Title: Acute cholecystitis in old adults: the impact of advanced age on the clinical characteristics
of the disease and on the surgical outcomes of laparoscopic cholecystectomy
Version: 1 Date: 11 May 2023
Reviewer's report:
I would congratulate with the authors for the nice manuscript which highlights the risk factors
associated with laparoscopic cholecystectomy in elderly patients with acute cholecystitis. I
would agree that patients' selection is key to provide safe surgical care in this group of patients.
This is an important take home message.
I have some points I would like to raise, as follows:
Methods
1)  I have not clear if all the subjects included in the study underwent emergency LC. Can the
authors clarify, please?
2) If patients underwent emergency surgery, what was the mean time between admission and
LC?
3) Given that some had PTGBD first, I would imagine LC was performed at a later stage. In
such cases, was LC performed during the same admission or electively?
Results
1) Male sex was more represented in the whole study population. It is common evidence that
AC occurs more frequently in female patients, at least in Western countries. Is the epidemiology
of AC different in the authors' area?
2) Subjects in group 3 had higher ASA and CCI. The Tokyo guidelines state that ASA > 3 and
CCI > 6 are risk factors of poor surgical outcomes, in case urgent LC was taken into account.
Can the authors clarify if patients with high ASA and CCI received emergency surgery or if
they were optimised before having LC?
2) Given that CCI scores increases with age, I think it is not surprising that group 3 had higher
CCI. May I suggest that the authors mention that in the discussion.
3) In those patient who had PTGBD first, what was the mean time between PTGBD and LC?
4) The estimated blood loss was higher in group 3. Can the authors explain why?
5) The authors mentioned that 353 patients were found having CBD stones. How were they
treated, with ERCP followed by LC or LC and CBD exploration?
5a) In case of preoperative ERCP, what was the mean time between ERCP and LC? I think   this
information should be mentioned in the results.
5b) If patients underwent CBD exploration, how was that performed, via the trans cystic or
trans choledochal route? Did they develop postoperative complications? I think that would be
mentioned as well.
6) The hospital stay was longer in group 3. I would imagine that such a result was secondary
to the higher rate of complications. However, in common practice elderly subjects would likely
need physiotherapy to improve their postoperative mobilization. Also, it is not infrequent to deal
with social issues in this category of patients (i.e., those who live alone and need support in their
daily care). I think these aspects would account for a longer hospital stay too. Can the author
comment on that, please? I would also suggest to comment this aspect in the discussion.
Title: Acute cholecystitis in old adults: the impact of advanced age on the clinical characteristics
of the disease and on the surgical outcomes of laparoscopic cholecystectomy
Version: 1 Date: 11 May 2023
Reviewer's report:
I would congratulate with the authors for the nice manuscript which highlights the risk factors
associated with laparoscopic cholecystectomy in elderly patients with acute cholecystitis. I
would agree that patients' selection is key to provide safe surgical care in this group of patients.
This is an important take home message.
I have some points I would like to raise, as follows:
Methods
1)  I have not clear if all the subjects included in the study underwent emergency LC. Can the
authors clarify, please?
2) If patients underwent emergency surgery, what was the mean time between admission and
LC?
3) Given that some had PTGBD first, I would imagine LC was performed at a later stage. In
such cases, was LC performed during the same admission or electively?
Results
1) Male sex was more represented in the whole study population. It is common evidence that
AC occurs more frequently in female patients, at least in Western countries. Is the epidemiology
of AC different in the authors' area?
2) Subjects in group 3 had higher ASA and CCI. The Tokyo guidelines state that ASA > 3 and
CCI > 6 are risk factors of poor surgical outcomes, in case urgent LC was taken into account.
Can the authors clarify if patients with high ASA and CCI received emergency surgery or if
they were optimised before having LC?
2) Given that CCI scores increases with age, I think it is not surprising that group 3 had higher
CCI. May I suggest that the authors mention that in the discussion.
3) In those patient who had PTGBD first, what was the mean time between PTGBD and LC?
4) The estimated blood loss was higher in group 3. Can the authors explain why?
5) The authors mentioned that 353 patients were found having CBD stones. How were they
treated, with ERCP followed by LC or LC and CBD exploration?
5a) In case of preoperative ERCP, what was the mean time between ERCP and LC? I think   this
information should be mentioned in the results.
5b) If patients underwent CBD exploration, how was that performed, via the trans cystic or
trans choledochal route? Did they develop postoperative complications? I think that would be
mentioned as well.
6) The hospital stay was longer in group 3. I would imagine that such a result was secondary
to the higher rate of complications. However, in common practice elderly subjects would likely
need physiotherapy to improve their postoperative mobilization. Also, it is not infrequent to deal
with social issues in this category of patients (i.e., those who live alone and need support in their
daily care). I think these aspects would account for a longer hospital stay too. Can the author
comment on that, please? I would also suggest to comment this aspect in the discussion.
Please review this paper.
user
Title: Acute cholecystitis in old adults: the impact of advanced age on the clinical characteristics
of the disease and on the surgical outcomes of laparoscopic cholecystectomy
Version: 1 Date: 11 May 2023
Reviewer's report:
I would congratulate with the authors for the nice manuscript which highlights the risk factors
associated with laparoscopic cholecystectomy in elderly patients with acute cholecystitis. I
would agree that patients' selection is key to provide safe surgical care in this group of patients.
This is an important take home message.
I have some points I would like to raise, as follows:
Methods
1)  I have not clear if all the subjects included in the study underwent emergency LC. Can the
authors clarify, please?
2) If patients underwent emergency surgery, what was the mean time between admission and
LC?
3) Given that some had PTGBD first, I would imagine LC was performed at a later stage. In
such cases, was LC performed during the same admission or electively?
Results
1) Male sex was more represented in the whole study population. It is common evidence that
AC occurs more frequently in female patients, at least in Western countries. Is the epidemiology
of AC different in the authors' area?
2) Subjects in group 3 had higher ASA and CCI. The Tokyo guidelines state that ASA > 3 and
CCI > 6 are risk factors of poor surgical outcomes, in case urgent LC was taken into account.
Can the authors clarify if patients with high ASA and CCI received emergency surgery or if
they were optimised before having LC?
2) Given that CCI scores increases with age, I think it is not surprising that group 3 had higher
CCI. May I suggest that the authors mention that in the discussion.
3) In those patient who had PTGBD first, what was the mean time between PTGBD and LC?
4) The estimated blood loss was higher in group 3. Can the authors explain why?
5) The authors mentioned that 353 patients were found having CBD stones. How were they
treated, with ERCP followed by LC or LC and CBD exploration?
5a) In case of preoperative ERCP, what was the mean time between ERCP and LC? I think   this
information should be mentioned in the results.
5b) If patients underwent CBD exploration, how was that performed, via the trans cystic or
trans choledochal route? Did they develop postoperative complications? I think that would be
mentioned as well.
6) The hospital stay was longer in group 3. I would imagine that such a result was secondary
to the higher rate of complications. However, in common practice elderly subjects would likely
need physiotherapy to improve their postoperative mobilization. Also, it is not infrequent to deal
with social issues in this category of patients (i.e., those who live alone and need support in their
daily care). I think these aspects would account for a longer hospital stay too. Can the author
comment on that, please? I would also suggest to comment this aspect in the discussion.
assistant