## 4 Discussion
Second, prior to 2013, the majority of the patients who had a delayed cholecystectomy had a higher surgical risk and more comorbidities, as well as a higher mortality rate. After 2013, however, the surgeons followed the 2013 Tokyo guidelines, which suggested that patients should generally undergo surgery after their condition had improved following internal drainage. By delaying the surgical time in the patients who were previously at a lower surgical risk, the mortality rate of delayed cholecystectomy has improved. In most prospective studies, early laparoscopic cholecystectomy was shown to be safe and effective and was shown to provide a better quality of life than initially having conservative treatment followed by delayed surgery [19; 20; 21]. It appears likely that ELC is superior to either ILC or DLC, and ELC is strongly recommended. If ELC cannot be performed (because adequate surgical expertise is not available), DLC appears to be superior to ILC [9]. Several trials have advocated the performance of laparoscopic cholecystectomy within 3 days after ERCP [20; 21]. However, evidence of moderate quality has been found, mainly because of the lack of blinding in the trials. Furthermore, there is no evidence of a difference between DLC and ILC, and the ACDC trial comparing ELC versus ILC showed that a significant proportion of patients undergoing ILC developed serious adverse events [22]. Our results, on the other hand, demonstrate the opposite outcome. The recurrence rate and the mortality rate were found to be statistically insignificant compared to early cholecystectomy. We found that the intermediate cholecystectomy after ERCP group, with recurrence and mortality rates equivalent to those of the early cholecystectomy group, had a lower complication rate. It appears likely that ILC is superior to either ELC or DLC, and DLC appears to be superior to ELC. The primary reason for this could be that these studies focused on acute cholecystitis rather than focusing on patients with secondary choledocholithiasis. The optimal timing of the cholecystectomy in secondary choledocholithiasis patients has rarely been directly studied to date. After reviewing the development of laparoscopic cholecystectomy, it is obvious that the earlier concerns about the development of fibrosis in Calot's triangle following the resolution of the initial bout of inflammation after acute cholecystitis have been considered the main causal factor for a technically difficult surgery, and the development of fibrosis is associated with a higher risk of bile duct injury [4]. However, when simply analyzing the definition of acute obstructive cholangitis, which is characterized by a complete obstruction of the common bile duct with the accumulation of purulent material under pressure, the obstruction is most commonly due to calculi in the common bile duct, and strictures, neoplasms, pancreatitis, and parasites may also be other provoking agents [23]. All of the obstructions in our study were due to calculi only. In other words, if the condition is due to isolated cholangitis and when the inflammation is improved by internal drainage, ELC may not be the appropriate timing for cholecystectomy, as described in the literature. In our analysis, ILC is a superior alternative. In comparison with the existing literature, our study is characterized by a large sample size and revealed differences between early, intermediate, and delayed cholecystectomy while using an improved patient characterization, including comorbidities and standardized methods for the evaluation of patient parameters, and by a precise subgroup analysis. From our study results, it is obvious that the best time to perform a laparoscopic cholecystectomy in individuals who undergo therapeutic ERCP for choledocholithiasis should be ILC (within 2 months after admission). ELC is associated with a measurable risk of complications.