risk mod showed the best discrimination (AUC 0.786) and the strongest association per one-standard-deviation increase (OR 4.10; 95% CI 2.47–6.79). Other scores showed lower performance: Chole-Risk (AUC 0.755), CCI (0.736), POSSUM Physiological Score (0.707), and APACHE II (0.696). For prolonged LOS, Chole-Risk demonstrated the highest discrimination (AUC 0.713). Decision curve analysis confirmed a net clinical benefit for Chole-Risk–based models across a broad range of decision thresholds. Conclusions: Disease-specific scores incorporating variables related to biliary pathology outperform general physiological and comorbidity indices in predicting adverse outcomes after cholecystectomy for acute cholecystitis. These findings suggest that the severity of the local inflammatory process may influence postoperative risk more strongly than the patient’s overall physiological burden. Prospective multicenter validation is warranted.