Cholecystectomy outcomes across income levels: analysis of the SPRiMACC global database

Background: Acute calculous cholecystitis (ACC) is a common surgical emergency globally, with laparoscopic cholecystectomy (LC) representing the gold standard treatment. However, access to LC varies significantly across countries with different income levels, reflecting broader global disparities in surgical care. This study aims to compare the clinical characteristics and perioperative outcomes of ACC patients undergoing cholecystectomy across high-, middle-, and low-income countries, with a focus on laparoscopic surgery. Methods: This is a post hoc analysis of the prospective SPRiMACC study, which included 1253 patients from 79 centers across 19 countries. Patients were stratified into two groups based on World Bank income classifications: high-income countries (HICs) and middle-/low-income countries (LMICs). Propensity score matching (PSM) was used to balance patient characteristics across groups. Outcomes assessed included complication rates, mortality, length of hospital stay (LOS), use of bail-out procedures, and conversion to open surgery. Results: Prior to matching, significant differences were observed in comorbidity indices (including the Charlson comorbidity index and the American Society of Anesthesiologists index) and ACC severity between HICs and LMICs. After PSM, 366 matched patients were analyzed. No significant differences were found in intraoperative complications, conversion rates, or mortality. However, LOS > 10 days was more frequent in HICs (12.6% vs. 3.8%, p = 0.004), while bail-out procedures were more common in LMICs (11.5% vs. 3.3%, p = 0.004). These findings suggest that surgical outcomes are largely comparable, though they are influenced by contextual factors such as resource availability and health system capacity. Conclusions: This study highlights the feasibility of safe laparoscopic surgery for ACC across diverse economic settings while also exposing persistent disparities in access, surgical strategies, and health system efficiency. Expanding access to laparoscopic techniques in resource-limited settings will require targeted investments in training, infrastructure, and policy reform. These efforts align with global surgery goals and the Sustainable Development Goals, particularly SDG 3 (Good Health and Well-Being) and SDG 10 (Reduced Inequalities).